Volume 11, Issue 14 April 9, 2019

CDC Science Clips: Volume 11, Issue 14, April 9, 2019

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

  1. 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. Elevated serum anion gap in adults with moderate chronic kidney disease increases risk for progression to end stage renal diseaseExternal
        Banerjee T, Crews D, Wesson DE, McCulloch C, Johansen K, Saydah S, Rios Burrows N, Saran R, Gillespie B, Bragg-Gresham J, Powe NR.
        Am J Physiol Renal Physiol. 2019 Mar 25.
        BACKGROUND: Acid retention associated with reduced GFR exacerbates nephropathy progression in partial nephrectomy models of CKD and might be reflected in CKD patients with reduced eGFR by increased anion gap (AG). METHODS: We explored the presence of AG and its association with CKD in 14,924 adults, aged >/=20 years and eGFR>/=15ml/min/1.73m(2), enrolled in the National Health and Nutrition Examination Survey III, 1988-1994 using multivariable regression analysis. The model was adjusted for socio-demographic characteristics, diabetes, and hypertension. We further examined the association between AG and incident end-stage renal disease using frailty models, adjusting for demographics, clinical factors, BMI, serum albumin, bicarbonate, eGFR, and urinary albumin-to-creatinine ratio, by following 558 adults with moderate CKD for 12 years via the United States Renal Data System. Laboratory measures determined AG using the traditional, albumin-corrected, and full AG definitions. RESULTS: Individuals with moderate CKD (eGFR 30-59 ml/min/1.73 m(2)) had a greater AG than those with eGFR>/=60 ml/min in multivariable regression analysis with adjustment for covariates. We found a graded relationship between the adjusted mean for all three definitions of AG and eGFR categories (p trend<0.0001). During follow-up, 9.2% of adults with moderate CKD developed ESRD. Those with AG in the highest tertile had a higher risk of ESRD, after adjusting for covariates in a frailty model (Relative risk [95% CI] for traditional AG:1.8[1.2-2.3]), compared to those in the middle tertile. CONCLUSIONS: The data suggest that high AG, even after adjusting for serum bicarbonate, is a contributing acid-base mechanism to CKD progression in moderate CKD.

      2. Amyotrophic lateral sclerosis among patients with a Medicare Advantage prescription drug plan; prevalence, survival and patient characteristicsExternal
        Bhattacharya R, Harvey RA, Abraham K, Rosen J, Mehta P.
        Amyotroph Lateral Scler Frontotemporal Degener. 2019 Mar 20:1-9.
        OBJECTIVE: To estimate amyotrophic lateral sclerosis (ALS) prevalence, 5-year survival, and explore factors associated with survival in a Medicare population. METHODS: A validated administrative claims algorithm was used to classify individual’s ages 18-89 years at index date (first claim with a diagnosis of motor neuron disease or ALS between 1 January 2007 and 31 December 2011) with Medicare Advantage prescription drug coverage into mutually exclusive categories: ALS, no ALS, and possible ALS. Crude prevalence and cumulative survival from index date to the date of death, disenrollment or end of the study were calculated. Cox-proportional hazards were used to estimate and explore factors associated with survival. RESULTS: Of 2631 eligible individuals, the algorithm identified 1271 (48 %), 1157 (44 %), 203 (8 %) as ALS, no ALS and possible ALS, respectively. The 5-year period prevalence and the 2011 point prevalence of ALS were 20.5 and 11.8 per 100,000, respectively. Evidence of death was documented in 81%, 35%, and 1.6% of the ALS, no ALS or possible ALS groups, respectively. Unadjusted median survival time was 388, 542 and 1473 days for the ALS, no ALS and possible ALS groups, respectively. Seeing a psychiatrist or neurologist at the index visit, having respiratory or genitourinary comorbidities, and the number of pre-index acute inpatient admissions were associated with shorter survival. CONCLUSIONS: Surveillance data from a Medicare population demonstrated a higher prevalence of ALS. Results highlight the need for effective ALS treatment options and resources for patients with ALS who will likely face limited therapeutic choices and care options at the end of life.

      3. [No abstract]

      4. Awareness among US adults of dental sealants for caries preventionExternal
        Junger ML, Griffin SO, Lesaja S, Espinoza L.
        Prev Chronic Dis. 2019 Mar 14;16:E29.
        INTRODUCTION: Dental sealants applied in childhood can help prevent caries, but knowledge of the availability of sealants and their function is not widespread. We assessed knowledge of dental sealants among US adults and adult parents of children younger than 18 and the differences in knowledge among demographic and socioeconomic groups. METHODS: We used data on 3,550 respondents to the 2015 FallStyles B survey of noninstitutionalized US adults aged 18 or older. Authors constructed estimates by using weights provided to reflect the distribution of the US population. Knowledge of dental sealants was assessed by sex, age, race/ethnicity, education, household income, and parental status. Multivariate analysis was conducted by using a main effects logistic regression model. RESULTS: Overall, 46.3% of adults and 55.1% of parents of children younger than 18 had knowledge of dental sealants. Sealant knowledge was highest among parents, women, respondents aged 45 to 59, and respondents with incomes greater than 200% of the federal poverty level and more than a high school education. Non-Hispanic blacks had less than half the odds of non-Hispanic whites of having knowledge of sealants (adjusted odds ratio [OR] = 0.4), and nonparents had half the odds as parents (OR = 0.5) of knowing. The strongest predictors of parental sealant knowledge were race/ethnicity, sex, and income. CONCLUSION: Disparities in sealant knowledge correspond to disparities in sealant prevalence. Increasing knowledge among low-income and racial/ethnic minority parents could reduce disparities in sealant prevalence and untreated caries.

      5. Serious psychological distress (SPD) includes mental health problems severe enough to cause moderate-to-serious impairment in daily activities and to require treatment. Serious psychological distress is based on answers to six survey questions from the Kessler-6 scale used internationally in public health surveillance systems to assess recent feelings of sadness, restlessness, hopelessness, nervousness, worthlessness, and the sense that everything is an effort. We combined nationally representative samples in the National Health Interview Survey (NHIS) from 2010 (N=27,157), 2013 (N=34,557), 2015 (N=33,672), and 2017 (N=26,742). We used a validated surveillance case definition to classify adults as having epilepsy if they reported a history of doctor-diagnosed epilepsy or seizure disorder (n=2251). We further classified those with epilepsy as having active epilepsy (n=1380) if they reported either taking epilepsy medications or having at least one seizure in the past 12months or as having inactive epilepsy (n=871) if they did not take epilepsy medication and had not had any seizures in the past 12months. We used an NHIS recoded variable that classifies adults by Hispanic origin and race. Following age adjustment, among adults with active epilepsy, SPD prevalence was 13.7% among non-Hispanic white adults, 11.2% among non-Hispanic black adults, 20.7% among Hispanic adults, and 17.5% among non-Hispanic other adults. Compared with adults without epilepsy, adults with active epilepsy were 4.8 times more likely, and adults with inactive epilepsy 2.6 times more likely, to report SPD. In each racial/ethnic group, SPD among adults with active epilepsy is significantly higher than in adults without epilepsy. Among adults with active epilepsy, SPD prevalence did not differ by racial/ethnic groups. However, only among non-Hispanic white adults with inactive epilepsy did SPD prevalence significantly exceed that among non-Hispanic white adults without epilepsy. Epilepsy stakeholders can use these estimates to target culturally appropriate community-based and clinic-based interventions to reduce the high burden of psychological distress among adults with active epilepsy and inactive epilepsy.

      6. Health care industry insights: Why the use of preventive services is still lowExternal
        Levine S, Malone E, Lekiachvili A, Briss P.
        Prev Chronic Dis. 2019 Mar 14;16:E30.

        [No abstract]

      7. Establishing effective patient navigation programs in oncologyExternal
        Lopez D, Pratt-Chapman ML, Rohan EA, Sheldon LK, Basen-Engquist K, Kline R, Shulman LN, Flores EJ.
        Support Care Cancer. 2019 Mar 18.
        PURPOSE: Recent advances in cancer treatment have resulted in greatly improved survival, and yet many patients in the USA have not benefited due to poor access to healthcare and difficulty accessing timely care across the cancer care continuum. Recognizing these issues and the need to facilitate discussions on how to improve navigation services for patients with cancer, the National Cancer Policy Forum of the National Academies of Sciences, Engineering, and Medicine (NASEM) held a workshop entitled, “Establishing Effective Patient Navigation Programs in Oncology. The purpose of this manuscript is to disseminate the conclusions of this workshop while providing a clinically relevant review of patient navigation in oncology. DESIGN: Narrative literature review and summary of workshop discussions RESULTS: Patient navigation has been shown to be effective at improving outcomes throughout the spectrum of cancer care. Work remains to develop consensus on scope of practice and evaluation criteria and to align payment incentives and policy. CONCLUSION: Patient navigation plays an essential role in overcoming patient- and system-level barriers to improve access to cancer care and outcomes for those most in need.

      8. Serious psychological distress (SPD) can adversely impact health and quality of life after cancer. The purpose of this study is to examine the association between SPD and the receipt of preventive care services and cancer screening among survivors and adults without a cancer history. A total of 12,564 cancer survivors and 160,023 adults without a cancer history as comparison group were identified from the population-based Medical Expenditure Panel Survey (2008-2015). SPD was assessed using the 6-item Kessler Psychological Distress Scale. We examined use of preventive care and cancer screening services in cancer survivors and comparison adults with/without SPD. Multivariable logistic regression models were conducted for each outcome: preventive service (i.e. blood pressure, cholesterol, influenza vaccination, routine and dental check-up) or cancer screening (i.e. mammography, Papanicolau test, colorectal cancer screening) adjusting for demographic, comorbidity, usual source of care covariates. Adjusted odds ratios and 95% confidence intervals were calculated. Prevalence of SPD was 9.8% in cancer survivors compared to 4.6% in comparison adults. Survivors with SPD were more frequent utilizers of medical care, reporting 10 or more visits to the doctor’s office in the past 12months (29.3% vs. 14.1% without SPD). Having SPD was associated with lower odds of being up-to-date with preventive service use and cancer screening among age- and gender-eligible individuals. The magnitude of the effect was greater in adults’ age >/=65years. Better coordination of care and patient-physician discussions are likely needed to improve delivery of recommended preventive services for persons with SPD.

    • Communicable Diseases
      1. Age-related differences in past or present HCV infection among people who inject drugs – National HIV Behavioral Surveillance, eight U.S cities, 2015External
        Abara WE, Trujillo L, Broz D, Finlayson T, Teshale E, Paz-Bailey G, Glick S, Al-Tayyib AA, Robinson WT, Masiello-Schuette S, Sey EK, Anderson BJ, Poe J, Braunstein S.
        J Infect Dis. 2019 Mar 27.
        INTRODUCTION: Historically, older people who inject drugs (PWID) have had the highest hepatitis C burden, however, young PWID account for recent increases in HCV infection. We assessed factors associated with past or present HCV infection (HCV antibody-positive) among young (</=35 years) and older PWID (>35 years). METHODS: Using Poisson regression, we calculated adjusted prevalence ratios (aPR) to examine socio-demographic and past 12-month injection risk behaviors associated with HCV infection. RESULTS: Of 4,094 PWID, 55.2% were HCV antibody-positive (anti-HCV). Among young PWID, anti-HCV prevalence was 42.1% and associated with </=high school diploma/GED (aPR=1.17, 95%CI=1.03-1.32), receptive syringe sharing (aPR=1.37, 95%CI=1.21-1.56), sharing injection equipment (aPR=1.16, 95%CI=1.01-1.35), arrest history (aPR=1.14, 95%CI=1.02-1.29), and injecting speedball (aPR=1.37, 95%CI=1.16-1.61). Among older PWID, anti-HCV prevalence was 62.2% and associated with </=high school diploma/GED (aPR= 1.08, 95%CI=1.02-1.15), sharing injection equipment (aPR=1.08, 95% CI=1.02-1.15), high injection frequency (aPR=1.16, 95%CI=1.01-1.34), and injecting speedball (aPR=1.09, 95%CI=1.01-1.16). CONCLUSION: Anti-HCV positivity prevalence is high and associated with risky injection practices. Almost half of young PWID were anti-HCV positive. Improving access to direct-acting antiviral treatment, syringe service programs, and medication-assisted therapy are critical to reducing HCV transmission risk and infection burden, particularly among young PWID who are more likely to be newly infected.

      2. Candida bloodstream infections among persons who inject drugs – Denver metropolitan area, Colorado, 2017-2018External
        Barter DM, Johnston HL, Williams SR, Tsay SV, Vallabhaneni S, Bamberg WM.
        MMWR Morb Mortal Wkly Rep. 2019 Mar 29;68(12):285-288.
        Candidemia, a bloodstream infection caused by Candida species, is typically considered a health care-associated infection, with known risk factors including the presence of a central venous catheter, receipt of total parenteral nutrition or broad-spectrum antibiotics, recent abdominal surgery, admission to an intensive care unit, and prolonged hospitalization (1,2). Injection drug use (IDU) is not a common risk factor for candidemia; however, in the context of the ongoing opioid epidemic and corresponding IDU increases, IDU has been reported as an increasingly common condition associated with candidemia (3) and methicillin-resistant Staphylococcus aureus bacteremia (4). Little is known about the epidemiology of candidemia among persons who inject drugs. The Colorado Department of Public Health and Environment (CDPHE) conducts population-based surveillance for candidemia in the five-county Denver metropolitan area, encompassing 2.7 million persons, through CDC’s Emerging Infections Program (EIP). As part of candidemia surveillance, CDPHE collected demographic, clinical, and IDU behavior information for persons with Candida-positive blood cultures during May 2017-August 2018. Among 203 candidemia cases reported, 23 (11%) occurred in 22 patients with a history of IDU in the year preceding their candidemia episode. Ten (43%) of the 23 cases were considered community-onset infections, and four (17%) cases were considered community-onset infections with recent health care exposures. Seven (32%) of the 22 patients had disseminated candidiasis with end-organ dysfunctions; four (18%) died during their hospitalization. In-hospital IDU was reported among six (27%) patients, revealing that IDU can be a risk factor in the hospital setting as well as in the community. In addition to community interventions, opportunities to intervene during health care encounters to decrease IDU and unsafe injection practices might prevent infections, including candidemia, among persons who inject drugs.

      3. Accelerating measles and rubella elimination through research and innovation – Findings from the Measles & Rubella Initiative research prioritization process, 2016External
        Grant GB, Masresha BG, Moss WJ, Mulders MN, Rota PA, Omer SB, Shefer A, Kriss JL, Hanson M, Durrheim DN, Linkins R, Goodson JL.
        Vaccine. 2019 Mar 20.
        The Measles & Rubella Initiative (M&RI) identified five key strategies to achieve measles and rubella elimination, including research and innovation to support cost-effective operations and improve vaccination and diagnostic tools. In 2016, the M&RI Research and Innovation Working Group (R&IWG) completed a research prioritization process to identify key research questions and update the global research agenda. The R&IWG reviewed meeting reports and strategic planning documents and solicited programmatic inputs from vaccination experts at the program operational level through a web survey, to identify previous research priorities and new research questions. The R&IWG then convened a meeting of experts to prioritize the identified research questions in four strategic areas: (1) epidemiology and economics, (2) surveillance and laboratory, (3) immunization strategies, and (4) demand creation and communications. The experts identified 19 priority research questions in the four strategic areas to address key areas of work necessary to further progress toward elimination. Future commitments from partners will be needed to develop a platform for improved coordination with adequate and predictable resources for research implementation and innovation to address these identified priorities.

      4. Imported toxin-producing cutaneous diphtheria – Minnesota, Washington, and New Mexico, 2015-2018External
        Griffith J, Bozio CH, Poel AJ, Fitzpatrick K, DeBolt CA, Cassiday P, Kenyon C, Smelser C, Vagnone PS, Culbreath K, Acosta AM.
        MMWR Morb Mortal Wkly Rep. 2019 Mar 29;68(12):281-284.
        From September 2015 to March 2018, CDC confirmed four cases of cutaneous diphtheria caused by toxin-producing Corynebacterium diphtheriae in patients from Minnesota (two), Washington (one), and New Mexico (one). All patients had recently returned to the United States after travel to countries where diphtheria is endemic. C. diphtheriae infection was not clinically suspected in any of the patients; treating institutions detected the organism through matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry (MALDI-TOF) testing of wound-derived coryneform isolates. MALDI-TOF is a rapid screening platform that uses mass spectrometry to identify bacterial pathogens. State public health laboratories confirmed C. diphtheriae through culture and sent isolates to CDC’s Pertussis and Diphtheria Laboratory for biotyping, polymerase chain reaction (PCR) testing, and toxin production testing. All isolates were identified as toxin-producing C. diphtheriae. The recommended public health response for cutaneous diphtheria is similar to that for respiratory diphtheria and includes treating the index patient with antibiotics, identifying close contacts and observing them for development of diphtheria, providing chemoprophylaxis to close contacts, testing patients and close contacts for C. diphtheriae carriage in the nose and throat, and providing diphtheria toxoid-containing vaccine to incompletely immunized patients and close contacts. This report summarizes the patient clinical information and response efforts conducted by the Minnesota, Washington, and New Mexico state health departments and CDC and emphasizes that health care providers should consider cutaneous diphtheria as a diagnosis in travelers with wound infections who have returned from countries with endemic diphtheria.

      5. Trends in incidence of norovirus-associated acute gastroenteritis in four Veterans Affairs Medical Center populations in the United States, 2011-2015External
        Grytdal S, Browne H, Collins N, Vargas B, Rodriguez-Barradas MC, Rimland D, Beenhouwer DO, Brown ST, Bidwell Goetz M, Lucero-Obusan C, Holodniy M, Kambhampati A, Parashar U, Vinje J, Lopman B, Hall AJ, Cardemil CV.
        Clin Infect Dis. 2019 Mar 1.
        BACKGROUND: Norovirus is an important cause of epidemic acute gastroenteritis (AGE), yet the burden of endemic disease in adults has not been well documented. We estimated the prevalence and incidence of outpatient and community-acquired inpatient norovirus AGE at 4 Veterans Affairs Medical Centers (VAMC) (Atlanta, Bronx, Houston, and Los Angeles) and examined trends over 4 surveillance years. METHODS: From November 2011 to September 2015, stool specimens collected within 7 days of AGE symptom onset for clinician-requested diagnostic testing were tested for norovirus and positive samples were genotyped. Incidence was calculated by multiplying norovirus prevalence among tested specimens by AGE-coded outpatient encounters and inpatient discharges, and dividing by the number of unique patients served. RESULTS: Of 1,603 stool specimens, 6% tested were positive for norovirus; GII.4 viruses (GII.4 New Orleans [17%] and GII.4 Sydney [47%]) were the most common genotypes. Overall prevalence and outpatient and inpatient community-acquired incidence followed a seasonal pattern, with higher median rates during November-April (9.2%, 376/100,000, and 45/100,000 respectively) compared to May-October (3.0%, 131/100,000 and 13/100,000, respectively). An alternate-year pattern was also detected, with highest peak prevalence, outpatient, and inpatient community-acquired norovirus incidence rates in the first and third years of surveillance (14-25%, 349-613/100,000, and 43-46/100,000). CONCLUSION: This multiyear analysis of laboratory-confirmed AGE surveillance from 4 VAMCs demonstrates dynamic intra- and inter-annual variability in prevalence and incidence of outpatient and inpatient community-acquired norovirus in US Veterans, highlighting the burden of norovirus disease in this adult population.

      6. Influence of county sampling on past estimates of latent tuberculosis infection prevalenceExternal
        Haddad MB, Raz KM, Hill AN, Navin TR, Castro KG, Winston CA, Gandhi NR, Lash TL.
        Ann Am Thorac Soc. 2019 Mar 19.

        [No abstract]

      7. Hepatitis B testing, care linkage, and vaccination coverage within a registry of hepatitis C infected patientsExternal
        Harris AM, Millman AJ, Lora M, Osinubi A, Lom J, Miller LS.
        Vaccine. 2019 Apr 10;37(16):2188-2193.
        BACKGROUND: Hepatitis B virus (HBV) infection testing among persons with hepatitis C virus (HCV) infection is necessary to appropriately care for these patients, yet uptake of HBV testing and vaccination in this population is suboptimal. METHODS: In a retrospective cohort analysis, we describe the prevalence of hepatitis B testing, linkage to hepatitis B care, and hepatitis B vaccination in patients with HCV infection within a large urban safety-net health system. Using a registry of HCV-infected patients with patient-level electronic health record data, that included demographic, clinical, and laboratory information from 2004 to 2016 from Grady Health System in Atlanta, GA, we describe (1) The prevalence of hepatitis B testing (hepatitis B surface antigen [HBsAg], core antibody [anti-HBc], surface antibody [anti-HBs]); (2) The proportion of HBsAg-positive persons receiving HBV DNA and e-antigen (HBeAg) as indicators for linkage to hepatitis B-directed care; and (3) The proportion of persons receiving hepatitis B vaccine. RESULTS: Of 4224 HCV-infected patients, 3629 (86%) had test results for HBsAg and 43 (1.2%) were HBsAg-positive. Of 2342 (55%) with test results for all three HBV serological markers, median age was 60 years, 67% were male, and 83% were African-American, 789 (34%) anti-HBc positive only, 678 (29%) anti-HBc/anti-HBs positive, 190 (8.1%) anti-HBs positive only, and 642 (27%) were HBV-susceptible. Of HBsAg-positive patients, 21% received HBV DNA and 40% HBeAg testing. The proportion of HBV-susceptible patients receiving at least 1 dose of hepatitis B vaccine was 322/642 (50%). CONCLUSIONS: In a large cohort of HCV-infected patients, we found a high prevalence of current or past HBV infection, but there were gaps in complete hepatitis B testing, hepatitis B-directed care, and hepatitis B vaccination. Strategies are needed to increase hepatitis B testing, linkage to care, and administration of the hepatitis B vaccine for HCV-infected persons in this healthcare system.

