Volume 11, Issue 11 March 12, 2019

CDC Science Clips: Volume 11, Issue 11, March 12, 2019

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

  1. Top Articles of the Week

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

    The names of CDC authors are indicated in bold text.
    • Communicable Diseases
      • Selecting evidence-based HIV prevention behavioral interventions for HIV-negative persons for national disseminationExternal
        Collins CB, Baack BN, Tomlinson H, Lyles C, Cleveland JC, Purcell DW, Ortiz-Ricard A, Mermin J.
        AIDS Behav. 2019 Feb 23.
        This paper describes the development of a formula to determine which evidence-based behavioral interventions (EBIs) targeting HIV-negative persons would be cost-saving in comparison to the lifetime cost of HIV treatment and the process by which this formula was used to prioritize those with greatest potential impact for continued dissemination. We developed a prevention benefit index (PBI) to rank risk-reduction EBIs for HIV-negative persons based on their estimated cost for achieving the behavior change per one would-be incident infection of HIV. Inputs for calculating the PBI included the mean estimated cost-per-client served, EBI effect size for the behavior change, and the HIV incidence per 100,000 persons in the target population. EBIs for which the PBI was </= $402,000, the estimated lifetime cost of HIV care, were considered cost-saving. We were able to calculate a PBI for 35 EBI and target population combinations. Ten EBIs were cost-saving having a PBI below $402,000. One EBI did not move forward for dissemination due to high start-up dissemination costs. DHAP now supports the dissemination of 9 unique EBIs targeting 13 populations of HIV-negative persons. The application of a process, such as the PBI, may assist other health-field policymakers when making decisions about how to select and fund implementation of EBIs.

      • Respiratory illness associated with emergent human adenovirus genome type 7d, New Jersey, 2016-2017External
        Killerby ME, Rozwadowski F, Lu X, Caulcrick-Grimes M, McHugh L, Haldeman AM, Fulton T, Schneider E, Sakthivel SK, Bhatnagar J, Rabeneck DB, Zaki S, Gerber SI, Watson JT.
        Open Forum Infect Dis. 2019 Feb;6(2):ofz017.
        Background: Human adenoviruses (HAdVs) are known causes of respiratory illness outbreaks in congregate settings, but cases and clusters are less well described from community settings in the United States. During December 2016-February 2017, the New Jersey Department of Health received reports of HAdV infections from 3 sources in 3 adjacent counties. We investigated to characterize the epidemiologic, laboratory, and clinical features of this HAdV outbreak. Methods: A case was defined as a New Jersey resident with acute respiratory illness during December 1, 2016-March 31, 2017 with laboratory identification of HAdV genome type 7d (HAdV-7d). Human adenovirus was detected by real-time and conventional polymerase chain reaction and molecular typed by partial hexon capsid protein gene sequencing. The HAdV genome type was identified by whole genome sequencing analysis. Available medical, public health, and surveillance records were reviewed. Results: We identified 12 cases, including 3 treatment facility patients, 7 college students, and 2 cases at a tertiary-care hospital. Four cases died; all had underlying comorbidities. Nine HAdV-7d whole genome sequences obtained from all 3 sites were nearly identical. Conclusions: Transmission of HAdV-7d occurred in community and congregate settings across 3 counties and resulted in severe morbidity and mortality in some cases with underlying comorbidities. Clinicians and local and state health departments should consider HAdV in patients with severe respiratory infection.

      • An evaluation of a bucket chlorination campaign during a cholera outbreak in rural CameroonExternal
        Murphy J, Cartwright E, Johnson B, Ayers T, Worthington W, Mintz ED.
        Waterlines. 2018 ;37(4):266-279.
        Bucket chlorination (where workers stationed at water sources manually add chlorine solution to recipients’ water containers during collection) is a common emergency response intervention with little evidence to support its effectiveness in preventing waterborne disease. We evaluated a bucket chlorination intervention implemented during a cholera outbreak by visiting 234 recipients’ homes across five intervention villages to conduct an unannounced survey and test stored household drinking water for free chlorine residual (FCR). Overall, 89 per cent of survey respondents reported receiving bucket chlorination, and 80 per cent reported receiving the intervention in the previous 24 hours. However, only 8 per cent of stored household water samples that were reportedly treated only with bucket chlorination in the previous 24 hours had FCR >/=0.2 mg/l. Current international guidelines for bucket chlorination recommend an empirically derived dosage determined 30 minutes after chlorine addition, and do not account for water storage in the home. In controlled investigations we conducted, an initial FCR of 1.5 mg/l resulted in FCR >/=0.5 mg/l for 24 hours in representative household plastic and clay storage containers. To ensure reduction of the risk of waterborne disease, we recommend revising bucket chlorination protocols to recommend a chlorine dosage sufficient to maintain FCR >/=0.2 mg/l for 24 hours in recipients’ household stored drinking water.

    • Disease Reservoirs and Vectors
      • Efficacy of novel indoor residual spraying methods targeting pyrethroid-resistant Aedes aegypti within experimental housesExternal
        Dunbar MW, Correa-Morales F, Dzul-Manzanilla F, Medina-Barreiro A, Bibiano-Marin W, Morales-Rios E, Vadillo-Sanchez J, Lopez-Monroy B, Ritchie SA, Lenhart A, Manrique-Saide P, Vazquez-Prokopec GM.
        PLoS Negl Trop Dis. 2019 Feb;13(2):e0007203.
        Challenges in maintaining high effectiveness of classic vector control in urban areas has renewed the interest in indoor residual spraying (IRS) as a promising approach for Aedes-borne disease prevention. While IRS has many benefits, application time and intrusive indoor applications make its scalability in urban areas difficult. Modifying IRS to account for Ae. aegypti resting behavior, named targeted IRS (TIRS, spraying walls below 1.5 m and under furniture) can reduce application time; however, an untested assumption is that modifications to IRS will not negatively impact entomological efficacy. We conducted a comparative experimental study evaluating the residual efficacy of classically-applied IRS (as developed for malaria control) compared to two TIRS application methods using a carbamate insecticide against a pyrethroid-resistant, field-derived Ae. aegypti strain. We performed our study within a novel experimental house setting (n = 9 houses) located in Merida (Mexico), with similar layouts and standardized contents. Classic IRS application (insecticide applied to full walls and under furniture) was compared to: a) TIRS: insecticide applied to walls below 1.5 m and under furniture, and b) Resting Site TIRS (RS-TIRS): insecticide applied only under furniture. Mosquito mortality was measured eight times post-application (out to six months post-application) by releasing 100 Ae. aegypti females /house and collecting live and dead individuals after 24 hrs exposure. Compared to Classic IRS, TIRS and RS-TIRS took less time to apply (31% and 82% reduction, respectively) and used less insecticide (38% and 85% reduction, respectively). Mortality of pyrethroid-resistant Ae. aegypti did not significantly differ among the three IRS application methods up to two months post application, and did not significantly differ between Classic IRS and TIRS up to four months post application. These data illustrate that optimizing IRS to more efficiently target Ae. aegypti can both reduce application time and insecticide volume with no apparent reduction in entomological efficacy.

    • Environmental Health
      • Endocrine disrupting chemical exposure and maladaptive behavior during adolescenceExternal
        Shoaff JR, Calafat AM, Schantz SL, Korrick SA.
        Environ Res. 2018 Dec 22;172:231-241.
        BACKGROUND: Studies suggest that exposure to endocrine disrupting chemicals (EDCs), including phthalates, phenols, and parabens may influence childhood behavior, but the relationship during adolescence has not been assessed. OBJECTIVE: We investigated the association between urinary biomarker concentrations of potential EDCs, including some phthalate and bisphenol A replacement chemicals, and behavior in adolescents. METHODS: Participants were from the New Bedford Cohort (NBC), a prospective birth cohort of residents near the New Bedford Harbor Superfund site in Massachusetts. We measured urinary concentrations of 16 phthalate metabolites or replacements, 8 phenols, and 4 parabens in 205 NBC adolescents and estimated associations between select EDCs and adolescent behavior assessed with the Behavior Assessment System for Children, Second Edition -Teacher Rating Scale (BASC-2). Of note, up to 32 of the 205 in our assessment had missing outcome information imputed. RESULTS: Increased urinary concentrations of the sum of 11 antiandrogenic phthalate metabolites were associated with an increase in maladaptive behaviors (Externalizing Behavior, Behavioral Symptoms Index, and Developmental Social Disorders or DSD), and a decrease in Adaptive Skills. For example, a doubling of urinary concentrations of antiandrogenic phthalate metabolites was associated with an increased risk of Externalizing Behavior (RR=1.04; 95% CI: 1.01-1.08). While associations were generally stronger in males, sex differences were not statistically significant. Urine concentrations of phenols and parabens were not associated with adverse behavior. CONCLUSION: Our findings support the importance of exposure to antiandrogenic phthalates during adolescence as a potential correlate of maladaptive behaviors including Externalizing Behavior, DSD behaviors, and decrements in Adaptive Skills.

    • Health Disparities
      • Familial economic hardship, an adverse childhood experience (ACE) that increases children’s risk for exposure to additional ACEs, can derail optimal child development. A compelling area with potential for reducing economic hardship and promoting healthy child development is housing. In the US, the largest contributor to family wealth is homeownership, which may contribute to a family’s ability to provide their children opportunities to do better than previous generations. The objective of the current study was to examine the influence of homeownership on children’s economic outcomes in adulthood. This study used data from two surveys conducted in the US, the National Longitudinal Survey of Youth 1979 (NLSY79) and the NLSY79 Young Adult survey, to examine the association between mothers’ homeownership in 1994 and children’s economic outcomes 20 years later. Adults whose mothers owned homes in 1994 were over 1.5 times more likely to own homes, attained higher education, and were moderately less likely to receive public assistance in 2014 compared to adults whose mothers did not own homes. This paper highlights the potential of homeownership to break the intergenerational continuity of poverty. Programs that help families purchase affordable housing hold promise in helping ensure children reach their full potential and improving economic outcomes in future generations.

    • Health Economics
      • The Diabetes Prevention Impact Tool Kit: An online tool kit to assess the cost-effectiveness of preventing type 2 diabetesExternal
        Lanza A, Soler R, Smith B, Hoerger T, Neuwahl S, Zhang P.
        J Public Health Manag Pract. 2019 Feb 14.
        The National Diabetes Prevention Program lifestyle change program demonstrated health benefits and potential for health care cost-savings. For many states, employers, and insurers, there is a strong business case for paying for type 2 diabetes prevention, which will likely result in medical and nonmedical cost-savings as well as improved quality of life after a few years. Using an iterative feedback process with multiple stakeholders, the Centers for Disease Control and Prevention developed the Diabetes Prevention Impact Tool kit,, which forecasts the cost impact the lifestyle change program can have for states, employers, and health insurers. We conducted key informant interviews and a qualitative analysis to evaluate the tool kit. We found that end users recognized its utility for decision making. They valued the detail of the tool kit’s underlying calculations and appreciated the option of either using the default settings or revising assumptions based on their own data. The Diabetes Prevention Impact Tool kit can be a helpful tool for organizations that wish to forecast the economic costs and benefits of implementing or covering the National Diabetes Prevention Program lifestyle change program.

    • Healthcare Associated Infections
    • Immunity and Immunization
      • Health departments’ experience with mumps outbreak response and use of a third dose of measles, mumps, and rubella vaccineExternal
        Marlow MA, Moore K, DeBolt C, Patel M, Marin M.
        J Public Health Manag Pract. 2019 Feb 22.
        CONTEXT: During January 2016 to June 2017, US health departments (HDs) reported 150 mumps outbreaks. Most occurred among populations with high 2-dose measles, mumps, and rubella (MMR) vaccine coverage, prompting the Advisory Committee on Immunization Practices to examine the evidence for use of a third dose of MMR vaccine. OBJECTIVE: To evaluate HD experiences with mumps outbreak control and use of a third MMR dose during outbreaks. DESIGN: An online survey assessing mumps outbreak characteristics, outbreak response measures, challenges, and lessons learned from previous outbreaks was distributed to all 81 Council of State and Territorial Epidemiologists member HDs in August 2017. RESULTS: Sixty-one (75%) HDs responded; 46 (75%) had experience with >/=1 mumps outbreak(s) during January 2016 to August 2017. Twenty (43%) HDs recommended a third or outbreak MMR dose during mumps outbreaks; of these, 19 completed the section on use of a third dose and 8 (40%) rated the intervention “somewhat effective” or better. Health departments that used a third/outbreak dose suggested implementing the recommendation early and to a targeted group. Forty-three (73%) HDs reported having a policy for excluding persons without presumptive immunity from outbreak settings; of these, 37 (86%) had some degree of legal authority to implement this policy. Exclusion compliance improved with the use of personalized notification letters, focus groups of excluded persons and the community, and standardized messaging. Other outbreak control measures included cohorting of exposed or susceptible persons, mobile vaccination clinics and home visits, contact monitoring via text messaging, and facilitating student isolation with meal delivery and excused class absences. CONCLUSIONS: Our study revealed heterogeneity across HDs’ mumps outbreak responses but also identified common challenges that will inform future Centers for Disease Control and Prevention guidance. These results were considered in the October 2017 Advisory Committee on Immunization Practices recommendation for use of a third dose of MMR vaccine for persons at increased risk for mumps during an outbreak and in the development of Centers for Disease Control and Prevention guidance for HDs when applying the Advisory Committee on Immunization Practices recommendation.

