Volume 11, Issue 12 March 18, 2019

CDC Science Clips: Volume 11, Issue 12, March 18, 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!

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

This issue also features scientific articles related to March’s CDC Public Health Grand Rounds, Preventing Suicidal Behavior in American Indian and Alaska Native Communities: A Health Equity Issue.

  1. CDC Vital Signs
    • Communicable Diseases – HIV Transmission Risk
      1. *HIV Treatment as Prevention
        Centers for Disease Control and Prevention .
        National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention. 2018 .
        People with HIV should take medicine to treat HIV as soon as possible. HIV medicine is called antiretroviral therapy, or ART. If taken as prescribed, HIV medicine reduces the amount of HIV in the body (viral load) to a very low level, which keeps the immune system working and prevents illness. This is called viral suppression-defined as having less than 200 copies of HIV per milliliter of blood. HIV medicine can even make the viral load so low that a test can?t detect it. This is called an undetectable viral load. Getting and keeping an undetectable viral load is the best thing people with HIV can do to stay healthy. Another benefit of reducing the amount of virus in the body is that it helps prevent transmission to others through sex or syringe sharing, and from mother to child during pregnancy, birth, and breastfeeding. This is sometimes referred to as treatment as prevention. There is strong evidence about treatment as prevention for some of the ways HIV can be transmitted, but more research is needed for other ways.

      2. *Ending the HIV Epidemic: A Plan for the United StatesExternal
        Fauci AS, Redfield RR, Sigounas G, Weahkee MD, Giroir BP.
        Jama. 2019 Feb 7.

        [No abstract]

      3. Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort studyExternal
        Bavinton BR, Pinto AN, Phanuphak N, Grinsztejn B, Prestage GP, Zablotska-Manos IB, Jin F, Fairley CK, Moore R, Roth N, Bloch M, Pell C, McNulty AM, Baker D, Hoy J, Tee BK, Templeton DJ, Cooper DA, Emery S, Kelleher A, Grulich AE.
        Lancet HIV. 2018 Aug;5(8):e438-e447.
        BACKGROUND: Evidence on viral load and HIV transmission risk in HIV-serodiscordant male homosexual couples is limited to one published study. We calculated transmission rates in couples reporting condomless anal intercourse (CLAI), when HIV-positive partners were virally suppressed, and daily pre-exposure prophylaxis (PrEP) was not used by HIV-negative partners. METHODS: In the Opposites Attract observational cohort study, serodiscordant male homosexual couples were recruited from 13 clinics in Australia, one in Brazil, and one in Thailand. At study visits, HIV-negative partners provided information on sexual behaviour and were tested for HIV and sexually transmitted infections; HIV-positive partners had HIV viral load tests, CD4 cell count, and sexually transmitted infection tests done. Viral suppression was defined as less than 200 copies per mL. Linked within-couple HIV transmissions were identified with phylogenetic analysis. Incidence was calculated per couple-year of follow-up, focusing on periods with CLAI, no use of daily PrEP, and viral suppression. One-sided upper 95% CI limits for HIV transmission rates were calculated with exact Poisson methods. FINDINGS: From May 8, 2012, to March 31, 2016, in Australia, and May 7, 2014, to March 31, 2016, in Brazil and Thailand, 358 couples were enrolled. 343 couples had at least one follow-up visit and were followed up for 588.4 couple-years. 258 (75%) of 343 HIV-positive partners had viral loads consistently less than 200 copies per mL and 115 (34%) of 343 HIV-negative partners used daily PrEP during follow-up. 253 (74%) of 343 couples reported within-couple CLAI during follow-up, with a total of 16 800 CLAI acts. Three new HIV infections occurred but none were phylogenetically linked. There were 232.2 couple-years of follow-up and 12 447 CLAI acts in periods when CLAI was reported, HIV-positive partners were virally suppressed, and HIV-negative partners did not use daily PrEP, resulting in an upper CI limit of 1.59 per 100 couple-years of follow-up for transmission rate. INTERPRETATION: HIV treatment as prevention is effective in men who have sex with men. Increasing HIV testing and linking to immediate treatment is an important strategy in HIV prevention in homosexual men. FUNDING: National Health and Medical Research Council; amfAR, The Foundation for AIDS Research; ViiV Healthcare; and Gilead Sciences.

      4. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settingsExternal
        Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, Clark JE.
        MMWR Recomm Rep. 2006 Sep 22;55(Rr-14):1-17; quiz CE1-4.
        These recommendations for human immunodeficiency virus (HIV) testing are intended for all health-care providers in the public and private sectors, including those working in hospital emergency departments, urgent care clinics, inpatient services, substance abuse treatment clinics, public health clinics, community clinics, correctional health-care facilities, and primary care settings. The recommendations address HIV testing in health-care settings only. They do not modify existing guidelines concerning HIV counseling, testing, and referral for persons at high risk for HIV who seek or receive HIV testing in nonclinical settings (e.g., community-based organizations, outreach settings, or mobile vans). The objectives of these recommendations are to increase HIV screening of patients, including pregnant women, in health-care settings; foster earlier detection of HIV infection; identify and counsel persons with unrecognized HIV infection and link them to clinical and prevention services; and further reduce perinatal transmission of HIV in the United States. These revised recommendations update previous recommendations for HIV testing in health-care settings and for screening of pregnant women (CDC. Recommendations for HIV testing services for inpatients and outpatients in acute-care hospital settings. MMWR 1993;42[No. RR-2]:1-10; CDC. Revised guidelines for HIV counseling, testing, and referral. MMWR 2001;50[No. RR-19]:1-62; and CDC. Revised recommendations for HIV screening of pregnant women. MMWR 2001;50[No. RR-19]:63-85). Major revisions from previously published guidelines are as follows: For patients in all health-care settings HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening). Persons at high risk for HIV infection should be screened for HIV at least annually. Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings. For pregnant women HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women. HIV screening is recommended after the patient is notified that testing will be performed unless the patient declines (opt-out screening). Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. Repeat screening in the third trimester is recommended in certain jurisdictions with elevated rates of HIV infection among pregnant women.

      5. Behavioral and clinical characteristics of persons receiving medical care for HIV infection-Medical Monitoring Project, United States, 2014 cycle (June 2014-May 2015)Cdc-pdf
        Centers for Disease Control and Prevention .
        HIV surveillance special report no. 17. 2016 ;Atlanta, GA: US Department of Health and Human Services, CDC.

        [No abstract]

      6. Antiretroviral therapy for the prevention of HIV-1 transmissionExternal
        Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, Hakim JG, et al .
        N Engl J Med. 2016 Sep 1;375(9):830-9.
        BACKGROUND: An interim analysis of data from the HIV Prevention Trials Network (HPTN) 052 trial showed that antiretroviral therapy (ART) prevented more than 96% of genetically linked infections caused by human immunodeficiency virus type 1 (HIV-1) in serodiscordant couples. ART was then offered to all patients with HIV-1 infection (index participants). The study included more than 5 years of follow-up to assess the durability of such therapy for the prevention of HIV-1 transmission. METHODS: We randomly assigned 1763 index participants to receive either early or delayed ART. In the early-ART group, 886 participants started therapy at enrollment (CD4+ count, 350 to 550 cells per cubic millimeter). In the delayed-ART group, 877 participants started therapy after two consecutive CD4+ counts fell below 250 cells per cubic millimeter or if an illness indicative of the acquired immunodeficiency syndrome (i.e., an AIDS-defining illness) developed. The primary study end point was the diagnosis of genetically linked HIV-1 infection in the previously HIV-1-negative partner in an intention-to-treat analysis. RESULTS: Index participants were followed for 10,031 person-years; partners were followed for 8509 person-years. Among partners, 78 HIV-1 infections were observed during the trial (annual incidence, 0.9%; 95% confidence interval [CI], 0.7 to 1.1). Viral-linkage status was determined for 72 (92%) of the partner infections. Of these infections, 46 were linked (3 in the early-ART group and 43 in the delayed-ART group; incidence, 0.5%; 95% CI, 0.4 to 0.7) and 26 were unlinked (14 in the early-ART group and 12 in the delayed-ART group; incidence, 0.3%; 95% CI, 0.2 to 0.4). Early ART was associated with a 93% lower risk of linked partner infection than was delayed ART (hazard ratio, 0.07; 95% CI, 0.02 to 0.22). No linked infections were observed when HIV-1 infection was stably suppressed by ART in the index participant. CONCLUSIONS: The early initiation of ART led to a sustained decrease in genetically linked HIV-1 infections in sexual partners. (Funded by the National Institute of Allergy and Infectious Diseases; HPTN 052 number, NCT00074581 .).

      7. Vital Signs: Human Immunodeficiency Virus Testing and Diagnosis Delays – United StatesExternal
        Dailey AF, Hoots BE, Hall HI, Song R, Hayes D, Fulton P, Prejean J, Hernandez AL, Koenig LJ, Valleroy LA.
        MMWR Morb Mortal Wkly Rep. 2017 Dec 1;66(47):1300-1306.
        BACKGROUND: Persons unaware of their human immunodeficiency virus (HIV) infection account for approximately 40% of ongoing transmissions in the United States. Persons are unaware of their infection because of delayed HIV diagnoses that represent substantial missed opportunities to improve health outcomes and prevent HIV transmission. METHODS: Data from CDC’s National HIV Surveillance System were used to estimate, among persons with HIV infection diagnosed in 2015, the median interval (and range) from infection to diagnosis (diagnosis delay), based on the first CD4 test after HIV diagnosis and a CD4 depletion model indicating disease progression and, among persons living with HIV in 2015, the percentage with undiagnosed infection. Data from CDC’s National HIV Behavioral Surveillance were analyzed to determine the percentage of persons at increased risk for HIV infection who had tested in the past 12 months and who had missed opportunities for testing. RESULTS: An estimated 15% of persons living with HIV in 2015 were unaware of their infection. Among the 39,720 persons with HIV infection diagnosed in 2015, the estimated median diagnosis delay was 3.0 years (interquartile range = 0.7-7.8 years); diagnosis delay varied by race/ethnicity (from 2.2 years among whites to 4.2 years among Asians) and transmission category (from 2.0 years among females who inject drugs to 4.9 years among heterosexual males). Among persons interviewed through National HIV Behavioral Surveillance, 71% of men who have sex with men, 58% of persons who inject drugs, and 41% of heterosexual persons at increased risk for HIV infection reported testing in the past 12 months. In each risk group, at least two thirds of persons who did not have an HIV test had seen a health care provider in the past year. CONCLUSIONS: Delayed HIV diagnoses continue to be substantial for some population groups and prevent early entry to care to improve health outcomes and reduce HIV transmission to others. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Health care providers and others providing HIV testing can reduce HIV-related adverse health outcomes and risk for HIV transmission by implementing routine and targeted HIV testing to decrease diagnosis delays.

      8. Progression and Transmission of HIV/AIDS (PATH 2.0)External
        Gopalappa C, Farnham PG, Chen YH, Sansom SL.
        Med Decis Making. 2017 Feb;37(2):224-233.
        BACKGROUND: HIV transmission is the result of complex dynamics in the risk behaviors, partnership choices, disease stage and position along the HIV care continuum-individual characteristics that themselves can change over time. Capturing these dynamics and simulating transmissions to understand the chief sources of transmission remain important for prevention. METHODS: The Progression and Transmission of HIV/AIDS (PATH 2.0) is an agent-based model of a sample of 10,000 people living with HIV (PLWH), who represent all men who have sex with men (MSM) and heterosexuals living with HIV in the U.S.A. Persons uninfected were modeled as populations, stratified by risk and gender. The model included detailed individual-level data from several large national surveillance databases. The outcomes focused on average annual transmission rates from 2008 through 2011 by disease stage, HIV care continuum, and sexual risk group. RESULTS: The relative risk of transmission of those in the acute phase was nine-times [5(th) and 95(th) percentile simulation interval (SI): 7, 12] that of those in the non-acute phase, although, on average, those with acute infections comprised 1% of all PLWH. The relative risk of transmission was 24- to 50-times as high for those in the non-acute phase who had not achieved viral load suppression as compared with those who had. The relative risk of transmission among MSM was 3.2-times [SI: 2.7, 4.0] that of heterosexuals. Men who have sex with men and women generated 46% of sexually acquired transmissions among heterosexuals. CONCLUSIONS: The model results support a continued focus on early diagnosis, treatment and adherence to ART, with an emphasis on prevention efforts for MSM, a subgroup of whom appear to play a role in transmission to heterosexuals.

      9. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapyExternal
        Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, van Lunzen J, Corbelli GM, et al .
        Jama. 2016 Jul 12;316(2):171-81.
        IMPORTANCE: A key factor in assessing the effectiveness and cost-effectiveness of antiretroviral therapy (ART) as a prevention strategy is the absolute risk of HIV transmission through condomless sex with suppressed HIV-1 RNA viral load for both anal and vaginal sex. OBJECTIVE: To evaluate the rate of within-couple HIV transmission (heterosexual and men who have sex with men [MSM]) during periods of sex without condoms and when the HIV-positive partner had HIV-1 RNA load less than 200 copies/mL. DESIGN, SETTING, AND PARTICIPANTS: The prospective, observational PARTNER (Partners of People on ART-A New Evaluation of the Risks) study was conducted at 75 clinical sites in 14 European countries and enrolled 1166 HIV serodifferent couples (HIV-positive partner taking suppressive ART) who reported condomless sex (September 2010 to May 2014). Eligibility criteria for inclusion of couple-years of follow-up were condomless sex and HIV-1 RNA load less than 200 copies/mL. Anonymized phylogenetic analysis compared couples’ HIV-1 polymerase and envelope sequences if an HIV-negative partner became infected to determine phylogenetically linked transmissions. EXPOSURES: Condomless sexual activity with an HIV-positive partner taking virally suppressive ART. MAIN OUTCOMES AND MEASURES: Risk of within-couple HIV transmission to the HIV-negative partner. RESULTS: Among 1166 enrolled couples, 888 (mean age, 42 years [IQR, 35-48]; 548 heterosexual [61.7%] and 340 MSM [38.3%]) provided 1238 eligible couple-years of follow-up (median follow-up, 1.3 years [IQR, 0.8-2.0]). At baseline, couples reported condomless sex for a median of 2 years (IQR, 0.5-6.3). Condomless sex with other partners was reported by 108 HIV-negative MSM (33%) and 21 heterosexuals (4%). During follow-up, couples reported condomless sex a median of 37 times per year (IQR, 15-71), with MSM couples reporting approximately 22,000 condomless sex acts and heterosexuals approximately 36,000. Although 11 HIV-negative partners became HIV-positive (10 MSM; 1 heterosexual; 8 reported condomless sex with other partners), no phylogenetically linked transmissions occurred over eligible couple-years of follow-up, giving a rate of within-couple HIV transmission of zero, with an upper 95% confidence limit of 0.30/100 couple-years of follow-up. The upper 95% confidence limit for condomless anal sex was 0.71 per 100 couple-years of follow-up. CONCLUSIONS AND RELEVANCE: Among serodifferent heterosexual and MSM couples in which the HIV-positive partner was using suppressive ART and who reported condomless sex, during median follow-up of 1.3 years per couple, there were no documented cases of within-couple HIV transmission (upper 95% confidence limit, 0.30/100 couple-years of follow-up). Additional longer-term follow-up is necessary to provide more precise estimates of risk.