      8. Enterovirus D68-associated acute respiratory illness – New Vaccine Surveillance Network, United States, July-October, 2017 and 2018External
        Kujawski SA, Midgley CM, Rha B, Lively JY, Nix WA, Curns AT, Payne DC, Englund JA, Boom JA, Williams JV, Weinberg GA, Staat MA, Selvarangan R, Halasa NB, Klein EJ, Sahni LC, Michaels MG, Shelley L, McNeal M, Harrison CJ, Stewart LS, Lopez AS, Routh JA, Patel M, Oberste MS, Watson JT, Gerber SI.
        MMWR Morb Mortal Wkly Rep. 2019 Mar 29;68(12):277-280.
        In the fall of 2014, an outbreak of enterovirus D68 (EV-D68)-associated acute respiratory illness (ARI) occurred in the United States (1,2); before 2014, EV-D68 was rarely reported to CDC (2,3). In the United States, reported EV-D68 detections typically peak during late summer and early fall (3). EV-D68 epidemiology is not fully understood because testing in clinical settings seldom has been available and detections are not notifiable to CDC. To better understand EV-D68 epidemiology, CDC recently established active, prospective EV-D68 surveillance among pediatric patients at seven U.S. medical centers through the New Vaccine Surveillance Network (NVSN) (4). This report details a preliminary characterization of EV-D68 testing and detections among emergency department (ED) and hospitalized patients with ARI at all NVSN sites during July 1-October 31, 2017, and the same period in 2018. Among patients with ARI who were tested, EV-D68 was detected in two patients (0.8%) in 2017 and 358 (13.9%) in 2018. Continued active, prospective surveillance of EV-D68-associated ARI is needed to better understand EV-D68 epidemiology in the United States.

      9. Factors associated with viral suppression among HIV-positive Kenyan gay and bisexual men who have sex with menExternal
        Kunzweiler CP, Bailey RC, Mehta SD, Okall DO, Obondi E, Djomand G, Nyunya BO, Otieno FO, Graham SM.
        AIDS Care. 2018 Aug;30(sup5):S76-s88.
        The UNAIDS 90-90-90 target has prioritized achieving high rates of viral suppression. We identified factors associated with viral suppression among HIV-positive gay, bisexual, and other men who have sex with men (GBMSM) in Kisumu, Kenya. HIV-positive participants in the Anza Mapema study were offered antiretroviral therapy (ART) regardless of CD4 count. HIV viral load was assessed at baseline and after 6 and 12 months of follow-up. Viral suppression was defined as <1,000 copies/mL. Sociodemographic, sexual behaviors, and psychosocial characteristics were assessed via audio computer-assisted self interview. We used generalized estimating equations to estimate the associations between baseline and time-dependent predictors and viral suppression at 6 and 12 months. Seventy-five HIV-positive men were enrolled in the Anza Mapema study, of which 63 had at least one viral load measured during follow-up. Among 52 men with a viral load measure at month 6, 37 (71%) were on ART and virally suppressed. Among 59 men with a viral load measure at month 12, 37 (63%) were on ART and virally suppressed. In the final multivariable model, men who reported receptive or versatile sexual position during anal intercourse with a male partner had reduced odds of viral suppression (aOR = 0.20; 95% CI: 0.08-0.50). Greater levels of coping self-efficacy were associated with increased odds of viral suppression (aOR = 1.10; 95% CI: 1.03-1.16). Despite extensive initiation, retention, and adherence support, the rate of viral suppression in this population did not meet the UNAIDS 90-90-90 target (81% for individuals aware of their HIV status). Pervasive stigma against male-male sex, especially men who practice receptive anal sex, may underlie our findings, which highlight the need for advocacy and stigma reduction efforts. Because coping self-efficacy was a protective factor, efforts to promote resilience in addition to healthy sexual identity development may lead to improved care outcomes among GBMSM in this area.

      10. Vital signs: HIV transmission along the continuum of care – United States, 2016External
        Li Z, Purcell DW, Sansom SL, Hayes D, Hall HI.
        MMWR Morb Mortal Wkly Rep. 2018 Mar 22;68(11):267-272.
        BACKGROUND: In 2016, an estimated 1.1 million persons had human immunodeficiency virus (HIV) infection in the United States; 38,700 were new infections. Knowledge of HIV infection status, behavior change, and antiretroviral therapy (ART) all prevent HIV transmission. Persons who achieve and maintain viral suppression (achieved by most persons within 6 months of starting ART) can live long, healthy lives and pose effectively no risk of HIV transmission to their sexual partners. METHODS: A model was used to estimate transmission rates in 2016 along the HIV continuum of care. Data for sexual and needle-sharing behaviors were obtained from National HIV Behavioral Surveillance. Estimated HIV prevalence, incidence, receipt of care, and viral suppression were obtained from National HIV Surveillance System data. RESULTS: Overall, the HIV transmission rate was 3.5 per 100 person-years in 2016. Along the HIV continuum of care, the transmission rates from persons who were 1) acutely infected and unaware of their infection, 2) non-acutely infected and unaware, 3) aware of HIV infection but not in care, 4) receiving HIV care but not virally suppressed, and 5) taking ART and virally suppressed were 16.1, 8.4, 6.6, 6.1, and 0 per 100 person-years, respectively. The percentages of all transmissions generated by each group were 4.0%, 33.6%, 42.6%, 19.8%, and 0%, respectively. CONCLUSION: Approximately 80% of new HIV transmissions are from persons who do not know they have HIV infection or are not receiving regular care. Going forward, increasing the percentage of persons with HIV infection who have achieved viral suppression and do not transmit HIV will be critical for ending the HIV epidemic in the United States.

      11. Initiation of anti-tuberculosis treatment in children following gastric aspirate testing, Botswana, 2008-2012External
        Lo TQ, Matlhare L, Mugisha K, Lere TD, Ho-Foster A, Boyd R, Cavanaugh J, Ncube R, Steenhoff AP, Arscott-Mills T.
        Int J Tuberc Lung Dis. 2019 Mar 1;23(3):315-321.
        SETTING: Diagnosing pediatric tuberculosis (TB) is difficult; to improve diagnosis, gastric aspiration (GA) was performed in 121 Botswana health facilities. OBJECTIVE: To describe treatment initiation and outcomes in children with a positive GA result and those treated empirically. METHODS: Children with smear or culture-positive GA or those clinically diagnosed were referred for anti-tuberculosis treatment. Treatment initiation and outcomes were assessed from February 2008 to December 2012 using name-based matching algorithms of the GA database; treatment initiation was captured in the electronic TB registry. Analyses included descriptive statistics and regression models. RESULTS: GA was conducted in 1268 children. Among these, 121 (9.5%) were GA-positive; and treatment was initiated in 90 (74.3%). An additional 137 (11.9%) were treated empirically. More than a third (36.4%) had known human immunodeficiency virus status (positive or negative); this was significantly associated with TB treatment initiation (adjusted odds ratio [aOR] 1.8, 95%CI 1.3-2.5); P < 0.05). Among the 90 children with a positive GA result, nearly all either completed treatment (78.9%) or were on treatment (20.0%) at the time of data collection. CONCLUSION: We could not find documentation of treatment for more than a quarter of the children with laboratory-confirmed TB, an important gap that calls for further examination. The failure to initiate prompt treatment requires investigation and urgent action.

      12. Leave no one behind: response to new evidence and guidelines for the management of cryptococcal meningitis in low-income and middle-income countriesExternal
        Loyse A, Burry J, Cohn J, Ford N, Chiller T, Ribeiro I, Koulla-Shiro S, Mghamba J, Ramadhani A, Nyirenda R, Aliyu SH, Wilson D, Le T, Oladele R, Lesikari S, Muzoora C, Kalata N, Temfack E, Mapoure Y, Sini V, Chanda D, Shimwela M, Lakhi S, Ngoma J, Gondwe-Chunda L, Perfect C, Shroufi A, Andrieux-Meyer I, Chan A, Schutz C, Hosseinipour M, Van der Horst C, Klausner JD, Boulware DR, Heyderman R, Lalloo D, Day J, Jarvis JN, Rodrigues M, Jaffar S, Denning D, Migone C, Doherty M, Lortholary O, Dromer F, Stack M, Molloy SF, Bicanic T, van Oosterhout J, Mwaba P, Kanyama C, Kouanfack C, Mfinanga S, Govender N, Harrison TS.
        Lancet Infect Dis. 2018 Oct 18.
        In 2018, WHO issued guidelines for the diagnosis, prevention, and management of HIV-related cryptococcal disease. Two strategies are recommended to reduce the high mortality associated with HIV-related cryptococcal meningitis in low-income and middle-income countries (LMICs): optimised combination therapies for confirmed meningitis cases and cryptococcal antigen screening programmes for ambulatory people living with HIV who access care. WHO’s preferred therapy for the treatment of HIV-related cryptococcal meningitis in LMICs is 1 week of amphotericin B plus flucytosine, and the alternative therapy is 2 weeks of fluconazole plus flucytosine. In the ACTA trial, 1-week (short course) amphotericin B plus flucytosine resulted in a 10-week mortality of 24% (95% CI -16 to 32) and 2 weeks of fluconazole and flucytosine resulted in a 10-week mortality of 35% (95% CI -29 to 41). However, with widely used fluconazole monotherapy, mortality because of HIV-related cryptococcal meningitis is approximately 70% in many African LMIC settings. Therefore, the potential to transform the management of HIV-related cryptococcal meningitis in resource-limited settings is substantial. Sustainable access to essential medicines, including flucytosine and amphotericin B, in LMICs is paramount and the focus of this Personal View.

      13. Global epidemiology of tuberculosis and progress toward achieving global targets – 2017External
        MacNeil A, Glaziou P, Sismanidis C, Maloney S, Floyd K.
        MMWR Morb Mortal Wkly Rep. 2019 Mar 22;68(11):263-266.
        Worldwide, tuberculosis (TB) is the leading cause of death from a single infectious disease agent (1) and the leading cause of death among persons living with human immunodeficiency virus (HIV) infection, accounting for approximately 40% of deaths in this population (2). The United Nations’ (UN) Sustainable Development Goals (3) and the World Health Organization’s (WHO’s) End TB Strategy (4) have defined ambitious targets for 2020-2035, including a 35% reduction in the absolute number of TB deaths and a 20% reduction in TB incidence by 2020, compared with 2015 (4). Since 2000, WHO has produced annual TB estimates for all countries (1). Global and regional disease estimates were evaluated for 2017 to determine progress toward meeting targets. In 2017, an estimated 10 million incident cases of TB and 1.57 million TB deaths occurred, representing 1.8% and 3.9% declines, respectively, from 2016. Numbers of TB cases and disease incidence were highest in the WHO South-East Asia and Africa regions, and 9% of cases occurred among persons with HIV infection. Rifampicin-resistant (RR) or multidrug-resistant (MDR) (resistance to at least both isoniazid and rifampicin) TB occurred among 3.6% and 18% of new and previously treated TB cases, respectively (5.6% among all cases). Overall progress in global TB elimination was modest in 2017, consistent with that in recent years (1); intensified efforts to improve TB diagnosis, treatment, and prevention are required to meet global targets for 2020-2035.

      14. Coccidioidomycosis among American Indians and Alaska Natives, 2001-2014External
        McCotter O, Kennedy J, McCollum J, Bartholomew M, Iralu J, Jackson BR, Haberling D, Benedict K.
        Open Forum Infect Dis. 2019 Mar;6(3):ofz052.
        Background: American Indians and Alaska Natives (AI/ANs) may be uniquely vulnerable to coccidioidomycosis given the large population residing in the Southwestern United States. We describe coccidioidomycosis-associated hospitalizations and outpatient visits during 2001-2014 in the Indian Health Service (IHS) system and compare hospitalizations with data from the Agency for Healthcare Research and Quality’s National (Nationwide) Inpatient Sample (NIS). Methods: We identified hospitalizations in the IHS and the NIS and outpatient visits in the IHS using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes 114.0-114.9. We calculated average annual hospitalization and outpatient visit rates per 1 000 000 population and used Poisson regression to calculate rate ratios (RRs) and 95% confidence intervals (CIs). We used multivariable logistic regression to assess factors associated with IHS hospitalization. Results: AI/ANs had the highest average annual hospitalization rate (58.0; 95% CI, 49.5-66.6) of any racial/ethnic group in the NIS, compared with 13.4 (95% CI, 12.7-14.2) for non-Hispanic whites. IHS data showed a hospitalization rate of 37.0; the median length of stay (interquartile range) was 6 (3-10) days. The average annual outpatient visit rate in IHS was 764.2, and it increased from 529.9 in 2001 to 845.9 in 2014. Male sex, age >/=65 years, diabetes, and extrapulmonary or progressive coccidioidomycosis were independently associated with increased risk for hospitalization. Twenty-four percent of patients had ICD-9-CM codes for community-acquired pneumonia in the 3 months before coccidioidomycosis diagnosis. Conclusions: AI/ANs experience high coccidioidomycosis-associated hospitalization rates, high morbidity, and possible missed opportunities for earlier diagnosis. Yearly trends in IHS data were similar to the general increase in hospitalizations and reported cases nationwide in the same period.

      15. Willingness to take multidrug-resistant tuberculosis (MDR-TB) preventive therapy among adult and adolescent household contacts of MDR-TB Index Cases: An international multi-site cross-sectional studyExternal
        Suryavanshi N, Murrill M, Gupta A, Hughes M, Hesseling A, Kim S, Naini L, Jones L, Smith B, Gupte N, Dawson R, Mave V, Meshram S, Mendoza-Ticona A, Sanchez J, Kumarasamy N, Comins K, Conradie F, Shenje J, Nerette Fontain S, Garcia-Prats A, Asmelash A, Nedsuwan S, Mohapi L, Lalloo U, Ferreira AC, Okeyo E, Swindells S, Churchyard G, Shah NS.
        Clin Infect Dis. 2019 Mar 28.
        BACKGROUND: Household contacts (HHCs) of individuals with multidrug-resistant tuberculosis (MDR-TB) are at high risk of infection and subsequent disease. There is limited evidence on the willingness of MDR-TB HHCs to take MDR-TB preventive therapy (TPT) to decrease their risk of TB disease. METHODS: In this cross-sectional study of HHCs of MDR and rifampicin resistant (RR)-TB index cases from 16 clinical research sites in eight countries, enrollees were interviewed to assess willingness to take a hypothetical, newly-developed MDR TPT if offered. In order to identify factors associated with willingness to take MDR TPT, a marginal logistic model was fitted using generalized estimating equations to account for household-level clustering. RESULTS: From 278 MDR/RR-TB index case households, 743 HHCs were enrolled; the median age of HHCs was 33 years (IQR 22-49) and 62% were women. HHC willingness to take hypothetical MDR TPT was high (79%) and remained high even with the potential for mild side effects (70%). Increased willingness was significantly associated with current employment or schooling [adjusted Odds Ratio (aOR) 1.83, 95% confidence interval (95%CI) 1.07-3.13], appropriate TB-related knowledge (aOR 2.22, 95%CI 1.23-3.99), confidence in taking TPT (aOR 7.16, 95%CI 3.33-15.42), and being comfortable telling others about taking MDR TPT (aOR 2.29, 95%CI 1.29-4.06). CONCLUSIONS: The high percentage of HHCs of MDR/RR-TB index cases willing to take hypothetical MDR TPT provides important evidence for the potential uptake of effective MDR TPT when implemented. Identified HHC-level variables associated with willingness may inform education and counseling efforts to increase HHC confidence in and uptake of MDR TPT.

      16. Cytomegalovirus infection among infants in neonatal intensive care units, California, 2005 to 2016External
        Tran C, Bennett MV, Gould JB, Lee HC, Lanzieri TM.
        Am J Perinatol. 2019 Mar 20.
        AIM: The main purpose of this article is to assess trends in cytomegalovirus (CMV) infection reported among infants in California neonatal intensive care units (NICUs) during 2005 to 2016. STUDY DESIGN: The California Perinatal Quality Care Collaborative collects data on all very low birth weight (VLBW, birth weight </= 1,500 g) and acutely ill infants > 1,500 g, representing 92% of NICUs in California. We compared clinical characteristics and length of hospital stay among infants with and without reported CMV infection (CMV-positive viral culture or polymerase chain reaction). RESULTS: During 2005 to 2016, CMV infection was reported in 174 VLBW infants and 145 infants > 1,500 g, or 2.7 (range: 1.5-4.7) and 1.2 (range: 0.8-1.7) per 1,000 infants, respectively (no significant annual trend). Among infants > 1,500 g, 12 (8%) versus 4,928 (4%) of those reported with versus without CMV infection died (p < 0.05). The median hospital stay was significantly longer among infants reported with versus without CMV infection for both VLBW infants (98 vs. 46 days) and infants > 1,500 g (61 vs. 14 days) (p < 0.001). CONCLUSION: Reports of CMV infection remained stable over a 12-year period. Although we were not able to assess whether infection was congenital or postnatal, CMV infection among infants > 1,500 g was associated with increased mortality.

      17. The impact of influenza and tuberculosis interaction on mortality among individuals aged >/=15 years hospitalized with severe respiratory illness in South Africa, 2010-2016External
        Walaza S, Tempia S, Dawood H, Variava E, Wolter N, Dreyer A, Moyes J, Von Mollendorf C, McMorrow M, Von Gottberg A, Haffejee S, Venter M, Treurnicht FK, Hellferscee O, Martinson NA, Ismail N, Cohen C.
        Open Forum Infect Dis. 2019 Mar;6(3):ofz020.
        Background: Data on the prevalence and impact of influenza-tuberculosis coinfection on clinical outcomes from high-HIV and -tuberculosis burden settings are limited. We explored the impact of influenza and tuberculosis coinfection on mortality among hospitalized adults with lower respiratory tract infection (LRTI). Methods: We enrolled patients aged >/=15 years admitted with physician-diagnosed LRTI or suspected tuberculosis at 2 hospitals in South Africa from 2010 to 2016. Combined nasopharyngeal and oropharyngeal swabs were tested for influenza and 8 other respiratory viruses. Tuberculosis testing of sputum included smear microscopy, culture, and/or Xpert MTB/Rif. Results: Among 6228 enrolled individuals, 4253 (68%) were tested for both influenza and tuberculosis. Of these, the detection rate was 6% (239/4253) for influenza, 26% (1092/4253) for tuberculosis, and 77% (3113/4053) for HIV. One percent (42/4253) tested positive for both influenza and tuberculosis. On multivariable analysis, among tuberculosis-positive patients, factors independently associated with death were age group >/=65 years compared with 15-24 years (adjusted odds ratio [aOR], 3.6; 95% confidence interval [CI], 1.2-11.0) and influenza coinfection (aOR, 2.3; 95% CI, 1.02-5.2). Among influenza-positive patients, laboratory-confirmed tuberculosis was associated with an increased risk of death (aOR, 4.5; 95% CI, 1.5-13.3). Coinfection with other respiratory viruses was not associated with increased mortality in patients positive for tuberculosis (OR, 0.7; 95% CI, 0.4-1.1) or influenza (OR, 1.6; 95% CI, 0.4-5.6). Conclusions: Tuberculosis coinfection is associated with increased mortality in individuals with influenza, and influenza coinfection is associated with increased mortality in individuals with tuberculosis. These data may inform prioritization of influenza vaccines or antivirals for tuberculosis patients and inform tuberculosis testing guidelines for patients with influenza.

      18. Genomic survey of Bordetella pertussis diversity, United States, 2000-2013External
        Weigand MR, Williams MM, Peng Y, Kania D, Pawloski LC, Tondella ML.
        Emerg Infect Dis. 2019 Apr;25(4):780-783.
        We characterized 170 complete genome assemblies from clinical Bordetella pertussis isolates representing geographic and temporal diversity in the United States. These data capture genotypic shifts, including increased pertactin deficiency, occurring amid the current pertussis disease resurgence and provide a foundation for needed research to direct future public health control strategies.

    • Community Health Services
      1. In Minneapolis-St Paul, Minnesota, factors such as cultural and linguistic diversity make it difficult for public health agencies to reach immigrant and racial/ethnic minority populations with health initiatives. Founded in 2006, the Minnesota Immunization Networking Initiative (MINI) is a community project that has provided more than 80 000 free influenza vaccinations to vulnerable populations, including immigrants and racial/ethnic minority groups. MINI administered 5910 vaccinations through 99 community-based vaccination clinics during the 2017-2018 influenza season and surveyed the clients in their own language about influenza vaccination knowledge and practices. Among those surveyed, 2545 (43.1%) were uninsured and 408 (6.9%) received a first-time influenza vaccination at the MINI clinic. A total of 2893 (49.0%) respondents heard about the clinic through their faith community. Lessons learned included the importance of building relationships with community leaders and involving them as full partners, holding clinics in community-based settings to bring vaccinations to clients, and reporting outcomes to partners.