      • Trends in human papillomavirus vaccine types 16 and 18 in cervical precancers, 2008-2014External
        McClung NM, Gargano JW, Bennett NM, Niccolai LM, Abdullah N, Griffin MR, Park IU, Cleveland AA, Querec TD, Unger ER, Markowitz LE.
        Cancer Epidemiol Biomarkers Prev. 2019 Feb 21.
        Background: The impact of human papillomavirus (HPV) vaccination has been observed in the United States through declining cervical precancer incidence in young women. To further evaluate vaccine impact, we described trends in HPV vaccine types 16/18 in cervical precancers, 2008-2014.Methods: We analyzed data from a 5-site, population-based surveillance system. Archived specimens from women age 18-39 years diagnosed with cervical intraepithelial neoplasia grades 2-3 or adenocarcinoma in situ (CIN2+) were tested for 37 HPV types. We described the proportion and estimated number of cases of CIN2+ by HPV-type groups over time. Trends in HPV16/18-positive CIN2+ were examined, overall and by vaccination status, age, histologic grade, and race/ethnicity, using Cochrane-Armitage tests.Results: In 10,206 cases, the proportion and estimated number of cases of HPV16/18-positive CIN2+ declined from 52.7% (1,235 cases) in 2008 to 44.1% (819 cases) in 2014 (P < 0.001). Declining trends in the proportion of HPV16/18-positive CIN2+ were observed among vaccinated (55.2%-33.3%, P < 0.001) and unvaccinated (51.0%-47.3%, P = 0.03) women; ages 18-20 (48.7%-18.8%, P = 0.02), 21-24 (53.8%-44.0%, P < 0.001), 25-29 (56.9%-42.4%, P < 0.001), and 30-34 (49.8%-45.8%, P = 0.04) years; CIN2 (40.8%-29.9%, P < 0.001) and CIN2/3 (61.8%-46.2%, P < 0.001); non-Hispanic white (59.5%-47.9%, P < 0.001) and non-Hispanic black (40.7%-26.5%, P < 0.001).Conclusions: From 2008-2014, the proportion of HPV16/18-positive CIN2+ declined, with the greatest declines in vaccinated women; declines in unvaccinated women suggest herd protection.Impact: The declining proportion of HPV16/18-positive CIN2+ provides additional evidence of vaccine impact in the United States.

    • Laboratory Sciences
      • A high-throughput and rapid method for accurate identification of emerging multidrug-resistant Candida aurisExternal
        Ahmad A, Spencer JE, Lockhart SR, Singleton S, Petway DJ, Bagarozzi DA, Herzegh OT.
        Mycoses. 2019 Feb 23.
        Candida auris is an emerging multidrug-resistant yeast associated with invasive infection in healthcare settings. Recently, C. auris cases in the US have been detected in 11 states with the majority of cases in New York, New Jersey, and Illinois. Rapid and accurate identification of C. auris is critical for patient care and the implementation of public health measures to control the spread of infection. Our aim was to develop and validate a rapid DNA extraction method using the Roche MagNA Pure 96 instrument and a TaqMan real-time PCR assay for reliable, high throughput identification of C. auris. We evaluated 247 patient dermal swab samples previously analyzed by culture/MALDI-TOF. The diagnostic sensitivity and specificity were 93.6% and 97.2%, respectively. The assay was highly reproducible with a detection limit of 1 C. auris CFU/10muL. A ROC curve analysis of the real-time PCR data showed an area of 0.982 under the curve, with a CT cutoff value of </=37.0. The turnaround time from DNA extraction to real-time PCR results was approximately 200 samples/day. In conclusion, we successfully validated a rapid and high throughput method for accurate and reproducible identification of C. auris with a significantly reduced turnaround time compared to culture/MALDI-TOF based methods. This article is protected by copyright. All rights reserved.

    • Nutritional Sciences
      • Impact of a municipal policy restricting trans fatty acid use in New York City restaurants on serum trans fatty acid levels in adultsExternal
        Wright M, McKelvey W, Curtis CJ, Thorpe LE, Vesper HW, Kuiper HC, Angell SY.
        Am J Public Health. 2019 Feb 21:e1-e3.
        OBJECTIVES: To estimate the impact of the 2006 policy restricting use of trans fatty acids (TFAs) in New York City restaurants on change in serum TFA concentrations in New York City adults. METHODS: Two cross-sectional population-based New York City Health and Nutrition Examination Surveys conducted in 2004 (n = 212) and 2013-2014 (n = 247) provided estimates of serum TFA exposure and average frequency of weekly restaurant meals. We estimated the geometric mean of the sum of serum TFAs by year and restaurant meal frequency by using linear regression. RESULTS: Among those who ate less than 1 restaurant meal per week, geometric mean of the sum of serum TFAs declined 51.1% (95% confidence interval [CI] = 42.7, 58.3)-from 44.6 (95% CI = 39.7, 50.1) to 21.8 (95% CI = 19.3, 24.5) micromoles per liter. The decline in the geometric mean was greater (P for interaction = .04) among those who ate 4 or more restaurant meals per week: 61.6% (95% CI = 55.8, 66.7) or from 54.6 (95% CI = 49.3, 60.5) to 21.0 (95% CI = 18.9, 23.3) micromoles per liter. CONCLUSIONS: New York City adult serum TFA concentrations declined between 2004 and 2014. The indication of greater decline in serum TFAs among those eating restaurant meals more frequently suggests that the municipal restriction on TFA use was effective in reducing TFA exposure. Public Health Implications. Local policies focused on restaurants can promote nutritional improvements. (Am J Public Health. Published online ahead of print February 21, 2019: e1-e3. doi:10.2105/AJPH.2018.304930).

  2. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Chronic Diseases and Conditions
      1. Effect of insulin resistance on BMD and fracture risk in older adultsExternal
        Napoli N, Conte C, Pedone C, Strotmeyer ES, Barbour KE, Black DM, Samelson EJ, Schwartz AV.
        J Clin Endocrinol Metab. 2019 Feb 25.
        CONTEXT: Adults with type 2 diabetes (T2D) have higher fracture risk as compared to non-diabetics despite having higher bone mineral density (BMD). Insulin resistance (IR) has been associated with increased BMD. However, it is not known if IR increases fracture risk. OBJECTIVE: We investigated the relationship between IR (HOMA-IR), BMD and incident non-spine fractures in non-diabetic individuals. Design. Participants included 2,398 community-dwelling non-diabetic older adults (age 74+/-3 years, 53% women, 38% black) in the Health, Aging and Body Composition prospective cohort study (median follow-up: 12 [interquartile range: 6] years). RESULTS: The cut-off values for the HOMA-IR quartiles were 1.05, 1.54 and 2.33. Total hip BMD was 0.104 g/cm2 higher in the 4thversus the 1st HOMA-IR quartile (p<0.001). This difference was attenuated after adjustment for BMI (adjusted mean difference 0.007 g/cm2; p=0.371). In unadjusted models, fracture risk was lower in those with higher HOMA-IR (hazard ratio [HR] 0.86 [95% CI 0.73-1.01] and 0.65 [95% CI 0.47-0.89] for the 3rd and 4th quartile, respectively, versus the 1st quartile). However, after adjustment for BMD and BMI, fracture risk was significantly higher in the 3rd quartile (HR 1.19, 95% CI 1.00-1.41) and tended to be increased in the 4th quartile (HR 1.12, 95% CI 0.87-1.46), versus the 1st quartile. CONCLUSIONS: Greater IR is associated with higher BMD in non-diabetic older adults. In contrast to the relationship between T2D and fracture risk, we did not find consistent evidence that greater IR is associated with increased fracture risk after adjustment for BMI and BMD.

    • Communicable Diseases
      1. Better outcomes among HIV-infected Rwandan children 18-60 months of age after the implementation of “Treat All”External
        Arpadi S, Lamb M, Nzeyimana IN, 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. 2019 Mar 1;80(3):e74-e83.
        BACKGROUND: In 2012, Rwanda introduced a Treat All approach for HIV-infected children younger than 5 years. 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 and December 2011 [Before Treat All (BTA) cohort] and between July 2012 and April 2015 [Treat All (TA) cohort]. 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 1 year, vs. 89% in the TA cohort. Median time to ART initiation was 68 days (interquartile range 14-494) for BTA and 9 days (interquartile range 0-28) for TA (P < 0.0001), with 9 (5%) undergoing same-day initiation in BTA compared with 50 (37%) in TA (P < 0.0001). Before ART initiation, 59% in the BTA reported at least one health condition compared with 35% in the TA cohort (P < 0.0001). Although overall loss to follow-up was similar between cohorts (BTA: 13%, TA: 8%, P = 0.18), loss to follow-up before ART was significantly higher in the BTA (8%) compared with the TA cohort (2%) (P = 0.02). CONCLUSIONS: Nearly 90% of Rwandan children started on ART within 1 year of enrollment, most within 1 month, with greater than 90% retention after implementation of TA. TA was also associated with fewer morbidities.

      2. Recent US Centers for Disease Control and Prevention activities to reduce HIV stigmaExternal
        Beer L, McCree DH, Jeffries Wt, Lemons A, Sionean C.
        J Int Assoc Provid AIDS Care. 2019 Jan-Dec;18:2325958218823541.
        HIV stigma affects many persons living with HIV in the United States, and reducing stigma is central to the US Centers for Disease Control and Prevention’s (CDC) mission to promote health and prevent HIV transmission. To this end, CDC funds and implements programmatic activities, research, communication campaigns, and monitoring through data collection and public health surveillance. Centers for Disease Control and Prevention-funded programs have developed promising interventions and educational materials for reducing HIV stigma. Research conducted by CDC staff and their collaborators have made important contributions to the scientific literature on stigma, which have informed current CDC programmatic efforts, including public education activities and social marketing campaigns. By monitoring HIV stigma in multiple populations, CDC can evaluate the population-level effectiveness of stigma-reduction efforts and identify key populations in need of support and intervention. This article describes these and other recent CDC efforts to address HIV stigma, and discusses new strategies with the potential to further reduce stigma.

      3. Adenovirus-associated influenza-like illness among college students, Pennsylvania, USAExternal
        Biggs HM, Lu X, Dettinger L, Sakthivel S, Watson JT, Boktor SW.
        Emerg Infect Dis. 2018 Nov;24(11):2117-2119.
        Among students with influenza-like illness at a Pennsylvania college student health center during 2016-2017, 44 (15%) of 288 with respiratory specimens tested positive for human adenovirus (HAdV). HAdV-3, -7, and -4 predominated, and types clustered temporally. HAdV infection should be considered among college students with acute respiratory illness.

      4. Epidemic control is necessary to eliminate HIV infection. We assessed epidemic control in the United States using four proposed UNAIDS metrics applied to national surveillance data between 2010 and 2015. Although epidemic control in the United States is possible, progress by UNAIDS metrics has been mixed.

      5. The Louisiana Wellness Centers Program for HIV/STD prevention among gay and bisexual men and transgender personsExternal
        Burgess S, Beltrami J, Kearns L, Gruber D.
        J Public Health Manag Pract. 2019 Feb 22.
        CONTEXT: During the conduct of the described demonstration project (2012-2015), the Centers for Disease Control and Prevention funding standard for HIV testing was 1.0% newly diagnosed positivity in non-health care settings. For linkage to HIV medical care, the National HIV/AIDS Strategy goal was 85%, and the funding standard was 80% (the Centers for Disease Control and Prevention and National HIV/AIDS Strategy had no other quantified goals/standards relevant to the project). OBJECTIVE: To determine aggregate quantitative results of HIV/STD testing and engagement in HIV care. DESIGN: Information sources used for this case study analysis included the Louisiana Department of Health funding application, progress and final reports submitted to the Centers for Disease Control and Prevention, and records of communications between these agencies. SETTING: Six community-based Wellness Centers throughout Louisiana. PARTICIPANTS: Gay and bisexual men and transgender persons. MAIN OUTCOME MEASURES: New HIV/STD diagnoses from testing, linkage to HIV care, and reengagement in HIV medical care. RESULTS: The percentage of persons who were newly diagnosed with HIV was 1.4% (44/3214). Of the newly diagnosed persons, 91% (40/44) were linked to HIV medical care. Of persons who were identified as out of care, 83% (5/6) were reengaged in HIV medical care. STD testing results showed that 9.0% (294/3251) of the syphilis tests were positive, and 8.3% (803/9719) of the chlamydia/gonorrhea tests were positive. The pharyngeal chlamydia/gonorrhea positivity was 7.6% (256/3375); the rectal chlamydia/gonorrhea positivity was 13% (374/2948); and the urine chlamydia/gonorrhea positivity was 5.1% (173/3396). CONCLUSIONS: The demonstration project was successful. The results were used to discontinue funding for a less effective HIV screening program, continue demonstration project activities with other funds, and make policy changes so that extragenital screening for chlamydia/gonorrhea is now the standard at Louisiana clinics that serve gay and bisexual men and transgender persons.

      6. Association between HIV-1 subtype and drug resistance in Nigerian infantsExternal
        Chaplin B, Akanmu AS, Inzaule SC, Samuels JO, Okonkwo P, Ilesanmi O, Adewole IF, Asadu C, Khamofu H, Mpazanje R, Ndembi N, Odafe S, Sigaloff KC, Ngige EN, Abatta EO, Akinbiyi G, Dakum P, Rinke de Wit TF, Kanki P.
        J Antimicrob Chemother. 2019 Jan 1;74(1):172-176.
        Background: Many lines of evidence point to HIV-1 subtype-specific differences in the development of drug resistance mutations. While variation between subtype C and others has been extensively explored, there has been less emphasis on subtypes common to West Africa. We examined a previously described national survey of pretreatment drug resistance in HIV-1-infected Nigerian children aged <18 months, to explore the association between subtypes and patterns of resistance. Methods: Five hundred and forty-nine dried blood spots, from 15 early infant diagnostic facilities in Nigeria, were amplified and HIV-1 polymerase was sequenced. Four hundred and twenty-four were analysed for surveillance drug resistance mutations (SDRMs). Associations between subtype and SDRMs were evaluated by Fisher’s exact test and logistic regression analysis, controlling for geographical region and exposure. Results: Using the sub-subtypes of HIV-1 G defined by Delatorre et al. (PLoS One 2014. 9: e98908) the most common subtypes were CRF02_AG (174, 41.0%), GWA-I (128, 30.2%), GWA-II (24, 5.7%), GCA (11, 2.6%), A (21, 5.0%) and CRF06_cpx (18, 4.2%). One hundred and ninety infants (44.8%) had >/=1 NNRTI mutation, 92 infants (21.7%) had >/=1 NRTI mutation and 6 infants (1.4%) had >/=1 PI mutation. By logistic regression, 67N was more common in GWA-II/GCA than CRF02_AG (OR 12.0, P = 0.006), as was 70R (OR 23.1, P = 0.007), 184I/V (OR 2.92, P = 0.020), the presence of >/=1 thymidine analogue mutation (TAM) (OR 3.87, P = 0.014), >/=1 type 2 TAM (OR 7.61, P = 0.001) and >/=1 NRTI mutation (OR 3.26, P = 0.005). Conclusions: This dataset reveals differences among SDRMs by subtype; in particular, between the GWA-II and GCA subclades, compared with CRF02_AG and GWA-I.