      10. U=U taking off in 2017External
        The Lancet HIV .
        Lancet HIV. 2017 Nov;4(11):e475.

        [No abstract]

  2. CDC Public Health Grand Rounds
    • Injury and Violence – Preventing Suicidal Behavior in American Indian and Alaska Native Communities
      1. Work as an Inclusive Part of Population Health Inequities Research and PreventionExternal
        Ahonen EQ, Fujishiro K, Cunningham T, Flynn M.
        Am J Public Health. 2018 Mar;108(3):306-311.
        Despite its inclusion in models of social and ecological determinants of health, work has not been explored in most health inequity research in the United States. Leaving work out of public health inequities research creates a blind spot in our understanding of how inequities are created and impedes our progress toward health equity. We first describe why work is vital to our understanding of observed societal-level health inequities. Next, we outline challenges to incorporating work in the study of health inequities, including (1) the complexity of work as a concept; (2) work’s overlap with socioeconomic position, race, ethnicity, and gender; (3) the development of a parallel line of inquiry into occupational health inequities; and (4) the dearth of precise data with which to explore the relationships between work and health status. Finally, we summarize opportunities for advancing health equity and monitoring progress that could be achieved if researchers and practitioners more robustly include work in their efforts to understand and address health inequities.

      2. Depression management interests among Alaska Native and American Indian adults in primary careExternal
        Avey JP, Dirks LG, Dillard DA, Manson SM, Merrick M, Smith JJ, Prickette GC, Tetpon S, Galbreath D, Triplett B, Robinson RF.
        J Affect Disord. 2018 Oct 15;239:214-219.
        BACKGROUND: Depression remains the second leading cause of disability worldwide. Symptoms of depression are expressed and experienced differently across cultural groups, impacting treatment decisions. Patient preferences predict service utilization, treatment selection and persistence, as well as health outcomes for medical and behavioral health conditions, including depression. We identified depression management preferences of Alaska Native and American Indian (AN/AI) people who receive care within a comprehensive, integrated, tribally owned and operated healthcare facility in Anchorage, Alaska. METHODS: Adult AN/AI patients who screened positive for depression (10 or greater on the Patient Health Questionnaire – 9 (PHQ-9)) completed a culturally-tailored decision-support tool to assess their depression management interests. RESULTS: The 125 eligible patients, who screened positive for depression, preferred counseling and medications to peer support groups, herbal remedies, and spiritual support. Those 18-39 years of age were more likely to prefer medications and less likely to prefer spirituality and peer support than those 40 years of age and older. Patients with moderate and severe depression were more likely to prefer exercise, healthy eating, and stress reduction than individuals with mild depression. LIMITATIONS: Women comprised 78% of the sample. Responses may not adequately represent the views of men. CONCLUSIONS: Counseling and medications should consistently be made available earlier in the course of depression management. Patient interest in exercise, stress reduction, and healthy eating to manage depression, especially among those with moderate and severe depression, offers opportunity for additional collaboration in an integrated care setting.

      3. Suicides – United States, 2005-2009External
        Crosby AE, Ortega L, Stevens MR.
        MMWR Suppl. 2013 Nov 22;62(3):179-83.
        Injury from self-directed violence, which includes suicidal behavior and its consequences, is a leading cause of death and disability. In 2009, suicide was the 10th-leading cause of death in the United States and the cause of 36,909 deaths. In 2005, the estimated cost of self-directed violence (fatal and nonfatal treated) was $41.2 billion (including $38.9 billion in productivity losses and $2.2 billion in medical costs). Suicide is a complex human behavior that results from an interaction of multiple biological, psychological, social, political, and economic factors. Although self-directed violence affects members of all racial/ethnic groups in the United States, it often is misperceived to be a problem affecting primarily non-Hispanic white males.

      4. Demographic, Clinical, and Service Utilization Factors Associated with Suicide-Related Visits among Alaska Native and American Indian AdultsExternal
        Dillard DA, Avey JP, Robinson RF, Smith JJ, Beals J, Manson SM, Comtois KA.
        Suicide Life Threat Behav. 2017 Feb;47(1):27-37.
        Alaska Native and American Indian people (AN/AIs) are disproportionately affected by suicide. Within a large AN/AI health service organization, demographic, clinical, and service utilization factors were compared between those with a suicide-related health visit and those without. Cases had higher odds of a behavioral health diagnosis, treatment for an injury, behavioral health specialty care visits, and opioid medication dispensation in the year prior to a suicide-related visit compared to gender-, age-, and residence- (urban versus rural) matched controls. Odds of a suicide-related visit were lower among those with private insurance and those with non-primary care ambulatory clinic visits.

      5. The impact of patient and provider factors on depression screening of American Indian and Alaska Native people in primary careExternal
        Dillard DA, Muller CJ, Smith JJ, Hiratsuka VY, Manson SM.
        J Prim Care Community Health. 2012 Apr 1;3(2):120-4.
        INTRODUCTION: The US Preventive Services Task Force recommends routine depression screening in primary care, yet regular screening does not occur in most health systems serving Alaska Native and American Indian people. The authors examined factors associated with administration of depression screening among Alaska Native and American Indian people in a large urban clinic. METHODS: Medical records of 18 625 Alaska Native and American Indian adults were examined 1 year after implementation of a depression screening initiative. Multilevel logistic regression models examined associations between patient and provider factors and administration of the Patient Health Questionnaire-9. RESULTS: Forty-seven percent of patients were screened. Women were more likely than men to be screened (50% vs 43%, P < .001). Increased screening odds were associated with older age, increased service use, and chronic disease (P < .001) but not with substance abuse disorders or prior antidepressant dispensation. Women previously diagnosed with depression had higher odds of screening (P = .002). Men seen by male providers had higher odds of screening than did men seen by female providers (P = .040). Screening rates peaked among providers with 2 to 5 years of employment with the clinic. LIMITATIONS: Cross-sectional analysis of medical record data was of unknown reliability; there were limited sociodemographic data. CONCLUSIONS: Even with significant organizational support for annual depression screening, primary care providers systematically missed men and patients with infrequent primary care visits. Outreach to male patients and additional supports for primary care providers, especially in the first years of practice, may improve screening and treatment for depression among Alaska Native and American Indian people.

      6. The Association Between Positive Relationships with Adults and Suicide-Attempt Resilience in American Indian Youth in New MexicoExternal
        FitzGerald CA, Fullerton L, Green D, Hall M, Penaloza LJ.
        Am Indian Alsk Native Ment Health Res. 2017 ;24(2):40-53.
        This study examined the 2013 New Mexico Youth Risk and Resiliency Survey (NM-YRRS) to determine whether cultural connectedness and positive relationships with adults protected against suicide attempts among American Indian and Alaska Native (AI/AN) youth and whether these relationships differed by gender. The sample included 2,794 AI/AN students in grades 9 to 12 who answered the question about past-year suicide attempts. Protective factor variables tested included relationships with adults at home, school, and the community. The language spoken at home was used as a proxy measure for cultural connectedness. Positive relationships with adults were negatively associated with the prevalence of past-year suicide attempts in bivariate analysis. However, language spoken at home was not associated with the prevalence of suicide attempts. Multivariate analysis showed that among girls, relationships with adults at home, at school, and in the community were independently associated with lower suicide-attempt prevalence. Among boys, only relationships with adults at home showed such an association. These results have important implications for the direction of future research about protective factors associated with AI/AN youth suicide risk as well as in the design of suicide intervention and prevention programs.

      7. Leveraging the Domain of Work to Improve Migrant HealthExternal
        Flynn MA, Wickramage K.
        Int J Environ Res Public Health. 2017 Oct 19;14(10).
        Work is a principal driver of current international migration, a primary social determinant of health, and a fundamental point of articulation between migrants and their host society. Efforts by international organizations to promote migrant health have traditionally focused on infectious diseases and access to healthcare, while international labor organizations have largely focused on issues of occupational health. The underutilization of the domain of work in addressing the health of migrants is truly a missed opportunity for influencing worker well-being and reducing societal economic burden. Understanding of the relationships among migration, work, and health would facilitate further integration of migrant health concerns into the policy agenda of governments and international agencies that work at the nexus of labor, health and development. The domain of work offers an opportunity to capitalize on the existing health and development infrastructure and leverage technical resources, programs and research to promote migrant health. It also provides the opportunity to advance migrant health through new and innovative approaches and partnerships.

      8. American Indian Life Skills: A community-based intervention for indigenous mental health
        LaFromboise TD, Fatemi A.
        In H. Fitzgerald (Ed.), Child Psychology and Mental Health: Cultural and Ethno-Racial Perspectives. Santa Barbara, CA: Praeger. 2012 .

        [No abstract]

      9. A culturally-informed approach to American Indian/Alaska Native youth suicide prevention
        LaFromboise TD, Malik S.
        In N. Zane, G. Bernal, & F. Leong (Eds.), Culturally-informed Evidence-based Practices for Ethnic Minorities: Challenges and Solutions (pp. 223-245). Washington, DC: American Psychological Association. 2015 .

        [No abstract]

      10. Suicides Among American Indian/Alaska Natives – National Violent Death Reporting System, 18 States, 2003-2014External
        Leavitt RA, Ertl A, Sheats K, Petrosky E, Ivey-Stephenson A, Fowler KA.
        MMWR Morb Mortal Wkly Rep. 2018 Mar 2;67(8):237-242.
        Suicide disproportionately affects American Indians/Alaska Natives (AI/AN). The suicide rate among AI/AN has been increasing since 2003 (1), and in 2015, AI/AN suicide rates in the 18 states participating in the National Violent Death Reporting System (NVDRS) were 21.5 per 100,000, more than 3.5 times higher than those among racial/ethnic groups with the lowest rates.* To study completed suicides across all ages of AI/AN, NVDRS data collected from 2003 to 2014 were analyzed by comparing differences in suicide characteristics and circumstances between AI/AN and white decedents. Group differences were assessed using chi-squared tests and logistic regression. Across multiple demographics, incident characteristics, and circumstances, AI/AN decedents were significantly different from white decedents. More than one third (35.7%) of AI/AN decedents were aged 10-24 years (versus 11.1% of whites). Compared with whites, AI/AN decedents had 6.6 times the odds of living in a nonmetropolitan area, 2.1 times the odds of a positive alcohol toxicology result, and 2.4 times the odds of a suicide of a friend or family member affecting their death. Suicide prevention efforts should incorporate evidence-based, culturally relevant strategies at individual, interpersonal, and community levels (2) and need to account for the heterogeneity among AI/AN communities (3,4).

      11. Indian Health Focus: InjuriesCdc-pdfExternal
        US Department of Health and Human Services , Indian Health Service .
        2015 Edition. 2016 :1-118.
        During the 60 years that the Indian Health Service (IHS) has collected health and injury statistics, unintentional injuries have posed a significant challenge for American Indian and Alaska Native (AI/AN) communities. Despite improvements in health status over the decades, among American Indians and Alaska Natives between the ages of 1 to 44 years old, injury remains the leading cause of death. Compared to the U.S. All Races population, AI/AN people continue to have disproportionately higher rates of unintentional injury and injury related mortality. Working in partnership with Tribes and key stakeholders, the reliable and locally generated injury data has been vital to identifying health disparities, patterns of injury, and trends within this population. This in turn, has bolstered ability to leverage Agency resources and best practices to develop injury prevention and public health interventions that meet specific community needs. Indian Health Focus: Injuries catalogues AI/AN-specific injury data to assess and evaluate program effectiveness. It also furthers the development of health policy and strategies to reduce or minimize the impact of injuries in AI/AN communities.

      12. To Live To See the Great Day That Dawns: Preventing Suicide by American Indian and Alaska Native Youth and Young AdultsExternal
        US Department of Health and Human Services , Substance Abuse and Mental Health Services Administration .
        DHHS Publication SMA (10)-4480, CMHS-NSPL-0196. Rockville, MD: DHHS, SAMHSA, Center for Mental Health Services. 2010 .
        This manual lays the groundwork for community-based suicide prevention and mental health promotion plans for American Indian and Alaska Native teens and young adults. It addresses risks, protective factors and awareness, and describes prevention models for action.

      13. Advancing suicide prevention research with rural American Indian and Alaska Native populationsExternal
        Wexler L, Chandler M, Gone JP, Cwik M, Kirmayer LJ, LaFromboise T, Brockie T, O’Keefe V, Walkup J, Allen J.
        Am J Public Health. 2015 May;105(5):891-9.
        As part of the National Action Alliance for Suicide Prevention’s American Indian and Alaska Native (AI/AN) Task Force, a multidisciplinary group of AI/AN suicide research experts convened to outline pressing issues related to this subfield of suicidology. Suicide disproportionately affects Indigenous peoples, and remote Indigenous communities can offer vital and unique insights with relevance to other rural and marginalized groups. Outcomes from this meeting include identifying the central challenges impeding progress in this subfield and a description of promising research directions to yield practical results. These proposed directions expand the alliance’s prioritized research agenda and offer pathways to advance the field of suicide research in Indigenous communities and beyond.

  3. 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. Primary care clinician adherence with asthma guidelines: the National Asthma Survey of PhysiciansExternal
        Akinbami LJ, Salo PM, Cloutier MM, Wilkerson JC, Elward KS, Mazurek JM, Williams S, Zeldin DC.
        J Asthma. 2019 Mar 1:1-13.
        BACKGROUND AND OBJECTIVES: Although primary care clinicians provide >60% of U.S. asthma care, no nationally representative study has examined variation in adherence among primary care groups to four cornerstone domains of the Expert Panel Report-3 asthma guidelines: assessment/monitoring, patient education, environmental assessment, and medications. We used the 2012 National Asthma Survey of Physicians: National Ambulatory Medical Care Survey to compare adherence by family/general medicine practitioners (FM/GM), internists, pediatricians and Community Health Center mid-level clinicians (CHC). METHODS: Adherence was self-reported (n = 1355 clinicians). Adjusted odds of almost always adhering to each recommendation (>/=75% of the time) were estimated controlling for clinician/practice characteristics, and agreement and self-efficacy with guideline recommendations. RESULTS: A higher percentage of pediatricians adhered to most assessment/monitoring recommendations compared to FM/GM and other groups (e.g. 71.6% [SE 4.0] almost always assessed daytime symptoms versus 50.6% [SE 5.1]-51.1% [SE 5.8], t-test p < 0.05) but low percentages from all groups almost always performed spirometry (6.8% [SE 2.0]-16.8% [SE 4.7]). Pediatricians were more likely to provide asthma action/treatment plans than FM/GM and internists. Internists were more likely to assess school/work triggers than pediatricians and CHC (environmental assessment). All groups prescribed inhaled corticosteroids for daily control (84.0% [SE 3.7]-90.7% [SE 2.5]) (medications). In adjusted analyses, pediatric specialty, high self-efficacy and frequent specialist referral were associated with high adherence. CONCLUSIONS: Pediatricians were more likely to report high adherence than other clinicians. Self- efficacy and frequent referral were also associated with adherence. Adherence was higher for history-taking recommendations and lower for recommendations involving patient education, equipment and expertise.

      2. Eye care utilization among insured people with diabetes in the U.S., 2010-2014External
        Benoit SR, Swenor B, Geiss LS, Gregg EW, Saaddine JB.
        Diabetes Care. 2019 Mar;42(3):427-433.
        OBJECTIVE: Diabetic retinopathy (DR) is the leading cause of blindness among working-age adults, and although screening with eye exams is effective, screening rates are low. We evaluated eye exam visits over a 5-year period in a large population of insured patients 10-64 years of age with diabetes. RESEARCH DESIGN AND METHODS: We used claims data from IBM Watson Health to identify patients with diabetes and continuous insurance coverage from 2010 to 2014. Diabetes and DR were defined using ICD-9 Clinical Modification codes. We calculated eye exam visit frequency by diabetes type over a 5-year period and estimated period prevalence and cumulative incidence of DR among those receiving an eye exam. RESULTS: Among the 298,383 insured patients with type 2 diabetes and no diagnosed DR, almost half had no eye exam visits over the 5-year period and only 15.3% met the American Diabetes Association (ADA) recommendations for annual or biennial eye exams. For the 2,949 patients with type 1 diabetes, one-third had no eye exam visits and 26.3% met ADA recommendations. The 5-year period prevalence and cumulative incidence of DR were 24.4% and 15.8%, respectively, for patients with type 2 diabetes and 54.0% and 33.4% for patients with type 1 diabetes. CONCLUSIONS: The frequency of eye exams was alarmingly low, adding to the abundant literature that systemic changes in health care may be needed to detect and prevent vision-threatening eye disease among people with diabetes.