    • Disaster Control and Emergency Services
      1. Development and performance of a checklist for initial triage after an anthrax mass exposure eventExternal
        Hupert N, Person M, Hanfling D, Traxler RM, Bower WA, Hendricks K.
        Ann Intern Med. 2019 Mar 19.
        Background: Population exposure to Bacillus anthracis spores could cause mass casualties requiring complex medical care. Rapid identification of patients needing anthrax-specific therapies will improve patient outcomes and resource use. Objective: To develop a checklist that rapidly distinguishes most anthrax from nonanthrax illnesses on the basis of clinical presentation and identifies patients requiring diagnostic testing after a population exposure. Design: Comparison of published anthrax case reports from 1880 through 2013 that included patients seeking anthrax-related care at 2 epicenters of the 2001 U.S. anthrax attacks. Setting: Outpatient and inpatient. Patients: 408 case patients with inhalation, ingestion, and cutaneous anthrax and primary anthrax meningitis, and 657 control patients. Measurements: Diagnostic test characteristics, including positive and negative likelihood ratios (LRs) and patient triage assignation. Results: Checklist-directed triage without diagnostic testing correctly classified 95% (95% CI, 93% to 97%) of 353 adult anthrax case patients and 76% (CI, 73% to 79%) of 647 control patients (positive LR, 3.96 [CI, 3.45 to 4.55]; negative LR, 0.07 [CI, 0.04 to 0.11]; false-negative rate, 5%; false-positive rate, 24%). Diagnostic testing was needed for triage in up to 5% of case patients and 15% of control patients and improved overall test characteristics (positive LR, 8.90 [CI, 7.05 to 11.24]; negative LR, 0.06 [CI, 0.04 to 0.09]; false-negative rate, 5%; false-positive rate, 11%). Checklist sensitivity and specificity were minimally affected by inclusion of pediatric patients. Sensitivity increased to 97% (CI, 94% to 100%) and 98% (CI, 96% to 100%), respectively, when only inhalation anthrax cases or higher-quality case reports were investigated. Limitations: Data on case patients were limited to nonstandardized, published observational reports, many of which lacked complete data on symptoms and signs of interest. Reporting bias favoring more severe cases and lack of intercurrent outbreaks (such as influenza) in the control populations may have improved test characteristics. Conclusion: A brief checklist covering symptoms and signs can distinguish anthrax from other conditions with minimal need for diagnostic testing after known or suspected population exposure. Primary Funding Source: U.S. Department of Health and Human Services.

      2. Monitoring and dose assessment for children following a radiation emergency – part II: Calibration factors for thyroid monitoringExternal
        Li C, Tremblay M, Capello K, Kurihara O, Youngman M, Etherington G, Ansari A, Lopez MA, Franck D, Dewji S.
        Health Phys. 2019 Mar 21.
        Past radiological and nuclear accidents have demonstrated that monitoring a large number of children following a radiological and nuclear emergency can be challenging, in accommodating their needs as well as adapting monitoring protocols and applying age-specific biokinetics to account for various ages and body sizes. This paper presents the derived calibration factors for thyroid monitoring of children of all ages recommended by the International Commission on Radiological Protection using four selected detectors at given times following a short-term (acute) intake of I by inhalation. These calibration factors were derived by Monte Carlo simulations using the models of various detectors and pediatric voxel phantoms. A collection of lookup tables is presented in this paper which may be directly used as a quick reference by emergency response personnel or technical experts performing thyroid monitoring and assessment without doing time-consuming calculations.

      3. Maximizing the resilience of healthcare workers in multi-hazard events: Lessons from the 2014-2015 Ebola response in AfricaExternal
        Schreiber M, Cates DS, Formanski S, King M.
        Mil Med. 2019 Mar 1;184(Supplement_1):114-120.
        There is increasing knowledge that health care workers (HCWs) can experience a variety of emotional impacts when responding to disasters and terrorism events. The Anticipate, Plan and Deter (APD) Responder Risk and Resilience Model was developed to provide a new, evidence-informed method for understanding and managing psychological impacts among HCWs. APD includes pre-deployment development of an individualized resilience plan and an in-theater, real-time self-triage system, which together allow HCWs to assess and manage the full range of psychological risk and resilience for themselves and their families. The inclusion of objective mental health risk factors to prompt activation of a coping plan, in connection with unit leadership real-time situational awareness, enables the first known evidence-driven “targeted action” plan to address responder risk early before Post Traumatic Stress Disorder and impairment become established. This paper describes pilot work using the self-triage system component in Alameda County’s Urban Shield and the Philippines’ Typhoon Haiyan, and then reports a case example of the full APD model implementation in West Africa’s Ebola epidemic.

    • Disease Reservoirs and Vectors
      1. Feline herpesvirus vectored-rabies vaccine in cats: A dual protectionExternal
        Chen T, Zhou X, Qi Y, Mi L, Sun X, Zhang S, Liu Y, Olson V, Qiu W, Wu X, Hu R.
        Vaccine. 2019 Apr 10;37(16):2224-2231.
        In China, cats cause about 5% of human rabies cases. Rabies control in cats plays a role in achieving the ultimate goal of elimination of dog rabies-mediated human deaths. However, there is no cat-specific rabies vaccine in China yet. In this study, we constructed a recombinant rabies vaccine by using a felid herpesvirus 1 (FHV-1) isolate, and deleted the gI/E in the FHV-1 and replaced the region with a glycoprotein (G) of rabies virus (RABV) strain BD06 through homologous recombination. The recombinant virus FHV-RVG was recovered and purified, and the expression of RABV glycoprotein was verified by indirect immunofluorescent assay. For potency in cats, each animal was inoculated intranasally with 1ml FHV-RVG at 10(6.5) TCID50. Blood samples were collected at defined intervals for antibody titration. The animals were challenged by herpes and rabies after completion of vaccination on day 180 and day 194, respectively. Our results demonstrated all vaccinated cats generated antibodies against both FHV-1 and RABV, and reached an arbitrary protective titer>0.5IU/ml for rabies viral neutralizing antibody (VNA) by day 14 post inoculation (dpi) and titer peaked on 30 dpi with VNA at 24.5+/-10.23IU/ml. All vaccinated cats presented no clinical signs of FHV-1 infection and survived rabies challenge, while the control cats had severe rhinotracheitis and died from rabies after challenge. All this demonstrated that the FHV-based recombinant vaccine is effective in protection against both FHV-1 and RABV infections.

      2. Tularemia ( Francisella tularensis) in a black-tailed prairie dog ( Cynomys ludovicianus) colonyExternal
        Cherry CC, Kwit NA, Ohms RE, Hammesfahr AM, Pappert R, Petersen JM, Nelson CA, Buttke DE.
        J Wildl Dis. 2019 Mar 28.
        Tularemia is a bacterial zoonosis caused by Francisella tularensis. We conducted a serosurvey of black-tailed prairie dogs ( Cynomys ludovicianus) in Devils Tower National Monument, Wyoming, following an epizootic in voles ( Microtus spp.) due to F. tularensis. Only 1 of 44 (2%) sampled prairie dogs was seropositive for F. tularensis, providing evidence of survival and potentially limited spread among free-ranging prairie dogs.

    • Environmental Health
      1. Pre and postnatal polybrominated diphenyl ether concentrations in relation to thyroid parameters measured during early childhoodExternal
        Cowell W, Sjodin A, Jones RL, Wang Y, Wang S, Whyatt R, Factor-Litvak P, Bradwin G, Hassoun A, Oberfield S, Herbstman J.
        Thyroid. 2019 Mar 23.
        BACKGROUND: Penta brominated diphenyl ethers (PentaBDEs) are endocrine disrupting chemicals that structurally resemble thyroid hormones and were widely used as flame retardants in household consumer products from 1975-2004. Polybrominated diphenyl ethers (PBDEs) cross the placenta and evidence suggests that for many children, body burdens may peak during toddler years. We aimed to understand the impact of exposure timing by examining both pre and postnatal exposure to BDE-47, the predominant PentaBDE congener detected in humans, in relation to thyroid hormone parameters measured during early childhood. METHODS: The Columbia Center for Children’s Environmental Health Mothers and Newborns Study is a prospective birth cohort of African American and Dominican maternal-child pairs. Pregnant women were recruited from two prenatal clinics in Northern Manhattan and the South Bronx between 1998 and 2006. Participants included 158 children with 1) plasma PBDE concentrations measured at birth and toddler years (age 2-3), and 2) serum thyroid parameters measured at 3 and/or 5 years. Outcomes included concentrations of serum thyroid stimulating hormone (TSH), free thyroxine (fT4) and total thyroxine (T4). RESULTS: Children with high exposure to BDE-47 during the prenatal period (-17%, 95% CI -29, -2) or toddler age (-19%, 95% CI: -31, -5) had significantly lower geometric mean TSH levels compared to children with low BDE-47 exposure throughout early life. Associations with T4 were also inverse, however, they did not reach statistical significance at the p=0.05 level. Sex-stratified models suggest associations with postnatal exposure may be stronger among boys compared to girls. CONCLUSIONS: The thyroid regulatory system may be sensitive to BDE-47 during prenatal and postnatal periods.

      2. A preliminary study on prenatal polybrominated diphenyl ether serum concentrations and intrinsic functional network organization and executive functioning in childhoodExternal
        de Water E, Curtin P, Zilverstand A, Sjodin A, Bonilla A, Herbstman JB, Ramirez J, Margolis AE, Bansal R, Whyatt RM, Peterson BS, Factor-Litvak P, Horton MK.
        J Child Psychol Psychiatry. 2019 Mar 18.
        BACKGROUND: The prenatal period is a period of vulnerability during which neurotoxic exposures exert persistent changes in brain development and behavior. Polybrominated diphenyl ethers (PBDEs), used as flame retardants in commercial products, are known to be developmental neurotoxicants. PBDEs were phased out of use in the United States a decade ago, but exposure remains widespread due to their release from existing products and biopersistence. Despite consistent animal and epidemiological evidence of developmental neurotoxicity, the neural substrates linking prenatal PBDE serum concentrations to impaired neurodevelopment are poorly understood. METHODS: In the present study, we used resting state functional magnetic resonance imaging (fMRI) to examine associations between prenatal PBDE concentrations measured in maternal serum and intrinsic functional network organization (i.e., global and local efficiency; estimated using a graph-theoretical approach) in 5-year-old children (n = 34). We explored whether PBDE serum concentrations were associated with executive functioning (EF) assessed using a parent-report questionnaire (BRIEF-P) (n = 106) and whether changes in intrinsic functional network organization linked the association between prenatal PBDE serum concentrations and EF problems. RESULTS: Children with higher prenatal PBDE serum concentrations showed: (a) increased global efficiency of brain areas involved in visual attention (e.g., inferior occipital gyrus) (beta’s = .01, FDR-corrected p’s </= .05); (b) more reported EF problems (beta’s = .001, FDR-corrected p’s </= .05). Higher global efficiency of brain areas involved in visual attention was associated with more EF problems (beta’s = .01, FDR-corrected p’s < .05). CONCLUSIONS: Intrinsic functional network organization of visual attention brain areas linked prenatal PBDE concentrations to EF problems in childhood. Visual attention may contribute to the development of higher-order cognitive functions, such as EF, which could be explored in future studies.

      3. Identifying periods of susceptibility to the impact of phthalates on children’s cognitive abilitiesExternal
        Li N, Papandonatos GD, Calafat AM, Yolton K, Lanphear BP, Chen A, Braun JM.
        Environ Res. 2019 Mar 5;172:604-614.
        BACKGROUND: Early-life phthalate exposures may adversely affect children’s neurodevelopment by disrupting thyroid function, reducing gonadal hormone levels, or altering fatty acid concentrations in the brain. This study aimed to identify periods of heightened susceptibility during gestation, infancy, and childhood to the impact of phthalates on children’s cognitive abilities. METHODS: We used data from 253 mother-child pairs in the Health Outcomes and Measures of the Environment (HOME) Study (Cincinnati, Ohio), a longitudinal pregnancy and birth cohort. We quantified urinary concentrations of 11 phthalate metabolites in samples collected twice during gestation and 6 times during study visits when children were aged 1-8 years using a modified method of on-line solid phase extraction coupled with isotope dilution-high performance liquid chromatography-tandem mass spectrometry. We assessed children’s intelligence (IQ) at ages 5 and 8 years using the Wechsler Preschool and Primary Scale of Intelligence-III and Wechsler Intelligence Scale for Children-IV, respectively. We estimated covariate-adjusted associations between a 1-standard deviation increase in log10-transformed urinary phthalate metabolite concentrations at each visit and children’s IQ, adjusting for demographic, perinatal, and child factors; we tested for differences in these associations across visits using multiple informant models. RESULTS: Associations between some phthalate metabolites and IQ varied by visit (phthalate x visit interaction p-values<0.20). The sum of di(2-ethylhexyl) phthalate metabolites (SigmaDEHP), mono(3-carboxypropyl) phthalate, and monoethyl phthalate at age 3 years, and monobenzyl phthalate at 16 weeks gestation and child ages 3, 5, and 8 years were inversely associated with children’s full-scale IQ. For example, each 1-standard deviation increase in SigmaDEHP at age 3 was associated with a 1.9-point decrease in full-scale IQ (95% confidence interval: -3.7, -0.2). Mono-n-butyl phthalate and mono-isobutyl phthalate at age 4 years were positively associated with children’s full-scale IQ. CONCLUSION: Urinary concentrations of several phthalate metabolites at age 3 years, compared to other time periods, were more strongly associated with decreased cognitive abilities in these children.

      4. Public perceptions of environmental public health risks in the United StatesExternal
        Shin M, Werner AK, Strosnider H, Hines LB, Balluz L, Yip FY.
        Int J Environ Res Public Health. 2019 Mar 22;16(6).
        Understanding public perceptions about environmental health hazards, exposures, and health impacts can help environmental public health practitioners to target and prioritize community activities, policy needs, and communication strategies. The online cross-sectional 2013 summer wave of the ConsumerStyles survey sampled U.S. adults and used questions from the Centers for Disease Control’s Environmental Public Health Tracking Program to measure public awareness of governmental efforts to track environmental exposures and links to health impacts, as well as perceptions of environmental health issues. Unadjusted and adjusted logistic regressions examined the associations between demographic characteristics and level of awareness of government environmental public health efforts or level of concern about health risks associated with environmental pollutants. Responses were received from 4033 participants, yielding a response rate of 66.0%. More than half of respondents (57.8%) noted concerns about health risks from environmental pollutants. More than one-third (40.0%) of respondents reported awareness of government efforts. Nearly 40% of respondents felt that none of the health impacts listed in the survey were related to environmental issues. Multiple logistic regression models showed that non-Hispanic blacks, other races, females, people with a college or higher education, and people living in the Midwest or South regions were more likely than their counterparts to be concerned about how the environment affects their health. Future work should focus on improving risk communication, filling the information gap on environmental health issues, and understanding how perceptions change over time.

    • Epidemiology and Surveillance
      1. Applied epidemiology training needs for the modern epidemiologistExternal
        Bensyl DM, King ME, Greiner A.
        Am J Epidemiol. 2019 Mar 16.
        Applied epidemiology training occurs throughout an epidemiologist’s career, beginning with academic instruction before workforce entry, continuing as professional development while working, and culminating with mentoring the next generation. Epidemiologists need ongoing training on advancements and relevant topics (e.g., informatics, laboratory science, emerging topics) to maintain and improve their skills. Even epidemiologists with advanced skills often want training on methodologic innovations or to practice a skill. Effective applied epidemiology training includes blended learning components of instruction that incorporate hands-on experiences such as simulations and experiential learning, allowing for real-time workflows and incorporation of feedback. To prepare epidemiologists for the future, public health training courses in applied epidemiology must consider the evolution in public health towards a focus on including informatics, technologic innovation, molecular epidemiology, multidisciplinary teams, delivery of population health services, and global health security. Supporting epidemiologists to increase skills as part of their career path ensures a strong workforce able to tackle public health issues. This paper explores how to meet current training challenges for the epidemiology workforce, especially given limited resources, based on research and the authors’ experience in workforce development across federal agencies, state/local health departments, and with international governments and organizations.

      2. Kuantim mi tu (“Count me too”): Using multiple methods to estimate the number of female sex workers, men who have sex with men, and transgender women in Papua New Guinea in 2016 and 2017External
        Weikum D, Kelly-Hanku A, Hou P, Kupul M, Amos-Kuma A, Badman SG, Dala N, Coy KC, Kaldor JM, Vallely AJ, Hakim AJ.
        JMIR Public Health Surveill. 2019 Mar 21;5(1):e11285.
        BACKGROUND: Female sex workers (FSW), men who have sex with men (MSM), and transgender women (TGW) are at high risk of acquiring HIV in many settings, such as Papua New Guinea (PNG). An understanding of the approximate size of these populations can inform resource allocation for HIV services for FSW, MSM, and TGW. OBJECTIVE: An objective of this multi-site survey was to conduct updated population size estimations (PSE) of FSW and MSM/TGW. METHODS: Respondent-driven sampling (RDS) biobehavioral surveys of FSW and MSM/TGW were conducted in 3 major cities-(1) Port Moresby, (2) Lae, and (3) Mount Hagen-between June 2016 and December 2017. Eligibility criteria for FSW included: (1) >/=12 years of age, (2) born female, (3) could speak English or Tok Pisin (PNG Pidgin), and (4) had sold or exchanged sex with a man in the past six months. Eligibility for MSM/TGW included: (1) >/=12 years of age, (2) born male, (3) could speak English, or Tok Pisin, and (4) had engaged in oral or anal sex with another person born male in the past six months. PSE methods included unique object multiplier, service multiplier, and successive sampling-population size estimation (SS-PSE) using imputed visibility. Weighted data analyses were conducted using RDS-Analyst and Microsoft Excel. RESULTS: Sample sizes for FSW and MSM/TGW in Port Moresby, Lae, and Mount Hagen included: (1) 673 and 400, (2) 709 and 352, and (3) 709 and 111 respectively. Keychains were used for the unique object multiplier method and were distributed 1 week before the start of each RDS survey. HIV service testing data were only available in Port Moresby and Mount Hagen and SS-PSE estimates were calculated for all cities. Due to limited service provider data and uncertain prior size estimation knowledge, unique object multiplier weighted estimations were chosen for estimates. In Port Moresby, we estimate that there are 16,053 (95% CI 8232-23,874) FSW and 7487 (95% CI 3975-11,000) MSM/TGW, approximately 9.5% and 3.8% of the female and male populations respectively. In Lae, we estimate that there are 6105 (95% CI 4459-7752) FSW and 4669 (95% CI 3068-6271) MSM/TGW, approximately 14.4% and 10.1% of the female and male populations respectively. In Mount Hagen, we estimate that there are 2646 (95% CI 1655-3638) FSW and 1095 (95% CI 913-1151) MSM/TGW using service multiplier and successive sampling, respectively. This is approximately 17.1% and 6.3% of the female and male populations respectively. CONCLUSIONS: As the HIV epidemic in PNG rapidly evolves among key populations, PSE should be repeated to produce current estimates for timely comparison and future trend analysis.

    • Food Safety
      1. Assessing the maximum size of annual foodborne outbreaks in the United States: An analysis of 1973-2016 outbreaksExternal
        Ebel ED, Williams MS, Ward-Gokhale LA, Kisselburgh HM.
        Microbial Risk Analysis. 2019 .
        Foodborne disease outbreaks are rare events that can be extremely costly in terms of public health as well as monetary losses for industry and government. These events can overwhelm the local public healthcare network and exceed the capacity of epidemiologists and local public health officials to investigate and manage the outbreak. Planning and allocation of sufficient resources requires an understanding of both the frequency and magnitude of large foodborne outbreaks. Describing these two characteristics is difficult because most statistical methods describe central tendencies of the phenomena under study. An exception is extreme value theory (EVT), which intends to estimate the size and frequency of adverse events as large as, or larger than, those previously observed. This study applies extreme value theory methods to foodborne disease outbreak data collected in the United States between 1973 and 2016. A brief summary of the data, including changes in the surveillance system and their effect on the outbreak data, is provided. Estimates of the outbreak size expected to be exceeded within time periods of 10, 20, 40 and 100 years, referred to as the return level, ranged from 2500 to 10,400. The estimated time period time between outbreaks (i.e., the return period) of at least 500, 5,000, 10,000 and 20,000 cases ranged from 1 to greater than 400 years.

    • Genetics and Genomics
      1. BACKGROUND: We recently described a method for unbiased detection of all known human papillomaviruses (HPV) types with the potential for the determination of their variant and integration from the resulting whole genome sequence data. Considering the complex workflow for target-enriched next generation sequencing (NGS), we focused on the reproducibility and limit of detection (LOD) of this new universal HPV typing assay in this study. RESULTS: We evaluated the reproducibility and LOD for HPV genotyping based on our recently published method that used RNA-baits targeting whole genomes of 191 HPV types, Agilent SureSelect protocol for target enrichment and Illumina HiSeq 2500 for sequencing (eWGS, enriched whole genome sequencing). Two libraries, prepared from pooled plasmids representing 9 vaccine HPV types at varying input (1-625 copies/reaction), were sequenced twice giving four replicates for evaluating reproducibility and LOD. eWGS showed high correlation in the number of reads mapped to HPV reference genomes between the two flow-cell lanes within (R(2) = 1) and between experiments (R(2) = 0.99). The number of mapped reads was positively correlated to copy number (beta = 13.9, p < 0.0001). The limit of blank (LOB) could be calculated based on mapped reads to HPV types not included in each sample. HPV genotyping was reproducible for all 9 types at 625 copies using multiple cut-off criteria but LOD was 25 copies based on number of reads above LOB even when multiple types were present. eWGS showed no bias for HPV genotyping under single or multiple infection (p = 0.16-0.99). CONCLUSIONS: The universal eWGS method for HPV genotyping has sensitivity, competitive with widely used consensus PCR methods with reduced type competition, and with the potential for determination of variant and integration status. The protocol used in this study, using defined samples varying in complexity and copy number, analyzed in replicate and duplicate assays, is applicable to most WGS methods.