      7. Clinical outcomes of young black men receiving HIV medical care in the United States, 2009-2014External
        Chowdhury P, Beer L, Shouse RL, Bradley H.
        J Acquir Immune Defic Syndr. 2019 Feb 13.
        BACKGROUND: More than one-quarter of 2016 HIV diagnoses among blacks in the U.S. occurred among persons aged 15-24 years, and three-quarters were among men. Although the prevalence of viral suppression at all tests in the past 12 months (durable viral suppression) among persons receiving HIV care increased from 58% to 68% during 2009-2013, we do not know whether this same improvement was seen among young black men receiving care. METHODS: We analyzed 2009-2014 Medical Monitoring Project (MMP) data collected from 336 black men aged 18-24 years. We estimated the proportion of young black men receiving HIV care who were prescribed antiretroviral therapy (ART), adherent to ART, and durably virally suppressed. We assessed changes in clinical outcomes over time and their association with patient characteristics, health behaviors, and depression. RESULTS: During 2009-2014, 80% of young black men receiving HIV care were prescribed ART, 73% were adherent to ART, and 36% had durable viral suppression. There was no significant change in viral suppression over this period. ART prescription and durable viral suppression were significantly higher among those receiving Ryan White HIV/AIDS Program assistance compared with those did not. Durable viral suppression was significantly lower among those who used drugs compared with those who did not. CONCLUSIONS: Viral suppression among young black men during 2009-2014 was lower than among the overall population receiving HIV care in 2013 (36% vs. 68%). Increasing viral suppression is essential to improve health and reduce HIV transmissions in this key population.

      8. CNS melioidosis in a traveler returning from Cabo, MexicoExternal
        Donahue MA, Newcomb G, Spinella S, Prasad P, Liesveld J, Egan CT, Smith GL, Newman AP, Bower WA, Blaney DD, Gee JE, Elrod MG, Chuang S, Babu TM.
        Open Forum Infect Dis. 2019 Feb;6(2):ofz005.
        Melioidosis is caused by the gram-negative bacillus Burkholderia pseudomallei, endemic to northern Australia and Southeast Asia. We present a patient who traveled to Mexico, returned to the United States, and developed progressive manifestations of melioidosis, culminating as central nervous system disease. Standard therapy was contraindicated, and a prolonged intensive phase was employed.

      9. Improving estimates of district HIV prevalence and burden in South Africa using small area estimation techniquesExternal
        Gutreuter S, Igumbor E, Wabiri N, Desai M, Durand L.
        PLoS One. 2019 ;14(2):e0212445.
        Many countries, including South Africa, have implemented population-based household surveys to estimate HIV prevalence and the burden of HIV infection. Most household HIV surveys are designed to provide reliable estimates down to only the first subnational geopolitical level which, in South Africa, is composed of nine provinces. However HIV prevalence estimates are needed down to at least the second subnational level in order to better target the delivery of HIV care, treatment and prevention services. The second subnational level in South Africa is composed of 52 districts. Achieving adequate precision at the second subnational level therefore requires either a substantial increase in survey sample size or use of model-based estimation capable of incorporating other pre-existing data. Our purpose is demonstration of the efficacy of relatively simple small-area estimation of HIV prevalence in the 52 districts of South Africa using data from the South African National HIV Prevalence, Incidence and Behavior Survey, 2012, district-level HIV prevalence estimates obtained from testing of pregnant women who attended antenatal care (ANC) clinics in 2012, and 2012 demographic data. The best-fitting model included only ANC prevalence and dependency ratio as out-of-survey predictors. Our key finding is that ANC prevalence was the superior auxiliary covariate, and provided substantially improved precision in many district-level estimates of HIV prevalence in the general population. Inclusion of a district-level spatial simultaneously autoregressive covariance structure did not result in improved estimation.

      10. Notes from the field: Enteroinvasive Escherichia coli outbreak associated with a potluck party – North Carolina, June-July 2018External
        Herzig CT, Fleischauer AT, Lackey B, Lee N, Lawson T, Moore ZS, Hergert J, Mobley V, MacFarquhar J, Morrison T, Strockbine N, Martin H.
        MMWR Morb Mortal Wkly Rep. 2019 Feb 22;68(7):183-184.

        [No abstract]

      11. Global burden of maternal and congenital syphilis and associated adverse birth outcomes-Estimates for 2016 and progress since 2012External
        Korenromp EL, Rowley J, Alonso M, Mello MB, Wijesooriya NS, Mahiane SG, Ishikawa N, Le LV, Newman-Owiredu M, Nagelkerke N, Newman L, Kamb M, Broutet N, Taylor MM.
        PLoS One. 2019 ;14(2):e0211720.
        BACKGROUND: In 2007 the World Health Organization (WHO) launched the global initiative to eliminate mother-to-child transmission of syphilis (congenital syphilis, or CS). To assess progress towards the goal of <50 CS cases per 100,000 live births, we generated regional and global estimates of maternal and congenital syphilis for 2016 and updated the 2012 estimates. METHODS: Maternal syphilis estimates were generated using the Spectrum-STI model, fitted to sentinel surveys and routine testing of pregnant women during antenatal care (ANC) and other representative population data. Global and regional estimates of CS used the same approach as previous WHO estimates. RESULTS: The estimated global maternal syphilis prevalence in 2016 was 0.69% (95% confidence interval: 0.57-0.81%) resulting in a global CS rate of 473 (385-561) per 100,000 live births and 661,000 (538,000-784,000) total CS cases, including 355,000 (290,000-419,000) adverse birth outcomes (ABO) and 306,000 (249,000-363,000) non-clinical CS cases (infants without clinical signs born to un-treated mothers). The ABOs included 143,000 early fetal deaths and stillbirths, 61,000 neonatal deaths, 41,000 preterm or low-birth weight births, and 109,000 infants with clinical CS. Of these ABOs- 203,000 (57%) occurred in pregnant women attending ANC but not screened for syphilis; 74,000 (21%) in mothers not enrolled in ANC, 55,000 (16%) in mothers screened but not treated, and 23,000 (6%) in mothers enrolled, screened and treated. The revised 2012 estimates were 0.70% (95% CI: 0.63-0.77%) maternal prevalence, and 748,000 CS cases (539 per 100,000 live births) including 397,000 (361,000-432,000) ABOs. The estimated decrease in CS case rates between 2012 and 2016 reflected increased access to ANC and to syphilis screening and treatment. CONCLUSIONS: Congenital syphilis decreased worldwide between 2012 and 2016, although maternal prevalence was stable. Achieving global CS elimination, however, will require improving access to early syphilis screening and treatment in ANC, clinically monitoring all women diagnosed with syphilis and their infants, improving partner management, and reducing syphilis prevalence in the general population by expanding testing, treatment and partner referral beyond ANC.

      12. Geographic correlates of primary and secondary syphilis among men who have sex with men in the United StatesExternal
        Leichliter JS, Grey JA, Cuffe KM, de Voux A, Cramer R, Hexem S, Chesson HW, Bernstein KT.
        Ann Epidemiol. 2019 Feb 5.
        PURPOSE: Primary and secondary (P&S) syphilis in men who have sex with men (MSM) has been increasing; however, there is a lack of research on geographic factors associated with MSM P&S syphilis. METHODS: We used multiple data sources to examine associations between social and environmental factors and MSM P&S syphilis rates at the state- and county-level in 2014 and 2015, separately. General linear models were used for state-level analyses, and hurdle models were used for county-level models. Bivariate analyses (P < .25) were used to select variables for adjusted models. RESULTS: In 2014 and 2015 state models, a higher percentage of impoverished persons (2014 beta = 1.24, 95% confidence interval, 0.28-2.20; 2015 beta = 1.19; 95% confidence interval, 0.42-1.97) was significantly associated with higher MSM P&S syphilis rates. In the 2015 county model, policies related to sexual orientation (marriage, housing, hate crimes) were significant correlates of MSM P&S syphilis rates (P < .05). CONCLUSIONS: Our state-level findings that poverty is associated with MSM P&S syphilis are consistent with research at the individual level across different subpopulations and various sexually transmitted diseases. Our findings also suggest that more research is needed to further evaluate potential associations between policies and sexually transmitted diseases. Geographic-level interventions to address these determinants may help curtail the rising syphilis rates and their sequelae in MSM.

      13. The impact of HIV infection on TB disparities among US-born black and white tuberculosis patients in the United StatesExternal
        Marks SM, Katz DJ, Davidow AL, Pagaoa MA, Teeter LD, Graviss EA.
        J Public Health Manag Pract. 2019 Feb 14.
        BACKGROUND/OBJECTIVES: US-born non-Hispanic black persons (blacks) (12% of the US population) accounted for 41% of HIV diagnoses during 2008-2014. HIV infection significantly increases TB and TB-related mortality. TB rate ratios were 6 to 7 times as high in blacks versus US-born non-Hispanic whites (whites) during 2013-2016. We analyzed a sample of black and white TB patients to assess the impact of HIV infection on TB racial disparities. METHODS: In total, 552 black and white TB patients with known HIV/AIDS status were recruited from 10 US sites in 2009-2010. We abstracted data from the National TB Surveillance System, medical records, and death certificates and interviewed 477 patients. We estimated adjusted odds ratios (AORs) with 95% confidence intervals (CIs) for associations of TB with HIV infection, late HIV diagnosis (</=3 months before or any time after TB diagnosis), and mortality during TB treatment. RESULTS: Twenty-one percent of the sample had HIV/AIDS infection. Blacks (AOR = 3.4; 95% CI, 1.7-6.8) and persons with recent homelessness (AOR = 2.5; 95% CI, 1.5-4.3) had greater odds of HIV infection than others. The majority of HIV-infected/TB patients were diagnosed with HIV infection 3 months or less before (57%) or after (4%) TB diagnosis. Among HIV-infected/TB patients, blacks had similar percentages to whites (61% vs 57%) of late HIV diagnosis. Twenty-five percent of HIV-infected/TB patients died, 38% prior to TB diagnosis and 62% during TB treatment. Blacks did not have significantly greater odds of TB-related mortality than whites (AOR = 1.1; 95% CI, 0.6-2.1). CONCLUSIONS: Black TB patients had greater HIV prevalence than whites. While mortality was associated with HIV infection, it was not significantly associated with black or white race.

      14. The role of human immunodeficiency virus in influenza- and respiratory syncytial virus-associated hospitalizations in South African children, 2011-2016External
        McMorrow ML, Tempia S, Walaza S, Treurnicht FK, Moyes J, Cohen AL, Pretorius M, Hellferscee O, Wolter N, von Gottberg A, Nguweneza A, McAnerney JM, Naby F, Mekgoe O, Venter M, Madhi SA, Cohen C.
        Clin Infect Dis. 2019 Feb 15;68(5):773-780.
        BACKGROUND: Data describing influenza- or respiratory syncytial virus (RSV)-associated hospitalized illness in children aged <5 years in Africa are limited. METHODS: During 2011-2016, we conducted surveillance for severe respiratory illness (SRI) in children aged <5 years in 3 South African hospitals. Nasopharyngeal aspirates were tested for influenza and RSV using real-time reverse transcription polymerase chain reaction. We estimated rates of influenza- and RSV-associated hospitalized SRI by human immunodeficiency virus (HIV) status and compared children who tested positive for influenza vs RSV using multivariable penalized logistic regression. RESULTS: Among 3650 hospitalized children, 203 (5.6%) tested positive for influenza viruses, 874 (23.9%) for RSV, and 19 (0.5%) for both. The median age of children hospitalized with influenza was 13.9 months vs 4.4 months for RSV (P < .01). Annual influenza-associated hospitalization rates per 100000 were highest among infants aged 6-11 months (545; 95% confidence interval [CI], 409-703), while RSV-associated hospitalization rates were highest in infants aged 0-2 months (6593; 95% CI, 5947-7217). HIV exposure was associated with increased incidence of influenza- and RSV-associated hospitalization in infants aged 0-5 months, with relative risk (RR) 2.2 (95% CI, 1.4-3.4) and 1.4 (95% CI, 1.3-1.6), respectively. HIV infection was associated with increased incidence of influenza- and RSV-associated hospitalization in all age groups; RR 2.7 (95% CI, 2.0-3.5) and 3.8 (95% CI, 3.1-4.8), respectively. CONCLUSIONS: Influenza- and RSV-associated hospitalizations are common among South African infants. HIV infection and HIV exposure in infants increase risk of influenza- and RSV-associated hospitalization.

      15. Campylobacteriosis outbreak associated with contaminated municipal water supply – Nebraska, 2017External
        Pedati C, Koirala S, Safranek T, Buss BF, Carlson AV.
        MMWR Morb Mortal Wkly Rep. 2019 Feb 22;68(7):169-173.
        In March 2017, the Nebraska Department of Health and Human Services (NDHHS) and the Southwest Nebraska Public Health Department were notified of an apparent cluster of Campylobacter jejuni infections in city A and initiated an investigation. Overall, 39 cases were investigated, including six confirmed and 33 probable. Untreated, unboiled city A tap water (i.e., well water) was the only exposure significantly associated with illness (odds ratio [OR] = 7.84; 95% confidence interval [CI] = 1.69-36.36). City A is served by four untreated wells and an interconnected distribution system. Onsite investigations identified that a center pivot irrigation system intended to pump livestock wastewater from a nearby concentrated animal feeding operation onto adjacent farmland had malfunctioned, allowing excessive runoff to collect in a road ditch near two wells that supplied water to the city. These wells were promptly removed from service, after which no subsequent cases occurred. This coordinated response rapidly identified an important risk to city A’s municipal water supply and provided the evidence needed to decommission the affected wells, with plans to build a new well to safely serve this community.