      3. Validity of ICD-10-CM codes for determination of diabetes type for persons with youth-onset type 1 and type 2 diabetesCdc-pdfExternal
        Chi GC, Li X, Tartof SY, Slezak JM, Koebnick C, Lawrence JM.
        BMJ Open Diabetes Res Care. 2019 ;7(1).
        Objective: Diagnosis codes might be used for diabetes surveillance if they accurately distinguish diabetes type. We assessed the validity of International Classification of Disease, 10th Revision, Clinical Modification (ICD-10-CM) codes to discriminate between type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) among health plan members with youth-onset (diagnosis age <20 years) diabetes. Research design and methods. Diabetes case identification and abstraction of diabetes type was done as part of the SEARCH for Diabetes in Youth Study. The gold standard for diabetes type is the physician-assigned diabetes type documented in patients’ medical records. Using all healthcare encounters with ICD-10-CM codes for diabetes, we summarized codes within each encounter and determined diabetes type using percent of encounters classified as T2DM. We chose 50% as the threshold from a receiver operating characteristic curve because this threshold yielded the largest Youden’s index. Persons with ?50% T2DM-coded encounters were classified as having T2DM. Otherwise, persons were classified as having T1DM. We calculated sensitivity, specificity, positive and negative predictive values, and accuracy overall and by demographic characteristics. Results: According to the gold standard, 1911 persons had T1DM and 652 persons had T2DM (mean age (SD): 19.1 (6.5) years). We obtained 90.6% (95% CI 88.4% to 92.9%) sensitivity, 96.3% (95% CI 95.4% to 97.1%) specificity, 89.3% (95% CI 86.9% to 91.6%) positive predictive value, 96.8% (95% CI 96.0% to 97.6%) negative predictive value, and 94.8% (95% CI 94.0% to 95.7%) accuracy for discriminating T2DM from T1DM. Conclusions ICD-10-CM codes can accurately classify diabetes type for persons with youth-onset diabetes, showing promise for rapid, cost-efficient diabetes surveillance.

      4. Gastric cancer mortality rates among US and foreign-born persons: United States 2005-2014External
        Hallowell BD, Endeshaw M, Senkomago V, Razzaghi H, McKenna MT, Saraiya M.
        Gastric Cancer. 2019 Mar 4.
        BACKGROUND: Historically, foreign-born individuals in the US have had an elevated risk of dying from gastric cancer when compared to US-born individuals. This is primarily due to factors that occur prior to their immigration to the US, including diet and underlying risk of H. pylori infection. METHODS: National mortality data from 2005 to 2014 were obtained from the CDC’s National Center for Health Statistics. Annual population estimates were obtained from the US Census Bureau’s American Community Survey for foreign-born and US-born persons. Age-adjusted gastric cancer mortality rates and rate ratios (RR) were calculated stratified by birth place, age, race/ethnicity, and geographic location. RESULTS: From 2005 to 2014, 111,718 deaths from malignant gastric cancer occurred in the US, of which 24,583 (22%) occurred among foreign-born individuals. Overall, foreign-born individuals had higher mortality rates compared with US-born individuals (RR 1.82; 95% CI 1.80, 1.85) and this difference remained after stratifying by sex, age, and geographic location. However, this finding was primarily driven by the low rate of gastric cancer mortality among US-born whites, with similar mortality rates observed among all other foreign-born and US-born groups. Gastric cancer mortality rates significantly decreased during the study period overall (AAPC – 2.50; 95% CI – 3.21, – 1.79) with significant declines observed among US-born (AAPC – 2.81; 95% CI – 3.55, – 2.07) and the foreign-born (AAPC – 2.53; 95% CI – 3.20, – 1.86) population. CONCLUSIONS: Efforts directed at reducing the prevalence of gastric cancer risk factors could help reduce the elevated burden observed among foreign-born individuals and US-born minority groups.

    • Communicable Diseases
      1. Evaluation of diarrheal disease surveillance in the Minawao refugee camp – Cameroon, 2016External
        Amabo FC, Seukap EC, Mathieu E, Etoundi GA.
        Int J Infect Dis. 2019 Feb 26.
        BACKGROUND: Between 2013 and 2015, the Minawao refugee camp in Cameroon received about 51,000 refugees fleeing Boko Haram. Rapid population increase and inadequate sanitary installations increase the risk of diarrheal disease, thus we assessed the structure and attributes of the surveillance system in Minawao. METHODS: We used updated CDC guidelines for evaluating public health surveillance systems. Information sources included health registers, surveillance reports, and key informant interviews. We used scorecards to assess the system’s simplicity, flexibility, data quality, acceptability, sensitivity, timeliness, stability and usefulness. RESULTS: Surveillance in Minawao is both passive and active, integrating four diseases reported weekly/immediately. All key informants agreed that surveillance was part of their routine work. Of 138 surveillance reports reviewed, all were complete; 91 (66%) were timely. Overall, 143 (100%) cases of diarrheal disease identified in health registers were reported to the next level. Only two (20%) surveillance personnel could correctly state standardized case definitions (SCD); three (30%) were unable to identify cases of diarrheal disease based on SCD. CONCLUSIONS: In Minawao, diarrheal disease surveillance is acceptable, flexible, sensitive, and useful. To improve timeliness and use of SCD, we recommend using mobile phones for reporting and displaying SCD in health facilities.

      2. Associations among school absenteeism, gastrointestinal and respiratory illness, and income – United States, 2010-2016External
        Berendes D, Andujar A, Barrios LC, Hill V.
        MMWR Morb Mortal Wkly Rep. 2019 Mar 8;68(9):209-213.
        Control of communicable diseases in children, including respiratory and diarrheal illnesses that affect U.S. school-aged children, might require public health preventive efforts both in the home and at school, a primary setting for transmission. National Health Interview Survey (NHIS) data on school absenteeism and gastrointestinal illness in the United States during 2010-2016 were analyzed to identify associations among income, illness, and absenteeism. Prevalence of gastrointestinal and respiratory illnesses in the 2 weeks preceding the survey increased as income decreased. Although the likelihood of missing any school days during the past year decreased with reduced income, among children missing school, those from low-income households missed more days of school than did children from higher income households. Although the reason for absenteeism cannot be ascertained from this analysis, these data underscore the importance of preventive measures, such as hand hygiene promotion and education, and the opportunity for both homes and schools to serve as an important point for implementation of public health preventive measures, including hand hygiene practice and education.

      3. Evaluation of a rapid syphilis test in an emergency department setting in Detroit, MichiganExternal
        Fakile YF, Markowitz N, Zhu W, Mumby K, Dankerlui D, McCormick JK, Ham DC, Hopkins A, Manteuffel J, Sun Y, Huang YA, Peters PJ, Hoover KW.
        Sex Transm Dis. 2019 Mar 4.
        BACKGROUND: Syphilis transmission can be prevented by prompt diagnosis and treatment of primary and secondary infection. We evaluated the performance of a point-of-care rapid syphilis treponemal test (RST) in an emergency department (ED) setting. METHODS: Between June 2015 and April 2016, men aged 18-34 years seeking services in a Detroit ED, and with no history of syphilis, were screened for syphilis with the RST, rapid plasma reagin (RPR) test, and Treponema pallidum particle agglutination assay (TP-PA). A positive reference standard was both a reactive RPR and a reactive TP-PA. We compared test results in self-reported MSM to non-MSM. RESULTS: Among 965 participants, 10.9% of RSTs were reactive in MSM and only 1.5% in non-MSM (p<0.001). Sensitivity of the RST was 76.9% and specificity was 99.0% (PPV 50.0%) compared to the positive reference standard. Three discordant specimens found negative with the RST but positive with the reference standard had an RPR titer of 1:1, compared with 10 specimens with concordant positive results that had a median RPR titer of 1:16. The RST sensitivity was 50.0% (PPV 68.4%) compared to the TP-PA test alone. Among men seeking care in an ED, the RST detected 76.9% of participants with a reactive RPR and TP-PA. CONCLUSIONS: The RST detected all of the participants with an RPR titer > 1:2 but less than 20% of participants with a positive TP-PA and negative RPR. The RST was useful to detect a high proportion of participants with an active syphilis in an urban ED.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

      4. HCV transmission in high-risk communities in BulgariaExternal
        Ganova-Raeva L, Dimitrova Z, Alexiev I, Punkova L, Sue A, Xia GL, Gancheva A, Dimitrova R, Kostadinova A, Golkocheva-Markova E, Khudyakov Y.
        PLoS One. 2019 ;14(3):e0212350.
        BACKGROUND: The rate of HIV infection in Bulgaria is low. However, the rate of HCV-HIV-coinfection and HCV infection is high, especially among high-risk communities. The molecular epidemiology of those infections has not been studied before. METHODS: Consensus Sanger sequences of HVR1 and NS5B from 125 cases of HIV/HCV coinfections, collected during 2010-2014 in 15 different Bulgarian cities, were used for preliminary phylogenetic evaluation. Next-generation sequencing (NGS) data of the hypervariable region 1 (HVR1) analyzed via the Global Hepatitis Outbreak and Surveillance Technology (GHOST) were used to evaluate genetic heterogeneity and possible transmission linkages. Links between pairs that were below and above the established genetic distance threshold, indicative of transmission, were further examined by generating k-step networks. RESULTS: Preliminary genetic analyses showed predominance of HCV genotype 1a (54%), followed by 1b (20.8%), 2a (1.4%), 3a (22.3%) and 4a (1.4%), indicating ongoing transmission of many HCV strains of different genotypes. NGS of HVR1 from 72 cases showed significant genetic heterogeneity of intra-host HCV populations, with 5 cases being infected with 2 different genotypes or subtypes and 6 cases being infected with 2 strains of same subtype. GHOST revealed 8 transmission clusters involving 30 cases (41.7%), indicating a high rate of transmission. Four transmission clusters were found in Sofia, three in Plovdiv, and one in Peshtera. The main risk factor for the clusters was injection drug use. Close genetic proximity among HCV strains from the 3 Sofia clusters, and between HCV strains from Peshtera and one of the two Plovdiv clusters confirms a long and extensive transmission history of these strains in Bulgaria. CONCLUSIONS: Identification of several HCV genotypes and many HCV strains suggests a frequent introduction of HCV to the studied high-risk communities. GHOST detected a broad transmission network, which sustains circulation of several HCV strains since their early introduction in the 3 cities. This is the first report on the molecular epidemiology of HIV/HCV coinfections in Bulgaria.

      5. Cortical and bithalamic hypometabolism by FDG-PET/CT in a patient with sporadic fatal insomniaExternal
        Haight T, Mendiola C, Solnes L, Cohen M, Safar J, Schonberger LB, Probasco JC.
        Neurology. 2019 Mar 6.

        [No abstract]

      6. Association of immunosuppression and HIV viraemia with non-Hodgkin lymphoma risk overall and by subtype in people living with HIV in Canada and the USA: a multicentre cohort studyExternal
        Hernandez-Ramirez RU, Qin L, Lin H, Leyden W, Neugebauer RS, Althoff KN, Achenbach CJ, Hessol NA, D’Souza G, Gebo KA, Gill MJ, Grover S, Horberg MA, Li J, Mathews WC, Mayor AM, Park LS, Rabkin CS, Salters K, Justice AC, Moore RD, Engels EA, Silverberg MJ, Dubrow R.
        Lancet HIV. 2019 Feb 27.
        BACKGROUND: Research is needed to better understand relations between immunosuppression and HIV viraemia and risk for non-Hodgkin lymphoma, a common cancer in people living with HIV. We aimed to identify key CD4 count and HIV RNA (viral load) predictors of risk for non-Hodgkin lymphoma, overall and by subtype. METHODS: We studied people living with HIV during 1996-2014 from 21 Canadian and US cohorts participating in the North American AIDS Cohort Collaboration on Research and Design. To determine key independent predictors of risk for non-Hodgkin lymphoma, we assessed associations with time-updated recent, past, cumulative, and nadir or peak measures of CD4 count and viral load, using demographics-adjusted, cohort-stratified Cox models, and we compared models using Akaike’s information criterion. FINDINGS: Of 102 131 people living with HIV during the study period, 712 people developed non-Hodgkin lymphoma. The key independent predictors of risk for overall non-Hodgkin lymphoma were recent CD4 count (ie, lagged by 6 months; <50 cells per muL vs >/=500 cells per muL, hazard ratio [HR] 3.2, 95% CI 2.2-4.7) and average viral load during a 3-year window lagged by 6 months (a cumulative measure; >/=100 000 copies per mL vs </=500 copies per mL, HR 9.6, 95% CI 6.5-14.0). These measures were also the key predictors of risk for diffuse large B-cell lymphoma (recent CD4 count <50 cells per muL vs >/=500 cells per muL, HR 2.4, 95% CI 1.4-4.2; average viral load >/=100 000 copies per mL vs </=500 copies per mL, HR 7.5, 95% CI 4.5-12.7). However, recent CD4 count was the sole key predictor of risk for CNS non-Hodgkin lymphoma (<50 cells per muL vs >/=500 cells per muL, HR 426.3, 95% CI 58.1-3126.4), and proportion of time viral load was greater than 500 copies per mL during the 3-year window (a cumulative measure) was the sole key predictor for Burkitt lymphoma (100% vs 0%, HR 41.1, 95% CI 9.1-186.6). INTERPRETATION: Both recent immunosuppression and prolonged HIV viraemia have important independent roles in the development of non-Hodgkin lymphoma, with likely subtype heterogeneity. Early and sustained antiretroviral therapy to decrease HIV replication, dampen B-cell activation, and restore overall immune function is crucial for preventing non-Hodgkin lymphoma. FUNDING: National Institutes of Health, Centers for Disease Control and Prevention, US Agency for Healthcare Research and Quality, US Health Resources and Services Administration, Canadian Institutes of Health Research, Ontario Ministry of Health and Long Term Care, and the Government of Alberta.

      7. HIV diagnoses and the HIV care continuum among women and girls aged >/=13 years – 39 states and the District of Columbia, 2015-2016External
        Hoover KW, Hu X, Porter SE, Buchacz K, Bond MD, Siddiqi AE, Haynes SG.
        J Acquir Immune Defic Syndr. 2019 Feb 25.
        BACKGROUND: In 2017, 19% of new HIV diagnoses in the United States were in women. HIV acquisition can be prevented with preexposure prophylaxis (PrEP), and HIV transmission with viral suppression. HIV viral suppression is achieved by linking women to care and supporting adherence to antiretroviral (ARV) medications. The national HIV prevention goal for viral suppression is 80%. SETTING: United States METHODS: We analyzed data reported by 40 U.S. jurisdictions to the Centers for Disease Control and Prevention’s National HIV Surveillance System to determine the number and rate of HIV diagnoses per 100,000 women in 2016. We also determined the percentages of women with diagnosed HIV who were linked to care within 1 and 3 months, received HIV care, were retained in HIV care, and were virally suppressed in 2015. Findings were stratified by demographic characteristics and HIV transmission category. RESULTS: In 2016, 6,407 women were diagnosed with HIV. Black women had a rate of 783.7 per 100,000, Hispanic/Latino women 182.7, and white women 43.6. In 2015, 190,735 women were living with diagnosed HIV. Viral suppression increased with age, ranging from 46.5% among women aged 13-24 years to 62.3% among women aged >/=45 years. Black women had the lowest rate of viral suppression (55.5%). No age group of women achieved 80% viral suppression. CONCLUSION: PrEP implementation for women at high risk for HIV infection can help to decrease new infections. Women living with HIV would benefit from interventions that support linkage to HIV care and ARV medication adherence to increase viral suppression.