    • Health Communication and Education
      1. Physical education policies in US schools: Differences by school characteristicsExternal
        Michael SL, Brener N, Lee SM, Clennin M, Pate RR.
        J Sch Health. 2019 Mar 28.
        BACKGROUND: We assessed the extent to which schools in the United States implement physical education policies identified in SHAPE America’s Essential Components of Physical Education document and how implementation of these policies varies by school characteristics. METHODS: School policy data were collected as part of the 2014 School Health Policies and Practices Study via computer-assisted personal interviews in a nationally representative sample of K-12 schools and were linked to extant data on school characteristics. Bivariate analyses and Poisson regression model were used to examine how physical education policies differed by school characteristics. RESULTS: Five physical education policies varied by region and 3 varied by school level. Requiring certified, licensed, or endorsed physical education teachers varied by all school characteristics except school level and percentage of students eligible for free or reduced-price lunch. The average number of physical education policies implemented by schools was 3.0. The number of policies varied by metropolitan status and school level. CONCLUSIONS: The findings suggest many schools are only implementing a few of the physical education policies that can strengthen their physical education programs. These findings can be used to target professional development and technical assistance for physical education practitioners on policy and implementation.

    • Health Disparities
      1. Economic dimensions of health inequities: The role of implementation researchExternal
        Engelgau MM, Zhang P, Jan S, Mahal A.
        Ethn Dis. 2019 ;29(Suppl 1):103-112.
        Health inequities are well-documented, but their economic dimensions have received less attention. In this report, we describe four economic dimensions of health inequities in the United States. First, we describe an economic conceptual framework that connects poverty and health inequities at both individual and population levels and conveys the concept of reverse causality, where poverty worsens health inequities and health inequities worsen poverty. This framework can help us understand the key elements of health inequity and its drivers. Second, we describe economic measurements used for quantifying the economic burden of health inequalities and summarize the empirical findings from studies. Third, we review the evidence on the return-on-investment of economic interventions that are aimed at reducing health inequities. Finally, we highlight the importance of cross disciplinary perspectives from economics and implementation research in effectively delivering interventions that can mitigate health inequities.

      2. The integration of genomic data into screening, prevention, diagnosis, and treatment for clinical and public health practices has been slow and challenging. Implementation science can be applied in tackling the barriers and challenges as well as exploring opportunities and best practices for integrating genomic data into routine clinical and public health practice.In this article, we define the state of disparities in genomic medicine and focus predominantly on late-stage research findings. We use case studies from genetic testing for cardiovascular diseases (familial hypercholesterolemia) and cancer (Lynch syndrome and hereditary breast and ovarian cancer syndrome) in high-risk populations to consider current disparities and related barriers in turning genomic advances into population health impact to advance health equity. Finally, we address how implementation science can address these translational barriers and we discuss the strategic importance of collaborative multi-stakeholder approaches that engage public health agencies, professional societies, academic health and research centers, community clinics, and patients and their families to work collectively to improve population health and reduce or eliminate health inequities.

    • Health Economics
      1. We used administrative claims data from 2014 on people with employer-sponsored health insurance to assess the proportion of patients taking antihypertensive medications, rates of nonadherence to these medication regimens, and out-of-pocket costs paid by patients. We performed multivariate logistic regression analysis to examine the association between out-of-pocket costs and nonadherence. Results indicated that patients filled the equivalent of 13 monthly prescriptions and paid $76 out of pocket over the calendar year; the likelihood of nonadherence increased as out-of-pocket costs increased (adjusted odds ratios ranged from 1.04 to 1.78; P < .001). These findings suggest a need for improvement in adherence among patients with employer-sponsored insurance.

      2. BACKGROUND & AIMS: Most persons infected with hepatitis C virus (HCV) in the United States were born from 1945 through 1965; testing is recommended for this cohort. However, HCV incidence is increasing among younger persons in many parts of the country and treatment is recommended for all adults with HCV infection. We aimed to estimate the cost effectiveness of universal 1-time screening for HCV infection in all adults living in the United States and to determine the prevalence of HCV antibody above which HCV testing is cost effective. METHODS: We developed a Markov state transition model to estimate the effects of universal 1-time screening of adults 18 years or older in the United States, compared with the current guideline-based strategy of screening adults born from 1945 through 1965. We compared potential outcomes of 1-time universal screening of adults or birth cohort screening followed by antiviral treatment of those with HCV infection vs no screening. We measured effectiveness with quality-adjusted life-years (QALY), and costs with 2017 US dollars. RESULTS: Based on our model, universal 1-time screening of US residents with a general population prevalence of HCV antibody greater than 0.07% cost less than $50,000/QALY compared with a strategy of no screening. Compared with 1-time birth cohort screening, universal 1-time screening and treatment cost $11,378/QALY gained. Universal screening was cost effective compared with birth cohort screening when the prevalence of HCV antibody positivity was greater than 0.07% among adults not in the cohort born from 1945 through 1965. CONCLUSIONS: Using a Markov state transition model, we found a strategy of universal 1-time screening for chronic HCV infection to be cost effective compared with either no screening or birth cohort-based screening alone.

      3. A systematic review of vaccine preventable disease surveillance cost studiesExternal
        Erondu NA, Ferland L, Haile BH, Abimbola T.
        Vaccine. 2019 Mar 19.
        BACKGROUND: Planning and monitoring vaccine introduction and effectiveness relies on strong vaccine-preventable disease (VPD) surveillance. In low and middle-income countries (LMICs) especially, cost is a commonly reported barrier to VPD surveillance system maintenance and performance; however, it is rarely calculated or assessed. This review describes and compares studies on the availability of cost information for VPD surveillance systems in LMICs to facilitate the design of future cost studies of VPD surveillance. METHODS: PubMed, Web of Science, and EconLit were used to identify peer-reviewed articles and Google was searched for relevant grey literature. Studies selected described characteristics and results of VPD surveillance systems cost studies performed in LMICs. Studies were categorized according to the type of VPD surveillance system, study aim, the annual cost of the system, and per capita costs. RESULTS: Eleven studies were identified that assessed the cost of VPD surveillance systems. The studies assessed systems from six low-income countries, two low-middle-income countries, and three middle-income countries. The majority of the studies (n=7) were conducted in sub-Saharan Africa and fifteen distinct VPD surveillance systems were assessed across the studies. Most studies aimed to estimate incremental costs of additional surveillance components and presented VPD surveillance system costs as mean annual costs per resource category, health structure level, and by VPD surveillance activity. Staff time/personnel cost represents the largest cost driver, ranging from 21% to 61% of total VPD surveillance system costs across nine studies identifying a cost driver. CONCLUSIONS: This review provides a starting point to guide LMICs to invest and advocate for more robust VPD surveillance systems. Critical gaps were identified including limited information on the cost of laboratory surveillance, challenges with costing shared resources, and missing data on capital costs. Appropriate guidance is needed to guide LMICs conducting studies on VPD surveillance system costs.

      4. INTRODUCTION: For most Americans, health insurance is obtained through employers. Health insurance coverage can lead to better health outcomes, yet disparities in coverage exist among workers with different sociodemographic and job characteristics. This study compared uninsured rates among workers with different work arrangements. METHODS: Data from the 2010 and 2015 National Health Interview Survey-Occupational Health Supplements were used to capture a representative sample of the U.S. civilian, non-institutionalized population. Associations between work arrangement and lack of health insurance were analyzed, adjusting for covariates. Analyses were performed during 2016-2018. RESULTS: The percentage of workers aged 18-64years without health insurance coverage decreased significantly by 6.8% among workers in all work arrangement categories between 2010 and 2015. However, workers in nonstandard work arrangements were still more likely than standard workers to have no health insurance coverage. In 2015, for workers to have no health insurance the ORs were 4.92 (95% CI=3.91, 6.17) in independent, 2.87 (95% CI=2.00, 4.12) in temporary or contract, and 2.79 (95% CI=0.34, 0.41) in other work arrangements. Standard full-time workers in small establishments and standard part-time workers were also more likely to have no health insurance coverage (OR=2.74, 95% CI=2.27, 3.31, and OR=1.65, 95% CI=1.25, 2.18, respectively). CONCLUSIONS: Important disparities in health insurance coverage among workers with different work arrangements existed in 2010 and persisted in 2015. Further research is needed to monitor coverage trends among workers.

    • Healthcare Associated Infections
      1. Changes in US outpatient antibiotic prescriptions from 2011-2016External
        King LM, Bartoces M, Fleming-Dutra KE, Roberts RM, Hicks LA.
        Clin Infect Dis. 2019 Mar 16.
        BACKGROUND: While antibiotics are life-saving drugs, their use is not without risk, including adverse events and antibiotic resistance. The majority of US antibiotic prescriptions are prescribed in outpatient settings, making outpatient antibiotic prescribing an important antibiotic stewardship target. The primary objective of this study was to describe trends in US outpatient oral antibiotic prescriptions from 2011-2016. METHODS: We estimated annual oral antibiotic prescription rates using national prescription dispensing count data from IQVIA Xponent divided by census estimates for 2011-2016. We calculated the ratio of broad- to narrow-spectrum prescriptions by dividing broad-spectrum prescription rates by narrow-spectrum prescription rates. We used Poisson models to estimate prevalence rate ratios comparing 2011 and 2016 antibiotic prescription rates and linear models to evaluate temporal trends throughout the study period. RESULTS: Oral antibiotic prescription rates decreased 5% from 877 prescriptions per 1,000 persons in 2011 to 836 per 1,000 persons in 2016. During this period, rates of prescriptions dispensed to children decreased 13% while adult rates increased 2%. The ratio of broad- to narrow-spectrum antibiotics decreased from 1.62 in 2011 to 1.49 in 2016, driven by decreases in macrolides and fluoroquinolones. The proportion of prescriptions written by nurse practitioners and physician assistants increased during the study period; in 2016, these providers prescribed over one-quarter of all antibiotic prescriptions. CONCLUSIONS: Outpatient antibiotic prescription rates, especially of broad-spectrum agents, have decreased in recent years. Clinicians who prescribe to adults, including nurse practitioners and physician assistants, are important targets for antibiotic stewardship.

      2. Modeling regional transmission and containment of a healthcare-associated multidrug-resistant organismExternal
        Paul P, Slayton RB, Kallen AJ, Walters MS, Jernigan JA.
        Clin Infect Dis. 2019 Mar 28.
        BACKGROUND: CDC recently published Interim Guidance for a Public Health Response to Contain Novel or Targeted Multidrug-resistant Organisms (MDROs). We assessed the impact of implementing the strategy in a U.S. state using a mathematical model. METHODS: We used a deterministic compartmental model, parametrized via a novel analysis of Carbapenem-resistant Enterobacteriaceae (CRE) data reported to the National Healthcare Safety Network and patient transfer data from the Center for Medicare & Medicaid Services. The simulations assumed that after the importation of the MDRO and its initial detection by clinical culture at an index hospital, fortnightly prevalence surveys for colonization and additional infection control interventions were implemented at the index facility; similar surveys were then also implemented at those facilities known to be connected most strongly to it as measured by patient transfer data; and, prevalence surveys were discontinued after two consecutive negative surveys. RESULTS: If additional infection control interventions are assumed to lead to a 20% reduction in transmissibility in intervention facilities, prevalent case count in the state 3 years after importation would be reduced by 76% (IQR: 73%-77%). During the third year, these additional infection control measures would be applied in facilities accounting for 42% (37%-46%) of inpatient days. CONCLUSIONS: CDC guidance for containing MDROs, when used in combination with information on transfer of patients among hospitals, is predicted to be effective, enabling targeted and efficient use of prevention resources during an outbreak response. Even modestly effective infection control measures may lead to a substantial reduction in transmission events.

      3. Probable donor-derived human adenovirus type 34 infection in 2 kidney transplant recipients from the same donorExternal
        Pettengill MA, Babu TM, Prasad P, Chuang S, Drage MG, Menegus M, Lamson DM, Lu X, Erdman D, Pecora N.
        Open Forum Infect Dis. 2019 Mar;6(3):ofy354.
        Human adenovirus type 34 (HAdV-34) infection is a recognized cause of transplant-associated hemorrhagic cystitis and, in rare cases, tubulointerstitial nephritis. The source of such infections is often difficult to assess, that is, whether acquired as a primary infection, exposure to a pathogen in the transplanted organ, or reactivation of an endogenous latent infection. We present here 2 cases of likely transplant-acquired HAdV-34 infection from the same organ donor, manifesting as tubulointerstitial nephritis in 1.

      4. A combination antibiogram evaluation for Pseudomonas aeruginosa in respiratory and blood sources from intensive care unit (ICU) and non-ICU settings in U.S. hospitalsExternal
        Puzniak L, DePestel DD, Srinivasan A, Ye G, Murray J, Merchant S, DeRyke CA, Gupta V.
        Antimicrob Agents Chemother. 2019 Apr;63(4).
        Pseudomonas aeruginosa is an important pathogen associated with significant morbidity and mortality. U.S. guidelines for the treatment of hospital-acquired and ventilator-associated pneumonia recommend the use of two antipseudomonal drugs for high-risk patients to ensure that >/=95% of patients receive active empirical therapy. We evaluated the utility of combination antibiograms in identifying optimal anti-P. aeruginosa drug regimens. We conducted a retrospective cross-sectional analysis of the antimicrobial susceptibility of all nonduplicate P. aeruginosa blood and respiratory isolates collected between 1 October 2016 and 30 September 2017 from 304 U.S. hospitals in the BD Insights Research Database. Combination antibiograms were used to determine in vitro rates of susceptibility to potential anti-P. aeruginosa combination regimens consisting of a backbone antibiotic (an extended-spectrum cephalosporin, carbapenem, or piperacillin-tazobactam) plus an aminoglycoside or fluoroquinolone. Single-agent susceptibility rates for the 11,701 nonduplicate P. aeruginosa isolates ranged from 72.7% for fluoroquinolones to 85.0% for piperacillin-tazobactam. Susceptibility rates were higher for blood isolates than for respiratory isolates (P < 0.05). Antibiotic combinations resulted in increased susceptibility rates but did not achieve the goal of 95% antibiotic coverage. Adding an aminoglycoside resulted in higher susceptibility rates than adding a fluoroquinolone; piperacillin-tazobactam plus an aminoglycoside resulted in the highest susceptibility rate (93.3%). Intensive care unit (ICU) isolates generally had lower susceptibility rates than non-ICU isolates. Commonly used antipseudomonal drugs, either alone or in combination, did not achieve 95% coverage against U.S. hospital P. aeruginosa isolates, suggesting that new drugs are needed to attain this goal. Local institutional use of combination antibiograms has the potential to optimize empirical therapy of infections caused by difficult-to-treat pathogens.

    • Immunity and Immunization
      1. BACKGROUND: In some countries that have introduced oral rotavirus vaccines, a small but elevated risk of intussusception-a rare bowel disorder-has been reported. Updated estimates on the global epidemiology of intussusception are needed to help predict the potential number of intussusception cases that could be caused by the vaccine in different settings. METHODS: We estimated incidence rates, age distributions and case-fatality ratios (CFRs) for intussusception hospital admissions among children aged <5 years, before the introduction of rotavirus vaccines. We included all articles identified in a systematic review between January 2002 and January 2018, and contacted authors for more granular unpublished data on age distributions. RESULTS: We identified 128 articles containing 227 country datasets (61 age distributions, 71 incidence rates and 95 CFRs). The median age of intussusception ranged from 29 weeks in Africa (83% of cases in the first year of life) to 70 weeks in the Western Pacific region (35% of cases in the first year of life). The median (range) annual incidence of intussusception hospital admissions per 100 000 aged <1 year ranged from 34 (13-56) in Africa to 90 (9-380) in the Western Pacific region. We found extreme differences between the CFRs in Africa (1 death in every 10 hospital admissions) and the rest of the world (fewer than 1 death in every 100-2000 hospital admissions). CONCLUSION: Intussusception epidemiology varies by country and region. Understanding and recognizing these differences will be important when assessing the potential number of intussusception cases associated with rotavirus vaccines.

      2. Research priorities for accelerating progress toward measles and rubella elimination identified by a cross-sectional web-based surveyExternal
        Kriss JL, Grant GB, Moss WJ, Durrheim DN, Shefer A, Rota PA, Omer SB, Masresha BG, Mulders MN, Hanson M, Linkins RW, Goodson JL.
        Vaccine. 2019 Mar 18.
        BACKGROUND: In 2012, the World Health Assembly endorsed the Global Vaccine Action Plan (GVAP) that set a target to eliminate measles and rubella in five of the six World Health Organization (WHO) regions by 2020. Significant progress has been made toward achieving this goal through intensive efforts by countries and Measles & Rubella Initiative (M&RI) partners. Accelerating progress will require evidence-based approaches to improve implementation of the core strategies in the Global Measles and Rubella Strategic Plan. The M&RI Research and Innovation Working Group (R&IWG) conducted a web-based survey as part of a process to identify measles and rubella research priorities. Survey findings were used to inform discussions during a meeting of experts convened by the M&RI at the Pan American Health Organization in November 2016. METHODS: The cross-sectional web-based survey of scientific and programmatic experts included questions in four main topic areas: (1) epidemiology and economics (epidemiology); (2) new tools for surveillance, vaccine delivery, and laboratory testing (new tools); (3) immunization strategies and outbreak response (strategies); and (4) vaccine demand and communications (demand). Analyses were stratified by the six WHO regions and by global, regional, or national/sub-national level of respondents. RESULTS: The six highest priority research questions selected by survey respondents from the four topic areas were the following: (1) What are the causes of outbreaks in settings with high reported vaccination coverage? (epidemiology); (2) Can affordable diagnostic tests be developed to confirm measles and rubella cases rapidly and accurately at the point of care? (new tools); (3) What are effective strategies for increasing coverage of the routine first dose of measles vaccine administered at 9 or 12months? (strategies); (4) What are effective strategies for increasing coverage of the second dose given after the first year of life? (strategies); (5) How can communities best be engaged in planning, implementing and monitoring health services including vaccinations? (demand); (6) What capacity building is needed for health workers to be able to identify and work more effectively with community leaders? (demand). Research priorities varied by region and by global/regional/national levels for all topic areas. CONCLUSIONS: Research and innovation will be critical to make further progress toward achieving the GVAP measles and rubella elimination goals. The results of this survey can be used to inform decision-making for investments in research activities at the global, regional, and national levels.

      3. Maternal vaccination in Argentina: Tdap vaccine effectiveness during pregnancy in preventing pertussis in infants less than 2 months of ageExternal
        Romanin V, Acosta AM, Juarez MD, Briere E, Sanchez SM, Cordoba BL, Sevilla ME, Lucion MF, Urrutia A, Sagradini S, Skoff TH, Vizzotti C.
        Clin Infect Dis. 2019 Mar 16.
        BACKGROUND: In 2011, Argentina experienced the highest pertussis incidence and mortality rates in the last decade; 60% of deaths were among infants aged <2 months. In response, a dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine was recommended for all pregnant women at >/=20 weeks of gestation. Although recent studies suggest maternal Tdap vaccination is effective at preventing infant disease, no data have come from low or middle-income countries, nor from ones using whole-cell pertussis vaccines for primary immunization. METHODS: We conducted a matched case-control evaluation to assess the effectiveness of maternal Tdap vaccination in preventing pertussis among infants aged <2 months in Argentina. Pertussis case-patients identified from September 2012 to March 2016 at six hospital sites and confirmed by polymerase chain reaction testing were included. Five randomly selected controls were matched to each case-patient by hospital site and mother’s health district. We used multivariable conditional logistic regression to calculate odds ratios (ORs). Vaccine effectiveness (VE) was estimated as (1 – OR) x 100%. RESULTS: Seventy-one case-patients and 300 controls were included in the analysis. Forty-nine percent of case-patients and 78% of controls had mothers who were vaccinated during pregnancy. Overall Tdap VE was estimated at 80.7% (95% confidence intervals: 52.1%-92.2%). We found similar VE whether Tdap was administered during the second or third trimester. CONCLUSIONS: Tdap vaccination during pregnancy is effective in preventing pertussis in infants aged <2 months in Argentina, with similar effectiveness whether administered during the second or third trimester of pregnancy.

      4. Herd protection or herding cats?External
        van der Linden M, Whitney CG.
        Thorax. 2019 Mar 6.

        [No abstract]

    • Informatics
      1. Co-authorship network analysis of Prevention Research Centers: An exploratory studyExternal
        Marcelin RA, Rabarison KM, Rabarison MK.
        Public Health Rep. 2019 Mar 26.
        OBJECTIVE: The Centers for Disease Control and Prevention’s Prevention Research Centers (PRCs) collaborate on public health activities with community agencies and organizations. We evaluated these collaborations by studying the relationships between co-authors from the PRCs and community agencies that published at least 1 article together in the first year of the program. METHODS: We identified all the authors of articles published by PRCs and collaborating members in peer-reviewed journals between September 2014 and September 2015 and constructed a network showing the links between and among all the authors. We characterized the network with 4 measures of social structure (network components, network density, average clustering coefficient, average distance) and 3 measures of individual author performances (degree-, betweenness-, and closeness-centrality). RESULTS: The 413 articles had 1804 individual authors and 7995 co-authorship relationships (links) in 212 peer-reviewed journals. These authors and co-authors formed 44 separate, nonoverlapping groups (components). The largest “giant” component containing most of the links involved 66.3% (n = 1196) of the authors and 73.7% (n = 5889) of the links. We identified 136 “information brokers” (authors with high closeness centrality: those who have the shortest links to the most authors). Two authors with high betweenness centrality (who had the highest number of co-authors; 104 and 107) had the greatest ability to mediate co-authorships. Network density was low; only 0.5% of all potential co-authorships were realized (7995 actual co-authorship/1 628 110 potential co-authorships). CONCLUSION: Information brokers and co-authorship mediators should be encouraged to communicate more with each other to increase the number of collaborations between network members and, hence, the number of co-authorships.