      16. The global campaign to eliminate HBV and HCV infection: International Viral Hepatitis Elimination Meeting and core indicators for development towards the 2030 elimination goalsExternal
        Popping S, Bade D, Boucher C, van der Valk M, El-Sayed M, Sigurour O, Sypsa V, Morgan T, Gamkrelidze A, Mukabatsinda C, Deuffic-Burban S, Ninburg M, Feld J, Hellard M, Ward J.
        J Virus Erad. 2019 Jan 1;5(1):60-66.
        Hepatitis B virus (HBV) and hepatitis C virus (HCV) affect more than 320 million people worldwide, which is more than HIV, tuberculosis (TB) and malaria combined. Elimination of HBV and HCV will, therefore, produce substantial public health and economic benefits and, most importantly, the prevention of 1.2 million deaths per year. In 2016, member states of the World Health Assembly unanimously adopted a resolution declaring that viral hepatitis should be eliminated by 2030. Currently, few countries have elimination programmes in place and even though the tools to achieve elimination are available, the right resources, commitments and allocations are lacking. During the fifth International Viral Hepatitis Elimination Meeting (IVHEM), 7-8 December 2018, Amsterdam, the Netherlands, an expert panel of clinicians, virologists and public health specialists discussed the current status of viral hepatitis elimination programmes across multiple countries, challenges in achieving elimination and the core indicators for monitoring progress, approaches that have failed and successful elimination plans.

      17. Higher rates of tuberculosis among class B1 Filipino immigrants to Hawaii compared to nationwide, 2010-2014External
        Schmit KM, Brostrom R, Largen A, Pyan A, Wang Z, Mase S, Morris S.
        J Immigr Minor Health. 2019 Feb 26.
        BACKGROUND: Immigrants to the United States from countries with a high burden of tuberculosis (TB) who have abnormal chest radiographs but negative sputum cultures during pre-immigration screening (TB Class B1) have a high risk of being diagnosed with TB disease within 1 year of arrival. METHODS: Using 2010-2014 national surveillance data, we compared proportions of Class B1 Filipino immigrants who received a diagnosis of TB disease within 1 year of arrival to Hawaii to proportions in other U.S. states (not including Hawaii) using chi-squared tests. RESULTS: In Hawaii, 40/1190 (3.4%) of Class B1 Filipino immigrants to Hawaii received a diagnosis of TB disease within 1 year of arrival compared with 220/16,035 (1.4%) nationwide (P < .01). CONCLUSIONS: During 2010-2014, the percentage of recent Class B1 Filipino immigrants in Hawaii with TB disease diagnosed within 1 year of arrival was over twice that as nationwide.

      18. Prevalence and patterns of antiretroviral therapy prescription in the United StatesCdc-pdfExternal
        Tie Y, Skarbinski J, Qin G, Frazier EL.
        Open AIDS Journal. 2018 ;12(1):181-194.
        Background: The use of Antiretroviral Therapy (ART) in HIV-infected persons has proven to be effective in the reduction of risk of disease progression and prevention of HIV transmission. Objective: U.S. Antiretroviral Therapy (ART) guidelines specify recommended initial, alternative initial, and not-recommended regimens, but data on ART prescribing practices and real-world effectiveness are sparse. Methods: Nationally representative annual cross sectional survey of HIV-infected adults receiving medical care in the United States, 2009-2012 data cycles. Using data from 18,095 participants, we assessed percentages prescribed ART regimens based on medical record documentation and the associations between ART regimens and viral suppression (most recent viral load test <200 copies/ml in past year) and ART-related side effects. Results: Among HIV-infected adults receiving medical care in the United States, 91.8% were prescribed ART; median time since ART initiation to interview date was 9.8 years. The percentage prescribed ART was significantly higher in 2012 compared to 2009 (92.7% vs 88.7%; p < 0.001). Of those prescribed ART, 51.6% were prescribed recommended initial regimens, 6.1% alternative initial regimens, 29.0% not-recommended as initial regimens, and 13.4% other regimens. Overall, 79.5% achieved viral suppression and 15.7% reported side effects. Of those prescribed ART and initiated ART in the past year, 80.5% were prescribed recommended initial regimens. Conclusion: Among persons prescribed ART, the majority were prescribed recommended initial regimens. Monitoring of ART use should be continued to provide ongoing assessments of ART effectiveness and tolerability in the United States.

      19. [No abstract]

      20. Progress toward hepatitis B control and elimination of mother-to-child transmission of hepatitis B virus – Western Pacific Region, 2005-2017External
        Woodring J, Pastore R, Brink A, Ishikawa N, Takashima Y, Tohme RA.
        MMWR Morb Mortal Wkly Rep. 2019 Mar 1;68(8):195-200.
        Hepatitis B vaccine (HepB), which has been available since 1982, provides lifelong protection against hepatitis B virus (HBV) infection and the associated 20%-30% increased lifetime risk for developing cirrhosis or hepatocellular carcinoma among >95% of vaccine recipients (1). Before HepB introduction into national childhood immunization schedules, the estimated hepatitis B surface antigen (HBsAg) prevalence in the World Health Organization (WHO) Western Pacific Region (WPR)* was >8% in 1990 (2). In 2005, the WPR was the first WHO region to establish a hepatitis B control goal, with an initial target of reducing HBsAg prevalence to <2% among children aged 5 years by 2012. In 2013, the WPR set more stringent control targets to achieve by 2017, including reducing HBsAg prevalence to <1% in children aged 5 years and increasing national coverage with both timely HepB birth dose (HepB-BD) (defined as administration within 24 hours of birth) and the third HepB dose (HepB3) to >/=95% (3). All WPR countries/areas endorsed the Regional Action Plan for Viral Hepatitis in the Western Pacific Region 2016-2020 in 2015 (4) and the Regional Framework for the Triple Elimination of Mother-to-Child Transmission of human immunodeficiency virus (HIV), Hepatitis B and Syphilis in Asia and the Pacific 2018-2030 (triple elimination framework) in 2017 (5). These regional targets and strategies are aligned with program targets established by the WHO Global Health Sector Strategy on Viral Hepatitis 2016-2021 that aim to reduce HBsAg prevalence among children aged 5 years to </=1% by 2020 and to </=0.1% by 2030 (6). This report describes progress made to achieve hepatitis B control in the WPR and the steps taken to eliminate mother-to-child transmission (MTCT) of HBV during 2005-2017. During this period, regional timely HepB-BD and HepB3 coverage increased from 63% to 85% and from 76% to 93%, respectively. As of December 2017, 15 (42%) countries/areas achieved >/=95% timely HepB-BD coverage; 18 (50%) reached >/=95% HepB3 coverage; and 19 (53%) countries/areas as well as the region as a whole were verified to have achieved the regional and global target of <1% HBsAg prevalence among children aged 5 years. Continued implementation of proven vaccination strategies will be needed to make further progress toward WPR hepatitis B control targets. In addition to high HepB-BD and HepB3 coverage, enhanced implementation of complementary hepatitis B prevention services through the triple elimination framework, including routine HBsAg testing of pregnant women, timely administration of hepatitis B immunoglobulin to exposed newborns, and antiviral treatment of mothers with high viral loads, will be needed to achieve the global hepatitis B elimination target by 2030.

    • Disaster Control and Emergency Services
      1. Public health emergency risk communication and social media reactions to an errant warning of a ballistic missile threat – Hawaii, January 2018External
        Murthy BP, Krishna N, Jones T, Wolkin A, Avchen RN, Vagi SJ.
        MMWR Morb Mortal Wkly Rep. 2019 Feb 22;68(7):174-176.
        On January 13, 2018, at 8:07 a.m. Hawaii Standard Time, an errant emergency alert was sent to persons in Hawaii. An employee at the Hawaii Emergency Management Agency (EMA) sent the errant alert via the Wireless Emergency Alert (WEA) system and the Emergency Alert System (EAS) during a ballistic missile preparedness drill, advising persons to seek shelter from an incoming ballistic missile. WEA delivers location-based warnings to wireless carrier systems, and EAS sends alerts via television and radio (1). After 38 minutes, at 8:45 a.m., Hawaii EMA retracted the alert via WEA and EAS (2). To understand the impact of the alert, social media responses to the errant message were analyzed. Data were extracted from Twitter* using a Boolean search for tweets (Twitter postings) posted on January 13 regarding the false alert. Tweets were analyzed during two 38-minute periods: 1) early (8:07-8:45 a.m.), the elapsed time the errant alert circulated until the correction was issued and 2) late (8:46-9:24 a.m.), the same amount of elapsed time after issuance of the correction. A total of 5,880 tweets during the early period and 8,650 tweets during the late period met the search criteria. Four themes emerged during the early period: information processing, information sharing, authentication, and emotional reaction. During the late period, information sharing and emotional reaction themes persisted; denunciation, insufficient knowledge to act, and mistrust of authority also emerged as themes. Understanding public interpretation, sharing, and reaction to social media messages related to emergencies can inform development and dissemination of accurate public health messages to save lives during a crisis.

      2. Public health emergency preparedness practices and the management of frontline communicable disease responseExternal
        Sullivan AD, Strickland CJ, Howard KM.
        J Public Health Manag Pract. 2019 Feb 14.

        [No abstract]

      3. Getting the message out: Social media and word-of-mouth as effective communication methods during emergenciesExternal
        Wolkin AF, Schnall AH, Nakata NK, Ellis EM.
        Prehosp Disaster Med. 2018 Dec 26:1-6.
        Effective communication is a critical part of managing an emergency. During an emergency, the ways in which health agencies normally communicate warnings may not reach all of the intended audience. Not all communities are the same, and households within communities are diverse. Because different communities prefer different communication methods, community leaders and emergency planners need to know their communities’ preferred methods for seeking information about an emergency. This descriptive report explores findings from previous community assessments that have collected information on communication preferences, including television (TV), social media, and word-of-mouth (WoM) delivery methods. Data were analyzed from 12 Community Assessments for Public Health Emergency Response (CASPERs) conducted from 2014-2017 that included questions regarding primary and trusted communication sources. A CASPER is a rapid needs assessment designed to gather household-based information from a community. In 75.0% of the CASPERs, households reported TV as their primary source of information for specific emergency events (range = 24.0%-83.1%). Households reporting social media as their primary source of information differed widely across CASPERs (3.2%-41.8%). In five of the CASPERs, nearly one-half of households reported WoM as their primary source of information. These CASPERs were conducted in response to a specific emergency (ie, chemical spill, harmful algal bloom, hurricane, and flood). The CASPERs conducted as part of a preparedness activity had lower percentages of households reporting WoM as their primary source of information (8.3%-10.4%). The findings in this report demonstrate the need for emergency plans to include hybrid communication models, combining traditional methods with newer technologies to reach the broadest audience. Although TV was the most commonly reported preferred source of information, segments of the population relied on social media and WoM messaging. By using multiple methods for risk communication, emergency planners are more likely to reach the whole community and engage vulnerable populations that might not have access to, trust in, or understanding of traditional news sources. Multiple communication channels that include user-generated content, such as social media and WoM, can increase the timeliness of messaging and provide community members with message confirmation from sources they trust encouraging them to take protective public health actions.Wolkin AF, Schnall AH, Nakata NK, Ellis EM. Getting the message out: social media and word-of-mouth as effective communication methods during emergencies.

    • Disease Reservoirs and Vectors
      1. BACKGROUND: Insecticide-based interventions play an integral role in malaria vector control. However, the continued spread of insecticide resistance threatens to undermine progress made thus far and may ultimately lead to operational failure of current control measures. Clothianidin and chlorfenapyr both have unique modes of action and have expanded the number of insecticide classes available to vector control programmes. Prior to field use, it is imperative to establish their toxicity against local mosquito populations and evaluate potential cross-resistance with other chemicals used contemporarily or historically. The aim of this study was to determine the diagnostic doses of clothianidin and chlorfenapyr and their efficacies against Anopheles arabiensis, the predominant Ethiopian malaria vector species. METHODS: A range of doses of clothianidin and chlorfenapyr were tested, using modified WHO susceptibility tests and CDC bottle bioassays, respectively, against an Ethiopian susceptible laboratory strain and a wild population of An. arabiensis collected from Oromia Region, Ethiopia. Cross-resistance to other public health insecticides: carbamates (bendiocarb and propoxur), organophosphate (malathion) and pyrethroids (deltamethrin and permethrin), was assessed in the same mosquito populations using CDC bottle bioassays. RESULTS: Complete mosquito mortality was observed with the laboratory strain using the recommended diagnostic doses for clothianidin (2%/filter paper) and chlorfenapyr (100 microg/bottle). The field population was resistant to malathion (83% mortality), capable of surviving 2x, 5x and 10x the diagnostic dose of both deltamethrin and permethrin, but susceptible to bendiocarb and propoxur. The field population of An. arabiensis was significantly more susceptible to clothianidin, reaching 100% mortality by day 2 compared to the laboratory strain (100% mortality by day 3). In contrast, the wild population was less susceptible to chlorfenapyr, with the highest mortality of 99% at 72 h using 200 microg/bottle compared to the laboratory colony, which reached complete mortality at 50 microg/bottle by 24 h. CONCLUSIONS: The putative diagnostic doses of clothianidin and chlorfenapyr are appropriate for monitoring resistance in An. arabiensis from Ethiopia. The unique modes of action and an absence of cross-resistance render clothianidin and chlorfenapyr potential candidates for inclusion in the National Malaria Control Programme vector control efforts, particularly in areas with high pre-existing or emergent resistance to other insecticide classes.

    • Environmental Health
      1. Nitromethane exposure from tobacco smoke and diet in the U.S. population: NHANES, 2007-2012External
        Espenship MF, Silva LK, Smith MM, Capella KM, Reese CM, Rasio JP, Woodford AM, Geldner NB, Rey deCastro B, De Jesus VR, Blount BC.
        Environ Sci Technol. 2019 Feb 19;53(4):2134-2140.
        Nitromethane is a known toxicant and suspected human carcinogen. Exposure to nitromethane in a representative sample of the civilian, noninstitutionalized population in the United States >/=12 years old was assessed using 2007-2012 National Health and Nutritional Examination Survey (NHANES) data. Nitromethane was detected in all 8000 human blood samples collected, of which 6730 were used for analyses reported here. Sample-weighted median blood nitromethane was higher among exclusive combusted tobacco users (exclusive smokers; 774 ng/L) than nonusers of tobacco products (625 ng/L). In stratified sample-weighted regression analysis, smoking 0.5 pack of cigarettes per day was associated with a statistically significant increase in blood nitromethane by 150 ng/L, and secondhand smoke exposure (serum cotinine >0.05 ng/mL and <10 ng/mL) was statistically significant with a 31.1 ng/L increase in blood nitromethane. Certain dietary sources were associated with small but statistically significant increases in blood nitromethane. At median consumption levels, blood nitromethane was associated with an increase of 7.55 ng/L (meat/poultry), 9.32 ng/L (grain products), and 14.5 ng/L (vegetables). This is the first assessment of the magnitude and relative source apportionment of nitromethane exposure in the U.S. population.