      8. Gonorrhoea and chlamydia diagnosis as an entry point for HIV pre-exposure prophylaxis: a modelling studyExternal
        Kasaie P, Schumacher CM, Jennings JM, Berry SA, Tuddenham SA, Shah MS, Rosenberg ES, Hoover KW, Gift TL, Chesson H, German D, Dowdy DW.
        BMJ Open. 2019 Mar 4;9(3):e023453.
        OBJECTIVES: Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) increase the risk of HIV transmission among men who have sex with men (MSM). Diagnosis of NG/CT may provide an efficient entry point for prevention of HIV through the delivery of pre-exposure prophylaxis (PrEP); however, the additional population-level impact of targeting PrEP to MSM diagnosed with NG/CT is unknown. DESIGN: An agent-based simulation model of NG/CT and HIV cocirculation among MSM calibrated against census data, disease surveillance reports and the US National HIV Behavioral Surveillance study. SETTING: Baltimore City, Maryland, USA. INTERVENTIONS: PrEP implementation was modelled under three alternative scenarios: (1) PrEP delivery at NG/CT diagnosis (targeted delivery), (2) PrEP evaluation at NG/CT screening/testing and (3) PrEP evaluation in the general community (untargeted). MAIN OUTCOME: The projected incidence of HIV after 20 years of PrEP delivery under two alternatives: when equal numbers of MSM are (1) screened for PrEP or (2) receive PrEP in each year. RESULTS: Assuming 60% uptake and 60% adherence, targeting PrEP to MSM diagnosed with NG/CT could reduce HIV incidence among MSM in Baltimore City by 12.4% (95% uncertainty range (UR) 10.3% to 14.4%) in 20 years, relative to no PrEP. Expanding the coverage of NG/CT screening (such that individuals experience a 50% annual probability of NG/CT screening and evaluation for PrEP on NG/CT diagnosis) can further increase the impact of targeted PrEP to generate a 22.0% (95% UR 20.1% to 23.9%) reduction in HIV incidence within 20 years. When compared with alternative implementation scenarios, PrEP evaluation at NG/CT diagnosis increased impact of PrEP on HIV incidence by 1.5(95% UR 1.1 to 1.9) times relative to a scenario in which PrEP evaluation happened at the time of NG/CT screening/testing and by 1.6 (95% UR 1.2 to 2.2) times relative to evaluating random MSM from the community. CONCLUSIONS: Targeting MSM infected with NG/CT increases the efficiency and effectiveness of PrEP delivery. If high levels of sexually transmitted infection screening can be achieved at the community level, NG/CT diagnosis may be a highly effective entry point for PrEP initialisation.

      9. Respiratory syncytial virus-associated outpatient visits among children younger than 24 monthsExternal
        Lively JY, Curns AT, Weinberg GA, Edwards KM, Staat MA, Prill MM, Gerber SI, Langley GE.
        J Pediatric Infect Dis Soc. 2019 Mar 6.

        [No abstract]

      10. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal InfluenzaaExternal
        Uyeki TM, Bernstein HH, Bradley JS, Englund JA, File TM, Fry AM, Gravenstein S, Hayden FG, Harper SA, Hirshon JM, Ison MG, Johnston BL, Knight SL, McGeer A, Riley LE, Wolfe CR, Alexander PE, Pavia AT.
        Clin Infect Dis. 2019 Mar 5;68(6):895-902.

        [No abstract]

    • Disaster Control and Emergency Services
      1. 9/11 residential exposures: the impact of World Trade Center dust on respiratory outcomes of lower Manhattan residentsExternal
        Antao VC, Pallos LL, Graham SL, Shim YK, Sapp JH, Lewis B, Bullard S, Alper HE, Cone JE, Farfel MR, Brackbill RM.
        Int J Environ Res Public Health. 2019 Mar 5;16(5).
        Thousands of lower Manhattan residents sustained damage to their homes following the collapse of the Twin Towers on 11 September 2001. Respiratory outcomes have been reported in this population. We sought to describe patterns of home damage and cleaning practices in lower Manhattan and their impacts on respiratory outcomes among World Trade Center Health Registry (WTCHR) respondents. Data were derived from WTCHR Wave 1 (W1) (9/2003(-)11/2004) and Wave 2 (W2) (11/2006(-)12/2007) surveys. Outcomes of interest were respiratory symptoms (shortness of breath (SoB), wheezing, persistent chronic cough, upper respiratory symptoms (URS)) first occurring or worsening after 9/11 W1 and still present at W2 and respiratory diseases (asthma and chronic obstructive pulmonary disease (COPD)) first diagnosed after 9/11 W1 and present at W2. We performed descriptive statistics, multivariate logistic regression and geospatial analyses, controlling for demographics and other exposure variables. A total of 6447 residents were included. Mean age on 9/11 was 45.1 years (+/-15.1 years), 42% were male, 45% had ever smoked cigarettes, and 44% reported some or intense dust cloud exposure on 9/11. The presence of debris was associated with chronic cough (adjusted OR (aOR) = 1.56, CI: 1.12(-)2.17), and upper respiratory symptoms (aOR = 1.56, CI: 1.24(-)1.95). A heavy coating of dust was associated with increased shortness of breath (aOR = 1.65, CI: 1.24(-)2.18), wheezing (aOR = 1.43, CI: 1.03(-)1.97), and chronic cough (aOR = 1.59, CI: 1.09(-)2.28). Dusting or sweeping without water was the cleaning behavior associated with the largest number of respiratory outcomes, such as shortness of breath, wheezing, and URS. Lower Manhattan residents who suffered home damage following the 9/11 attacks were more likely to report respiratory symptoms and diseases compared to those who did not report home damage.

      2. Prevalence of mental disorders and epidemiological associations in post-conflict primary care attendees: a cross-sectional study in the Northern Province of Sri LankaExternal
        Doherty S, Hulland E, Lopes-Cardozo B, Kirupakaran S, Surenthirakumaran R, Cookson S, Siriwardhana C.
        BMC Psychiatry. 2019 Mar 4;19(1):83.
        BACKGROUND: Experiencing conflict and displacement can have a negative impact on an individual’s mental health. Currently, prevalence of mental health disorders (MHDs) at the primary care level in post-conflict areas within the Northern Province of Sri Lanka is unknown. We aimed to explore this prevalence in conflict-affected populations attending primary care, using a structured package of validated screening tools for MHDs. METHODS: This cross-sectional study aimed to determine factors related to mental health disorders at the primary care level in Northern Province, Sri Lanka. A structured interview was conducted with internally displaced adults attending 25 randomly selected primary care facilities across all districts of Northern Sri Lanka (Jaffna, Mannar, Mullaitivu, Vavuniya). Participants were screened for depression, anxiety, psychosis, PTSD, and somatoform symptoms. RESULTS: Among 533 female and 482 male participants (mean age 53.2 years), the prevalence rate for any MHD was 58.8% (95% CI, 53.8-61.4), with 42.4% screening positive for two or more disorders (95% CI, 38.6-46.1). Anxiety prevalence was reported at 46.7% (95% CI, 41.9-51.5), depression at 41.1% (95% CI, 38.7-44.5), PTSD at 13.7% (95% CI, 10.6-16.8), somatoform symptoms at 27.6% (95% CI, 23.6-31.5), and psychosis with hypomania at 17.6% (95% CI, 13.3-21.9). CONCLUSION: This is the first study at the primary care level to investigate prevalence of MHDs among conflict-affected populations in the Northern Province, Sri Lanka. Results highlight unmet mental health needs in the region. Training intervention to integrate mental health services into primary care is planned.

      3. Disaster-related surveillance among US Virgin Islands (USVI) shelters during the hurricanes Irma and Maria responseExternal
        Schnall AH, Roth JJ, Ekpo LL, Guendel I, Davis M, Ellis EM.
        Disaster Med Public Health Prep. 2019 Feb;13(1):38-43.
        OBJECTIVES: Two Category 5 storms, Hurricane Irma and Hurricane Maria, hit the U.S. Virgin Islands (USVI) within 13 days of each other in September 2017. These storms caused catastrophic damage across the territory, including widespread loss of power, destruction of homes, and devastation of critical infrastructure. During large scale disasters such as Hurricanes Irma and Maria, public health surveillance is an important tool to track emerging illnesses and injuries, identify at-risk populations, and assess the effectiveness of response efforts. The USVI Department of Health (DoH) partnered with shelter staff volunteers to monitor the health of the sheltered population and help guide response efforts. METHODS: Shelter volunteers collect data on the American Red Cross Aggregate Morbidity Report form that tallies the number of client visits at a shelter’s health services every 24 hours. Morbidity data were collected at all 5 shelters on St. Thomas and St. Croix between September and October 2017. This article describes the health surveillance data collected in response to Hurricanes Irma and Maria. RESULTS: Following Hurricanes Irma and Maria, 1130 health-related client visits were reported, accounting for 1655 reasons for the visits (each client may have more than 1 reason for a single visit). Only 1 shelter reported data daily. Over half of visits (51.2%) were for health care management; 17.7% for acute illnesses, which include respiratory conditions, gastrointestinal symptoms, and pain; 14.6% for exacerbation of chronic disease; 9.8% for mental health; and 6.7% for injury. Shelter volunteers treated many clients within the shelters; however, reporting of the disposition (eg, referred to physician, pharmacist) was often missed (78.1%). CONCLUSION: Shelter surveillance is an efficient means of quickly identifying and characterizing health issues and concerns in sheltered populations following disasters, allowing for the development of evidence-based strategies to address identified needs. When incorporated into broader surveillance strategies using multiple data sources, shelter data can enable disaster epidemiologists to paint a more comprehensive picture of community health, thereby planning and responding to health issues both within and outside of shelters. The findings from this report illustrated that managing chronic conditions presented a more notable resource demand than acute injuries and illnesses. Although there remains room for improvement because reporting was inconsistent throughout the response, the capacity of shelter staff to address the health needs of shelter residents and the ability to monitor the health needs in the sheltered population were critical resources for the USVI DoH overwhelmed by the disaster. (Disaster Med Public Health Preparedness. 2019;13:38-43).

      4. OBJECTIVES: Two category 5 storms hit the US Virgin Islands (USVI) within 13 days of each other in September 2017. This caused an almost complete loss of power and devastated critical infrastructure such as the hospitals and airports METHODS: The USVI Department of Health conducted 2 response Community Assessments for Public Health Emergency Response (CASPERs) in November 2017 and a recovery CASPER in February 2018. CASPER is a 2-stage cluster sampling method designed to provide household-based information about a community’s needs in a timely, inexpensive, and representative manner. RESULTS: Almost 70% of homes were damaged or destroyed, 81.2% of homes still needed repair, and 10.4% of respondents felt their home was unsafe to live in approximately 5 months after the storms. Eighteen percent of individual respondents indicated that their mental health was “not good” for 14 or more days in the past month, a significant increase from 2016. CONCLUSION: The CASPERs helped characterize the status and needs of residents after the devastating hurricanes and illustrate the evolving needs of the community and the progression of the recovery process. CASPER findings were shared with response and recovery partners to promote data-driven recovery efforts, improve the efficiency of the current response and recovery efforts, and strengthen emergency preparedness in USVI. (Disaster Med Public Health Preparedness. 2019;13:53-62).

    • Disease Reservoirs and Vectors
      1. Large-cage assessment of a transgenic sex-ratio distortion strain on populations of an African malaria vectorExternal
        Facchinelli L, North AR, Collins CM, Menichelli M, Persampieri T, Bucci A, Spaccapelo R, Crisanti A, Benedict MQ.
        Parasit Vectors. 2019 Feb 6;12(1):70.
        BACKGROUND: Novel transgenic mosquito control methods require progressively more realistic evaluation. The goal of this study was to determine the effect of a transgene that causes a male-bias sex ratio on Anopheles gambiae target populations in large insectary cages. METHODS: Life history characteristics of Anopheles gambiae wild type and Ag(PMB)1 (aka (gfp)124L-2) transgenic mosquitoes, whose progeny are 95% male, were measured in order to parameterize predictive population models. Ag(PMB)1 males were then introduced at two ratios into large insectary cages containing target wild type populations with stable age distributions and densities. The predicted proportion of females and those observed in the large cages were compared. A related model was then used to predict effects of male releases on wild mosquitoes in a west African village. RESULTS: The frequency of transgenic mosquitoes in target populations reached an average of 0.44 +/- 0.02 and 0.56 +/- 0.02 after 6 weeks in the 1:1 and in the 3:1 release ratio treatments (transgenic male:wild male) respectively. Transgenic males caused sex-ratio distortion of 73% and 80% males in the 1:1 and 3:1 treatments, respectively. The number of eggs laid in the transgenic treatments declined as the experiment progressed, with a steeper decline in the 3:1 than in the 1:1 releases. The results of the experiment are partially consistent with predictions of the model; effect size and variability did not conform to the model in two out of three trials, effect size was over-estimated by the model and variability was greater than anticipated, possibly because of sampling effects in restocking. The model estimating the effects of hypothetical releases on the mosquito population of a West African village demonstrated that releases could significantly reduce the number of females in the wild population. The interval of releases is not expected to have a strong effect. CONCLUSIONS: The biological data produced to parameterize the model, the model itself, and the results of the experiments are components of a system to evaluate and predict the performance of transgenic mosquitoes. Together these suggest that the Ag(PMB)1 strain has the potential to be useful for reversible population suppression while this novel field develops.

      2. Discovery and characterization of Bukakata orbivirus (Reoviridae:Orbivirus), a novel virus from a Ugandan batExternal
        Fagre AC, Lee JS, Kityo RM, Bergren NA, Mossel EC, Nakayiki T, Nalikka B, Nyakarahuka L, Gilbert AT, Peterhans JK, Crabtree MB, Towner JS, Amman BR, Sealy TK, Schuh AJ, Nichol ST, Lutwama JJ, Miller BR, Kading RC.
        Viruses. 2019 Mar 2;11(3).
        While serological and virological evidence documents the exposure of bats to medically-important arboviruses, their role as reservoirs or amplifying hosts is less well-characterized. We describe a novel orbivirus (Reoviridae:Orbivirus) isolated from an Egyptian fruit bat (Rousettus aegyptiacus leachii) trapped in 2013 in Uganda and named Bukakata orbivirus. This is the fifth orbivirus isolated from a bat, however genetic information had previously only been available for one bat-associated orbivirus. We performed whole-genome sequencing on Bukakata orbivirus and three other bat-associated orbiviruses (Fomede, Ife, and Japanaut) to assess their phylogenetic relationship within the genus Orbivirus and develop hypotheses regarding potential arthropod vectors. Replication kinetics were assessed for Bukakata orbivirus in three different vertebrate cell lines. Lastly, qRT-PCR and nested PCR were used to determine the prevalence of Bukakata orbivirus RNA in archived samples from three populations of Egyptian fruit bats and one population of cave-associated soft ticks in Uganda. Complete coding sequences were obtained for all ten segments of Fomede, Ife, and Japanaut orbiviruses and for nine of the ten segments for Bukakata orbivirus. Phylogenetic analysis placed Bukakata and Fomede in the tick-borne orbivirus clade and Ife and Japanaut within the Culicoides/phlebotomine sandfly orbivirus clade. Further, Bukakata and Fomede appear to be serotypes of the Chobar Gorge virus species. Bukakata orbivirus replicated to high titers (10(6)(-)10(7) PFU/mL) in Vero, BHK-21 [C-13], and R06E (Egyptian fruit bat) cells. Preliminary screening of archived bat and tick samples do not support Bukakata orbivirus presence in these collections, however additional testing is warranted given the phylogenetic associations observed. This study provided complete coding sequence for several bat-associated orbiviruses and in vitro characterization of a bat-associated orbivirus. Our results indicate that bats may play an important role in the epidemiology of viruses in the genus Orbivirus and further investigation is warranted into vector-host associations and ongoing surveillance efforts.