      2. Understanding open access data using visuals: Integrating prospective studies of children’s responses to natural disastersExternal
        Shah HJ, Lai BS, Leroux AJ, La Greca AM, Colgan CA, Medzhitova J.
        Child Youth Care Forum. 2019 .
        Background: As access to open data is increasing, researchers gain the opportunity to build integrated datasets and to conduct more powerful statistical analyses. However, using open access data presents challenges for researchers in understanding the data. Visuals allow researchers to address these challenges by facilitating a greater understanding of the information available. Objectives: This paper illustrates how visuals can address the challenges that researchers face when using open access data, such as: (1) becoming familiar with the data, (2) identifying patterns and trends within the data, and (3) determining how to integrate data from multiple studies. Method: This paper uses data from an integrative data analysis study that combined data from prospective studies of children’s responses to four natural disasters: Hurricane Andrew, Hurricane Charley, Hurricane Katrina, and Hurricane Ike. The integrated dataset assessed hurricane exposure, posttraumatic stress symptoms, anxiety, social support, and life events among 1707 participants (53.61% female). The children’s ages ranged from 7 to 16 years (M = 9.61, SD = 1.60). Results: Visuals serve as an effective method for understanding new and unfamiliar datasets. Conclusions: In response to the growth of open access data, researchers must develop the skills necessary to create informative visuals. Most research-based graduate programs do not require programming-based courses for graduation. More opportunities for training in programming languages need to be offered so that future researchers are better prepared to understand new data. This paper discusses implications of current graduate course requirements and standard journal practices on how researchers visualize data.

    • Injury and Violence
      1. A behavioral economic analysis of demand for texting while drivingExternal
        Hayashi Y, Friedel JE, Foreman AM, Wirth O.
        Psychol Rec. 2019 ;2019.
        The overarching goal of the present study was to determine whether a behavioral economic framework of demand analysis is applicable to texting while driving. To this end, we developed a novel hypothetical task designed to quantify the intensity and elasticity of the demand for social interaction from texting while driving. This task involved a scenario in which participants receive a text message while driving, and they rated the likelihood of replying to a text message immediately versus waiting to reply until arriving at a destination when the amounts of a fine for texting while driving ranged from $1 to $300. To assess the construct validity of the task, the scenario presented two delays to a destination (15 min and 60 min). The demand for social interaction from texting was more intense (greater at the lowest amount of the fine) and less elastic (less sensitive to the increase in the amounts of the fine) for drivers who self-reported a higher frequency of texting while driving than for those who self-reported a lower frequency of texting while driving. Demand was also more intense and less elastic under the 60-min delay condition than under the 15-min condition. The results of this proof-of-concept study suggest that behavioral economic demand analyses are potentially useful for understanding and predicting texting while driving.

      2. How well do EMS providers predict intracranial hemorrhage in head-injured older adults?External
        Hon S, Gaona SD, Faul M, Holmes JF, Nishijima DK.
        Prehosp Emerg Care. 2019 Mar 21:1-13.
        OBJECTIVE: To evaluate the accuracy of emergency medical services (EMS) provider judgment for traumatic intracranial hemorrhage (tICH) in older patients following head trauma in the field. We also compared EMS provider judgment with other sets of field triage criteria. METHODS: This was a prospective observational cohort study conducted with 5 EMS agencies and 11 hospitals in Northern California. Patients 55 years and older who experienced blunt head trauma, were transported by EMS between August 1, 2015 and September 30, 2016, and received an initial cranial computed tomography (CT) imaging, were eligible. EMS providers were asked, “What is your suspicion for the patient having intracranial hemorrhage (bleeding in the brain)?” Responses were recorded as ordinal categories (<1%, 1-5%, >5-10%, >10-50%, or >50%) and the incidences of tICH were recorded for each category. The accuracy of EMS provider judgment was compared to other sets of triage criteria, including current field triage criteria, current field triage criteria plus multivariate logistical regression risk factors, and actual transport. RESULTS: Among the 673 patients enrolled, 319 (47.0%) were male and the median age was 75 years (interquartile range 64-85). Seventy-six (11.3%) patients had tICH on initial cranial CT imaging. The increase in EMS provider judgment correlated with an increase in the incidence of tICH. EMS provider judgment had a sensitivity of 77.6% (95% CI 67.1-85.5%) and a specificity of 41.5% (37.7-45.5%) when using a threshold of 1% or higher suspicion for tICH. Current field triage criteria (Steps 1-3) was poorly sensitive (26.3%, 95% CI 17.7-37.2%) in identifying tICH and current field trial criteria plus multivariate logistical regression risk factors was sensitive (97.4%, 95% CI 90.9-99.3%) but poorly specific (12.9%, 95% CI 10.4-15.8%). Actual transport was comparable to EMS provider judgment (sensitivity 71.1%, 95% CI 60.0-80.0%; specificity 35.3%, 95% CI 31.6-38.3%). CONCLUSIONS: As EMS provider judgment for tICH increased, the incidence for tICH also increased. EMS provider judgment, using a threshold of 1% or higher suspicion for tICH, was more accurate than current field triage criteria, with and without additional risk factors included.

      3. Suicides among lesbian and gay male individuals: Findings from the National Violent Death Reporting SystemExternal
        Lyons BH, Walters ML, Jack SP, Petrosky E, Blair JM, Ivey-Stephenson AZ.
        Am J Prev Med. 2019 Apr;56(4):512-521.
        INTRODUCTION: Information regarding the epidemiology of suicide among lesbian and gay male individuals is limited, and comprehensive information is needed. This study seeks to describe the characteristics and precipitating circumstances of suicide among lesbian and gay male decedents when compared with non-lesbian and non-gay male decedents. METHODS: An analysis was conducted of National Violent Death Reporting System data from 18 U.S. states for the years 2003-2014. Sociodemographic characteristics and precipitating circumstances of suicide among lesbian and gay male decedents were compared with non-lesbian and non-gay male decedents. Logistic regression analysis was conducted to examine the association between precipitating circumstances and suicide by sexual orientation. The analysis was conducted in December 2017. RESULTS: There were a total of 123,289 suicide decedents from 18 states participating in National Violent Death Reporting System during 2003-2014; of those, 621 (0.5%) were identified as lesbian, gay, bisexual, or transgender. The majority of lesbian, gay, bisexual, or transgender decedents were identified as gay male (53.9%), followed by lesbian (28.0%), transgender (10.4%), and bisexual (7.5%). The analysis revealed several differences by age, mechanism of injury, and precipitating circumstances, including intimate partner problems among lesbian decedents, suicide planning and intent for both lesbian and gay male decedents, and mental health problems among gay male decedents. CONCLUSIONS: Findings highlight differences in the characteristics of suicide among lesbian and gay male and non-lesbian and non-gay male decedents. It is important for suicide prevention efforts to be culturally sensitive and consider the needs of sexual minority populations.

      4. Introduction: Concussions are a commonly reported injury in youth and high school sports and much of the responsibility related to concussion identification and response for young athletes is allocated to sports coaches. This paper presents findings on concussion-related education, access to resources, experiences, and attitudes among a large number of youth and high school sports coaches across a variety of sports nationwide. Methodology: Data were collected among coaches who completed the Centers for Disease Control and Prevention’s (CDC) HEADS UP online concussion training pre-test between November 2016 and November 2017. Coaches’ concussion-related education, access to resources, experiences, and attitudes were compared by age of athlete coached and level of contact of sport. Medium and large effect sizes were considered of practical significance for interpretation. Results: During the study period, 187,801 youth sports or high school sports coaches completed the CDC HEADS UP online training and corresponding pre-test. Access to previous concussion training significantly varied among respondents by age of athlete coached. For example, 27.4% of coaches of athletes aged 5 and younger had taken previous training compared to 72.9% of coaches of athletes aged 14?18. About one-quarter (27.4%) of all coaches reported ever having had to pull an athlete out of a game because of a possible concussion and 19.5% reported access to an athletic trainer at all games and practices. These variables differed significantly among coaches by age of athletes coached; coaches of older athletes were more likely to report access to an athletic trainer and having had to pull an athlete out of a game compared to coaches of younger athletes. No statistical differences by level of contact were considered to be of practical significance based on effect size. Conclusion: Most coaches in this study report having access to education and hold attitudes consistent with best practices about concussion safety; however, overall access to concussion-related resources is limited. While differences in access to concussion-related education, experience, resources, and attitudes among coaches of varying levels of contact were small, medium to large variations were identified by age of athlete coached. Practical applications: Coaches bear an important part of the responsibility to prevent, identify, and manage concussions in young athletes. Tailored educational efforts may assist coaches of young athletes with recognition of concussion signs and symptoms and with feeling comfortable deciding whether an athlete needs to be evaluated for a possible concussion.

    • Laboratory Sciences
      1. ISG15: It’s complicatedExternal
        Dzimianski JV, Scholte FE, Bergeron E, Pegan SD.
        J Mol Biol. 2019 Mar 16.
        Interferon-stimulated gene product 15 (ISG15) is a key component of host responses to microbial infection. Despite having been known for four decades, grasping the functions and features of ISG15 has been a slow and elusive process. Substantial work over the past two decades has greatly enhanced this understanding, revealing the complex and variable nature of this protein. This has unveiled multiple mechanisms of action that are only now beginning to be understood. In addition, it has uncovered diversity not only between how ISG15 affects different pathogens but also between the function and structure of ISG15 itself between different host species. Here we review the complexity of ISG15 within the context of viral infection, focusing primarily on its antiviral function and the mechanisms viruses employ to thwart its effects. We highlight what is known regarding the impact of ISG15 sequence and structural diversity on these interactions and discuss the aspects presenting the next frontier toward elucidating a more complete picture of ISG15 function.

      2. Non-targeted GC/MS analysis of exhaled breath samples: Exploring human biomarkers of exogenous exposure and endogenous response from professional firefighting activityExternal
        Geer Wallace MA, Pleil JD, Oliver KD, Whitaker DA, Mentese S, Fent KW, Horn GP.
        J Toxicol Environ Health A. 2019 Mar 23:1-17.
        A non-targeted analysis workflow was applied to analyze exhaled breath samples collected from firefighters pre- and post-structural fire suppression. Breath samples from firefighters functioning in attack and search positions were examined for target and non-target compounds in automated thermal desorption-GC/MS (ATD-GC/MS) selected ion monitoring (SIM)/scan mode and reviewed for prominent chemicals. Targeted chemicals included products of combustion such as benzene, toluene, xylenes, and polycyclic aromatic hydrocarbons (PAH) that serve as a standard assessment of exposure. Sixty unique chemical features representative of exogenous chemicals and endogenous compounds, including single-ring aromatics, polynuclear aromatic hydrocarbons, volatile sulfur-containing compounds, aldehydes, alkanes, and alkenes were identified using the non-targeted analysis workflow. Fifty-seven out of 60 non-targeted features changed by at least 50% from pre- to post-fire suppression activity in at least one subject, and 7 non-targeted features were found to exhibit significantly increased or decreased concentrations for all subjects as a group. This study is important for (1) alerting the firefighter community to potential new exposures, (2) expanding the current targeted list of toxicants, and (3) finding biomarkers of response to firefighting activity as reflected by changes in endogenous compounds. Data demonstrate that there are non-targeted compounds in firefighters’ breath that are indicative of environmental exposure despite the use of protective gear, and this information may be further utilized to improve the effectiveness of personal protective equipment.

      3. Transcriptome profiling of Plasmodium vivax in Saimiri monkeys identifies potential ligands for invasionExternal
        Gunalan K, Sa JM, Moraes Barros RR, Anzick SL, Caleon RL, Mershon JP, Kanakabandi K, Paneru M, Virtaneva K, Martens C, Barnwell JW, Ribeiro JM, Miller LH.
        Proc Natl Acad Sci U S A. 2019 Mar 14.
        Unlike the case in Asia and Latin America, Plasmodium vivax infections are rare in sub-Saharan Africa due to the absence of the Duffy blood group antigen (Duffy antigen), the only known erythrocyte receptor for the P. vivax merozoite invasion ligand, Duffy binding protein 1 (DBP1). However, P. vivax infections have been documented in Duffy-negative individuals throughout Africa, suggesting that P. vivax may use ligands other than DBP1 to invade Duffy-negative erythrocytes through other receptors. To identify potential P. vivax ligands, we compared parasite gene expression in Saimiri and Aotus monkey erythrocytes infected with P. vivax Salvador I (Sal I). DBP1 binds Aotus but does not bind to Saimiri erythrocytes; thus, P. vivax Sal I must invade Saimiri erythrocytes independent of DBP1. Comparing RNA sequencing (RNAseq) data for late-stage infections in Saimiri and Aotus erythrocytes when invasion ligands are expressed, we identified genes that belong to tryptophan-rich antigen and merozoite surface protein 3 (MSP3) families that were more abundantly expressed in Saimiri infections compared with Aotus infections. These genes may encode potential ligands responsible for P. vivax infections of Duffy-negative Africans.

      4. Zeptomole per milliliter detection and quantification of edema factor in plasma by LC-MS/MS yields insights into toxemia and the progression of inhalation anthraxExternal
        Lins RC, Boyer AE, Kuklenyik Z, Woolfitt AR, Goldstein J, Hoffmaster AR, Gallegos-Candela M, Leysath CE, Chen Z, Brumlow JO, Quinn CP, Bagarozzi DA, Leppla SH, Barr JR.
        Anal Bioanal Chem. 2019 Mar 26.
        Inhalation of Bacillus anthracis spores can cause a rapidly progressing fatal infection. B. anthracis secretes three protein toxins: lethal factor (LF), edema factor (EF), and protective antigen (PA). EF and LF may circulate as free or PA-bound forms. Both free EF (EF) and PA-bound-EF (ETx) have adenylyl cyclase activity converting ATP to cAMP. We developed an adenylyl cyclase activity-based method for detecting and quantifying total EF (EF+ETx) in plasma. The three-step method includes magnetic immunocapture with monoclonal antibodies, reaction with ATP generating cAMP, and quantification of cAMP by isotope-dilution HPLC-MS/MS. Total EF was quantified from 5PL regression of cAMP vs ETx concentration. The detection limit was 20 fg/mL (225 zeptomoles/mL for the 89 kDa protein). Relative standard deviations for controls with 0.3, 6.0, and 90 pg/mL were 11.7-16.6% with 91.2-99.5% accuracy. The method demonstrated 100% specificity in 238 human serum/plasma samples collected from unexposed healthy individuals, and 100% sensitivity in samples from 3 human and 5 rhesus macaques with inhalation anthrax. Analysis of EF in the rhesus macaques showed that it was detected earlier post-exposure than B. anthracis by culture and PCR. Similar to LF, the kinetics of EF over the course of infection were triphasic, with an initial rise (phase-1), decline (phase-2), and final rapid rise (phase-3). EF levels were ~ 2-4 orders of magnitude lower than LF during phase-1 and phase-2 and only ~ 6-fold lower at death/euthanasia. Analysis of EF improves early diagnosis and adds to our understanding of anthrax toxemia throughout infection. The LF/EF ratio may also indicate the stage of infection and need for advanced treatments.

      5. Challenges and clinical relevance of molecular detection of Bordetella pertussis in South AfricaExternal
        Moosa F, du Plessis M, Wolter N, Carrim M, Cohen C, von Mollendorf C, Walaza S, Tempia S, Dawood H, Variava E, von Gottberg A.
        BMC Infect Dis. 2019 Mar 21;19(1):276.
        BACKGROUND: We assessed the utility of a multi-target, real-time PCR assay for Bordetella pertussis detection and diagnosis in patients with severe respiratory illness (SRI), influenza-like illness (ILI), and asymptomatic controls. METHODS: Real-time PCR detection of IS481, pIS1001, hIS1001 and ptxS1 was performed on nasopharyngeal specimens (SRI, ILI and controls) and induced sputum (SRI) collected from June 2012 to May 2016 through respiratory illness surveillance. Using PCR cycle threshold (Ct) value cut-offs, IS481 positive cases were classified as confirmed (Ct < 35) or possible (Ct 35-39) pertussis disease. RESULTS: Among 12,922 samples, 146 (1.1%) were IS481 positive of which 62% (90/146) were classified as confirmed. The attributable fraction (AF) was 92.2% (95% CI, 65.6 to 98.2%) and 90.5% (95% CI, 57.5 to 97.9%) amongst SRI and ILI PCR-confirmed pertussis cases, respectively. Amongst possible pertussis cases, AF was 36.9% (95% CI, – 142.3 to 83.6%) and 67.5% (95% CI, – 30.6 to 91.9%) in the SRI and ILI groups, respectively. CONCLUSION: All IS481 positive specimens could be considered as B. pertussis infection, and potentially pertussis disease with supportive clinical information.

      6. Emergence of Neisseria gonorrhoeae strains harboring a novel combination of azithromycin-attenuating mutationsExternal
        Pham CD, Sharpe S, Schlanger K, St Cyr S, Holderman J, Steece R, Soge OO, Masinde G, Arno J, Schmerer M, Kersh EN.
        Antimicrob Agents Chemother. 2019 Apr;63(4).
        The nimbleness of Neisseria gonorrhoeae to evade the effect of antibiotics has perpetuated the fight against antibiotic-resistant gonorrhea for more than 80 years. The ability to develop resistance to antibiotics is attributable to its indiscriminate nature in accepting and integrating exogenous DNA into its genome. Here, we provide data demonstrating a novel combination of the 23S rRNA A2059G mutation with a mosaic-multiple transferable resistance (mosaic-mtr) locus haplotype in 14 N. gonorrhoeae isolates with high-level azithromycin MICs (>/=256 mug/ml), a combination that may confer more fitness than in previously identified isolates with high-level azithromycin resistance. To our knowledge, this is the first description of N. gonorrhoeae strains harboring this novel combination of resistance determinants. These strains were isolated at two independent jurisdictions participating in the Gonococcal Isolate Surveillance Project (GISP) and in the Strengthening the U.S. Response to Resistant Gonorrhea (SURRG) project. The data suggest that the genome of N. gonorrhoeae continues to shuffle its genetic material. These findings further illuminate the genomic plasticity of N. gonorrhoeae, which allows this pathogen to develop mutations to escape the inhibitory effects of antibiotics.

      7. Increased discrimination of Treponema pallidum strains by subtyping with a 4-component system incorporating a mononucleotide tandem repeat in rpsAExternal
        Pillay A, Lee MK, Slezak T, Katz SS, Sun Y, Chi KH, Morshed M, Philip S, Ballard RC, Chen CY.
        Sex Transm Dis. 2019 Apr;46(4):e42-e45.
        A guanine mononucleotide repeat in the rpsA (tp0279) gene was evaluated for improved strain discrimination using 72 Treponema pallidum-positive specimens. The tandem repeat combined with the enhanced Centers for Disease Control and Prevention typing system resulted in increased discrimination and should be useful for molecular epidemiologic studies on syphilis especially in outbreaks and among men who have sex with men.

      8. Swine-origin H1 influenza viruses isolated from humans exhibit sustained infectivity in an aerosol stateExternal
        Pulit-Penaloza JA, Belser JA, Tumpey TM, Maines TR.
        Appl Environ Microbiol. 2019 Mar 15.
        The relative importance of influenza virus transmission via aerosols is not fully understood, but experimental data suggests that aerosol transmission may represent a critical mode of influenza virus spread among humans. Decades ago, prototypical laboratory strains of influenza were shown to persist in aerosols; however, there is a paucity of data available covering currently circulating influenza viruses, which differ significantly from their predecessors. In this study, we evaluated the longevity of influenza viruses in aerosols generated in the laboratory. We selected a panel of H1 viruses that exhibit diverse transmission profiles in the ferret model, including four human isolates of swine-origin (referred to as variant) and a seasonal strain. By measuring the ratio of viral RNA to infectious virus maintained in aerosols over time, we show that influenza viruses known to transmit efficiently through the air, display enhanced stability in an aerosol state for prolonged periods compared with those viruses that do not transmit as efficiently. We then assessed whether H1 influenza virus was still capable of infecting and causing disease in ferrets after being aged in suspended aerosols. Ferrets exposed to very low levels of influenza virus (</=17 PFU) in aerosols aged for 15 or 30 min, became infected, with 5/6 ferrets shedding virus in nasal washes at titers on par with ferrets who inhaled higher doses of unaged influenza virus. We describe here, an underreported characteristic of influenza viruses, stability in aerosols, and make a direct connection to the role it plays in influenza transmission.Importance Each time a swine influenza virus transmits to a human, it provides an opportunity for the virus to acquire adaptations needed for sustained human-to-human transmission. Here, we use aerobiology techniques to test the stability of swine-origin H1 subtype viruses in aerosols and evaluate their infectivity in ferrets. Our results show that highly transmissible influenza viruses display enhanced stability in an aerosol state compared with viruses that do not transmit as efficiently. Similar to human-adapted strains, swine-origin influenza viruses are infectious in ferrets at low doses even after prolonged suspension in the air. These data underscore the risk of airborne swine-origin influenza viruses, and support the need for continued surveillance and refinement of innovative laboratory methods to investigate mammalian exposure to inhaled pathogens. Determination of molecular markers that affect longevity of airborne influenza viruses will improve our ability to quickly identify emerging strains that present the greatest threat to public health.