      2. Prenatal exposure to endocrine disrupting chemicals in relation to autism spectrum disorder and intellectual disabilityExternal
        Hamra GB, Lyall K, Windham GC, Calafat AM, Sjodin A, Volk H, Croen LA.
        Epidemiology. 2019 Feb 15.
        BACKGROUND: Exposure to endocrine disruptors is unavoidable. Many such compounds are suspected to impact neurological development of children, but most studies conducted have considered effects of individual chemicals in isolation. Because exposures co-occur, it is important to consider their health impacts in a single regression framework. METHODS: We applied Bayesian statistical tools (including shared mean and mixture priors for 25 unique chemicals) to study independent associations of endocrine disruptor biomarkers with autism spectrum disorder (ASD) (n=491) and intellectual disability (n=155), compared with 373 general population controls, in the Early Markers for Autism study. We measured biomarkers in maternal serum collected and stored from mid-pregnancy and considered them individually or as a class (ie, summed PCBs). We adjusted all models for original matching factors (child sex, month and year of birth), maternal age, maternal race/ethnicity, parity, and maternal education at the time samples were collected. We estimated the change in the odds of ASD or intellectual disability per 1 standard deviation increase in the z-score of measured biomarker concentration for each chemical. RESULTS: Odds of ASD and intellectual disability did not change with increasing concentration for any specific endocrine disruptor. The effect estimates for each chemical were centered on or near an OR of 1.00 in both models where we applied a shared mean or a mixture prior. CONCLUSION: Our mixtures analyses do not suggest an independent relationship with ASD or intellectual disability with any of the 25 chemicals examined together in this mixtures analysis.

    • Food Safety
      1. Foodborne illness outbreaks at retail establishments – National Environmental Assessment Reporting System, 16 state and local health departments, 2014-2016External
        Lipcsei LE, Brown LG, Coleman EW, Kramer A, Masters M, Wittry BC, Reed K, Radke VJ.
        MMWR Surveill Summ. 2019 Feb 22;68(1):1-20.
        PROBLEM/CONDITION: State and local public health departments report hundreds of foodborne illness outbreaks each year to CDC and are primarily responsible for investigations of these outbreaks. Typically, investigations involve epidemiology, laboratory, and environmental health components. Health departments voluntarily report epidemiologic and laboratory data from their foodborne illness outbreak investigations to CDC through the Foodborne Disease Outbreak Surveillance System (FDOSS); however, minimal environmental health data from outbreak investigations are reported to FDOSS. PERIOD COVERED: 2014-2016. DESCRIPTION OF SYSTEM: In 2014, CDC launched the National Environmental Assessment Reporting System (NEARS) to complement FDOSS surveillance and to use these data to enhance prevention efforts. State and local health departments voluntarily report data from their foodborne illness outbreak investigations of retail food establishments. These data include characteristics of foodborne illness outbreaks (e.g., agent), characteristics of establishments with outbreaks (e.g., number of meals served daily), food safety policies and practices of these establishments (e.g., glove use policies), and characteristics of outbreak investigations (e.g., timeliness of investigation activities). NEARS is the only available data source that includes characteristics of retail establishments with foodborne illness outbreaks. RESULTS: During 2014-2016, a total of 16 state and local public health departments reported data to NEARS on 404 foodborne illness outbreaks at retail establishments. The majority of outbreaks with a suspected or confirmed agent were caused by norovirus (61.1%). The majority of outbreaks with identified contributing factors had at least one factor associated with food contamination by a worker who was ill or infectious (58.6%). Almost half (47.4%) of establishments with outbreaks had a written policy excluding ill workers from handling food or working. Approximately one third (27.7%) had a written disposable glove use policy. Paid sick leave was available for at least one worker in 38.3% of establishments. For most establishments with outbreaks (68.7%), environmental health investigators initiated their component of the investigation soon after learning about the outbreak (i.e., the same day) and completed their component in one or two visits to the establishment (75.0%). However, in certain instances, contacting the establishment and completing the environmental health component of the investigation occurred much later (>8 days). INTERPRETATION: Most outbreaks reported to NEARS were caused by norovirus, and contamination of food by workers who were ill or infectious contributed to more than half of outbreaks with contributing factors; these findings are consistent with findings from other national outbreak data sets and highlight the role of workers in foodborne illness outbreaks. The relative lack of written policies for ill workers and glove use and paid sick leave for workers in establishments with outbreaks indicates gaps in food safety practices that might have a role in outbreak prevention. The environmental health component of the investigation for most outbreaks was initiated quickly, yet the longer initiation timeframe for certain outbreaks suggests the need for improvement. PUBLIC HEALTH ACTION: Retail establishments can reduce viral foodborne illness outbreaks by protecting food from contamination through proper hand hygiene and excluding workers who are ill or infectious from working. NEARS data can help prioritize training and interventions for state and local food safety programs and the retail food establishment industry by identifying gaps in food safety policies and practices and types of establishments vulnerable to outbreaks. Improvement of certain outbreak investigation practices (e.g., delayed initiation of environmental health investigations) can accelerate identification of the agent and implementation of interventions. Future analysis comparing establishments with and without outbreaks will contribute knowledge about how establishments’ characteristics and food safety policies and practices relate to foodborne illness outbreaks and provide information to develop effective prevention approaches.

      2. [No abstract]

    • Genetics and Genomics
      1. Near-complete human sapovirus genome sequences from KenyaExternal
        Diez-Valcarce M, Montmayeur A, Tatusov R, Vinje J.
        Microbiol Resour Announc. 2019 Feb;8(7).
        We report five near-complete sapovirus genome sequences, including GI.3, GII.2, and GII.6 and two novel GII.NA (not assigned) strains. These new sequences expand the collection of human sapoviruses, allowing for a more accurate phylogenetic analysis of circulating strains and for designing broadly reactive primers for their detection and typing.

    • Health Disparities
      1. [No abstract]

    • Health Economics
      1. Cost of responding to the 2017 University of Washington mumps outbreak: A prospective analysisExternal
        Pike J, Schwartz S, Kay M, Perez-Osorio A, Marin M, Jenkins M, Routh J, Duchin J, DeBolt C, Zhou F.
        J Public Health Manag Pract. 2019 Feb 22.
        OBJECTIVES: To estimate costs of labor and materials by the University of Washington (UW) and state and local public health departments (PHDs) to respond to the February to June 2017 UW mumps outbreak, where 42 cases were identified among students (primarily sorority and fraternity members), staff, and associated community members. DESIGN: We applied standard cost analysis methodology using a combined public health and university perspective to examine the cost of responding to the outbreak. SETTING: UW’s Seattle campus encompasses 703 acres with approximately 32 000 undergraduate students. Nearly 15% of the undergraduate population are members of fraternities or sororities. Housing for the fraternities and sororities is adjacent to the UW campus and consists of 50 houses. PARTICIPANTS: During the outbreak, customized costing tools based on relevant staff or faculty positions and activities were provided to the UW and Public Health-Seattle & King County, populated by each person participating in the outbreak response, and then collected and analyzed. Laboratory hours and material costs were collected from the Washington Department of Health and the Minnesota Department of Health. MAIN OUTCOME MEASURE: Labor and material costs provided by the UW and PHDs during the outbreak were collected and categorized by payer and activity. RESULTS: Total costs to the UW and PHDs in responding to the outbreak were $282 762 ($6692 per case). Of these, the UW spent $160 064, while PHDs spent $122 098. Labor accounted for 77% of total outbreak costs, and UW response planning and coordination accounted for the largest amount of labor costs ($75 493) overall. CONCLUSIONS: Given the current university and public health department budget constraints, the response to the outbreak amounted to a significant use of resources. Labor was the largest driver of costs for the outbreak response; UW labor costs-related to campus response planning and coordination-dominated the total economic burden from public health and university perspectives.

      2. The economic impacts from preventing health care-associated infections (HAIs) can differ for patients, health care providers, third-party payers, and all of society. Previous studies from the provider perspective have estimated an economic burden of approximately $10 billion annually for HAIs. The impact of using a societal cost perspective has been illustrated by modifying a previously published analysis to include the economic value of mortality risk reductions. The resulting costs to society from HAIs exceed $200 billion annually. This article describes an alternative hospital accounting framework outlining the cost of a quality model which can better incorporate the broader societal cost of HAIs into the provider perspective.

    • Healthcare Associated Infections
      1. Evaluating movement of patients with Carbapenem-Resistant Enterobacteriaceae infections in the Greater Atlanta Metropolitan Area using social network analysisExternal
        Bower CW, Fridkin DW, Wolford HM, Slayton RB, Kubes JN, Jacob JT, Ray SM, Fridkin SK.
        Clin Infect Dis. 2019 Feb 27.
        BACKGROUND: Carbapenem-resistant Enterobacteriaceae (CRE) are an urgent threat with potential for rapid spread. We evaluated the role of Medicare patient movement between facilities to model the spread of CRE within a region. METHODS: Through population-based CRE surveillance in the 8-county Atlanta Metropolitan area (population 4.1 million), all Escherichiacoli, Enterobacter spp, or Klebsiella spp. resistant to >/=1 carbapenem collected from urine or a normally sterile site were reported from residents. CRE was attributed to a facility based on timing of culture and facility exposures in the previous year; centrality metrics were calculated from 2016 Medicare data and compared to CRE-transfer derived centrality metrics by Spearman correlation. RESULTS: During 2016, 283 incident CRE cases with concurrent or prior year facility stays were identified; cases were attributed mostly to acute care hospitals (ACH: 141, 50%) and skilled nursing facilities (SNF: 113, 40%), and less frequently to long term acute care hospitals (LTACH: 29, 10%). Attribution was widespread, originating at 17 of 20 ACH (85%), 7 of 8 (88%) LTACH, but only 35 of 65 (54%) SNFs. Betweenness of Medicare patient-transfers strongly correlated with betweenness of CRE case-transfer data in ACHs (r=0.75; P<.01) and LTACHs (r=0.77; P=.03), but not in SNFs (r=0.02; p=0.85). We note six SNFs with high CRE-derived betweenness but low Medicare-derived betweenness. CONCLUSION: CRE infections originate from almost all ACHs and about half of SNFs. We identified a subset of SNFs very central to the CRE transfer network but not the Medicare transfer network; other factors may better explain CRE patient movement in these facilities.

      2. High burden of extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae bacteremia in older adults: A seven-year study in two rural Thai provincesExternal
        Sawatwong P, Sapchookul P, Whistler T, Gregory CJ, Sangwichian O, Makprasert S, Jorakate P, Srisaengchai P, Thamthitiwat S, Promkong C, Nanvatthanachod P, Vanaporn M, Rhodes J.
        Am J Trop Med Hyg. 2019 Feb 18.
        Bloodstream infection surveillance conducted from 2008 to 2014 in all 20 hospitals in Sa Kaeo and Nakhon Phanom provinces, Thailand, allowed us to look at disease burden, antibiotic susceptibilities, and recurrent infections caused by extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae. Of 97,832 blood specimens, 3,338 were positive for E. coli and 1,086 for K. pneumoniae. The proportion of E. coli isolates producing ESBL significantly increased from 19% to 22% in 2008-2010 to approximately 30% from 2011 to 2014 (P-value for trend = 0.02), whereas ESBL production among K. pneumoniae cases was 27.4% with no significant trend over time. Incidence of community-onset ESBL-producing E. coli increased from 5.4 per 100,000 population in 2008 to 12.8 in 2014, with the highest rates among persons aged >/= 70 years at 79 cases per 100,000 persons in 2014. From 2008 to 2014, community-onset ESBL-producing K. pneumoniae incidence was 2.7 per 100,000, with a rate of 12.9 among those aged >/= 70 years. Although most (93.6% of E. coli and 87.6% of K. pneumoniae) infections were community-onset, hospital-onset infections were twice as likely to be ESBL. Population-based surveillance, as described, is vital to accurately monitor emergence and trends in antimicrobial resistance, and in guiding the development of rational antimicrobial therapy recommendations.

      3. Trends in incidence of methicillin-resistant Staphylococcus aureus bloodstream infections differ by strain type and healthcare exposure, United States, 2005-2013External
        See I, Mu Y, Albrecht V, Karlsson M, Dumyati G, Hardy DJ, Koeck M, Lynfield R, Nadle J, Ray SM, Schaffner W, Kallen AJ.
        Clin Infect Dis. 2019 Feb 25.
        BACKGROUND: Previous reports suggested that U.S. methicillin-resistant Staphylococcus aureus (MRSA) strain epidemiology has changed since the rise of USA300 MRSA. We describe invasive MRSA trends by strain type. METHODS: Data came from five CDC Emerging Infections Program sites conducting population-based surveillance and collecting isolates for invasive MRSA (i.e., from normally sterile body sites), 2005-2013. MRSA bloodstream infection (BSI) incidence/100,000 population was stratified by strain type and epidemiologic classification of healthcare exposures. Invasive USA100 vs USA300 case characteristics from 2013 were compared through logistic regression. RESULTS: From 2005-2013, USA100 incidence decreased most notably for hospital-onset (6.1 vs 0.9 / 100,000 persons, P<0.0001) and healthcare-associated, community-onset (10.7 vs 4.9 / 100,000 persons, P<0.0001) BSIs. USA300 incidence for hospital-onset BSIs also decreased (1.5 vs 0.6 / 100,000 persons, P<0.0001). However, USA300 incidence did not significantly change for healthcare-associated, community-onset (3.9 vs 3.3 / 100,000 persons, P=0.05) or community-associated BSIs (2.5 vs 2.4 / 100,000 persons, P=0.19). Invasive MRSA was less likely to be USA300 in patients who were older (adjusted odds ratio [aOR] 0.97 per year, 95% confidence interval [CI] 0.96-0.98), previously hospitalized (aOR 0.36, 95% CI 0.24-0.54), or had central lines (aOR 0.44, 95% CI 0.27-0.74) and associated with USA300 in people who inject drugs (aOR 4.58, 95% CI 1.16-17.95). CONCLUSIONS: Most of the decline in MRSA BSIs was from decreases in USA100 BSI incidence. Prevention of USA300 MRSA BSIs in the community will be needed to further reduce burden from MRSA BSIs.