      3. Clinical, histopathologic, and immunohistochemical characterization of experimental Marburg virus infection in a natural reservoir host, the Egyptian rousette bat (Rousettus aegyptiacus)External
        Jones ME, Amman BR, Sealy TK, Uebelhoer LS, Schuh AJ, Flietstra T, Bird BH, Coleman-McCray JD, Zaki SR, Nichol ST, Towner JS.
        Viruses. 2019 Mar 2;11(3).
        Egyptian rousette bats (Rousettus aegyptiacus) are natural reservoir hosts of Marburg virus (MARV), and Ravn virus (RAVV; collectively called marburgviruses) and have been linked to human cases of Marburg virus disease (MVD). We investigated the clinical and pathologic effects of experimental MARV infection in Egyptian rousettes through a serial euthanasia study and found clear evidence of mild but transient disease. Three groups of nine, captive-born, juvenile male bats were inoculated subcutaneously with 10,000 TCID50 of Marburg virus strain Uganda 371Bat2007, a minimally passaged virus originally isolated from a wild Egyptian rousette. Control bats (n = 3) were mock-inoculated. Three animals per day were euthanized at 3, 5(-)10, 12 and 28 days post-inoculation (DPI); controls were euthanized at 28 DPI. Blood chemistry analyses showed a mild, statistically significant elevation in alanine aminotransferase (ALT) at 3, 6 and 7 DPI. Lymphocyte and monocyte counts were mildly elevated in inoculated bats after 9 DPI. Liver histology revealed small foci of inflammatory infiltrate in infected bats, similar to lesions previously described in wild, naturally-infected bats. Liver lesion severity scores peaked at 7 DPI, and were correlated with both ALT and hepatic viral RNA levels. Immunohistochemical staining detected infrequent viral antigen in liver (3(-)8 DPI, n = 8), spleen (3(-)7 DPI, n = 8), skin (inoculation site; 3(-)12 DPI, n = 20), lymph nodes (3(-)10 DPI, n = 6), and oral submucosa (8(-)9 DPI, n = 2). Viral antigen was present in histiocytes, hepatocytes and mesenchymal cells, and in the liver, antigen staining co-localized with inflammatory foci. These results show the first clear evidence of very mild disease caused by a filovirus in a reservoir bat host and provide support for our experimental model of this virus-reservoir host system.

      4. Prevalence of antibodies to orthopoxvirus in wild carnivores of northwestern Chihuahua, MexicoExternal
        Morgan CN, Lopez-Perez AM, Martinez-Duque P, Jackson FR, Suzan G, Gallardo-Romero NF.
        J Wildl Dis. 2019 Mar 1.
        The distribution of orthopoxviruses (OPXVs) across the North American continent is suggested to be widespread in a wide range of mammalian hosts on the basis of serosurveillance studies. To address the question of whether carnivores in northwestern Mexico are exposed to naturally circulating OPXVs, wild carnivores were collected by live trapping within four different habitat types during fall of 2013 and spring of 2014 within the Janos Biosphere Reserve in northwestern Chihuahua, Mexico. A total of 51 blood samples was collected for testing. Anti-OPXV immunoglobulin G enzyme-linked immunosorbent assay, western blot, and rapid fluorescent focus inhibition test (RFFIT) assays were conducted. About 47% (24/51) of the carnivores tested were seropositive for anti-OPXV binding antibodies and had presence of immunodominant bands indicative of OPXV infection. All samples tested were negative for rabies virus neutralizing antibodies by RFFIT, suggesting that the OPXV antibodies were due to circulating OPXV, and not from exposure to oral rabies vaccine (vaccinia-vectored rabies glycoprotein vaccine) bait distributed along the US-Mexico border. Our results indicated that there may be one or more endemic OPXV circulating within six species of carnivores in northwestern Mexico.

      5. Emergence of genetically and antigenically diverse strains of influenza to which the human population has no or limited immunity necessitates continuous risk assessments to determine the likelihood of these viruses acquiring adaptations that facilitate sustained human-to-human transmission. As the North American swine H1 virus population has diversified over the last century by means of both antigenic drift and shift, in vivo assessments to study multifactorial traits like mammalian pathogenicity and transmissibility of these emerging influenza viruses are critical. In this review, we examine genetic, molecular, and pathogenicity and transmissibility data from a panel of contemporary North American H1 subtype swine-origin viruses isolated from humans, as compared to H1N1 seasonal and pandemic viruses, including the reconstructed 1918 virus. We present side-by-side analyses of experiments performed in the mouse and ferret models using consistent experimental protocols to facilitate enhanced interpretation of in vivo data. Contextualizing these analyses in a broader context permits a greater appreciation of the role that in vivo risk assessment experiments play in pandemic preparedness. Collectively, we find that despite strain-specific heterogeneity among swine-origin H1 viruses, contemporary swine viruses isolated from humans possess many attributes shared by prior pandemic strains, warranting heightened surveillance and evaluation of these zoonotic viruses.

    • Environmental Health
      1. Urinary concentrations of bisphenol A, parabens and phthalate metabolite mixtures in relation to reproductive success among women undergoing in vitro fertilizationExternal
        Minguez-Alarcon L, Messerlian C, Bellavia A, Gaskins AJ, Chiu YH, Ford JB, Azevedo AR, Petrozza JC, Calafat AM, Hauser R, Williams PL.
        Environ Int. 2019 Feb 28;126:355-362.
        BACKGROUND: We have previously investigated whether urinary concentrations of bisphenol A (BPA), parabens, and phthalate metabolites were individually associated with reproductive outcomes among women undergoing in vitro fertilization (IVF) treatment. However, humans are typically exposed to many man-made chemicals simultaneously. Thus, investigating one chemical at a time may not represent the effect of mixtures. OBJECTIVE: To investigate whether urinary concentrations of BPA, parabens, and phthalate metabolite mixtures are associated with reproductive outcomes among women undergoing IVF. METHODS: This prospective cohort study included 420 women contributing 648 IVF cycles who provided up to two urine samples per cycle prior to oocyte retrieval (N=1145) between 2006 and 2017 at the Massachusetts General Hospital Fertility Center, and had available urine biomarker data. Urinary concentrations of BPA, parabens, and phthalate metabolites were quantified using isotope-dilution tandem mass spectrometry. Intermediate and clinical end-points of IVF treatments were abstracted from electronic medical records. Principal component analysis (PCA) and Bayesian kernel machine regression (BKMR) were used to identify main patterns of BPA, parabens, and phthalate metabolites concentrations. We used generalized linear mixed models to evaluate the association between PCA-derived factor scores, in quartiles, and IVF outcomes, using random intercepts to account for multiple IVF cycles and adjusting for known confounders. Because of temporal trends in exposure, we conducted a sensitivity analysis restricted to women who underwent IVF cycles in the earlier years of study (2006-2012). RESULTS: Urinary concentrations of BPA, parabens, and most phthalate metabolites were significantly lower during the second half of the study period (2013-2017) than during the first half (2006-2012). None of the three factors derived from the PCA [di(2-ethylhexyl) phthalate (DEHP), non-DEHP, and paraben] was associated with IVF outcomes in the main analyses. Similarly, BKRM analyses did not identify any associations of individual urinary concentrations of BPA, paraben and phthalate metabolites with IVF outcomes while accounting for correlation between exposures. However, in sensitivity analyses restricted to women who underwent IVF cycles from 2006 to 2012, where concentrations of most phthalates and phenols were higher, there were decreases in implantation, clinical pregnancy, and live birth across quartiles of the DEHP factor. Specifically, women in the highest quartile of the DEHP factor had, on average, lower probabilities of implantation (-22% p, trend=0.08), clinical pregnancy (-24% p, trend=0.14), and live birth (-38% p, trend=0.06) compared to women in the lowest quartile. Among this group of women, BKMR results did not identify any single contributor driving the decreased probabilities of live birth within the DEHP factor. CONCLUSIONS: We confirmed that women undergoing IVF are concurrently exposed to multiple endocrine disrupting chemicals (EDCs). While we found no overall significant associations, we observed diminished pregnancy success with specific clusters of chemicals among women who underwent IVF cycles in earlier years of study, when urinary concentrations of these EDCs were higher.

      2. Assessment of extreme heat and hospitalizations to inform early warning systemsExternal
        Vaidyanathan A, Saha S, Vicedo-Cabrera AM, Gasparrini A, Abdurehman N, Jordan R, Hawkins M, Hess J, Elixhauser A.
        Proc Natl Acad Sci U S A. 2019 Mar 4.
        Heat early warning systems and action plans use temperature thresholds to trigger warnings and risk communication. In this study, we conduct multistate analyses, exploring associations between heat and all-cause and cause-specific hospitalizations, to inform the design and development of heat-health early warning systems. We used a two-stage analysis to estimate heat-health risk relationships between heat index and hospitalizations in 1,617 counties in the United States for 2003-2012. The first stage involved a county-level time series quasi-Poisson regression, using a distributed lag nonlinear model, to estimate heat-health associations. The second stage involved a multivariate random-effects meta-analysis to pool county-specific exposure-response associations across larger geographic scales, such as by state or climate region. Using results from this two-stage analysis, we identified heat index ranges that correspond with significant heat-attributable burden. We then compared those with the National Oceanic and Atmospheric Administration National Weather Service (NWS) heat alert criteria used during the same time period. Associations between heat index and cause-specific hospitalizations vary widely by geography and health outcome. Heat-attributable burden starts to occur at moderately hot heat index values, which in some regions are below the alert ranges used by the NWS during the study time period. Locally specific health evidence can beneficially inform and calibrate heat alert criteria. A synchronization of health findings with traditional weather forecasting efforts could be critical in the development of effective heat-health early warning systems.

      3. Prenatal and childhood exposure to poly- and perfluoroalkyl substances (PFAS) and cognitive development in children at age 8 yearsExternal
        Vuong AM, Yolton K, Xie C, Dietrich KN, Braun JM, Webster GM, Calafat AM, Lanphear BP, Chen A.
        Environ Res. 2019 Feb 16;172:242-248.
        BACKGROUND: Toxicological studies indicate that poly- and perfluoroalkyl substances (PFAS) may be neurotoxic, but human studies have yet to provide compelling evidence for PFAS’ impact on cognitive abilities. OBJECTIVE: To test whether prenatal and childhood PFAS are associated with cognitive abilities at 8 years and whether sex modifies these associations. METHODS: We included 221 mother-child pairs from the Health Outcomes and Measures of the Environment (HOME) Study, a birth cohort in Cincinnati, OH (USA). We quantified PFAS in maternal serum at 16+/-3 weeks gestation and in child serum at 3 and 8 years. We used the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) at age 8 years, assessing Full Scale IQ (FSIQ), verbal comprehension, perceptual reasoning, working memory, and processing speed. We used multiple informant models to estimate covariate-adjusted differences in WISC-IV scores by repeated ln-transformed PFAS. RESULTS: Prenatal and childhood perfluorooctane sulfonate (PFOS) and perfluorohexane sulfonate (PFHxS) were not associated with WISC-IV measures. We observed an increase of 4.1-points (95% CI 0.3, 8.0) and 5.7-points (95% CI 1.2, 10.2) in working memory with 1-ln unit increase in prenatal perfluorooctanoate (PFOA) and perfluorononanoate (PFNA), respectively. In addition, PFNA at 3 years was associated with better FSIQ and perceptual reasoning. Child sex modified the relationship between prenatal PFOA and FSIQ; the association was positive in females only. Sex also modified the association between concurrent PFOS and FSIQ, with males having higher scores. CONCLUSION: We did not observe adverse associations between prenatal and childhood PFAS and cognitive function at age 8 years.

    • Genetics and Genomics
      1. PacBio genome sequences of eight Escherichia albertii strains isolated from humans in the United StatesExternal
        Lindsey RL, Rowe LA, Batra D, Smith P, Strockbine NA.
        Microbiol Resour Announc. 2019 Feb;8(9).
        Escherichia albertii is an emerging pathogen that is closely related to Escherichia coli and can carry some of the same virulence genes as E. coli. Here, we report the release of Illumina-corrected PacBio sequences for eight E. albertii genomes. Two of these strains carry Shiga toxin 2f.

      2. First report of the genomic characterization of rubella viruses circulating in CameroonExternal
        Mekanda FO, Monamele CG, Nemg FB, Yousseu FB, Ndjonka D, Kfutwah AK, Abernathy E, Demanou M.
        J Med Virol. 2019 Mar 1.
        Rubella is an acute, contagious viral infection whose gravidity resides in infection during pregnancy, which can result in miscarriage, foetal death, stillbirth, or infants with congenital malformations. This study aimed to describe the genome of Rubella viruses (RUBVs) circulating in Cameroon. Throat swabs were collected from health districts as part of the measles surveillance program from 2010 to 2016 and sent to the Centre Pasteur of Cameroon. Samples were amplified by genotyping RT-PCR in search of two overlapping fragments of the gene that encodes the E1 envelope glycoprotein of RUBV. PCR products were sequenced, and phylogenetic analysis was performed with MEGA 6 software. Overall, 9 of 43 samples (20.93%) were successfully amplified and sequenced but only 8 sequences could be exploited for phylogenetic analysis with respect to the required fragment length of 739 nucleotides. Analysis of viral sequences from Cameroon with other epidemiologically relevant sequences from around the world showed that all RUBVs belonged to lineage L1 of genotype 1G. Cameroon sequences clustered with viruses from West Africa including Nigeria, Ivory Coast and Ghana with a percent similarity of 95.4-99.2%.This study will enable an update on the molecular epidemiology of RUBV in Cameroon and help in monitoring circulating RUBV for a better implementation of elimination strategies. This article is protected by copyright. All rights reserved.

    • Global Health
      1. Global health security: Protecting the United States in an interconnected worldExternal
        Bunnell RE, Ahmed Z, Ramsden M, Rapposelli K, Walter-Garcia M, Sharmin E, Knight N.
        Public Health Rep. 2019 Jan/Feb;134(1):3-10.

        [No abstract]

      2. Alternative water transport and storage containers: Assessing sustained use of the PackH2O in rural HaitiExternal
        Martinsen A, Hulland E, Phillips R, Darius JA, Felker-Kantor E, Simpson D, Stephens M, Thomas E, Quick R, Handzel T.
        Am J Trop Med Hyg. 2019 Mar 4.
        The PackH2O water backpack carrier was developed to provide safe storage and relieve stress of head-loading during water transport with traditional containers such as buckets and jerry cans. We conducted an evaluation to assess both self-reported and observed use over a 6-month period between November 2014 and May 2015. A total of 866 packs were distributed to 618 households in six communities in rural Haiti, and 431 and 441 households were surveyed at midline and end line, respectively. We performed linear regression to assess change of self-reported use over time. Although 79.3% of respondents reported continued use of the 20-L pack after 6 months, other measures of self-reported use were low, with only 16.8% reporting to have used the pack the last time they collected water and 10.3% preferring the pack over other water collection containers. In addition, only 10.2% of all people collecting water at community sources were observed using packs and 12.0% of all households surveyed had water in the pack at the time of visit. Pack use varied by community and demographics. Although women were targeted during distribution, men preferred the pack and were more commonly observed using it at the community water sources. In conclusion, the use of the PackH2O was not widely adopted in rural Haiti; however, further research is needed to assess the pack acceptance in areas where back-loading is more common and in emergency settings.