      9. Evaluation of apparatus used to test liquid through protective materials: Comparison of a modified dot-blot apparatus to the ASTM penetration cellExternal
        Schwerin MR, Portnoff L, Furlong JL, Das SS, Gordon EA, Woods TO, Wood SC, Lucas AD.
        J Test Eval. 2020 ;48(1).
        Personal protective equipment (PPE), such as gowns used in the latest Ebola outbreak in Western Africa, are critical in preventing the spread of deadly diseases. Appropriate test systems and test soils are needed to adequately evaluate PPE. ASTM F903, Standard Test Method for Resistance of Materials Used in Protective Clothing to Penetration by Liquid, has been used for decades to test fabrics’ resistance to liquid penetration. However, this test apparatus requires at least 60 mL of test solutions, is labor intensive, and has problems with leakage around the gaskets. We compared the F903 test apparatus to a modified dot-blot apparatus to evaluate the visual penetration of a blood test soil. A series of commercially available gowns and drapes were tested in each apparatus. Using blood test soil at 2 psi, there was no statistically significant difference between the two methods except for in one gown. By comparing this gown in the ASTM test apparatus with and without a screen, the particular screen selected did not account for the difference between the dot-blot and F903 apparatuses; however, it is conceivable that a particular screen/fabric combination could account for this difference. The modified dot-blot apparatus was evaluated using three different test solutions: blood, vomit, and a labeled protein (goat anti-rabbit immunoglobulin G-horseradish peroxidase [GaR IgG-HRP]) in a blood test soil solution. This testing revealed significant difference in penetration for some of the PPE garments. The modified dot-blot had several large advantages over the ASTM apparatus-over six times less specimen volume and no edge or gasket leakage. In addition, nitrocellulose can be easily incorporated into the modified dot-blot apparatus, enabling the trapping of viruses and proteins that penetrate PPE-thus permitting the use of antibodies to quickly and sensitively detect penetration.

      10. Building the framework for standardized clinical laboratory reporting of next generation sequencing data for resistance-associated mutations in Mycobacterium tuberculosis complexExternal
        Tornheim JA, Starks AM, Rodwell TC, Gardy JL, Walker TM, Cirillo DM, Jayashankar L, Miotto P, Zignol M, Schito M.
        Clin Infect Dis. 2019 Mar 18.
        Tuberculosis is the primary infectious disease killer worldwide, with a growing threat from multidrug- resistant cases. Unfortunately, classic growth-based phenotypic drug susceptibility testing (DST) remains difficult, costly and time-consuming, while current rapid molecular testing options are limited by the diversity of antimicrobial resistant genotypes that can be detected at once. Next generation sequencing (NGS) offers the opportunity for rapid, comprehensive DST without the time or cost burden of phenotypic tests and can provide useful information for global surveillance. As access to NGS expands, it will be important to ensure that results are communicated clearly, are consistent, are comparable between laboratories, and are associated with clear guidance on clinical interpretation of results. This viewpoint summarizes two expert workshops regarding a standardized report format, focusing on relevant variables, terminology, and required minimal elements for clinical and laboratory reports with a proposed standardized template for clinical reporting of NGS results for Mycobacterium tuberculosis.

      11. Orthopoxviruses (OPXVs) have a broad host range in mammalian cells, but Chinese hamster ovary (CHO) cells are non-permissive for vaccinia virus (VACV). Here, we revealed a species-specific difference in host restriction factor SAMD9L as the cause for the restriction and identified orthopoxvirus CP77 as a unique inhibitor capable of antagonizing Chinese hamster SAMD9L (chSAMD9L). Two known VACV inhibitors of SAMD9 and SAMD9L (SAMD9&L);, K1 and C7, can bind human and mouse SAMD9&L;, but neither can bind chSAMD9L. CRISPR-Cas9 knockout of chSAMD9L from CHO cells removed the restriction for VACV, while ectopic expression of chSAMD9L imposed the restriction for VACV in a human cell line, demonstrating that chSAMD9L is a potent restriction factor for VACV. Contrary to K1 and C7, cowpox virus CP77 can bind chSAMD9L and rescue VACV replication in cells expressing chSAMD9L, indicating that CP77 is yet another SAMD9L inhibitor but has a unique specificity for chSAMD9L. Binding studies showed that the N-terminal 382 amino acids of CP77 were sufficient for binding chSAMD9L and that both K1 and CP77 target a common internal region of SAMD9L. Growth studies with nearly all OPXV species showed that the ability of OPXVs in antagonizing chSAMD9L correlates with CP77 gene status and that a functional CP77 ortholog was maintained in many OPXVs, including monkeypox virus. Our data suggest that species-specific difference in rodent SAMD9L poses a barrier for cross-species OPXV infection and that OPXVs have evolved three SAMD9&L inhibitors with different specificities to overcome this barrier.IMPORTANCE: Several OPXV species, including monkeypox virus and cowpox virus, cause zoonotic infection in humans. They are believed to use wild rodents as the reservoir or intermediate hosts, but the host or viral factors that are important for OPXV host range in rodents are unknown. Here, we showed that the abortive replication of several OPXV species in a Chinese hamster cell line was caused by a species-specific difference in the host antiviral factor SAMD9L, suggesting that SAMD9L divergence in different rodent species poses a barrier for cross-species OPXV infection. While the Chinese hamster SAMD9L could not be inhibited by two previously identified OPXV inhibitors of human and mouse SAMD9&L;, it can be inhibited by cowpox virus CP77, indicating that OPXVs encode three SAMD9&L inhibitors with different specificity. Our data suggest that OPXV host range in broad rodent species depends on three SAMD9&L inhibitors with different specificities.

    • Maternal and Child Health
      1. Health services use among children diagnosed with medium-chain acyl-CoA dehydrogenase deficiency through newborn screening: a cohort study in Ontario, CanadaExternal
        Karaceper MD, Khangura SD, Wilson K, Coyle D, Brownell M, Davies C, Dodds L, Feigenbaum A, Fell DB, Grosse SD, Guttmann A, Hawken S, Hayeems RZ, Kronick JB, Laberge AM, Little J, Mhanni A, Mitchell JJ, Nakhla M, Potter M, Prasad C, Rockman-Greenberg C, Sparkes R, Stockler S, Ueda K, Vallance H, Wilson BJ, Chakraborty P, Potter BK.
        Orphanet J Rare Dis. 2019 Mar 22;14(1):70.
        BACKGROUND: We describe early health services utilization for children diagnosed with medium-chain acyl-CoA dehydrogenase (MCAD) deficiency through newborn screening in Ontario, Canada, relative to a screen negative comparison cohort. METHODS: Eligible children were identified via newborn screening between April 1, 2006 and March 31, 2010. Age-stratified rates of physician encounters, emergency department (ED) visits and inpatient hospitalizations to March 31, 2012 were compared using incidence rate ratios (IRR) and incidence rate differences (IRD). We used negative binomial regression to adjust IRRs for sex, gestational age, birth weight, socioeconomic status and rural/urban residence. RESULTS: Throughout the first few years of life, children with MCAD deficiency (n = 40) experienced statistically significantly higher rates of physician encounters, ED visits, and hospital stays compared with the screen negative cohort. The highest rates of ED visits and hospitalizations in the MCAD deficiency cohort occurred from 6 months to 2 years of age (ED use: 2.1-2.5 visits per child per year; hospitalization: 0.5-0.6 visits per child per year), after which rates gradually declined. CONCLUSIONS: This study confirms that young children with MCAD deficiency use health services more frequently than the general population throughout the first few years of life. Rates of service use in this population gradually diminish after 24 months of age.

      2. Prevalence of selected birth defects by maternal nativity status, United States, 1999-2007External
        Kirby RS, Mai CT, Wingate MS, Janevic T, Copeland GE, Flood TJ, Isenburg J, Canfield MA.
        Birth Defects Res. 2019 Mar 28.
        OBJECTIVES: We investigated differences in prevalence of major birth defects by maternal nativity within racial/ethnic groups for 27 major birth defects. METHODS: Data from 11 population-based birth defects surveillance systems in the United States including almost 13 million live births (approximately a third of U.S. births) during 1999-2007 were pooled. We calculated prevalence estimates for each birth defect for five racial/ethnic groups. Using Poisson regression, crude and adjusted prevalence ratios (aPRs) were also calculated using births to US-born mothers as the referent group in each racial/ethnic group. RESULTS: Approximately 20% of case mothers and 26% of all mothers were foreign-born. Elevated aPRs for infants with foreign-born mothers were found for spina bifida and trisomy 13, 18, and 21, while lower prevalence patterns were found for pyloric stenosis, gastroschisis, and hypospadias. CONCLUSIONS: This study demonstrates that birth defects prevalence varies by nativity within race/ethnic groups, with elevated prevalence ratios for some specific conditions and lower prevalence for others. More detailed analyses focusing on a broader range of maternal behaviors and characteristics are required to fully understand the implications of our findings.

      3. The Legacy for Children randomized control trial: Effects on cognition through third grade for young children experiencing povertyExternal
        Perou R, Robinson LR, Danielson ML, Claussen AH, Visser SN, Scott KG, Beckwith L, Katz L, Smith DC.
        J Dev Behav Pediatr. 2019 Mar 26.
        OBJECTIVE: In an effort to promote the health and developmental outcomes of children born into poverty, the Centers for Disease Control and Prevention (CDC) conceptualized and designed the Legacy for Children (Legacy) public health prevention model. This article examines the impact of Legacy on children’s cognitive and language development (intelligence quotient [IQ], achievement, language skills, and early reading skills) using both standardized assessments and parent-reported indictors through third grade. METHODS: Data were collected from 2001 to 2014 from 541 mother-child dyads who were recruited into the 2 concurrent randomized controlled trials of Legacy in Miami and Los Angels. Cognitive and/or language outcomes of children were assessed annually from age 2 to 5 years as well as during a follow-up visit in the third grade. RESULTS: Children experiencing Legacy at the Los Angeles site had significantly higher IQ and achievement scores at 2 and 6 years postintervention, equivalent to approximately one-third of an SD (4 IQ points). IQ results persisted over time, and the difference between intervention and comparison groups on achievement scores widened. There were no significant differences in cognitive outcomes in the Miami sample. There were no significant differences in language outcomes for either site. CONCLUSION: Legacy shows evidence of effectiveness as an intervention to prevent cognitive delays among children living in poverty. The mixed findings across sites may not only reflect the impact of heterogeneous risk profiles noted by other intervention research programs but also warrant additional study.

      4. Use of benzodiazepine medications during pregnancy and potential risk for birth defects, National Birth Defects Prevention Study, 1997-2011External
        Tinker SC, Reefhuis J, Bitsko RH, Gilboa SM, Mitchell AA, Tran EL, Werler MM, Broussard CS.
        Birth Defects Res. 2019 Mar 19.
        BACKGROUND: Benzodiazepine medications can be used to treat anxiety, a condition affecting 15% of women of childbearing age in the United States. Studies have shown conflicting results for the association between benzodiazepine use during pregnancy and birth defects. METHODS: We analyzed 1997-2011 data from the National Birth Defects Prevention Study, a multisite, population-based case-control study. We assessed the prevalence of and factors associated with benzodiazepine use in pregnancy among mothers of live-born infants without a birth defect (control mothers). We used logistic regression to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for the association between specific birth defects and benzodiazepine use; we estimated crude odds ratios (cORs) for defect categories with 3-4 exposed cases. RESULTS: Exposure to benzodiazepines during pregnancy was rare (N = 93/11,614; 0.8%). Benzodiazepine use was more common among control mothers who were >/=30 years, non-Hispanic white, had more education, smoked, and took antidepressant medication. We observed significantly elevated ORs for any benzodiazepine and Dandy-Walker malformation (cOR: 3.1; 95% CI: 1.1, 8.6); for alprazolam and anophthalmia or microphthalmia (cOR: 4.0; 95% CI: 1.2, 13.1) and esophageal atresia or stenosis (aOR: 2.7; 95% CI: 1.2, 5.9); and lorazepam and pulmonary valve stenosis (cOR: 4.1; 95% CI: 1.2, 14.2), but sample sizes were limited and therefore CIs were wide. CONCLUSIONS: Our findings suggest that benzodiazepines use is rare and may be associated with risk for certain birth defects. However, these results need replication and should be interpreted with caution.

    • Occupational Safety and Health
      1. Musculoskeletal pain is impacted by job tasks in temporary construction workers hired through construction staffing agenciesExternal
        Caban-Martinez AJ, Santiago K, Baniak M, Jordan MM, Menger-Ogle L.
        J Occup Environ Med. 2019 Mar;61(3):e100-e103.

        [No abstract]

      2. Burden, need and impact: An evidence-based method to identify worker safety and health research prioritiesExternal
        Felknor SA, Schulte PA, Schnorr TM, Pana-Cryan R, Howard J.
        Ann Work Expo Health. 2019 Mar 27.
        The importance of research and recommendations to address workforce safety and health derives from the continuing toll from worker fatalities, injuries, and illnesses. Estimates of the societal cost of work-related fatalities, injuries, and illnesses range up to $2.2 trillion in the USA from 2007 to 2015, which may be an underestimate of total societal costs. The ongoing changes in the nature of work, the workforce, and the workplace in the USA challenge old paradigms of worker safety and health research and require new decision criteria that are more solution oriented than observational and that result in interventions that can be readily applied to new occupational hazards and exposures. As public funding for science research programs becomes more constrained, and the demand for increased accountability of government spending grows, the need to demonstrate the impact or return on taxpayers’ investment becomes a necessity for research agencies. The National Institute for Occupational Safety and Health has developed an evidence-based method that uses the criteria of ‘burden’, ‘need’, and ‘impact’ to identify research priorities and aid in the evaluation of the taxpayers’ investment in research. This approach, named the BNI method, may be useful to other public and private sector research agencies or entities that need a systematic way to set research priorities and allocate increasingly scarce resources for research while ensuring the maximal return on investment.

      3. US adolescents experience a higher rate of largely preventable job-related injuries compared with adults. Safety education is considered critical to the prevention of these incidents. This study evaluates the effectiveness of a foundational curriculum from the National Institute for Occupational Safety and Health (NIOSH), Talking Safety, to change adolescents’ workplace safety and health knowledge, attitude, subjective norm, self-efficacy, and behavioral intention to engage in workplace safety actions. The study also examines the impact of teacher fidelity of curriculum implementation on student outcomes. A multilevel evaluation, based on a modified theory of planned behavior, was conducted in 2016 with 1748 eighth-graders in Miami-Dade, Florida. Post-intervention, students had statistically significant increases (p < .05) in mean scores across outcomes: workplace safety knowledge (34%), attitude (5%), subjective norm (7%), self-efficacy (7%), and behavioral intention (7%). Consistent with theory, gains in attitude (b = 0.25, p < .001), subjective norm (b = 0.07, p < .01), and self-efficacy (b = 0.55, p < .001) were associated with gains in behavioral intention. Higher levels of implementation fidelity were associated with significant gains across outcome measures: knowledge (b = 0.60, p < .001), attitude (b = 0.08, p < .01), subjective norm (b = 0.04, p < .001), self-efficacy (b = 0.07, p < .01) and behavioral intention (b = 0.07, p < .01). Findings demonstrate the effectiveness of Talking Safety, delivered with fidelity, at positively changing measured outcomes, and provide support for using this curriculum as an essential component of any school-based, injury prevention program for young workers.

      4. INTRODUCTION: The NIOSH Fire Fighter Fatality Investigation and Prevention Program (FFFIPP) conducts independent investigations of selected fire fighter line-of-duty deaths (LODD) and offers recommendations to prevent similar deaths. The purpose of the current study was to provide information on more recent FFFIPP recommendations and to determine if recommendations have changed over time. METHODS: Fatality investigations completed from 2006 to 2014 were selected for this study with recommendations being assigned into twelve major categories when possible. The most frequently occurring recommendations were then rank ordered overall and then by medical and traumatic fire fighter LODD. RESULTS: There were 1,067 total recommendations made in the published fire fighter investigative reports for both medical and trauma-related fire fighter fatalities for the period 2006-2014. Of these, 784 (73%) could be placed within one of the 12 categories noted previously. The top 10 recommendation categories overall were: 1. Medical screening, 2. Fitness and wellness program, 3. Training, 4. Medical clearance, 5. Standard Operating Procedures/Standard Operating Guidelines (SOPs/SOGs), 6. Incident command, 7. Strategy and tactics, 8. Communications, 9. Personal protective equipment and 10. Staffing. CONCLUSIONS: The leading recommendations from the NIOSH FFFIPP medical investigations between 2006 and 2014 did not change compared to those made between 1998 and 2005, with the exception of the addition of “medical clearance for duty”. There were changes for the traumatic injury leading recommendations for 2006-2014, with the major change being “training”, which was the leading FFFIPP recommendation for traumatic injuries for this time period. Practical applications: The intent of the FFFIPP is to influence fire departments and fire fighters to critically assess and evaluate situations/circumstances similar to those identified by NIOSH investigations and implement the recommendations offered to prevent additional fire fighter fatalities.

      5. A definition and categorization system for advanced materials: The foundation for risk-informed environmental health and safety testingExternal
        Kennedy A, Brame J, Rycroft T, Wood M, Zemba V, Weiss C, Hull M, Hill C, Geraci C, Linkov I.
        Risk Anal. 2019 Mar 25.
        Novel materials with unique or enhanced properties relative to conventional materials are being developed at an increasing rate. These materials are often referred to as advanced materials (AdMs) and they enable technological innovations that can benefit society. Despite their benefits, however, the unique characteristics of many AdMs, including many nanomaterials, are poorly understood and may pose environmental safety and occupational health (ESOH) risks that are not readily determined by traditional risk assessment methods. To assess these risks while keeping up with the pace of development, technology developers and risk assessors frequently employ risk-screening methods that depend on a clear definition for the materials that are to be assessed (e.g., engineered nanomaterial) as well as a method for binning materials into categories for ESOH risk prioritization. The term advanced material lacks a consensus definition and associated categorization or grouping system for risk screening. In this study, we aim to establish a practitioner-driven definition for AdMs and a practitioner-validated framework for categorizing AdMs into conceptual groupings based on material characteristics. Results from multiple workshops and interviews with practitioners provide consistent differentiation between AdMs and conventional materials, offer functional nomenclature for application science, and provide utility for future ESOH risk assessment prioritization. The definition and categorization framework established here serve as a first step in determining if and when there is a need for specific ESOH and regulatory screening for an AdM as well as the type and extent of risk-related information that should be collected or generated for AdMs and AdM-enabled technologies.

      6. Potential occupational hazards of additive manufacturingExternal
        Roth GA, Geraci CL, Stefaniak A, Murashov V, Howard J.
        J Occup Environ Hyg. 2019 Mar 25:1-8.

        [No abstract]

      7. Effort-reward imbalance and overcommitment at work: Associations with police burnoutExternal
        Violanti JM, Mnatsakanova A, Andrew ME, Allison P, Gu JK, Fekedulegn D.
        Police Q. 2018 Dec 1;21(4):440-460.
        The present study examined associations of effort-reward imbalance (ERI) and over-commitment at work with burnout among police officers using data from 200 (mean age = 46 years, 29% women) officers enrolled in the Buffalo Cardio-Metabolic Occupational Police Stress Study. ERI and overcommitment were assessed using Siegrist’s “effort/reward” questionnaire. The Maslach Burnout Inventory-General Survey was used to assess burnout and its three subscales (exhaustion, cynicism, and professional efficacy). Analysis of covariance was used to examine mean values of burnout scores across quartiles of ERI and overcommitment. Linear regression was used to test for linear trend. ERI and overcommitment were positively and significantly associated with cynicism and exhaustion (trend p value < .001), while professional efficacy showed an inverse association with overcommitment (p = .026). Cynicism and exhaustion scores were significantly higher in officers who reported both overcommitment and ERI compared with their counterparts (p < .001). The results suggest that ERI and overcommitment at work are determinants of higher cynicism and exhaustion. The inverse association of overcommitment with professional efficacy (an indicator of engagement at work) suggests that extreme involvement in work may negatively affect efficacy. Overcommitment may be related to a need for approval and inability of officers to withdraw from work, even in an off-duty status. Police agencies should consider organizational remedies to maintain acceptable levels of commitment by officers. In addition, there is a need to monitor and improve effort-reward imbalance experienced by officers.

    • Occupational Safety and Health – Mining
      1. Laboratory results of a 3rd generation roof bolter canopy air curtain for respirable coal mine dust controlExternal
        Reed WR, Joy GJ, Shahan M, Klima S, Ross G.
        Int J Coal Sci Technol. 2019 ;6(1):15-26.
        Testing was completed on an earlier roof bolter CAC that used slots to provide a perimeter airflow. NIOSH tested it due to its unique design that differed from canopies that provided uniform airflow. Based upon NIOSH recommendations from the earlier testing, a 3rd generation roof bolter CAC has been developed by J.H. Fletcher & Co. The changes to this CAC involve design modifications to the plenum outlets, using a single row of outlets on the perimeter and a different material for the plenum. This laboratory testing was a continuation of the original perimeter slotted CAC design. Using gravimetric and instantaneous sampling of respirable dust concentrations underneath and outside of the CAC, the laboratory testing was completed using three different blower fans that delivered differing airflows. The maximum plenum airflow velocities ranged from 2.34 to 3.64 m/s (460-716 fpm). Results showed plenum respirable dust concentrations ranging from 34.6% to 49.3% lower than respirable dust concentrations outside the plenum protection zone, thus showing an improvement in protection for the roof bolter operators.