    • Immunity and Immunization
      1. Effects of the rotavirus vaccine program across age groups in the United States: analysis of national claims data, 2001-2016External
        Baker JM, Dahl RM, Cubilo J, Parashar UD, Lopman BA.
        BMC Infect Dis. 2019 Feb 22;19(1):186.
        BACKGROUND: The direct effectiveness of infant rotavirus vaccination implemented in 2006 in the United States has been evaluated extensively, however, understanding of population-level vaccine effectiveness (VE) is still incomplete. METHODS: We analyzed time series data on rotavirus gastroenteritis (RVGE) and all-cause acute gastroenteritis (AGE) hospitalization rates in the United States from the MarketScan(R) Research Databases for July 2001-June 2016. Individuals were grouped into ages 0-4, 5-9, 10-14, 15-24, 25-44, and 45-64 years. Negative binomial regression models were fitted to monthly RVGE and AGE data to estimate the direct, indirect, overall, and total VE. RESULTS: A total of 9211 RVGE and 726,528 AGE hospitalizations were analyzed. Children 0-4 years of age had the largest declines in RVGE hospitalizations with direct VE of 87% (95% CI: 83, 90%). Substantial indirect effects were observed across age groups and generally declined in each older group. Overall VE against RVGE hospitalizations for all ages combined was 69% (95% CI: 62, 76%). Total VE was highest among young children; a vaccinated child in the post-vaccine era has a 95% reduced risk of RVGE hospitalization compared to a child in the pre-vaccine era. We observed higher direct VE in odd post-vaccine years and an opposite pattern for indirect VE. CONCLUSIONS: Vaccine benefits extended to unvaccinated individuals in all age groups, suggesting infants are important drivers of disease transmission across the population. Imperfect disease classification and changing disease incidence may lead to bias in observed direct VE. TRIAL REGISTRATION: Not applicable.

      2. CDC guidance for use of a third dose of MMR vaccine during mumps outbreaksExternal
        Marlow MA, Marin M, Moore K, Patel M.
        J Public Health Manag Pract. 2019 Feb 14.
        CONTEXT: In response to numerous mumps outbreaks reported throughout the United States in 2016 and 2017, the Advisory Committee on Immunization Practices (ACIP) recommended a third dose of measles, mumps, and rubella (MMR) vaccine for groups of persons determined by public health authorities to be at increased risk for acquiring mumps because of an outbreak. OBJECTIVE: To provide guidance for health departments when implementing the ACIP recommendation. DESIGN: Draft guidance was developed by Centers for Disease Control and Prevention subject matter experts based on technical consultations with health departments and review of published and unpublished data regarding mumps outbreaks. The guidance was finalized based on input from experts from the ACIP Mumps Work Group and local and state epidemiologists through the Council of State and Territorial Epidemiologists and the National Association of County and City Health Officials. RESULTS: We developed guidance to assist public health authorities when determining which groups are at increased risk for acquiring mumps and should receive a third dose of MMR vaccine. During outbreaks, public health authorities identify groups of persons with known or likely close contact exposure to a mumps patient. Then, evidence of transmission and likelihood of transmission in a group’s setting can be used to determine whether these groups are at increased risk. Additional epidemiologic and implementation factors may also be considered. All persons in the group at increased risk for acquiring mumps should receive a dose of MMR vaccine, including those with unknown vaccination status or those who have evidence of presumptive immunity other than documented 2 doses of MMR vaccine; no additional dose is recommended for persons who had received 3 or more doses before the outbreak. CONCLUSION: This guidance provides a framework for public health authorities to use when considering a third dose of MMR in response to mumps outbreaks while maintaining flexibility to incorporate local factors related to individual outbreaks.

    • Informatics
      1. Leveraging informatics to identify reportable cases: Pilot findings on electronic case reporting of chlamydia and gonorrheaExternal
        Mishra NK, Jellison JB, Hamilton A, Carr JB, Padilla RM, Viator NA.
        J Public Health Manag Pract. 2019 Feb 14.
        Consensus-based technical guidance for electronic case reporting (eCR) of sexually transmitted infections was implemented within existing health information technologies to automatically detect chlamydia and gonorrhea cases based on diagnosis and laboratory observation codes and build a case report using industry standards. The process was evaluated using 12 420 ambulatory encounters among adolescents and adults 15 years and older seen at 8 Chicago-area community health centers between May 1 and June 30, 2017. We tabulated the frequency of matches between the case detection logic and patient data and compared the eCR identified cases with paper case reports. This study found that eCR increased provider reporting when compared with paper reporting alone. While additional work across stakeholder groups is needed, these early findings suggest that broadly adopted eCR will decrease both provider and public health burden while improving reporting timeliness and data completion to support case investigation.

    • Injury and Violence
      1. Enhancing the national dialogue on the prevention of intimate partner violenceExternal
        Estefan LF, Armstead TL, Rivera MS, Kearns MC, Carter D, Crowell J, El-Beshti R, Daniels B.
        Am J Community Psychol. 2019 Feb 25.
        Little systematic information exists about how community-based prevention efforts at the state and local levels contribute to our knowledge of intimate partner violence (IPV) prevention. The Centers for Disease Control and Prevention’s (CDC) DELTA FOCUS program funds ten state domestic violence coalitions to engage in IPV primary prevention through approaches addressing the outer layers of the social ecology. This paper explored the ways in which DELTA FOCUS recipients have contributed to a national-level dialogue on IPV prevention. Previously undefined, the authors define national-level dialogue and retrospectively apply the CDC Science Impact Framework (SIF) to describe contributions DELTA FOCUS recipients made to it. Authors conducted document review and qualitative content analysis of recipient semi-annual progress reports from 2014 to 2016 (N = 40) using NVivo. A semi-structured coding scheme was applied across the five SIF domains: Creating Awareness, Catalyzing Action, Effecting Change, Disseminating Science, and Shaping the Future. All recipients sought to promote IPV prevention by communicating and sharing with non-CDC-funded state coalitions, national partners, and other IPV stakeholders information and resources accumulated through practice-based prevention efforts. Through implementing and disseminating their prevention work in myriad ways, DELTA FOCUS recipients are building practice-based evidence on community-based IPV prevention.

    • Laboratory Sciences
      1. Harnessing alternative sources of antimicrobial resistance data to support surveillance in low-resource settingsExternal
        Ashley EA, Shetty N, Patel J, van Doorn R, Limmathurotsakul D, Feasey NA, Okeke IN, Peacock SJ.
        J Antimicrob Chemother. 2019 Mar 1;74(3):541-546.
        One of the most pressing challenges facing the global surveillance of antimicrobial resistance (AMR) is the generation, sharing, systematic analysis and dissemination of data in low-resource settings. Numerous agencies and initiatives are working to support the development of globally distributed microbiology capacity, but the routine generation of a sustainable flow of reliable data will take time to establish before it can deliver a clinical and public health impact. By contrast, there are a large number of pharma- and academia-led initiatives that have generated a wealth of data on AMR and drug-resistant infections in low-resource settings, together with high-volume data generation by private laboratories. Here, we explore how untapped sources of data could provide a short-term solution that bridges the gap between now and the time when routine surveillance capacity will have been established and how this could continue to support surveillance efforts in the future. We discuss the benefits and limitations of data generated by these sources, the mechanisms and barriers to making this accessible and how academia and pharma might support the development of laboratory and analytical capacity. We provide key actions that will be required to harness these data, including: a mapping exercise; creating mechanisms for data sharing; use of data to support national action plans; facilitating access to and use of data by the WHO Global Antimicrobial Resistance Surveillance System; and innovation in data capture, analysis and sharing.

      2. Use of FTA(R) cards to transport throat swabs and oral fluid samples for molecular detection and genotyping of measles and rubella virusesExternal
        Bankamp B, Sein C, Pukuta Simbu E, Anderson R, Abernathy E, Chen MH, Muyembe Tamfum JJ, Wannemuehler KA, Waku-Kouomou D, Lopareva EN, Icenogle JP, Rota PA, Goodson JL.
        J Clin Microbiol. 2019 Feb 27.
        The genetic characterization of measles viruses is an important tool for measles surveillance. Reverse cold chain requirements for the transportation of samples to reference laboratories are challenging in resource-limited settings. FTA(R) cards facilitate transport of virologic samples at ambient temperature as non-infectious material; however, the utility of FTA(R) cards for detection and genotyping of measles virus from clinical samples had not been evaluated. Throat swabs (TS) and oral fluid (OF) samples were collected from suspected measles cases in the Democratic Republic of the Congo. Virus detection (RT-qPCR) and genotyping (end-point RT-PCR) were compared for samples from 238 suspected cases; these samples were either transported using the reverse cold chain or at ambient temperature on FTA(R) cards. Virus detection showed excellent positive agreement for OF compared to TS (95.3%, CI [91.6, 97.4]), in contrast to 79.4% (CI 73.5, 84.3) for TS on FTA, and 85.5% (CI 80.2, 89.6) for OF on FTA compared to OF. Genotyping results obtained for a subset of samples indicated that 77.3% of all TS and 71.0% of OF would produce genotype information compared to 41.6% of TS and 41.3% of OF on FTA(R) cards. Similar results were found for 16 measles-negative samples that were confirmed as rubella cases. Measles genotype B3 and rubella genotype 2B were detected. FTA(R) cards have limited utility for virologic surveillance of sporadic cases of measles; however, they can be a useful tool for the expansion of virologic surveillance in countries where the reverse cold chain is not available.

      3. Nipah virus is a highly lethal zoonotic pathogen found in Southeast Asia that has caused human encephalitis outbreaks with 40%-70% mortality. NiV encodes its own RNA-dependent RNA polymerase within the large protein, L. Efficient polymerase activity requires the phosphoprotein, P, which tethers L to its template, the viral nucleocapsid. P is a multifunctional protein with modular domains. The central P multimerization domain is composed of a long, tetrameric coiled coil. We investigated the importance of structural features found in this domain for polymerase function using a newly constructed NiV bicistronic minigenome assay. We identified a conserved basic patch and central kink in the coiled coil that are important for polymerase function, with R555 being absolutely essential. This basic patch and central kink are conserved in the related human pathogens measles and mumps viruses, suggesting that this mechanism may be conserved.

      4. Complete genome sequences of human astrovirus prototype strains (types 1 to 8)External
        Castro CJ, Reynolds E, Monroe SS, Marine RL, Vinje J.
        Microbiol Resour Announc. 2019 Feb;8(7).
        We report the complete genome sequences of the eight human astrovirus Oxford prototype strains. These sequences share 94.9% to 99.9% nucleotide identity with open reading frame 2 (ORF2) genes of astrovirus genomes previously deposited in GenBank and include the first complete genome of human astrovirus type 7.

      5. Flavopereirine – an alkaloid derived from Geissospermum vellosii – presents leishmanicidal activity in vitroExternal
        da Silva ES, Cordovil Brigido HP, Oliveira de Albuquerque KC, Miranda Carvalho J, Ferreira Reis J, Vinhal Faria L, Coelho-Ferreira M, Silveira FT, da Silva Carneiro A, Percario S, do Rosario Marinho AM, Dolabela MF.
        Molecules. 2019 Feb 21;24(4).
        Chemotherapy is limited in the treatment of leishmaniasis due to the toxic effects of drugs, low efficacy of alternative treatments, and resistance of the parasite. This work assesses the in vitro activity of flavopereirine on promastigote cultures of Leishmania amazonensis. In addition, an in silico evaluation of the physicochemical characteristics of this alkaloid is performed. The extract and fractions were characterized by thin-layer chromatography and HPLC-DAD, yielding an alkaloid identified by NMR. The antileishmanial activity and cytotoxicity were assayed by cell viability test (MTT). The theoretical molecular properties were calculated on the Molinspiration website. The fractionation made it possible to isolate a beta-carboline alkaloid (flavopereirine) in the alkaloid fraction. Moreover, it led to obtaining a fraction with greater antileishmanial activity, since flavopereirine is very active. Regarding the exposure time, a greater inhibitory effect of flavopereirine was observed at 24 h and 72 h (IC50 of 0.23 and 0.15 mug/mL, respectively). The extract, fractions, and flavopereirine presented low toxicity, with high selectivity for the alkaloid. Furthermore, flavopereirine showed no violation of Lipinski’s rule of five, showing even better results than the known inhibitor of oligopeptidase B, antipain, with three violations. Flavopereirine also interacted with residue Tyr-499 of oligopeptidase B during the molecular dynamics simulations, giving a few insights of a possible favorable mechanism of interaction and a possible inhibitory pathway. Flavopereirine proved to be a promising molecule for its antileishmanial activity.

      6. Insights into the antigenic advancement of influenza A(H3N2) viruses, 2011-2018External
        Jorquera PA, Mishin VP, Chesnokov A, Nguyen HT, Mann B, Garten R, Barnes J, Hodges E, De La Cruz J, Xu X, Katz J, Wentworth DE, Gubareva LV.
        Sci Rep. 2019 Feb 25;9(1):2676.
        Influenza A(H3N2) viruses evade human immunity primarily by acquiring antigenic changes in the haemagglutinin (HA). HA receptor-binding features of contemporary A(H3N2) viruses hinder traditional antigenic characterization using haemagglutination inhibition and promote selection of HA mutants. Thus, alternative approaches are needed to reliably assess antigenic relatedness between circulating viruses and vaccines. We developed a high content imaging-based neutralization test (HINT) to reduce antigenic mischaracterization resulting from virus adaptation to cell culture. Ferret reference antisera were raised using clinical specimens containing viruses representing recent vaccine strains. Analysis of viruses circulating during 2011-2018 showed that gain of an N158-linked glycosylation in HA was a molecular determinant of antigenic distancing between A/Hong Kong/4801/2014-like (clade 3C.2a) and A/Texas/50/2012-like viruses (clade 3C.1), while multiple evolutionary HA F193S substitution were linked to antigenic distancing from A/Switzerland/97152963/2013-like (clade 3C.3a) and further antigenic distancing from A/Texas/50/2012-like viruses. Additionally, a few viruses carrying HA T135K and/or I192T showed reduced neutralization by A/Hong Kong/4801/2014-like antiserum. Notably, this technique elucidated the antigenic characteristics of clinical specimens, enabling direct characterization of viruses produced in vivo, and eliminating in vitro culture, which rapidly alters the genotype/phenotype. HINT is a valuable new antigenic analysis tool for vaccine strain selection.