    • Healthcare Associated Infections
      1. Molecular epidemiology of Candida auris in Colombia reveals a highly related, countrywide colonization with regional patterns in amphotericin B resistanceExternal
        Escandon P, Chow NA, Caceres DH, Gade L, Berkow EL, Armstrong P, Rivera S, Misas E, Duarte C, Moulton-Meissner H, Welsh RM, Parra C, Pescador LA, Villalobos N, Salcedo S, Berrio I, Varon C, Espinosa-Bode A, Lockhart SR, Jackson BR, Litvintseva AP, Beltran M, Chiller TM.
        Clin Infect Dis. 2019 Jan 1;68(1):15-21.
        Background: Candida auris is a multidrug-resistant yeast associated with hospital outbreaks worldwide. During 2015-2016, multiple outbreaks were reported in Colombia. We aimed to understand the extent of contamination in healthcare settings and to characterize the molecular epidemiology of C. auris in Colombia. Methods: We sampled patients, patient contacts, healthcare workers, and the environment in 4 hospitals with recent C. auris outbreaks. Using standardized protocols, people were swabbed at different body sites. Patient and procedure rooms were sectioned into 4 zones and surfaces were swabbed. We performed whole-genome sequencing (WGS) and antifungal susceptibility testing (AFST) on all isolates. Results: Seven of the 17 (41%) people swabbed were found to be colonized. Candida auris was isolated from 37 of 322 (11%) environmental samples. These were collected from a variety of items in all 4 zones. WGS and AFST revealed that although isolates were similar throughout the country, isolates from the northern region were genetically distinct and more resistant to amphotericin B (AmB) than the isolates from central Colombia. Four novel nonsynonymous mutations were found to be significantly associated with AmB resistance. Conclusions: Our results show that extensive C. auris contamination can occur and highlight the importance of adherence to appropriate infection control practices and disinfection strategies. Observed genetic diversity supports healthcare transmission and a recent expansion of C. auris within Colombia with divergent AmB susceptibility.

      2. Vital Signs: Trends in Staphylococcus aureus infections in Veterans Affairs Medical Centers – United States, 2005-2017External
        Jones M, Jernigan JA, Evans ME, Roselle GA, Hatfield KM, Samore MH.
        MMWR Morb Mortal Wkly Rep. 2019 Mar 8;68(9):220-224.
        INTRODUCTION: By 2007, all Department of Veterans Affairs medical centers (VAMCs) had initiated a multifaceted methicillin-resistant Staphylococcus aureus (MRSA) prevention program. MRSA and methicillin-susceptible S. aureus (MSSA) infection rates among VAMC inpatients from 2005 to 2017 were assessed. METHODS: Clinical microbiology data from any patient admitted to an acute-care VAMC in the United States from 2005 through 2017 and trends in hospital-acquired MRSA colonization were examined. RESULTS: S. aureus infections decreased by 43% overall during the study period (p<0.001), driven primarily by decreases in MRSA, which decreased by 55% (p<0.001), whereas MSSA decreased by 12% (p = 0.003). Hospital-onset MRSA and MSSA infections decreased by 66% (p<0.001) and 19% (p = 0.02), respectively. Community-onset MRSA infections decreased by 41% (p<0.001), whereas MSSA infections showed no significant decline. Acquisition of MRSA colonization decreased 78% during 2008-2017 (17% annually, p<0.001). MRSA infection rates declined more sharply among patients who had negative admission surveillance MRSA screening tests (annual 9.7% decline) compared with those among patients with positive admission MRSA screening tests (4.2%) (p<0.05). CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Significant reductions in S. aureus infection following the VAMC intervention were led primarily by decreases in MRSA. Moreover, MRSA infection declines were much larger among patients not carrying MRSA at the time of admission than among those who were. Taken together, these results suggest that decreased MRSA transmission played a substantial role in reducing overall S. aureus infections at VAMCs. Recent calls to withdraw infection control interventions designed to prevent MRSA transmission might be premature and inadvisable, at least until more is known about effective control of bacterial pathogen transmission in health care settings. Effective S. aureus prevention strategies require a multifaceted approach that includes adherence to current CDC recommendations for preventing not only device- and procedure-associated infections, but also transmission of health care-prevalent strains.

      3. Association between antibiotic use and hospital-onset Clostridioides difficile infection in U.S. acute care hospitals, 2006-2012: an ecologic analysisExternal
        Kazakova SV, Baggs J, McDonald LC, Yi SH, Hatfield KM, Guh A, Reddy SC, Jernigan JA.
        Clin Infect Dis. 2019 Mar 1.
        BACKGROUND: Unnecessary antibiotic use (AU) contributes to increased rates of Clostridioides difficile Infection (CDI). The impact of antibiotic restriction on hospital-onset CDI (HO-CDI) has not been assessed in a large group of U.S. acute care hospitals (ACHs). METHODS: We examined cross-sectional and temporal associations between rates of hospital-level AU and HO-CDI using data from 549 ACHs. HO-CDI, a discharge with a secondary ICD-9-CM for CDI (008.45) and treatment with metronidazole or oral vancomycin >/= 3 days after admission. Analyses were performed using multivariable generalized estimating equation models adjusting for patient and hospital characteristics. RESULTS: During 2006-2012, the unadjusted annual rates of HO-CDI and total AU were 7.3 per 10,000 patient-days (PD) (95% CI: 7.1-7.5) and 811 days of therapy (DOT)/1,000 PD (95% CI: 803-820), respectively. In the cross-sectional analysis, for every 50 DOT/1,000 PD increase in total AU, there was a 4.4% increase in HO-CDI. For every 10 DOT/1,000 PD increase in use of third- and fourth-generation cephalosporins or carbapenems there was a 2.1% and 2.9% increase in HO-CDI, respectively. In the time-series analysis, the 6 ACHs with a >/= 30% decrease in total AU had a 33% decrease in HO-CDI (rate ratio, 0.67; 95% CI, 0.47-0.96); ACHs with a >/= 20% decrease in fluoroquinolone or third- and fourth-generation cephalosporin use had a corresponding decrease in HO-CDI of 8% and 13%, respectively. CONCLUSIONS: At an ecologic level, reductions in total AU, use of fluoroquinolones and third- and fourth-generation cephalosporins were each associated with decreased HO-CDI rates.

      4. Vital Signs: Epidemiology and recent trends in methicillin-resistant and in methicillin-susceptible Staphylococcus aureus bloodstream infections – United StatesExternal
        Kourtis AP, Hatfield K, Baggs J, Mu Y, See I, Epson E, Nadle J, Kainer MA, Dumyati G, Petit S, Ray SM, Ham D, Capers C, Ewing H, Coffin N, McDonald LC, Jernigan J, Cardo D.
        MMWR Morb Mortal Wkly Rep. 2019 Mar 8;68(9):214-219.
        INTRODUCTION: Staphylococcus aureus is one of the most common pathogens in health care facilities and in the community, and can cause invasive infections, sepsis, and death. Despite progress in preventing methicillin-resistant S. aureus (MRSA) infections in health care settings, assessment of the problem in both health care and community settings is needed. Further, the epidemiology of methicillin-susceptible S. aureus (MSSA) infections is not well described at the national level. METHODS: Data from the Emerging Infections Program (EIP) MRSA population surveillance (2005-2016) and from the Premier and Cerner Electronic Health Record databases (2012-2017) were analyzed to describe trends in incidence of hospital-onset and community-onset MRSA and MSSA bloodstream infections and to estimate the overall incidence of S. aureus bloodstream infections in the United States and associated in-hospital mortality. RESULTS: In 2017, an estimated 119,247 S. aureus bloodstream infections with 19,832 associated deaths occurred. During 2005-2012 rates of hospital-onset MRSA bloodstream infection decreased by 17.1% annually, but the decline slowed during 2013-2016. Community-onset MRSA declined less markedly (6.9% annually during 2005-2016), mostly related to declines in health care-associated infections. Hospital-onset MSSA has not significantly changed (p = 0.11), and community-onset MSSA infections have slightly increased (3.9% per year, p<0.0001) from 2012 to 2017. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Despite reductions in incidence of MRSA bloodstream infections since 2005, S. aureus infections account for significant morbidity and mortality in the United States. To reduce the incidence of these infections further, health care facilities should take steps to fully implement CDC recommendations for prevention of device- and procedure-associated infections and for interruption of transmission. New and novel prevention strategies are also needed.

    • Immunity and Immunization
      1. Eradication of poliomyelitis remains a public health priority due to the paralytic effects of the virus on children and impact on global health system. However, existing gaps in surveillance can hinder eradication. Improved timeliness of identification and reporting of acute flaccid paralysis (AFP) cases with further confirmation of Wild Poliovirus (WPV) in stool samples, can help Nigeria achieve the performance indicators of non-polio AFP rate of >/= 2/100,000 population aged < 15 years and >/=80% stool sample collection adequacy. To ascertain the awareness of AFP case definition and detection by health care workers and to evaluate the impact of SMS-based reporting on the AFP surveillance system the study was conducted from November 2013 to July 2014. In Sokoto state, 112 health facilities (focal sites) were operational and participated in this study. All AFP focal points for the 112 facilities were included in the study. In addition to AFP focal points, two clinicians per facility where possible, were included in the study. The study focused exclusively on reports from focal sites. The methodology was a one group pretest-posttest design conducted in 3 phases. 1) Pre-intervention Knowledge, Attitude and Practices (KAP) survey, 2) SMS implementation and 3) Post-intervention KAP. Results were analysed using the independent sample t-test to assess the increase in knowledge, attitudes, or practice scores pre- and post- training. The study showed improved knowledge gap of health care workers on AFP surveillance between pre and post intervention. It shows that this approach of improved surveillance will be effective in countries in hard to reach, access compromised or countries/place without sufficient surveillance staff.

      2. Mumps outbreak in an unimmunized population – Luanshya District, Copperbelt Province, Zambia, 2015External
        Kateule E, Kumar R, Mulenga M, Daka V, Banda K, Anderson R, McNall R, McGrew M, Baggett HC, Kasongo W.
        Pan African Medical Journal. 2018 ;31 (3).
        Introduction: Mumps is a vaccine-preventable viral disease that may cause deafness, orchitis, encephalitis or death. However, mumps vaccine is not included in Zambia’s Expanded Program for Immunization. In January 2015, Integrated Disease Surveillance and Response data revealed an increase in reported mumps cases in Luanshya District. We investigated to confirm the etiology and generate epidemiological data on mumps in Zambia. Method(s): We conducted active case finding, examined possible case-patients, and administered a standard questionnaire. A suspected mumps case was defined as acute onset of salivary gland swelling in a Luanshya resident during January-June 2015. Eight case-patients provided serum samples to test for mumps-specific immunoglobulin IgM, and buccal swabs to test for mumps viral RNA by RT-PCR, and genotyping of mumps virus at the Centers for Disease Control and Prevention, Atlanta, Georgia, USA. Result(s): From January – June 2015, a total of 283 mumps cases were reported in Luanshya, peaking in April (71 cases) and clustering (81%) in two townships. Of 72 suspected case-patients interviewed, 81% were aged < 15 years (29%, 1-4 years) and 61% were female. Common clinical characteristics were buccal tenderness (29%) and fever > 37.5C (29%). Mumps virus genotype D was confirmed in five case-patients who tested positive by RT-PCR; six case-patients were sero-positive for anti-mumps IgM antibodies (total seven lab-confirmed cases). Conclusion(s): Our findings represent the first reported epidemiologic description of mumps in Zambia. While the epidemiology is consistent with prior descriptions of mumps in unimmunized populations and no serious complications arose, this report provides data to inform policy discussions regarding mumps vaccination in Zambia.

      3. Long term risk of developing type 1 diabetes after HPV vaccination in males and femalesExternal
        Klein NP, Goddard K, Lewis E, Ross P, Gee J, DeStefano F, Baxter R.
        Vaccine. 2019 Feb 28.
        INTRODUCTION: Despite minimal evidence, public concerns that the human papillomavirus (HPV) vaccine can cause autoimmune diseases (AD) persist. We evaluated whether HPV vaccine is associated with a long-term increased risk of diabetes mellitus type 1 (DM1). METHODS: This was a retrospective cohort study in which we identified all potential DM1 cases from Kaiser Permanente Northern California (KPNC) members who were between 11 and 26years old any time after June 2006 through December 2015. We chart reviewed a random sample of 100 DM1 cases to confirm diagnosis and to develop a computer algorithm that reliably determined symptom onset date. Our DM1 Analysis Population comprised all individuals who met membership criteria and who were age and sex eligible to have received HPV vaccine. We adjusted for age, sex, race, Medicaid, and years of prior KPNC membership by stratification using a Cox multiplicative hazards model with a calendar timeline. RESULTS: Our DM1 analysis included 911,648 individuals. Of 2613 DM1 cases identified, 338 remained in the analysis after applying our algorithm, HPV vaccine eligibility and membership criteria. Over the 10years of the study period, comparing vaccinated with unvaccinated persons, we did not find an increased risk of DM1 associated with HPV vaccine receipt (hazard ratio 1.21, 95% Confidence Interval 0.94, 1.57). CONCLUSIONS: We found no increased risk for development of DM1 following HPV vaccination. Our study provides reassurance that during the 10-year time period after HPV vaccine was introduced, there was no substantial increased risk for DM1 following HPV vaccination.

      4. Immunogenicity and safety of measles-rubella vaccine co-administered with attenuated Japanese encephalitis SA 14-14-2 vaccine in infants aged 8 months in China: a non-inferiority randomised controlled trialExternal
        Li Y, Chu SY, Yue C, Wannemuehler K, Xie S, Zhang F, Wang Y, Zhang Y, Ma R, Li Y, Zuo Z, Rodewald L, Xiao Q, Feng Z, Wang H, An Z.
        Lancet Infect Dis. 2019 Mar 1.
        BACKGROUND: In China, measles-rubella vaccine and live attenuated SA 14-14-2 Japanese encephalitis vaccine (LJEV) are recommended for simultaneous administration at 8 months of age, which is the youngest recommended age for these vaccines worldwide. We aimed to assess the effect of the co-administration of these vaccines at 8 months of age on the immunogenicity of measles-rubella vaccine. METHODS: We did a multicentre, open-label, non-inferiority, two-group randomised controlled trial in eight counties or districts in China. We recruited healthy infants aged 8 months who had received all scheduled vaccinations according to the national immunisation recommendations and who lived in the county of the study site. Enrolled infants were randomly assigned (1:1) to receive either measles-rubella vaccine and LJEV simultaneously (measles-rubella plus LJEV group) or measles-rubella vaccine alone (measles-rubella group). The primary outcome was the proportion of infants with IgG antibody seroconversion for measles 6 weeks after vaccination, and a secondary outcome was the proportion of infants with IgG antibody seroconversion for rubella 6 weeks after vaccination. Analyses included all infants who completed the study. We used a 5% margin to establish non-inferiority. This trial was registered at (NCT02643433). FINDINGS: 1173 infants were assessed for eligibility between Aug 13, 2015, and June 10, 2016. Of 1093 (93%) enrolled infants, 545 were randomly assigned to the measles-rubella plus LJEV group and 548 to the measles-rubella group. Of the infants assigned to each group, 507 in the measles-rubella plus LJEV group and 506 in the measles-rubella group completed the study. Before vaccination, six (1%) of 507 infants in the measles-rubella plus LJEV group and one (<1%) of 506 in the measles-rubella group were seropositive for measles; eight (2%) infants in the measles-rubella plus LJEV group and two (<1%) in the measles-rubella group were seropositive for rubella. 6 weeks after vaccination, measles seroconversion in the measles-rubella plus LJEV group (496 [98%] of 507) was non-inferior to that in the measles-rubella group (499 [99%] of 506; difference -0.8% [90% CI -2.6 to 1.1]) and rubella seroconversion in the measles-rubella plus LJEV group (478 [94%] of 507) was non-inferior to that in the measles-rubella group (473 [94%] of 506 infants; difference 0.8% [90% CI -1.8 to 3.4]). There were no serious adverse events in either group and no evidence of a difference between the two groups in the prevalence of any local adverse event (redness, rashes, and pain) or systemic adverse event (fever, allergy, respiratory infections, diarrhoea, and vomiting). Fever was the most common adverse event (97 [19%] of 507 infants in the measles-rubella plus LJEV group; 108 [21%] of 506 infants in the measles-rubella group). INTERPRETATION: The evidence of similar seroconversion and safety with co-administered LJEV and measles-rubella vaccines supports the co-administration of these vaccines to infants aged 8 months. These results will be important for measles and rubella elimination and the expansion of Japanese encephalitis vaccination in countries where it is endemic. FUNDING: US Centers for Disease Control and Prevention, US Department of Health and Human Services; China-US Collaborative Program on Emerging and Re-emerging Infectious Diseases.