      2. A field study of a roof bolter canopy air curtain (2nd generation) for respirable coal mine dust controlExternal
        Reed WR, Klima S, Shahan M, Ross GJ, Singh K, Cross R, Grounds T.
        Int J Coal Sci Technol. 2019 .
        A 2nd generation roof bolter canopy air curtain (CAC) design was tested by National Institute for Occupational Safety and Health (NIOSH) at a Midwestern underground coal mine. During the study, the roof bolter never operated downwind of the continuous miner. Using a combination of personal Data Rams (pDR) and gravimetric samplers, the dust control efficiency of the roof bolter CAC was ascertained. Performance evaluation was determined using three methods: (1) comparing roof bolter operator concentrations underneath the CAC to roof bolter concentrations outside the CAC, (2) comparing roof bolter operator concentrations underneath the CAC to the concentrations at the rear of the bolter, and finally, (3) using the gravimetric data directly underneath the CAC to correct roof bolter operator concentrations underneath the CAC and comparing them to the concentrations at the rear of the bolter. Method 1 dust control efficiencies ranged from -53.9% to 60.4%. Method 2 efficiencies ranged from -150.5% to 52.2%, and Method 3 efficiencies ranged from 40.7% to 91%. Reasons for negative and low dust control efficiencies are provided in this paper and include: incorrect sampling locations, large distance between CAC and operator, and contamination of intake air from line curtain. Low dust concentrations encountered during the testing made it difficult to discern whether differences in concentrations were due to the CAC or due to variances inherent in experimental dust measurement. However, the analyses, especially the Method 3 analysis, show that the CAC can be an effective dust control device.

    • Parasitic Diseases
      1. The tolerability of single low dose primaquine in glucose-6-phosphate deficient and normal falciparum-infected CambodiansExternal
        Dysoley L, Kim S, Lopes S, Khim N, Bjorges S, Top S, Huch C, Rekol H, Westercamp N, Fukuda MM, Hwang J, Roca-Feltrer A, Mukaka M, Menard D, Taylor WR.
        BMC Infect Dis. 2019 Mar 12;19(1):250.
        BACKGROUND: The WHO recommends single low-dose primaquine (SLDPQ, 0.25 mg/kg body weight) in falciparum-infected patients to block malaria transmission and contribute to eliminating multidrug resistant Plasmodium falciparum from the Greater Mekong Sub region (GMS). However, the anxiety regarding PQ-induced acute haemolytic anaemia in glucose-6-phosphate dehydrogenase deficiency (G6PDd) has hindered its use. Therefore, we assessed the tolerability of SLDPQ in Cambodia to inform national policy. METHODS: This open randomised trial of dihydroartemisinin-piperaquine (DHAPP) + SLDPQ vs. DHAPP alone recruited Cambodians aged >/=1 year with acute uncomplicated P. falciparum. Randomisation was 4:1 DHAPP+SLDPQ: DHAPP for G6PDd patients and 1:1 for G6PDn patients, according to the results of the qualitative fluorescent spot test. Definitive G6PD status was determined by genotyping. Day (D) 7 haemoglobin (Hb) concentration was the primary outcome measure. RESULTS: One hundred nine patients (88 males, 21 females), aged 4-76 years (median 23) were enrolled; 12 were G6PDd Viangchan (9 hemizygous males, 3 heterozygous females). Mean nadir Hb occurred on D7 [11.6 (range 6.4 horizontal line 15.6) g/dL] and was significantly lower (p = 0.040) in G6PDd (n = 9) vs. G6PDn (n = 46) DHAPP+SLDPQ recipients: 10.9 vs. 12.05 g/dL, Delta = -1.15 (95% CI: -2.24 horizontal line -0.05) g/dL. Three G6PDn patients had D7 Hb concentrations < 8 g/dL; D7-D0 Hbs were 6.4 horizontal line 6.9, 7.4 horizontal line 7.4, and 7.5 horizontal line 8.2 g/dL. For all patients, mean (range) D7-D0 Hb decline was -1.45 (-4.8 horizontal line 2.4) g/dL, associated significantly with higher D0 Hb, higher D0 parasitaemia, and receiving DHAPP; G6PDd was not a factor. No patient required a blood transfusion. CONCLUSIONS: DHAPP+SLDPQ was associated with modest Hb declines in G6PD Viangchan, a moderately severe variant. Our data augment growing evidence that SLDPQ in SE Asia is well tolerated and appears safe in G6PDd patients. Cambodia is now deploying SLDPQ and this should encourage other GMS countries to follow suit. TRIAL REGISTRATION: The reference number is NCT02434952 .

      2. Efficacy and safety of artemether-lumefantrine for the treatment of uncomplicated malaria and prevalence of Pfk13 and Pfmdr1 polymorphisms after a decade of using artemisinin-based combination therapy in mainland TanzaniaExternal
        Ishengoma DS, Mandara CI, Francis F, Talundzic E, Lucchi NW, Ngasala B, Kabanywanyi AM, Mahende MK, Kamugisha E, Kavishe RA, Muro F, Mohamed A, Mandike R, Mkude S, Chacky F, Paxton L, Greer G, Kitojo CA, Njau R, Martin T, Venkatesan M, Warsame M, Halsey ES, Udhayakumar V.
        Malar J. 2019 Mar 21;18(1):88.
        BACKGROUND: The World Health Organization recommends regular therapeutic efficacy studies (TES) to monitor the performance of first and second-line anti-malarials. In 2016, efficacy and safety of artemether-lumefantrine (AL) for the treatment of uncomplicated falciparum malaria were assessed through a TES conducted between April and October 2016 at four sentinel sites of Kibaha, Mkuzi, Mlimba, and Ujiji in Tanzania. The study also assessed molecular markers of artemisinin and lumefantrine (partner drug) resistance. METHODS: Eligible patients were enrolled at the four sites, treated with standard doses of AL, and monitored for 28 days with clinical and laboratory assessments. The main outcomes were PCR corrected cure rates, day 3 positivity rates, safety of AL, and prevalence of single nucleotide polymorphisms in Plasmodium falciparum kelch 13 (Pfk13) (codon positions: 440-600) and P. falciparum multi-drug resistance 1 (Pfmdr1) genes (codons: N86Y, Y184F and D1246Y), markers of artemisinin and lumefantrine resistance, respectively. RESULTS: Of 344 patients enrolled, three withdrew, six were lost to follow-up; and results were analysed for 335 (97.4%) patients. Two patients had treatment failure (one early treatment failure and one recrudescent infection) after PCR correction, yielding an adequate clinical and parasitological response of > 98%. Day 3 positivity rates ranged from 0 to 5.7%. Common adverse events included cough, abdominal pain, vomiting, and diarrhoea. Two patients had serious adverse events; one died after the first dose of AL and another required hospitalization after the second dose of AL (on day 0) but recovered completely. Of 344 samples collected at enrolment (day 0), 92.7% and 100% were successfully sequenced for Pfk13 and Pfmdr1 genes, respectively. Six (1.9%) had non-synonymous mutations in Pfk13, none of which had been previously associated with artemisinin resistance. For Pfmdr1, the NFD haplotype (codons N86, 184F and D1246) was detected in 134 (39.0%) samples; ranging from 33.0% in Mlimba to 45.5% at Mkuzi. The difference among the four sites was not significant (p = 0.578). All samples had a single copy of the Pfmdr1 gene. CONCLUSION: The study indicated high efficacy of AL and the safety profile was consistent with previous reports. There were no known artemisinin-resistance Pfk13 mutations, but there was a high prevalence of a Pfmdr1 haplotype associated with reduced sensitivity to lumefantrine (but no reduced efficacy was observed in the subjects). Continued TES and monitoring of markers of resistance to artemisinin and partner drugs is critical for early detection of resistant parasites and to inform evidence-based malaria treatment policies. Trial Registration NCT03387631.

      3. Field evaluation of malaria malachite green loop-mediated isothermal amplification in health posts in Roraima state, BrazilExternal
        Kudyba HM, Louzada J, Ljolje D, Kudyba KA, Muralidharan V, Oliveira-Ferreira J, Lucchi NW.
        Malar J. 2019 Mar 25;18(1):98.
        BACKGROUND: Microscopic detection of malaria parasites is the standard method for clinical diagnosis of malaria in Brazil. However, malaria epidemiological surveillance studies specifically aimed at the detection of low-density infection and asymptomatic cases will require more sensitive and field-usable tools. The diagnostic accuracy of the colorimetric malachite green, loop-mediated, isothermal amplification (MG-LAMP) assay was evaluated in remote health posts in Roraima state, Brazil. METHODS: Study participants were prospectively enrolled from health posts (healthcare-seeking patients) and from nearby villages (healthy participants) in three different study sites. The MG-LAMP assay and microscopy were performed in the health posts. Two independent readers scored the MG-LAMP tests as positive (blue/green) or negative (clear). Sensitivity and specificity of local microscopy and MG-LAMP were calculated using results of PET-PCR as a reference. RESULTS: A total of 91 participants were enrolled. There was 100% agreement between the two MG-LAMP readers (Kappa = 1). The overall sensitivity and specificity of MG-LAMP were 90.0% (95% confidence interval (CI) 76.34-97.21%) and 94% (95% CI 83.76-98.77%), respectively. The sensitivity and specificity of local microscopy were 83% (95% CI 67.22-92.66%) and 100% (95% CI 93.02-100.00%), respectively. PET-PCR detected six mixed infections (infection with both Plasmodium falciparum and Plasmodium vivax); two of these were also detected by MG-LAMP and one by microscopy. Microscopy did not detect any Plasmodium infection in the 26 healthy participants; MG-LAMP detected Plasmodium in five of these and PET-PCR assay detected infection in three. Overall, performing the MG-LAMP in this setting did not present any particular challenges. CONCLUSION: MG-LAMP is a sensitive and specific assay that may be useful for the detection of malaria parasites in remote healthcare settings. These findings suggest that it is possible to implement simple molecular tests in facilities with limited resources.

      4. Malaria parasite density in individuals with different rapid diagnostic test results and concentrations of HRP2 antigenExternal
        Plucinski MM, Dimbu R, Fortes F, Murphy SC, Smith NT, Cruz KR, Seilie AM, Halsey ES, Aidoo M, Rogier E.
        Am J Trop Med Hyg. 2019 Mar 25.
        Low-density malaria infections are a source of human morbidity in endemic settings and potentially contribute to ongoing malaria transmission. Conventional rapid diagnostic tests (RDTs) were designed to detect clinically relevant parasite and antigen levels, but it is largely unknown what proportion of parasite (and antigen positive) infections are missed by conventional RDTs. Furthermore, RDTs can also provide false positives from lingering histidine-rich protein 2 (HRP2) antigenemia from a past infection. We analyzed 207 samples from Angolan outpatients with a bead-based HRP2 antigen assay and by qRT-PCR for the presence of parasite nucleic acids. Among patients HRP2 positive but negative by conventional RDT, the rate of qRT-PCR positivity was 45% (95% CI: 35-56%), with a median parasitemia of 3.4 parasites/microL (interquartile range: 0.14-4.8). Only 15% (7-26%) of HRP2-negative samples were found to have parasite nucleic acids. A substantial proportion of persons with blood HRP2 antigen concentrations not detected by the conventional RDT were found to have evidence of active infection, but at low parasite density levels.

    • Physical Activity
      1. One hour a week: Moving to prevent disability in adults with lower extremity joint symptomsExternal
        Dunlop DD, Song J, Hootman JM, Nevitt MC, Semanik PA, Lee J, Sharma L, Eaton CB, Hochberg MC, Jackson RD, Kwoh CK, Chang RW.
        Am J Prev Med. 2019 Mar 13.
        INTRODUCTION: Physical activity guidelines recommend minimum thresholds. This study sought to identify evidence-based thresholds to maintain disability-free status over 4 years among adults with lower extremity joint symptoms. METHODS: Prospective multisite Osteoarthritis Initiative accelerometer monitoring cohort data from September 2008 through December 2014 were analyzed. Adults (n=1,564) aged >/=49 years at elevated disability risk because of lower extremity joint symptoms were analyzed for biennial assessments of disability-free status from gait speed >/=1meter/second (mobility disability-free) and self-report of no limitations in activities of daily living (activities of daily living disability-free). Classification tree analyses conducted in 2017-2018 identified optimal thresholds across candidate activity intensities (sedentary, light, moderate-vigorous, total light and moderate-vigorous activity, and moderate-vigorous accrued in bouts lasting >/=10 minutes). RESULTS: Minimal thresholds of 56 and 55 moderate-vigorous minutes/week best predicted disability-free status over 4 years from mobility and activities of daily living disabilities, respectively, across the candidate measures. Thresholds were consistent across sex, BMI, age, and knee osteoarthritis presence. Mobility disability onset was one eighth as frequent (3% vs 24%, RR=0.14, 95% CI=0.09, 0.20) and activities of daily living disability onset was almost half (12% vs 23%, RR=0.55, 95% CI=0.44, 0.70) among people above versus below the minimum threshold. CONCLUSIONS: Attaining an evidence-based threshold of approximately 1-hour moderate-vigorous activity/week significantly increased the likelihood of maintaining disability-free status over 4 years. This minimum threshold tied to maintaining independent living abilities has value as an intermediate goal to motivate adults to take action towards the many health benefits of a physically active lifestyle.

      2. Systematic review of how Play Streets impact opportunities for active play, physical activity, neighborhoods, and communitiesExternal
        Umstattd Meyer MR, Bridges CN, Schmid TL, Hecht AA, Pollack Porter KM.
        BMC Public Health. 2019 Mar 22;19(1):335.
        BACKGROUND: Active play and physical activity are important for preventing childhood obesity, building healthy bones and muscles, reducing anxiety and stress, and increasing self-esteem. Unfortunately, safe and accessible play places are often lacking in under-resourced communities. Play Streets (temporary closure of streets) are an understudied intervention that provide safe places for children, adolescents, and their families to actively play. This systematic review examines how Play Streets impact opportunities for children and adolescents to engage in safe active play and physical activity, and for communities and neighborhoods. Methods for evaluating Play Streets were also examined. METHODS: A systematic literature review was conducted in Academic Search Complete, CINHAL, PsycINFO, PubMED, Web of Science, and Google Scholar. Peer-reviewed intervention studies published worldwide were included if they were published in English, through December 2017 and documented free-to-access Play Streets or other temporary spaces that incorporated a designated area for children and/or adolescents to engage in active play. Systematic data extraction documented sample, implementation, and measurement characteristics and outcomes. RESULTS: Of 180 reviewed abstracts, 6 studies met inclusion criteria. Studies were conducted in five different countries (n = 2 in U.S.), using mostly cross-sectional study designs (n = 4). Physical activity outcomes were measured in half of the studies; one used observational and self-report measures, and two used device-based and self-report measures. In general, Play Streets provided safe places for child play, increased sense of community, and when measured, data suggest increased physical activity overall and during Play Streets. CONCLUSIONS: Play Streets can create safe places for children to actively play, with promise of increasing physical activity and strengthening community. Given the popularity of Play Streets and the potential impact for active play, physical activity, and community level benefits, more rigorous evaluations and systematic reporting of Play Streets’ evaluations are needed.

      3. National-level environmental perceptions and walking among urban and rural residents: Informing surveillance of walkabilityExternal
        Whitfield GP, Carlson SA, Ussery EN, Watson KB, Berrigan D, Fulton JE.
        Prev Med. 2019 Mar 13;123:101-108.
        Built environments that provide activity-friendly routes (e.g., sidewalks) to everyday destinations (e.g., shops) can increase physical activity. Surveillance of supports and destinations is important, and identifying which are associated with walking could prioritize surveillance questions. Our purpose was to identify the significant associations between supports and destinations with walking among a nationally-representative sample of urban- and rural-dwelling adults. Participants in the 2015 National Health Interview Survey, Cancer Control Supplement (n=29,925) reported the near-home presence of walkable supports (roads, sidewalks, paths, or trails; sidewalks on most streets), destinations (shops; transit; movies, libraries, or churches; relaxing places), and past-week walking for leisure or transportation. We used stepwise logistic regression to quantify associations between supports and destinations and walking, including by urban/rural residence. We calculated the prevalence of walking across counts of reported elements by urban/rural residence. Among all participants, roads, sidewalks, paths, or trails and relaxing destinations were associated with leisure walking. Among urban residents, sidewalks on most streets and all four destination types were associated with transportation walking; among rural residents, roads, sidewalks, paths, or trails; movies, libraries, or churches; and relaxing destinations were associated with transportation walking. Walking was more common when more environmental elements were reported. To improve efficiency, communities may match surveillance priorities to behavioral priorities (i.e., leisure versus transportation walking) and environmental context (i.e., urban/rural areas). Surveillance of environments supporting leisure walking might focus on recreation-oriented spaces. Surveillance of environments supporting transportation walking might differ for urban and rural areas, and assessing destinations may be particularly important.

    • Public Health Leadership and Management
      1. Public health workforce development needs: A national assessment of executives’ perspectivesExternal
        Leider JP, Coronado F, Bogaert K, Gould E.
        Am J Prev Med. 2019 Mar 15.
        INTRODUCTION: Workforce development is one of the ten essential public health services. Recent studies have better characterized individual worker perceptions regarding workforce interests and needs, but gaps remain around workforce needs from program managers’ perspectives. This study characterized management perspectives regarding subordinate’s abilities and training needs and perceived challenges to recruitment and retention. METHODS: In 2017, the Directors Assessment of Workforce Needs Survey was sent to 574 managers at state health agencies across the U.S. Respondents were invited based on the positions they held (i.e., to be included, respondents had to be employed as managers and oversee specific program areas). In 2018, descriptive statistics were calculated, including Fisher’s exact for inferential comparisons and Tukey’s test for multiple comparisons, as appropriate. RESULTS: Response rate was 49% after accounting for undeliverable e-mails; 226 respondents met the inclusion criteria. The largest perceived barriers to staff recruitment were wages or salaries (74%) and private sector competition (56%). Similarly, wages or salaries were identified as the main cause of turnover by 70% of respondents, followed by lack of opportunities for advancement (68%), and opportunities outside the agency (67%). CONCLUSIONS: The Directors Assessment of Workforce Needs Survey fills important knowledge gaps and complements previously identified evidence to guide refinement of workforce development efforts. Although competition from the private sector remains challenging, these findings indicate that recruitment and retention must be top priorities in state health agencies nationwide. Prioritizing individual state health agency workforce gaps and committing to provide specific local-level interventions to those priorities is crucial for individual health agencies.

      2. Road map for leadership and management in public health: a case study on noncommunicable diseases program managers’ training in RwandaExternal
        Muhimpundu MA, Joseph KT, Husain MJ, Uwinkindi F, Ntaganda E, Rwunganira S, Habiyaremye F, Niyonsenga SP, Bagahirwa I, Robie B, Bal DG, Billick LB.
        Int J Health Promot Educ. 2019 04 Mar;57(2):82-97.
        Ministries of Health (MoHs) and health organizations are compelled to work across sectors and build coalitions, strengthening health systems to abate the rise of noncommunicable diseases (NCDs). A critical element of NCD prevention and control involves significant and difficult changes in attitudes, policies and protective behavior at the population level. The population-level impact of NCD interventions depends on the strength of the health system that delivers them. In particular, low-resource settings are exploring efficiencies and linkages to existing systems or partnerships in ways that may alleviate redundancies and high delivery costs. These entail complex operational challenges, and can only be spearheaded by a competent and passionate workforce. There is a critical need to develop and strengthen the management and leadership skills of public health professionals so that they can take on the unique challenges of NCD prevention and control. An added component must include a shift from the traditional clinical approach to a community-based effort, focusing heavily on health education and community norm change. Strengthening the workforce capacity of program managers at MoHs and other implementing institutions is key to capturing, analyzing, advocating and communicating information and will, in turn, reinforce the scale-up of interventions fostering a robust health system. This paper summarizes the best practices and lessons learned from the NCD Program Managers short course conducted by the US Centers for Disease Control and Prevention (CDC) in December, 2016 in Rwanda.

      3. The state of the US governmental public health workforce, 2014-2017External
        Sellers K, Leider JP, Gould E, Castrucci BC, Beck A, Bogaert K, Coronado F, Shah G, Yeager V, Beitsch LM, Erwin PC.
        Am J Public Health. 2019 Mar 21:e1-e7.
        Public health workforce development efforts during the past 50 years have evolved from a focus on enumerating workers to comprehensive strategies that address workforce size and composition, training, recruitment and retention, effectiveness, and expected competencies in public health practice. We provide new perspectives on the public health workforce, using data from the Public Health Workforce Interests and Needs Survey, the largest nationally representative survey of the governmental public health workforce in the United States. Five major thematic areas are explored: workforce diversity in a changing demographic environment; challenges of an aging workforce, including impending retirements and the need for succession planning; workers’ salaries and challenges of recruiting new staff; the growth of undergraduate public health education and what this means for the future public health workforce; and workers’ awareness and perceptions of national trends in the field. We discussed implications for policy and practice. (Am J Public Health. Published online ahead of print March 21, 2019: e1-e7. doi:10.2105/AJPH.2019.305011).

    • Reproductive Health
      1. INTRODUCTION: Information, counseling, availability of contraceptives, and their adoption by post-abortion care (PAC) patients are central to the quality of PAC in healthcare facilities. Effective contraceptive adoption by these patients reduces the risks of unintended pregnancy and repeat abortion. METHODS: This study uses data from the Incidence and Magnitude of Unsafe Abortion Study of 2012 to assess the level and determinants of highly effective contraception among patients treated with complications from an unsafe abortion in healthcare facilities in Kenya. Highly effective contraception was defined as any method adopted by a PAC patient that reduces pregnancy rate by over 99%. RESULTS: Generally, contraceptive counseling was high among all PAC patients (90%). However, only 54% of them received a modern family planning method-45% a short-acting method and 9% a long-acting and permanent method. Adoption of highly effective contraception was determined by patient’s previous exposure to unintended pregnancies, induced abortion and modern family planning (FP). Facility level factors associated with the uptake of highly effective contraceptives included: facility ownership, availability of evacuation procedure room, whether the facility had a specialized obstetric-gynecologist, a facility that also had maternity services and the number of FP methods available for PAC patients. DISCUSSION AND CONCLUSION: For better adoption of highly effective FP, counseling of PAC patients requires an understanding of the patient’s past experience with contraception and their future fertility intentions and desires in order to meet their reproductive needs more specifically. Family planning integration with PAC can increase contraceptive uptake and improve the reproductive health of post-abortion care patients.