      7. Evaluation of the MicroScan colistin well and gradient diffusion strips for colistin susceptibility testing in EnterobacteriaceaeExternal
        Lutgring JD, Kim A, Campbell D, Karlsson M, Brown AC, Burd EM.
        J Clin Microbiol. 2019 Feb 27.
        Many laboratories are unable to perform colistin susceptibility testing. Diffusion-based antimicrobial susceptibility testing methods are not recommended and not all laboratories have the capacity to perform broth microdilution (BMD). Using a multi-step tiered approach, we investigated whether the adapted use of the MicroScan colistin well (4 mug/ml) could enhance laboratory capacity for the detection and subsequent molecular characterization of colistin-resistant Enterobacteriaceae For the MicroScan colistin well, categorical agreement with BMD was 92.7% and the very major error rate was 10.7%. For gradient diffusion strips, the categorical agreement was 86.4% and the very major error rate was 53.6%. The MicroScan colistin well detected all isolates carrying mcr-1 or mcr-2 genes (n=16) but gradient diffusion strips identified an MIC >/=4 for colistin for only 62.5% of these isolates. A six-month prospective phenotypic and genotypic study performed at a single clinical microbiology laboratory assessed isolates growing in the MicroScan colistin well for concordance. While 37 of 39 isolates growing in the MicroScan colistin well displayed a colistin MIC >/=4 by BMD, all were negative for the mcr-1 and mcr-2 genes by PCR. A retrospective review of all Escherichia coli, Klebsiella spp., and Enterobacter spp. tested by MicroScan at this laboratory in 2016 identified 260 of 7894 (3.3%) isolates that grew in the MicroScan colistin well. Based on the data presented, clinical and public health laboratories could use the MicroScan colistin well as a first screen for the detection of isolates displaying elevated colistin MICs which could then undergo further characterization.

      8. Culture of clinical specimens reveals extensive diversity of Legionella pneumophila strains in ArizonaExternal
        Raphael BH, Huynh T, Brown E, Smith JC, Ruberto I, Getsinger L, White S, Winchell JM.
        mSphere. 2019 Feb 27;4(1).
        Between 2000 and 2017, a total of 236 Legionella species isolates from Arizona were submitted to the CDC for reference testing. Most of these isolates were recovered from bronchoalveolar lavage specimens. Although the incidence of legionellosis in Arizona is less than the overall U.S. incidence, Arizona submits the largest number of isolates to the CDC for testing compared to those from other states. In addition to a higher proportion of culture confirmation of legionellosis cases in Arizona than in other states, all Legionella pneumophila isolates are forwarded to the CDC for confirmatory testing. Compared to that from other states, a higher proportion of isolates from Arizona were identified as belonging to L. pneumophila serogroups 6 (28.2%) and 8 (8.9%). Genome sequencing was conducted on 113 L. pneumophila clinical isolates not known to be associated with outbreaks in order to understand the genomic diversity of strains causing legionellosis in Arizona. Whole-genome multilocus sequence typing (wgMLST) revealed 17 clusters of isolates sharing at least 99% identical allele content. Only two of these clusters contained isolates from more than one individual with exposure at the same facility. Additionally, wgMLST analysis revealed a group of 31 isolates predominantly belonging to serogroup 6 and containing isolates from three separate clusters. Single nucleotide polymorphism (SNP) and pangenome analysis were used to further resolve genome sequences belonging to a subset of isolates. This study demonstrates that culture of clinical specimens for Legionella spp. reveals a highly diverse population of strains causing legionellosis in Arizona which could be underappreciated using other diagnostic approaches.IMPORTANCE Culture of clinical specimens from patients with Legionnaires’ disease is rarely performed, restricting our understanding of the diversity and ecology of Legionella Culture of Legionella from patient specimens in Arizona revealed a greater proportion of non-serogroup 1 Legionella pneumophila isolates than in other U.S. isolates examined. Disease caused by such isolates may go undetected using other diagnostic methods. Moreover, genome sequence analysis revealed that these isolates were genetically diverse, and understanding these populations may help in future environmental source attribution studies.

      9. Accurate and selective quantification of anthrax protective antigen in plasma by immunocapture and isotope dilution mass spectrometryExternal
        Solano MI, Woolfitt AR, Boyer AE, Lins RC, Isbell K, Gallegos-Candela M, Moura H, Pierce CL, Barr JR.
        Analyst. 2019 Feb 27.
        Anthrax protective antigen (83 kDa, PA83) is an essential component of two major binary toxins produced by Bacillus anthracis, lethal toxin (LTx) and edema toxin (ETx). During infection, LTx and ETx contribute to immune collapse, endothelial dysfunction, hemorrhage and high mortality. Following protease cleavage on cell receptors or in circulation, the 20 kDa (PA20) N-terminus is released, activating the 63 kDa (PA63) form which binds lethal factor (LF) and edema factor (EF), facilitating their entry into their cellular targets. Several ELISA-based PA methods previously developed are primarily qualitative or semi-quantitative. Here, we combined protein immunocapture, tryptic digestion and isotope dilution liquid chromatography-mass spectrometry (LC-MS/MS), to develop a highly selective and sensitive method for detection and accurate quantification of total-PA (PA83 + PA63) and PA83. Two tryptic peptides in the 63 kDa region measure total-PA and three in the 20 kDa region measure PA83 alone. Detection limits range from 1.3-2.9 ng mL-1 PA in 100 muL of plasma. Spiked recovery experiments with combinations of PA83, PA63, LF and EF in plasma showed that PA63 and PA83 were quantified accurately against the PA83 standard and that LF and EF did not interfere with accuracy. Applied to a study of inhalation anthrax in rhesus macaques, total-PA suggested triphasic kinetics, similar to that previously observed for LF and EF. This study is the first to report circulating PA83 in inhalation anthrax, typically at less than 4% of the levels of PA63, providing the first evidence that activated PA63 is the primary form of PA throughout infection.

      10. Evidence of recent genomic evolution in gonococcal strains with decreased susceptibility to cephalosporins or azithromycin in the United States, 2014-2016External
        Thomas JC, Seby S, Abrams AJ, Cartee J, Lucking S, Vidyaprakash E, Schmerer M, Pham CD, Hong J, Torrone E, St Cyr S, Shafer WM, Bernstein K, Kersh EN, Gernert KM.
        J Infect Dis. 2019 Feb 21.
        BACKGROUND: Given the lack of new antimicrobials or a vaccine, understanding the evolutionary dynamics of Neisseria gonorrhoeae is a significant public and global health priority. We investigated the emergence and spread of gonococcal strains with decreased susceptibility to cephalosporins and azithromycin using detailed genomic analyses of gonococcal isolates collected in the United States from 2014 to 2016. METHODS: We sequenced the genomes of 649 isolates collected through the Gonococcal Isolate Surveillance Project (GISP). We examined the genetic relatedness of isolates and assessed associations between clades and various genotypic and phenotypic combinations. RESULTS: We identified a large and clonal lineage of strains (MLST ST9363) associated with elevated azithromycin MICs (AZI em), characterized by a mosaic mtr locus (C-substitution in the mtrR promoter, mosaic mtrR and mtrD). Mutations in 23S rRNA were sporadically distributed among AZI em strains. Another clonal group (MLST ST1901) possessed seven unique PBP2 patterns, and it shared common mutations in other genes associated with cephalosporin resistance. CONCLUSIONS: Whole genome sequencing methods can enhance monitoring of antimicrobial resistant gonococcal strains by identifying gonococcal populations containing mutations of concern. These methods could inform the development of point-of-care diagnostic tests designed to determine the specific antibiotic susceptibility profile of a gonococcal infection within a patient.

      11. Human CYP2A6, CYP2B6, AND CYP2E1 atropselectively metabolize polychlorinated biphenyls to hydroxylated metabolitesExternal
        Uwimana E, Ruiz P, Li X, Lehmler HJ.
        Environ Sci Technol. 2019 Feb 19;53(4):2114-2123.
        Exposure to chiral polychlorinated biphenyls (PCBs) has been associated with neurodevelopmental disorders. Their hydroxylated metabolites (OH-PCBs) are also potentially toxic to the developing human brain; however, the formation of OH-PCBs by human cytochrome P450 (P450) isoforms is poorly investigated. To address this knowledge gap, we investigated the atropselective biotransformation of 2,2′,3,4′,6-pentachlorobiphenyl (PCB 91), 2,2′,3,5′,6-pentachlorobiphenyl (PCB 95), 2,2′,3,3′,4,6′-hexachlorobiphenyl (PCB 132), and 2,2′,3,3′,6,6′-hexachlorobiphenyl (PCB 136) by different human P450 isoforms. In silico predictions with ADMET Predictor and MetaDrug software suggested a role of CYP1A2, CYP2A6, CYP2B6, CYP2E1, and CYP3A4 in the metabolism of chiral PCBs. Metabolism studies with recombinant human enzymes demonstrated that CYP2A6 and CYP2B6 oxidized PCB 91 and PCB 132 in the meta position and that CYP2A6 oxidized PCB 95 and PCB 136 in the para position. CYP2B6 played only a minor role in the metabolism of PCB 95 and PCB 136 and formed meta-hydroxylated metabolites. Traces of para-hydroxylated PCB metabolites were detected in incubations with CYP2E1. No hydroxylated metabolites were present in incubations with CYP1A2 or CYP3A4. Atropselective analysis revealed P450 isoform-dependent and congener-specific atropselective enrichment of OH-PCB metabolites. These findings suggest that CYP2A6 and CYP2B6 play an important role in the oxidation of neurotoxic PCBs to chiral OH-PCBs in humans.

      12. Tropism and infectivity of a seasonal A(H1N1) and a highly pathogenic avian A(H5N1) influenza virus in primary differentiated ferret nasal epithelial cell culturesExternal
        Zeng H, Goldsmith CS, Kumar A, Belser JA, Sun X, Pappas C, Brock N, Bai Y, Levine M, Tumpey TM, Maines TR.
        J Virol. 2019 Feb 27.
        Ferrets represent an invaluable animal model to study influenza virus pathogenesis and transmission. To further characterize this model, we developed a differentiated primary ferret nasal epithelial cell (FNEC) culture model for investigation of influenza A virus infection and virus-host interactions. This well-differentiated culture consists of various cell types, a mucociliary clearance system, and tight junctions, representing the nasal ciliated pseudostratified respiratory epithelium. Both alpha2,6-linked and alpha2,3-linked sialic acid (SA) receptors, which preferentially bind the HA of human and avian influenza viruses, respectively, were detected on the apical surface of the culture with different cellular tropism. In accordance with distribution of SA receptors, we observed that a pre-2009 seasonal A(H1N1) virus infected both ciliated and non-ciliated cells, whereas a highly pathogenic avian influenza (HPAI) A(H5N1) virus primarily infected non-ciliated cells. Transmission electron microscopy revealed that virions were released from or associated with the apical membranes of ciliated, non-ciliated, and mucin-secretory goblet cells. Upon infection, the HPAI A(H5N1) virus replicated to titers higher than those of the human A(H1N1) virus at 37 degrees C, however, replication of the A(H5N1) virus was significantly attenuated at 33 degrees C. Furthermore, we found that infection with the A(H5N1) virus induced higher expression of immune mediator genes and resulted in more cell damage/loss when compared with the human A(H1N1) virus. This primary differentiated FNEC culture model, recapitulating the structure of the nasal epithelium, provides a useful model to bridge in vivo and in vitro studies of cellular tropism, infectivity, and pathogenesis of influenza viruses during the initial stages of infection.IMPORTANCE: Although ferrets serve as an important model of influenza virus infection, much remains unknown about virus-host interactions in this species at the cellular level. The development of differentiated primary cultures of ferret nasal epithelial cells is an important step toward understanding cellular tropism and the mechanisms of influenza virus infection and replication in the airway milieu of this model. Using lectin staining and microscopy techniques, we characterized sialic acid receptor distribution and the cellular composition of the culture model. We then evaluated the replication of and immune response to human and avian influenza viruses at relevant physiological temperatures. Our findings offer significant insight into this first line defense against influenza virus infection and provide a model for the evaluation of emerging influenza viruses in a well-controlled in vitro environmental setting.

    • Maternal and Child Health
      1. Leveraging existing birth defects surveillance infrastructure to build neonatal abstinence syndrome surveillance systems – Illinois, New Mexico, and Vermont, 2015-2016External
        Lind JN, Ailes EC, Alter CC, Fornoff JE, Brozicevic P, Garcia Saavedra LF, Tomedi LE, Gambatese M, Carroll B, Orantes L, Martin B, Horne AA, Reefhuis J.
        MMWR Morb Mortal Wkly Rep. 2019 Feb 22;68(7):177-180.
        Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome that can occur following prenatal exposure to opioids (1). NAS surveillance in the United States is based largely on diagnosis codes in hospital discharge data, without validation of these codes or case confirmation. During 2004-2014, reported NAS incidence increased from 1.5 to 8.0 per 1,000 U.S. hospital births (2), based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes identified in hospital discharge data, without case confirmation. However, little is known about how well these codes identify NAS or how the October 1, 2015, transition from ICD-9-CM to the tenth revision of ICD-CM (ICD-10-CM) codes affected estimated NAS incidence. This report describes a pilot project in Illinois, New Mexico, and Vermont to use birth defects surveillance infrastructure to obtain state-level, population-based estimates of NAS incidence among births in 2015 (all three states) and 2016 (Illinois) using hospital discharge records and other sources (varied by state) with case confirmation, and to evaluate the validity of NAS diagnosis codes used by each state. Wide variation in NAS incidence was observed across the three states. In 2015, NAS incidence for Illinois, New Mexico, and Vermont was 3.0, 7.5, and 30.8 per 1,000 births, respectively. Among evaluated diagnosis codes, those with the highest positive predictive values (PPVs) for identifying confirmed cases of NAS, based on a uniform case definition, were drug withdrawal syndrome in a newborn (ICD-9-CM code 779.5; state range = 58.6%-80.2%) and drug withdrawal, infant of dependent mother (ICD-10-CM code P96.1; state range = 58.5%-80.2%). The methods used to assess NAS incidence in this pilot project might help inform other states’ NAS surveillance efforts.