      5. Update on vaccine-derived poliovirus outbreaks – Democratic Republic of the Congo and Horn of Africa, 2017-2018External
        Mbaeyi C, Alleman MM, Ehrhardt D, Wiesen E, Burns CC, Liu H, Ewetola R, Seakamela L, Mdodo R, Ndoutabe M, Wenye PK, Riziki Y, Borus P, Kamugisha C, Wassilak SG.
        MMWR Morb Mortal Wkly Rep. 2019 Mar 8;68(9):225-230.
        Widespread use of live attenuated (Sabin) oral poliovirus vaccine (OPV) has resulted in marked progress toward global poliomyelitis eradication (1). However, in underimmunized populations, extensive person-to-person transmission of Sabin poliovirus can result in genetic reversion to neurovirulence and paralytic vaccine-derived poliovirus (VDPV) disease (1). This report updates (as of February 26, 2019) previous reports on circulating VDPV type 2 (cVDPV2) outbreaks during 2017-2018 in the Democratic Republic of the Congo (DRC) and in Somalia, which experienced a concurrent cVDPV type 3 (cVDPV3) outbreak* (2,3). In DRC, 42 cases have been reported in four cVDPV2 outbreaks; paralysis onset in the most recent case was October 7, 2018 (2). Challenges to interrupting transmission have included delays in outbreak-response supplementary immunization activities (SIAs) and difficulty reaching children in all areas. In Somalia, cVDPV2 and cVDPV3 were detected in sewage before the detection of paralytic cases (3). Twelve type 2 and type 3 cVDPV cases have been confirmed; the most recent paralysis onset dates were September 2 (cVDPV2) and September 7, 2018 (cVDPV3). The primary challenge to interrupting transmission is the residence of >300,000 children in areas that are inaccessible for vaccination activities. For both countries, longer periods of surveillance are needed before interruption of cVDPV transmission can be inferred.

      6. Serological response to influenza vaccination among adults hospitalized with community-acquired pneumoniaExternal
        Pratt CQ, Zhu Y, Grijalva CG, Wunderink RG, Mark Courtney D, Waterer G, Levine MZ, Jefferson S, Self WH, Williams DJ, Finelli L, Bramley AM, Edwards KM, Jain S, Anderson EJ.
        Influenza Other Respir Viruses. 2019 Mar;13(2):208-212.
        Ninety-five adults enrolled in the Etiology of Pneumonia in the Community study with negative admission influenza polymerase chain reaction (PCR) tests received influenza vaccination during hospitalization. Acute and convalescent influenza serology was performed. After vaccination, seropositive (>/=1:40) hemagglutination antibody titers (HAI) were achieved in 55% to influenza A(H1N1)pdm09, 58% to influenza A(H3N2), 77% to influenza B (Victoria), and 74% to influenza B (Yamagata) viruses. Sixty-six (69%) patients seroconverted (>/=4-fold HAI rise) to >/=1 strain. Failure to seroconvert was associated with diabetes, bacterial detection, baseline seropositive titers for influenza B (Yamagata), and influenza vaccination in the previous season.

      7. Vaccination differences among U.S. adults by their self-identified sexual orientation, National Health Interview Survey, 2013-2015External
        Srivastav A, O’Halloran A, Lu PJ, Williams WW, Hutchins SS.
        PLoS One. 2019 ;14(3):e0213431.
        INTRODUCTION: Very few studies have explored the associations between self-identified sexual orientation and comprehensive vaccination coverage. Most of the previous studies that reported health disparities among lesbian, gay and bisexual populations were not based on a nationally representative sample of U.S. adults, limiting the generalizability of the findings. Starting in 2013, the National Health Interview Survey (NHIS) included questions to ascertain the adult’s self-identified sexual orientation that allowed national level vaccination estimation by sexual orientation. This study examined associations of self-reported vaccination coverage for selected vaccines among U.S. adults by their sexual orientation. METHODS: We analyzed combined data from 2013-2015 NHIS, a nationally representative probability-based health survey of the noninstitutionalized U.S. population >/=18 years. For vaccines other than influenza, weighted proportions were calculated. Influenza coverage was calculated using the Kaplan-Meier procedure. Multivariable logistic regression models were used to calculate adjusted prevalence differences for each vaccine overall and stratified by sexual orientation and to identify factors independently associated with vaccination. RESULTS: Significant differences were observed by sexual orientation for self-reported receipt of human papillomavirus (HPV), hepatitis A (HepA), hepatitis B (HepB), and influenza vaccination. Bisexual females (51.6%) had higher HPV coverage than heterosexual females (40.2%). Gay males (40.3% and 53.6%, respectively) had higher HepA and HepB coverage than heterosexual males (25.4% and 32.6%, respectively). Bisexual females (33.9% and 58.5%, respectively) had higher HepA and HepB coverage than heterosexual females (23.5% and 38.4%, respectively) and higher HepB coverage than lesbian females (45.4%). Bisexual adults (34.1%) had lower influenza coverage than gay/lesbian (48.5%) and heterosexual adults (43.8%). Except for the association of having self-identified as gay/lesbian orientation with greater likelihood of HepA, HepB, and influenza vaccination, sexual orientation was not associated with higher or lower likelihood of vaccination. Health status or other behavioral characteristics studied had no consistent relationship with vaccination among all populations. CONCLUSION: Differences were identified in vaccination coverage among the U.S. adult population by self-reported sexual orientation. This study is the first to assess associations of sexual orientation with a comprehensive list of vaccinations. Findings from this study can serve as a baseline for monitoring changes over time. All populations could benefit from improved vaccination.

    • Injury and Violence
      1. The primary purpose of the present study was to examine the effectiveness of threat appeals in influencing impulsive decision making associated with texting while driving. The participants in the treatment group were exposed to a threatening message about the danger of texting while driving, whereas those in the control group were exposed to a non-threatening message. Following the exposure to either message, the participants completed a delay-discounting task that assessed the degree of impulsive decision making in a hypothetical texting-while-driving scenario. A comparison between the groups revealed that the threat appeals reduced the degree of impulsive decision making associated with texting while driving. In addition, the threat appeals led to greater anticipated regret from texting while driving, less favorable attitudes toward texting while driving, and decreased intentions to text while driving in the future in the treatment group. These results suggest that video-based threat appeals are promising intervention strategies for the public health challenge of texting while driving. Implications from the behavioral economic perspective are discussed.

      2. Temporal and geographic patterns of social media posts about an emerging suicide gameExternal
        Sumner SA, Galik S, Mathieu J, Ward M, Kiley T, Bartholow B, Dingwall A, Mork P.
        J Adolesc Health. 2019 Feb 25.
        PURPOSE: Rates of suicide are increasing rapidly among youth. Social media messages and online games promoting suicide are a concern for parents and clinicians. We examined the timing and location of social media posts about one alleged youth suicide game to better understand the degree to which social media data can provide earlier public health awareness. METHODS: We conducted a search of all public social media posts and news articles on the Blue Whale Challenge (BWC), an alleged suicide game, from January 1, 2013, through June 30, 2017. Data were retrieved through multiple keyword search; sources included social media platforms Twitter, YouTube, Reddit, Tumblr, as well as blogs, forums, and news articles. Posts were classified into three categories: individual “pro”-BWC posts (support for game), individual “anti”-BWC posts (opposition to game), and media reports. Timing and location of posts were assessed. RESULTS: Overall, 95,555 social media posts and articles about the BWC were collected. In total, over one-quarter (28.3%) were “pro”-BWC. The first U.S. news article related to the BWC was published approximately 4 months after the first English language U.S. social media post about the BWC and 9 months after the first U.S. social media post in any language. By the close of the study period, “pro”-BWC posts had spread to 127 countries. CONCLUSIONS: Novel online risks to mental health, such as prosuicide games or messages, can spread rapidly and globally. Better understanding social media and Web data may allow for detection of such threats earlier than is currently possible.

    • Laboratory Sciences
      1. Maternal engineered nanomaterial inhalation during gestation disrupts vascular kisspeptin reactivityExternal
        Bowdridge EC, Abukabda AB, Engles KJ, McBride CR, Batchelor TP, Goldsmith WT, Garner KL, Friend S, Nurkiewicz TR.
        Toxicol Sci. 2019 Mar 7.
        Maternal engineered nanomaterial (ENM) inhalation is associated with uterine vascular impairments and endocrine disruption that may lead to altered gestational outcomes. We have shown that nano-titanium dioxide (nano-TiO2) inhalation impairs endothelium-dependent uterine arteriolar dilation in pregnant rats. However, the mechanism underlying this dysfunction is unknown. Due to its role as a potent vasoconstrictor and essential reproductive hormone, we examined how kisspeptin is involved in nano-TiO2-induced vascular dysfunction and placental efficiency. Pregnant Sprague-Dawley rats were exposed (gestational day (GD) 10) to nano-TiO2 aerosols (cumulative dose=525+/-16 mug; n = 8) or sham-exposed (n = 6) and sacrificed on GD 20. Plasma was collected to evaluate estrogen (E2), progesterone (P4), prolactin (PRL), corticosterone (CORT), and kisspeptin. Pup and placental weights were measured to calculate placental efficiency (grams fetus/gram placental). Additionally, pressure myography was used to determine uterine artery vascular reactivity. Contractile responses were assessed via cumulative additions of kisspeptin (1 x 10-9 to 1 x 10-4 M). Estrogen was decreased at GD 20 in exposed (11.08+/-3 pg/mL) vs. sham-control rats (66.97+/-3 pg/mL), whereas there were no differences in P4, PRL, CORT or kisspeptin. Placental weights were increased in exposed (0.99+/-0.03 g) vs. sham-control rats (0.70+/-0.04 g), whereas pup weights (4.01+/-0.47 g vs. 4.15+/-0.15 g) and placental efficiency (4.5+/-0.2 vs. 6.4+/-0.5) were decreased in exposed rats. Maternal ENM inhalation exposure augmented uterine artery vasoconstrictor responses to kisspeptin (91.2%+/-2.0 vs. 98.6%+/-0.10). These studies represent initial evidence that pulmonary maternal ENM exposure perturbs the normal gestational endocrine vascular axis via a kisspeptin-dependent mechanism, and decreased placental, which may adversely affect health outcomes.

      2. BACKGROUND: There are limited data regarding the prevalence and concentration of isothiazolinone preservatives in consumer adhesives. OBJECTIVES: The aim of this study was to determine the prevalence and concentration of 5 specific isothiazolinones (methylisothiazolinone [MI], methylchloroisothiazolinone [MCI], benzisothiazolinone [BIT], butyl BIT, and octylisothiazolinone) in US adhesives. METHODS: Thirty-eight consumer adhesives were analyzed using ultrahigh-performance liquid chromatographic-mass spectrometry. Fisher exact tests were used to test for isothiazolinone content and: 1) glue format (2) application purpose and 3) extraction method. RESULTS: Nineteen adhesives (50%) had at least 1 isothiazolinone, and 15 contained 2 isothiazolinones. Frequencies and concentrations were as follows: MI (44.7%; 4-133 ppm), MCI (31.6%; 7-27 ppm), BIT (15.8%; 10-86 ppm), and octylisothiazolinone (2.6%; 1 ppm). Butyl BIT was not detected in any of the adhesives. Format (stick vs liquid) was not statistically associated with isothiazolinone presence. At least half of adhesives in the following application purposes had at least 1 isothiazolinone: shoe, craft, fabric, and school. All-purpose glues had a statistically significant lower concentration of MI and MCI, whereas craft glues were associated with higher concentrations of MI and MCI. Compared with other glues, fabric adhesives were associated with a higher risk of containing BIT. CONCLUSIONS: Half of the tested adhesives contained at least 1 isothiazolinone. Methylisothiazolinone and MCI were the most common. Consumers and dermatologists should be aware of adhesives as a source of isothiazolinones.

      3. Rapid quantification of two chemical nerve agent metabolites in serumExternal
        Kammer M, Kussrow A, Carter MD, Isenberg SL, Johnson RC, Batchelor RH, Jackson GW, Bornhop DJ.
        Biosens Bioelectron. 2019 Jan 31;131:119-127.
        Organophosphorus compounds (OPs) continue to represent a significant chemical threat to humans due to exposures from their use as weapons, their potential storage hazards, and from their continued use agriculturally. Existing methods for detection include ELISA and mass spectrometry. The new approach presented here provides an innovative first step toward a portable OP quantification method that surmounts conventional limitations involving sensitivity, selectivity, complexity, and portability. DNA affinity probes, or aptamers, represent an emerging technology that, when combined with a mix-and-read, free-solution assay (FSA) and a compensated interferometer (CI) can provide a novel alternative to existing OP nerve agent (OPNA) quantification methods. Here it is shown that FSA can be used to rapidly screen prospective aptamers in the biological matrix of interest, allowing the identification of a ‘best-in-class’ probe. It is also shown that combining aptamers with FSA-CI enables quantification of the OPNA metabolites, Sarin (NATO designation “G-series, B”, or GB) and Venomous Agent X (VX) acids, rapidly with high selectivity at detection limits of sub-10pg/mL in 25% serum (by volume in PBS). These results suggest there is potential to directly impact diagnostic specificity and sensitivity of emergency response testing methods by both simplifying sample preparation procedures and making a benchtop reader available for OPNA metabolite quantification.

    • Medicine
      1. Factors associated with accuracy of self-assessment compared with tested non-English language proficiency among primary care providersExternal
        Diamond L, Toro Bejarano M, Chung S, Ferguson W, Gonzalez J, Genoff Garzon M, Mujawar I, Gany F.
        Med Care. 2019 Mar 5.
        BACKGROUND: There are no accepted best practices for clinicians to report their non-English language (NEL) fluencies. Language discordance between patients with limited English proficiency and their clinicians may contribute to suboptimal quality of care. OBJECTIVES: To compare self-assessed clinician NEL proficiency with a validated oral language proficiency test. To identify clinician characteristics associated with self-assessment accuracy. SUBJECTS: Primary care providers from California and Massachusetts. RESEARCH DESIGN: We surveyed 98 clinicians about demographics and their NEL self-assessment using an adapted version of the Interagency Language Roundtable (ILR) scale followed by an oral proficiency interview: The Clinician Cultural and Linguistic Assessment (CCLA). We compared the ILR to the CCLA and analyzed factors associated with the accuracy of self-assessment. RESULTS: Ninety-eight primary care providers participated: 75.5% were women, 62.2% were white, and Spanish was the most common NEL reported (81.6%). The average CCLA score was 78/100 with a 70% passing-rate. There was a moderate correlation between the ILR and CCLA (0.512; P<0.0001). Participants whose self-reported levels were “fair” and “poor” had a 0% pass-rate and 100% who self-reported “excellent” passed the CCLA. Middle ILR levels showed a wider variance. Clinicians who reported a NEL other than Spanish and whose first language was not English were more likely to accurately self-assess their abilities. CONCLUSIONS: Self-assessment showed a moderate correlation with the validated CCLA test. Additional testing may be required for clinicians at the middle levels. Clinicians whose native languages were not English and those using languages other than Spanish with patients may be more accurate in their self-assessment.

    • Nutritional Sciences
      1. Ensuring safe, accessible drinking water in schools is a national health priority. The objective of this study was to identify whether there are differences in water quality, availability, and education- related practices in schools by demographic characteristics. In 2017-2018, we analyzed data from the 2014 School Health Policies and Practices Study (SHPPS), a nationally representative, cross-sectional survey of US schools. Analyses examined differences in water-related practices by school characteristics. Response rates for the 3 questionnaires used in this analysis ranged from 69%-94% (Ns ranged from 495 to 577). We found that less than half of schools flush drinking water outlets after periods of non-use (46.4%), conduct periodic inspections that test drinking water outlets for lead (45.8%), and require staff training on drinking water quality (25.6%). Most schools teach the importance of water consumption (81.1%) and offer free drinking water in the cafeteria (88.3%). Some water-related school practices differed by school demographic characteristics though no consistent patterns of associations by school characteristics emerged. In US schools, some water quality-related practices are limited, but water availability and education-related practices are more common. SHPPS data suggest many schools would benefit from support to implement best practices related to school-drinking water.

      2. BACKGROUND: Having a written breastfeeding policy that is routinely communicated to staff is important. Furthermore, hospitals seeking the Baby-Friendly designation are required to purchase infant formula at fair market value. We sought to determine the trends of model policies and receipt of free infant formula among hospitals with maternity care in the United States. METHODS: The Maternity Practices in Infant Nutrition and Care (mPINC) survey obtained information, every 2 years, on breastfeeding-related practices and policies from hospitals in the United States. We examined the prevalence of hospitals with a model breastfeeding policy, individual policy elements, and how policies were communicated as well as the receipt of free infant formula from 2009 to 2015. Statistical testing is not included because mPINC is a census. RESULTS: The proportion of hospitals with a model breastfeeding policy increased from 14.1% in 2009 to 33.1% in 2015. More hospitals incorporated policy elements on limited use of pacifiers (+21.0% points), early initiation of breastfeeding (+15.5% points), and limiting non-breast milk feeds of breastfed infants (+14.1% points). Fewer hospitals disseminated policies by word of mouth (-2.0% points), whereas, more posted policies (+8.1% points). The percent of hospitals not receiving free infant formula increased from 7.4% in 2009 to 28.7% in 2015. DISCUSSION: While more hospitals in the United States are implementing model breastfeeding policies and not receiving free infant formula, the majority do not adhere to these practices. Hospitals may consider reviewing their policies around infant feeding to improve care for new mothers.

    • Occupational Safety and Health – Mining
      1. The potential use of a NIOSH sound level meter smart device application in mining operationsExternal
        Sun K, Kardous CA, Shaw PB, Kim B, Mechling J, Azman AS.
        Noise Control Eng J. 2019 //;67(1):23-30.
        Many mobile sound measurement applications (apps) have been developed to take advantage of the built-in or fit-in sensors of the smartphone. One of the concerns is the accuracy of these apps when compared to professional sound measurement instruments. Previously, a research team from the National Institute for Occupational Safety and Health (NIOSH) developed the NIOSH Sound Level Meter (SLM) app for iOS smart devices. The team found the average accuracy of this app to be within 1 dBA when using calibrated external microphones with a type 1 reference device and measuring pink noise at levels from 65 to 95 dBA in 5-dBA increments. The studies were conducted in a reverberant noise chamber at the NIOSH Acoustics Laboratory in Cincinnati. However, it is still unknown how this app performs in measuring industrial/mining sound levels outside of a controlled laboratory environment. The current NIOSH study evaluates the NIOSH SLM app to measure sound levels from a jumbo drill (a large mining machine). The study was conducted in a hemi-anechoic chamber at the NIOSH Pittsburgh Mining Research Division and followed by a field evaluation in an underground metal mine. Six different iOS smart devices were used with two types of external microphones chosen from previous studies to measure sound levels during jumbo drill operations, and the results were compared with a reference device. Results show that the average sound levels measured by the NIOSH SLM app are within 1 dBA of the reference device both in the laboratory and field. However, the type of operation being performed, the selection and use of external microphones, distance from a noise source, and environmental factors (e.g., air movement) may all influence the accuracy of the app’s performance. Although additional validation is still needed, the results from this study suggest a potential for using the NIOSH SLM app, with calibrated external microphones, to measure sound levels in mining operations.

    • Reproductive Health
      1. “Every Newborn-INDEPTH” (EN-INDEPTH) study protocol for a randomised comparison of household survey modules for measuring stillbirths and neonatal deaths in five Health and Demographic Surveillance sitesExternal
        Baschieri A, Gordeev VS, Akuze J, Kwesiga D, Blencowe H, Cousens S, Waiswa P, Fisker AB, Thysen SM, Rodrigues A, Biks GA, Abebe SM, Gelaye KA, Mengistu MY, Geremew BM, Delele TG, Tesega AK, Yitayew TA, Kasasa S, Galiwango E, Natukwatsa D, Kajungu D, Enuameh YA, Nettey OE, Dzabeng F, Amenga-Etego S, Newton SK, Manu AA, Tawiah C, Asante KP, Owusu-Agyei S, Alam N, Haider MM, Alam SS, Arnold F, Byass P, Croft TN, Herbst K, Kishor S, Serbanescu F, Lawn JE.
        J Glob Health. 2019 Jun;9(1):010901.
        Background: Under-five and maternal mortality were halved in the Millennium Development Goals (MDG) era, with slower reductions for 2.6 million neonatal deaths and 2.6 million stillbirths. The Every Newborn Action Plan aims to accelerate progress towards national targets, and includes an ambitious Measurement Improvement Roadmap. Population-based household surveys, notably Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys, are major sources of population-level data on child mortality in countries with weaker civil registration and vital statistics systems, where over two-thirds of global child deaths occur. To estimate neonatal/child mortality and pregnancy outcomes (stillbirths, miscarriages, birthweight, gestational age) the most common direct methods are: (1) the standard DHS-7 with Full Birth History with additional questions on pregnancy losses in the past 5 years (FBH(+)) or (2) a Full Pregnancy History (FPH). No direct comparison of these two methods has been undertaken, although descriptive analyses suggest that the FBH(+) may underestimate mortality rates particularly for stillbirths. Methods: This is the protocol paper for the Every Newborn-INDEPTH study (INDEPTH Network, International Network for the Demographic Evaluation of Populations and their Health Every Newborn, Every Newborn Action Plan), aiming to undertake a randomised comparison of FBH(+) and FPH to measure pregnancy outcomes in a household survey in five selected INDEPTH Network sites in Africa and South Asia (Bandim in urban and rural Guinea-Bissau; Dabat in Ethiopia; IgangaMayuge in Uganda; Kintampo in Ghana; Matlab in Bangladesh). The survey will reach >68 000 pregnancies to assess if there is >/=15% difference in stillbirth rates. Additional questions will capture birthweight, gestational age, birth/death certification, termination of pregnancy and fertility intentions. The World Bank’s Survey Solutions platform will be tailored for data collection, including recording paradata to evaluate timing. A mixed methods assessment of barriers and enablers to reporting of pregnancy and adverse pregnancy outcomes will be undertaken. Conclusions: This large-scale study is the first randomised comparison of these two methods to capture pregnancy outcomes. Results are expected to inform the evidence base for survey methodology, especially in DHS, regarding capture of stillbirths and other outcomes, notably neonatal deaths, abortions (spontaneous and induced), birthweight and gestational age. In addition, this study will inform strategies to improve health and demographic surveillance capture of neonatal/child mortality and pregnancy outcomes.

      2. Being on the safe side: A qualitative study of condom use motivations by contraceptive type among adolescents in Atlanta, GAExternal
        Steiner RJ, Swartzendruber A, Cushing K, Gaydos LM, Pazol K, Kramer MR, Holt S, Sales JM.
        J Pediatr Adolesc Gynecol. 2019 Feb 27.
        STUDY OBJECTIVE: Quantitative data suggest that adolescent users of long-acting reversible contraception (LARC), as compared to short-acting methods (pill, patch, ring, depot medroxyprogesterone acetate [DMPA]), may be less likely to use condoms. We qualitatively describe and explain adolescent contraceptive users’ motivations for condom use, including variation by contraceptive type. DESIGN: Individual, in-depth qualitative interviews, analyzed thematically. PARTICIPANTS: Sexually active contraceptive users 17-19 years old (n=30), including LARC (n=10), DMPA (n=10), and oral contraceptive (n=10) users. SETTING: Participants were recruited from public family planning clinics and an adolescent medicine clinic as well as university and other community settings in Atlanta, GA. RESULTS: Overall, most participants (n=25; 83.3%) used condoms with their more effective contraceptive method, although many used them inconsistently (n=11; 44%). Oral contraceptive users were particularly motivated to use condoms for pregnancy prevention, given concerns about contraceptive method efficacy and a desire to be on “the safe side”. In contrast, LARC users were primarily motivated by sexually transmitted infection (STI) prevention. DMPA users’ motivations were more mixed. Across contraceptive type, factors influencing condom use motivations included sexual health education, personal awareness and/or experience, and perceived consequences and risk. CONCLUSIONS: Given that all participants were using an effective contraceptive method, it is notable that pregnancy prevention was a prominent motivator for using condoms, although LARC users reported STI prevention to be a more important motivation. Parental and school-based sexual health education that clearly addresses STI prevention in addition to pregnancy prevention has the potential to influence condom use motivations and behavior.

    • Social and Behavioral Sciences
      1. Mental health screening (MHS) during the initial health assessment is recommended within 90 days of arrival to the U.S. Yet, MHS prevalence is not well understood. Screening prevalence [prevalence ratio (PR), adjusted prevalence ratio (adjPR)] and factors associated with MHS were assessed among refugees, Special Immigrant Visa holders, parolees, asylees, and victims of human trafficking >/= 14 years old resettling in Georgia from 2014 to 2017. Of the 2019 individuals included, 55% received a MHS. Screening was more common among older individuals [reference: 13-22 years old; adjPR 23-35 = 1.20 (1.12-1.29), adjPR 36-49 = 1.14 (1.03-1.26), adjPR >/= 50 = 1.27 (1.15-1.41)] and those without Medicaid [adjPR Medicaid vs. none = 0.75 (0.63-0.89)]. MHS also differed by country of birth. Although MHS has increased within recent years, gaps exist within sub-populations and geographic regions. Efforts should focus on increasing MHS to ensure timely identification of concerns and linkage to services.

    • Substance Use and Abuse
      1. State-specific cessation behaviors among adult cigarette smokers – United States, 2014-2015External
        Wang TW, Walton K, Jamal A, Babb SD, Schecter A, Prutzman YM, King BA.
        Prev Chronic Dis. 2019 Mar 7;16:E26.
        This study assessed state-specific smoking cessation behaviors among US adult cigarette smokers aged 18 years or older. Estimates came from the 2014-2015 Tobacco Use Supplement to the Current Population Survey (N = 163,920). Prevalence of interest in quitting ranged from 68.9% (Kentucky) to 85.7% (Connecticut); prevalence of making a quit attempt in the past year ranged from 42.7% (Delaware) to 62.1% (Alaska); prevalence of recently quitting smoking ranged from 3.9% (West Virginia) to 11.1% (District of Columbia); and prevalence of receiving quit advice from a medical doctor in the past year ranged from 59.4% (Nevada) to 81.7% (Wisconsin). These findings suggest that opportunities exist to encourage and help more smokers to quit.

    • Vital Statistics
      1. Engaging communities in collecting and using results from verbal autopsies for child deaths: an example from urban slums in Freetown, Sierra LeoneExternal
        Hutain J, Perry HB, Koffi AK, Christensen M, Cummings O’Connor E, Jabbi SB, Samba TT, Kaiser R.
        J Glob Health. 2019 Jun;9(1):010419.
        Background: Verbal autopsies (VAs) can provide important epidemiological information about the causes of child deaths. Though studies have been conducted to assess the validity of various types of VAs, the programmatic experience of engaging local communities in collecting and using VA has received little attention in the published literature. Concern Worldwide, an international non-governmental organization (NGO), in collaboration with the Ministry of Health and Sanitation (MOHS), has implemented a VA protocol in five urban slums of Freetown, Sierra Leone. This paper provides VA results and describes lessons learned from the VA process. Methods: Under-five child deaths were registered by Community Health Workers (CHWs) in five urban slums between 2014 and 2017, and a specially trained local clinician used a VA protocol to interview caretakers. Symptoms were analysed using InterVA-4 computerized algorithm, a probabilistic expert-driven model to determine the most likely cause of death. Themes in care-seeking were extracted from multiple-choice and open-ended questions. VAs were implemented in collaboration with the community and the results were shared with community stakeholders in participatory review meetings. Results: Main challenges included limitations in death notification and capacity to conduct VA for all notified deaths. A total of 215 VA were available for analysis. Among 79 neonatal deaths aged 0-27 days, the most common cause of death was neonatal pneumonia (55%); among 136 children deaths aged 1-4 years, the most common causes were malaria (56%) and pneumonia (41%). Key themes in care-seeking identified included use of traditional medicine (14% of deaths), absence of care-seeking (23% of deaths), and difficultly reaching the health facility (8% of deaths that occurred at home) during fatal illness. Conclusions: Conducting VAs as a collaborative process with communities is challenging but can provide valuable data that can be used for local-level decision-making. The findings have practical implications for engaging the community and CHWs in reducing the number of these preventable deaths through expanded efforts at prevention, early and appropriate treatment, and reduction of barriers to care-seeking. A functional end-to-end VA system can enhance meaningful routine vital events monitoring by community, national, and international stakeholders.

    • Zoonotic and Vectorborne Diseases
      1. Endemic Zika virus transmission: implications for travellersExternal
        Honein MA, Cetron MS, Meaney-Delman D.
        Lancet Infect Dis. 2019 Feb 27.

        [No abstract]

      2. In the United States, multistate Salmonella outbreaks are most commonly linked to a food source; however, contact with live animals can also result in outbreaks of human illness. To characterize Salmonella outbreaks linked to animal contact and examine differences compared to foodborne outbreaks, we analysed data reported to the Centers for Disease Control and Prevention through the National Outbreak Reporting System (NORS) from 2009 to 2014 with a primary mode of transmission listed as “animal contact” or “food.” Four hundred and eighty-four outbreaks with animal contact or foodborne transmission were reported through NORS; of these outbreaks, 99 (20.5%) resulted from Salmonella transmission through animal contact and 385 (79.5%) resulted from foodborne transmission, which resulted in 3,604 (19.8%) and 13,568 (80.2%) illnesses, respectively. A higher proportion of illnesses among children aged <1 year and children aged 1-4 years were linked to animal contact outbreaks compared to foodborne outbreaks (15.2% vs. 1.4%, p < 0.01 and 24.5% vs. 5.6%, p < 0.01, respectively). Illnesses resulting in hospitalizations (OR: 1.81, 95% CI: 1.62, 2.02) were more likely to be associated with animal contact compared to food. Animal contact outbreaks reported to NORS were more likely to be multistate compared to foodborne outbreaks (OR: 5.43, 95% CI: 3.37, 8.76) and had a longer median duration (99.0 days vs. 9.0 days, p < 0.01). Characterizing the differences between outbreaks of illness linked to animal contact and outbreaks linked to food provides useful information to investigators to improve public health response.

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