    • Nutritional Sciences
      1. BACKGROUND: Experiences during the birth hospitalization affect breastfeeding outcomes. In the United States, hospital policies and practices supportive of breastfeeding are routinely assessed through the Maternity Practices in Infant Nutrition and Care (mPINC) survey; however, mPINC does not capture data on breastfeeding outcomes. MATERIALS AND METHODS: Data from the 2015 mPINC survey were linked to 2015 data from the Joint Commission (TJC), a major accreditor of health care systems in the United States (n = 1,305 hospitals). Each hospital participating in mPINC is given a total score, which is the average of seven subscores; all ranging from 0 to 100. TJC has hospital-specific data on the percentage of infants exclusively breastfeeding at hospital discharge. We used linear regression to estimate differences between quartiles of (1) total mPINC score and (2) each mPINC subscore with rates of exclusive breastfeeding at hospital discharge, adjusting for hospital type, teaching status, and number of annual births. We additionally used linear models to test for trend across quartiles of mPINC score. RESULTS: The mean percentage of in-hospital exclusive breastfeeding increased from 39.0% for hospitals in the lowest mPINC total score quartile (<75) to 60.4% for hospitals in the highest mPINC total score quartile (>/=89), an adjusted difference of 21.1 percentage points (95% confidence interval 18.6-23.6). The mean percentage of in-hospital exclusive breastfeeding significantly increased (p < 0.0001) as mPINC scores increased for total mPINC score and for each mPINC subscore. CONCLUSIONS: Higher mPINC scores were associated with higher rates of in-hospital exclusive breastfeeding. Hospitals can make improvements to their maternity care practices and policies to support breastfeeding.

    • Occupational Safety and Health
      1. Notes from the field: Lead and cadmium exposure in electronic recyclers – two states, 2015 and 2017External
        Grimes R, Beaucham C, Ramsey J.
        MMWR Morb Mortal Wkly Rep. 2019 Feb 22;68(7):181-182.

        [No abstract]

      2. [No abstract]

    • Occupational Safety and Health – Mining
      1. Detectability of a self-illuminating lifeline for self-escape in smoke conditions of an underground mineExternal
        Martell MJ, Sammarco JJ, Macdonald B, Rubinstein E.
        Lighting Research and Technology. 2019 .
        Lifelines are used to aid self-escape of underground miners, but they are difficult to find in low-visibility conditions of smoke, therefore a self-illuminating lifeline could facilitate miners in locating the lifeline. The detection distance, colour recognition, and miss rate for 10 subjects were determined for red-, green- and blue-lighted diffuse fibre-optic cables, used to create a lighted lifeline, and a traditional rope lifeline in a smoked-filled environment. The testing was conducted with and without a cap lamp. The use of a cap lamp resulted in all cases being undetected in 98.3% of trials. With the cap lamp off, there was no significant difference in the detection distance for blue- and green-lighted fibres; however, the miss rate for the green-lighted fibre was slightly higher. The red-lighted fibre was not detected in 93.3% of trials. The green- and blue-lighted fibres enabled the best visual performance, but subjects had difficulty correctly identifying the colour of the fibre. The lighted fibre-optic cable appears to have merit for improving self-escape from underground mines, and may have other mining and non-mining applications that include improving self-escape visibility.

    • Parasitic Diseases
      1. Malaria case management commodity supply and use by community health workers in Mozambique, 2017External
        Davlantes E, Salomao C, Wate F, Sarmento D, Rodrigues H, Halsey ES, Lewis L, Candrinho B, Zulliger R.
        Malar J. 2019 Feb 21;18(1):47.
        BACKGROUND: Community health workers (CHWs) provide preventive care and integrated community case management (iCCM) to people with low healthcare access worldwide. CHW programmes have helped reduce mortality in myriad countries, but little data on malaria supply chain management has been shared. This project evaluated the current composition, use, and delivery of malaria iCCM kit commodities in Mozambique-rapid diagnostic tests (RDTs) and artemether-lumefantrine (AL) treatments-to better tailor existing resources to the needs of CHWs in diverse practice settings. METHODS: Health facilities in Maputo (low malaria burden), Inhambane (moderate), and Nampula (high) Provinces were selected using probability proportionate to the number of CHWs at each facility. All CHWs and their supervisors at selected facilities were interviewed using a structured questionnaire to document experiences with kit commodities. Data were analysed to assess CHW commodity stock levels by province and season. RESULTS: In total, 216 CHWs and 56 supervisors were interviewed at 56 health facilities. CHWs reported receiving an average of 6.7 kits in the last year, although they are intended to receive kits monthly. One-tenth of CHWs reported receiving kits with missing RDTs, and 28% reported lacking some AL treatments. Commodity use was highest in the rainy season. Stockouts were reported by CHWs in all provinces, more commonly in the rainy season. Facility-level stockouts of RDTs or some AL formulation in the past year were reported by 66% of supervisors. Use of CHW kit materials by health facilities was reported by 43% of supervisors; this was most common at facilities experiencing stockouts. CONCLUSIONS: Variations in geographic and seasonal malaria commodity needs should be considered in CHW kit distribution planning in Mozambique. Improvements in provision of complete, monthly CHW kits are needed in parallel with improvements in the broader commodity system strengthening. The findings of this evaluation can help other CHW programmes determine best practices for management of iCCM supply chains.

      2. Community-based participatory research in travel medicine to identify barriers to preventing malaria in VFR travellersExternal
        Walz EJ, Wanduragala D, Adedimeji AA, Volkman HR, Gaines J, Angelo KM, Boumi AE, Coyle C, Dunlop SJ, Stauffer WM.
        J Travel Med. 2019 Jan 1;26(1).

        [No abstract]

    • Substance Use and Abuse
      1. Use of electronic vapor products before, during, and after pregnancy among women with a recent live birth – Oklahoma and Texas, 2015External
        Kapaya M, D’Angelo DV, Tong VT, England L, Ruffo N, Cox S, Warner L, Bombard J, Guthrie T, Lampkins A, King BA.
        MMWR Morb Mortal Wkly Rep. 2019 Mar 1;68(8):189-194.
        Electronic vapor products (EVPs) comprise a diverse group of devices, including electronic cigarettes (e-cigarettes). EVP users inhale an aerosol that typically contains nicotine, flavorings, and other additives (1). Nicotine is a developmental toxicant that adversely affects pregnancy and infant outcomes (2). Data from the 2015 Pregnancy Risk Assessment Monitoring System (PRAMS) for Oklahoma and Texas were analyzed to estimate population-based EVP use among women with a recent live birth. EVP use before pregnancy (defined as >3 months before pregnancy) and around the time of pregnancy (defined as any time during the 3 months before pregnancy, the last 3 months of pregnancy, or 2-6 months after delivery), reasons for EVP use, and dual use of EVPs and cigarettes were assessed. Prevalence of EVP use was 10.4% before pregnancy and 7.0% around the time of pregnancy, including 1.4% during the last 3 months of pregnancy. Among women using EVPs during the last 3 months of pregnancy, 38.4% reported use of EVPs containing nicotine, and 26.4% were unsure of nicotine content. Among women who had used EVPs and cigarettes, dual use prevalence was 38.0% in the 3 months before pregnancy, 7.7% during the last 3 months of pregnancy, and 11.8% in the 2-6 months after delivery. The most frequently reported reasons for EVP use around the time of pregnancy were curiosity (54.0%), the perception that EVPs might help with quitting or reducing cigarette smoking (45.2%), and the perception of reduced harm to the mother, when compared with cigarette smoking (45.2%). Clear messages that EVP use is not safe during pregnancy are needed, and broad, barrier-free access to evidence-based tobacco cessation strategies need to be made available.

      2. Cigar smoking prevalence and morbidity among US adults, 2000-2015External
        Rostron BL, Corey CG, Gindi RM.
        Prev Med Rep. 2019 Jun;14:100821.
        Cigar smoking causes many of the same health conditions as cigarettes, but less information is available on prevalence of use trends and the disease burden of cigar smoking in the US. To examine these issues, we analyzed cigar use and health condition data from the National Health Interview Survey from 2000, 2005, 2010, and 2015, estimating prevalence of use by year and over time. We also estimated the number of, and adjusted disease prevalence ratios for, US adults aged >/=35years with self-reported history of heart disease, stroke, or cancer attributable to cigar smoking. We found that prevalence of current cigar smoking has remained generally stable at around 2.3% among US adults aged >/=18years between 2000 and 2015 but has increased among female and non-Hispanic black adults. Former exclusive cigar smokers were more likely to report having had heart conditions (aPR=1.33, 95% CI=1.03-1.72), stroke (aPR=2.42, 95% CI=1.57-3.75), and cancer (aPR=1.44, 95% CI=1.09-1.88) than never cigar smokers. It is estimated that nearly 200,000 cardiovascular conditions and cancer cases among US adults are attributable to former exclusive cigar smoking. This analysis shows that prevalence of current cigar smoking has remained stable among US adults but has increased among certain demographic groups. Former exclusive cigar use is associated with increased prevalence of heart disease, stroke, and cancer, which may result in part from smoking cessation following disease onset.

    • Zoonotic and Vectorborne Diseases
      1. Human seroprevalence to 11 zoonotic pathogens in the U.S. Arctic, AlaskaExternal
        Miernyk KM, Bruden D, Parkinson AJ, Hurlburt D, Klejka J, Berner J, Stoddard RA, Handali S, Wilkins PP, Kersh GJ, Fitzpatrick K, Drebot MA, Priest JW, Pappert R, Petersen JM, Teshale E, Hennessy TW, Bruce MG.
        Vector Borne Zoonotic Dis. 2019 Feb 21.
        BACKGROUND: Due to their close relationship with the environment, Alaskans are at risk for zoonotic pathogen infection. One way to assess a population’s disease burden is to determine the seroprevalence of pathogens of interest. The objective of this study was to determine the seroprevalence of 11 zoonotic pathogens in people living in Alaska. METHODS: In a 2007 avian influenza exposure study, we recruited persons with varying wild bird exposures. Using sera from this study, we tested for antibodies to Cryptosporidium spp., Echinococcus spp., Giardia intestinalis, Toxoplasma gondii, Trichinella spp., Brucella spp., Coxiella burnetii, Francisella tularensis, California serogroup bunyaviruses, and hepatitis E virus (HEV). RESULTS: Eight hundred eighty-seven persons had sera tested, including 454 subsistence bird hunters and family members, 160 sport bird hunters, 77 avian wildlife biologists, and 196 persons with no wild bird exposure. A subset (n = 481) of sera was tested for California serogroup bunyaviruses. We detected antibodies to 10/11 pathogens. Seropositivity to Cryptosporidium spp. (29%), California serotype bunyaviruses (27%), and G. intestinalis (19%) was the most common; 63% (301/481) of sera had antibodies to at least one pathogen. Using a multivariable logistic regression model, Cryptosporidium spp. seropositivity was higher in females (35.7% vs. 25.0%; p = 0.01) and G. intestinalis seropositivity was higher in males (21.8% vs. 15.5%; p = 0.02). Alaska Native persons were more likely than non-Native persons to be seropositive to C. burnetii (11.7% vs. 3.8%; p = 0.005) and less likely to be seropositive to HEV (0.4% vs. 4.1%; p = 0.01). Seropositivity to Cryptosporidium spp., C. burnetii, HEV, and Echinococcus granulosus was associated with increasing age (p </= 0.01 for all) as was seropositivity to >/=1 pathogen (p < 0.0001). CONCLUSION: Seropositivity to zoonotic pathogens is common among Alaskans with the highest to Cryptosporidium spp., California serogroup bunyaviruses, and G. intestinalis. This study provides a baseline for use in assessing seroprevalence changes over time.

      2. Dengue knowledge, attitudes, and practices among Arizona health care providers, 2014-2015External
        Ruberto I, Yaglom H, Erhart LM, Plante L, Weiss J, Golenko C, Casal M, McCotter O, Adams L, Ernst K, Komatsu K.
        Vector Borne Zoonotic Dis. 2019 Feb 25.
        BACKGROUND: Detection of local dengue transmission requires an aware and engaged medical community, as health care providers are the front line of public health surveillance. To assess the knowledge, attitude, and practice about dengue, an online survey was distributed among Arizona health care providers during 2014 and 2015. MATERIALS AND METHODS: The survey consisted of a total of 10 knowledge, attitude, and practice questions divided as follows: 5 knowledge questions, 2 attitude questions, and 3 practice questions. The link to the Qualtrics survey was distributed through the Arizona Health Alert Network to a total of 4582 e-mail addresses, of which 335 participants opened the survey, and 196 completed and submitted their responses. RESULTS: Less than half the respondents reported choosing the right dengue diagnostic test (40.4%) or understanding the epidemiology of dengue in Arizona (40.9%). Slightly more than half the respondents reported frequently asking for travel history (59%), and three-fourth of them would notify the local health department on suspicion of a dengue patient (76.1%). Survey score was associated with providers specialized in infectious diseases (1.88, 95% CI: 0.42-3.33, p = 0.01), medical doctors or doctors of osteopathic medicine (1.82, 95% CI: 0.98-2.65, p < 0.0001), and respondents who reported to have heard about the increase in dengue cases in Sonora (Mexico) in fall 2014 (1.51, 95% CI: 0.67-2.34, p = 0.0005), indicating better survey performance. CONCLUSIONS: These results indicate that education for health care providers on dengue should be improved particularly among general practice noninfectious disease providers who might be the first point of care for dengue patients. Findings suggest that additional training on clinical management, asking travel history, and notifying the local health department on suspicion of a dengue patient are needed.

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

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