      2. Factors associated with postpartum use of long-acting reversible contraceptionExternal
        Oduyebo T, Zapata LB, Boutot ME, Tepper NK, Curtis KM, D’Angelo DV, Marchbanks PA, Whiteman MK.
        Am J Obstet Gynecol. 2019 Mar 15.
        BACKGROUND: Contraception use among postpartum women is important to prevent unintended pregnancies and optimize birth spacing. Long-acting reversible contraception (LARC), including intrauterine devices and implants, is highly effective, yet compared to less effective methods utilization rates are low. OBJECTIVES: We sought to estimate prevalence of LARC use among postpartum women and examine factors associated with LARC use among those using any reversible contraception. STUDY DESIGN: We analyzed 2012-2015 data from the Pregnancy Risk Assessment Monitoring System, a population-based survey among women with recent live births. We included data from 37 sites that achieved the minimum overall response rate threshold for data release. We estimated the prevalence of LARC use in our sample (n=143,335). We examined maternal factors associated with LARC use among women using reversible contraception (n=97,013) using multivariable logistic regression (LARC versus other type of reversible contraception) and multinomial regression (LARC versus other hormonal contraception and LARC versus other non-hormonal contraception). RESULTS: The prevalence of LARC use overall was 15.3%. Among postpartum women using reversible contraception, 22.5% reported LARC use, which varied by site, ranging from 11.2% in New Jersey to 37.6% in Alaska. Factors associated with postpartum LARC use versus use of another reversible contraceptive method included: age </=24 years (adjusted odds ratio [AOR] = 1.43; 95% confidence interval [CI] = 1.33-1.54) and >35 years (AOR = 0.87; 95 % CI = 0.80-0.96) versus 25-34 years; public insurance (AOR = 1.15; 95% CI = 1.08-1.24) and no insurance (AOR = 0.73; 95% CI = 0.55-0.96) versus private insurance at delivery; having a recent unintended pregnancy (AOR = 1.44; 95% CI=1.34-1.54) or being ambivalent about the recent pregnancy (AOR = 1.29; 95% CI=1.18-1.40) versus recent pregnancy intended; having >/=1 previous live birth (AOR = 1.40; 95% CI = 1.31-1.48) and having a postpartum check-up after recent live birth (AOR = 2.70; 95% CI = 2.35-3.11). Hispanic and non-Hispanic black postpartum women had a higher rate of LARC use (26.6% and 23.4% respectively) compared to non-Hispanic white women (21.5%),and there was significant race/ethnicity interaction with educational level. CONCLUSIONS: Nearly one in six (15.3%) postpartum women with a recent live birth and nearly one in four (22.5%) postpartum women using reversible contraception reported LARC use. Our analysis suggests that factors such as age, race/ethnicity, education, insurance, parity, intendedness of recent pregnancy, and postpartum visit attendance may be associated with postpartum LARC use. Ensuring all postpartum women have access to the full range of contraceptive methods, including LARC, is important to prevent unintended pregnancy and optimize birth spacing. Contraceptive access may be improved by public health efforts and programs that address barriers in the postpartum period, including increasing awareness of the availability, effectiveness, and safety of LARC (and other methods), as well as providing full reimbursement for contraceptive services, and removal of administrative and logistic barriers.

      3. Postpartum hormonal contraception use and incidence of postpartum depression: a systematic reviewExternal
        Ti A, Curtis KM.
        Eur J Contracept Reprod Health Care. 2019 Mar 28:1-8.
        PURPOSE: To evaluate the association between postpartum hormonal contraceptive use and postpartum depression. MATERIALS AND METHODS: We searched the literature through March 2018 on the association between postpartum hormonal contraception use and incident postpartum depression. We used the United States Preventive Services Task Force framework to assess study quality. RESULTS: Of 167 articles identified, four met inclusion criteria. Two studies found no differences in rates of postpartum depression between women using postpartum depot medroxyprogesterone and those not using hormonal contraception; however, a study of women receiving injectable norethisterone enanthate immediately postpartum found a 2-3-fold increased risk of depression at 6 weeks, though not at 3 months. One study compared combined hormonal contraception, progestin-only pills (POPs), etonogestrel implants and levonorgestrel intrauterine devices (LNG-IUDs) with no hormonal contraception, and found a 35-44% decreased risk of postpartum depression with POPs and LNG-IUDs, a small increased risk of postpartum antidepressant use among women using the etonogestrel implant and vaginal ring, and a decreased risk of antidepressant use with POPs. CONCLUSIONS: Limited evidence found no consistent associations between hormonal contraceptive use and incidence of postpartum depression. Future research would be strengthened by using validated diagnostic measures, careful consideration of confounders, and ensuring adequate follow-up time.

    • Substance Use and Abuse
      1. Variability in urine dilution complicates urine cannabinoid test interpretation. Normalizing urine cannabinoid concentrations to specific gravity (SG) or creatinine was proposed to account for donors’ hydration states. In this study, all urine voids were individually collected from eight frequent and eight occasional cannabis users for up to 85 hours after each received on separate occasions 50.6 mg Delta9-tetrahydrocannabinol (THC) by smoking, vaporization, and oral ingestion in a randomized, within-subject, double-blind, double-dummy, placebo-controlled protocol. Each urine void was analyzed for 11 cannabinoids and phase I and II metabolites by liquid chromatography-tandem mass spectrometry (LC-MS/MS), SG, and creatinine. Normalized urine concentrations were log10 transformed to create normal distributions, and Pearson correlation coefficients determined the degree of association between the two normalization methods. Repeated-measures linear regression determined if the degree of association differed by frequent or occasional cannabis use, or route of administration after adjusting for gender and time since dosing. Of 1880 urine samples examined, only 11-nor-9-carboxy-THC (THCCOOH), THCCOOH-glucuronide, THC-glucuronide, and 11-nor-9-carboxy-Delta9-tetrahydrocannabivarin (THCVCOOH) were greater than the method’s limits of quantification (LOQs). Associations between SG- and creatinine-normalized concentrations exceeded 0.90. Repeated-measures regression analysis found small but statistically significant differences in the degree of association between normalization methods for THCCOOH and THCCOOH-glucuronide in frequent vs occasional smokers, and in THCVCOOH and THC-glucuronide by route of administration. For the first time, SG- and creatinine-normalized urine cannabinoid concentrations were evaluated in frequent and occasional cannabis users and following oral, smoked, and inhaled cannabis. Both normalization methods reduced variability, improving the interpretation of urine cannabinoid concentrations and methods were strongly correlated.

      2. US emergency department visits for acute harms from prescription opioid use, 2016-2017External
        Lovegrove MC, Dowell D, Geller AI, Goring SK, Rose KO, Weidle NJ, Budnitz DS.
        Am J Public Health. 2019 Mar 21:e1-e8.
        OBJECTIVES: To estimate the number of US emergency department visits for prescription opioid harms by patient characteristics, intent, clinical manifestations, and active ingredient. METHODS: We used data from medical record-based surveillance from a nationally representative 60-hospital sample. RESULTS: Based on 7769 cases, there were 267 020 estimated emergency department visits annually (95% confidence interval [CI] = 209 833, 324 206) for prescription opioid harms from 2016 to 2017. Nearly half of visits (47.6%; 95% CI = 40.8%, 54.4%) were attributable to nonmedical opioid use, 38.9% (95% CI = 32.9%, 44.8%) to therapeutic use, and 13.5% (95% CI = 11.0%, 16.0%) to self-harm. Co-implication with other pharmaceuticals and concurrent illicit drug and alcohol use were common; prescription opioids alone were implicated in 31.5% (95% CI = 27.2%, 35.8%) of nonmedical use visits and 19.7% (95% CI = 15.7%, 23.7%) of self-harm visits. Unresponsiveness or cardiorespiratory failure (30.0%) and altered mental status (35.7%) were common in nonmedical use visits. Gastrointestinal effects (30.4%) were common in therapeutic use visits. Oxycodone was implicated in more than one third of visits across intents. CONCLUSIONS: Morbidity data can help target interventions, such as dispensing naloxone to family and friends of those with serious overdose, and screening and treatment of substance use disorder when opioids are prescribed long-term. (Am J Public Health. Published online ahead of print March 21, 2019: e1-e8. doi:10.2105/AJPH.2019.305007).

      3. E-cigarettes and young people: Communicating an emerging public health riskExternal
        Mitchko J, Lewis S, Marynak KL, Shannon C, Burnette D, King BA.
        Am J Health Promot. 2019 Mar 14:890117119835519.
        E-cigarettes are the most commonly used tobacco product among US youth. Most e-cigarettes contain nicotine, which can cause addiction and can harm the developing adolescent brain. In coordination with the release of a Surgeon General’s Report on e-cigarette use among young people, the Centers for Disease Control and Prevention collaborated with the Office of the Surgeon General to launch a campaign to educate parents, youth influencers, and young people about the risks of e-cigarettes. This article describes the development of communication products, including innovative media, about this public health risk, and shares lessons learned to inform public health practice.

      4. Identifying opioid prescribing patterns for high-volume prescribers via cluster analysisExternal
        Nataraj N, Zhang K, Guy GP, Losby JL.
        Drug Alcohol Depend. 2019 Apr 1;197:250-254.
        OBJECTIVE: Despite recent decreases in opioid prescribing rates, evidence suggests there is substantial variation in the way opioids are prescribed by providers. This study aims to identify patterns in high-volume opioid prescribing. METHODS: We conducted partitioning-around-medoids cluster analysis using the IQVIA Prescriber Profile dataset, including the number of opioid prescriptions filled at US retail pharmacies aggregated at the prescriber-level from July 2016 through June 2017. Clustering was used to identify prescription patterns within a sample of 10,000 high-volume opioid prescribers (defined as the top 10% of prescribers by number of opioid prescriptions during the 12-month period). Clustering variables included prescription counts by opioid type, and prescriber specialty, age, and region. RESULTS: Family medicine (32%), internal medicine (23%), and orthopedics (11%) were the most common high-volume prescribing specialties. Across specialties, hydrocodone and oxycodone were the most-frequently prescribed opioid types. Thirty-five clusters of prescribers were obtained, consistently comprised of a single majority specialty and region. All majority high-prescribing specialties were represented in Southern clusters, indicating consistently high volume opioid prescribing across specialties in the region. Prescribing patterns varied by drug type and region – across every Northeastern cluster, oxycodone prescribing was higher than hydrocodone. While clusters of pain medicine specialists had the highest median total prescriptions, emergency medicine specialist clusters had some of the lowest. CONCLUSIONS: These results provide a clearer picture of current patterns among high-volume prescribers, who accounted for almost two-thirds of all opioid prescriptions. In light of the ongoing opioid overdose epidemic, this knowledge is critical for prevention activities.

      5. Trends and patterns of geographic variation in opioid prescribing practices by state, United States, 2006-2017External
        Schieber LZ, Guy GP, Seth P, Young R, Mattson CL, Mikosz CA, Schieber RA.
        JAMA Netw Open. 2019 Mar 1;2(3):e190665.
        Importance: Risk of opioid use disorder, overdose, and death from prescription opioids increases as dosage, duration, and use of extended-release and long-acting formulations increase. States are well suited to respond to the opioid crisis through legislation, regulations, enforcement, surveillance, and other interventions. Objective: To estimate temporal trends and geographic variations in 6 key opioid prescribing measures in 50 US states and the District of Columbia. Design, Setting, and Participants: Population-based cross-sectional analysis of opioid prescriptions filled nationwide at US retail pharmacies between January 1, 2006, and December 31, 2017. Data were obtained from the IQVIA Xponent database. All US residents who had an opioid prescription filled at a US retail pharmacy were included. Main Outcomes and Measures: Primary outcomes were annual amount of opioids prescribed in morphine milligram equivalents (MME) per person; mean duration per prescription in days; and 4 separate prescribing rates-for prescriptions 3 or fewer days, those 30 days or longer, those with a high daily dosage (>/=90 MME), and those with extended-release and long-acting formulations. Results: Between 2006 and 2017, an estimated 233.7 million opioid prescriptions were filled in retail pharmacies in the United States each year. For all states combined, 4 measures decreased: (1) mean (SD) amount of opioids prescribed (mean [SD] decrease, 12.8% [12.6%]) from 628.4 (178.0) to 543.4 (158.6) MME per person, a statistically significant decrease in 23 states; (2) high daily dosage (mean [SD] decrease, 53.1% [13.6%]) from 12.3 (3.4) to 5.6 (1.7) per 100 persons, a statistically significant decrease in 49 states; (3) short-term (</=3 days) duration (mean [SD] decrease, 43.1% [9.4%]) from 18.0 (5.4) to 10.0 (2.5) per 100 persons, a statistically significant decrease in 48 states; and (4) extended-release and long-acting formulations (mean [SD] decrease, 14.7% [13.7%]) from 7.2 (1.9) to 6.0 (1.7) per 100 persons, a statistically significant decrease in 27 states. Two measures increased, each associated with the duration of prescription dispensed: (1) mean (SD) prescription duration (mean [SD] increase, 37.6% [6.9%]) from 13.0 (1.2) to 17.9 (1.4) days, a statistically significant increase in every state; and (2) prescriptions for a term of 30 days or longer (mean [SD] increase, 37.7% [28.9%]) from 18.3 (7.7) to 24.9 (10.7) per 100 persons, a statistically significant increase in 39 states. Two- to 3-fold geographic differences were observed across states, measured by comparing the ratio of each state’s 90th to 10th percentile for each measure. Conclusions and Relevance: In this study, across 12 years, the mean duration and prescribing rate for long-term prescriptions of opioids increased, whereas the amount of opioids prescribed per person and prescribing rate for high-dosage prescriptions, short-term prescriptions, and extended-release and long-acting formulations decreased. Some decreases were significant, but results were still high. Two- to 3-fold state variation in 5 measures occurred in most states. This information may help when state-specific intervention programs are being designed.

      6. Attitudes toward smoke-free casino policies among US adults, 2017External
        Tynan MA, Wang TW, Marynak KL, Lemos P, Babb SD.
        Public Health Rep. 2019 Mar 21:33354919834581.
        Research shows that there is no risk-free level of exposure to secondhand smoke (SHS) and that eliminating smoking indoors fully protects nonsmokers from indoor SHS exposure. Casinos often allow smoking indoors and can be a source of involuntary SHS exposure for employees and visitors. We examined attitudes toward smoke-free casino policies among US adults. During June and July 2017, we used a web-based survey to ask a nationally representative sample of 4107 adults aged >/=18 about their attitudes toward smoke-free casinos. Among 4048 respondents aged >/=18, a weighted 75.0% favored smoke-free casino policies, including respondents who visited casinos about once per year (74.1%), several times per year (75.3%), and at least once per month (74.2%). Although the sociodemographic characteristics of respondents who favored smoke-free casino policies varied, the majority in each group, except current smokers (45.4%), supported smoke-free policies. Allowing smoking inside casinos involuntarily exposes casino employees and visitors to SHS, a known and preventable health risk. Further assessment of public knowledge and attitudes toward smoke-free casinos at state and local levels may help inform tobacco control policy, planning, and practice.

      7. A spatial exploration of changes in drug overdose mortality in the United States, 2000-2016External
        Wilt GE, Lewis BE, Adams EE.
        Prev Chronic Dis. 2019 Mar 21;16:E33.

        [No abstract]

    • Vital Statistics
      1. BACKGROUND: The 2003 revision of the standard United States death certificate included a set of “pregnancy checkboxes” to ascertain whether a woman was pregnant at the time of her death or within the preceding year. Studies validating the pregnancy checkbox have indicated a potentially high number of errors, resulting in inflated maternal mortality rates. In response to concerns about pregnancy checkbox data quality, four state health departments implemented a quality assurance pilot project examining the accuracy of the pregnancy checkbox for 2016 deaths. METHODS: State staff conducted searches for birth or fetal death reports that matched a death certificate, within a year of death. If a pregnancy checkbox was marked, but no match was found between certificates, confirmation of the pregnancy was attempted through active follow-up with the death certifier. From December 2017 to January 2018, the quality assurance pilot was evaluated through three focus groups with key stakeholders. The evaluation aimed to describe opportunities and challenges to implementation, sustainability, and lessons learned. RESULTS: Opportunities for implementing the pilot included written documentation of the quality assurance process, improved certifier response, improved data quality, and increased data timeliness for Maternal Mortality Review Committees. Challenges included initial delays in certifier response, staff turnover, high caseloads in relation to resources, and lack of pilot prioritization in the health department. All four pilot states plan to sustain the pregnancy checkbox quality assurance process in some capacity. CONCLUSIONS: Implementing quality assurance processes for the pregnancy checkbox may ultimately improve state and national maternal death data quality.

    • Zoonotic and Vectorborne Diseases
      1. Community perspectives on contraception in the context of the Zika virus in the U.S. Virgin Islands: Implications for communication and messagingExternal
        Brittain AW, August EM, Romero L, Sheahan M, Krashin J, Ntansah C, Honein MA, Jamieson DJ, Ellis EM, Davis MS, Lathrop E.
        Womens Health Issues. 2019 Mar 13.
        BACKGROUND: Between January and October 2016, 575 symptomatic confirmed cases of Zika virus infection were reported in the U.S. Virgin Islands (USVI). Zika virus infection during pregnancy can cause serious birth defects. Preventing unintended pregnancy among women who choose to delay or avoid pregnancy is a primary strategy to reduce these adverse outcomes. METHODS: A rapid assessment, using one men’s and five women’s focus groups (N = 43), was conducted to inform communication efforts to increase awareness of contraception as a means for preventing unintended pregnancy in the context of a Zika outbreak in the USVI. RESULTS: Findings showed that people of reproductive age were aware of the relationship between Zika virus infection during pregnancy and adverse birth outcomes. However, when discussing methods for prevention, participants did not include preventing unintended pregnancy as a strategy to reduce these adverse outcomes. When asked about family planning in the USVI, participants discussed that, for some, planning pregnancies is not common. Participants wanted communications about contraception to include available methods, side effects, costs, and safety. Optimal communication channels included social media and local spokespersons. Participants identified health care providers as a trusted information source. CONCLUSIONS: Findings from this assessment informed the design of a culturally appropriate communication strategy to raise awareness of the prevention of unintended pregnancy as a primary strategy to reduce Zika-related adverse birth outcomes in the USVI.

      2. Clinicians who treat children with neurodevelopmental disabilities may encounter infants with congenital Zika syndrome or those exposed to Zika virus (ZIKV), either in utero or postnatally, in their practice and may have questions about diagnosis, management, and prognosis. In this special report, we reviewed the current literature to provide a comprehensive understanding of the findings and needs of children exposed to ZIKV in utero and postnatally. The current literature is sparse, and thus, this review is preliminary. We found that infants and children exposed to ZIKV in utero have a variety of health and developmental outcomes that suggest a wide range of lifelong physical and developmental needs. Postnatal exposure does not seem to have significant long-lasting health or developmental effects. We provide a comprehensive examination of the current knowledge on health and developmental care needs in children exposed to Zika in utero and postnatally. This can serve as a guide for health care professionals on the management and public health implications of this newly recognized population.

      3. Depressive symptoms and care demands among primary caregivers of young children with evidence of congenital Zika virus infection in BrazilExternal
        Kotzky K, Allen JE, Robinson LR, Satterfield-Nash A, Bertolli J, Smith C, Ornelas Pereira I, Faria e Silva Santelli AC, Peacock G.
        J Dev Behav Pediatr. 2019 Mar 26.
        OBJECTIVE: Evidence suggests that caring for a child with special health care needs can affect many domains of family life, including caregiver mental health. However, few studies have examined these outcomes among families impacted by the Zika virus (ZIKV). This study examines depressive symptom severity and care demands among primary caregivers of children, aged 15 to 26 months, with evidence of congenital Zika virus infection (ZVI). METHODS: A sample of primary caregivers of children with evidence of congenital ZVI in northeastern Brazil (n = 150) reported on depressive symptoms, care demands, and their children’s development. Children were categorized into groups according to their developmental delay status. Bivariate analyses were run to test for differences between groups. A path analysis model was used to examine the indirect effects of developmental delay on depressive symptoms through economic challenges and time spent providing health care at home and whether these associations varied by child care support. RESULTS: Compared to primary caregivers of children without developmental delay, primary caregivers of children with developmental delay had higher depression scores (p = 0.002), reported more economic (p < 0.001) and child care (p < 0.001) challenges, and spent more time providing health care at home (p < 0.001). Among primary caregivers who did not have child care support, developmental delay had a significant indirect effect on depressive symptoms through economic challenges but not through time spent providing health care at home. CONCLUSION: For families impacted by the ZIKV outbreak in Brazil, economic and child care challenges may be associated with primary caregiver mental health.

      4. Notes from the Field: Investigation of Colorado tick fever virus disease cases – Oregon, 2018External
        McDonald E, George D, Rekant S, Curren E, DeBess E, Hedberg K, Lutz J, Faith J, Kaisner H, Fawcett R, Sherer R, Kanyuch R, Gudmundsson A, Gardner N, Salt M, Kosoy O, Velez J, Staples E, Fischer M, Gould C.
        MMWR Morb Mortal Wkly Rep. 2019 Mar 29;68(12):289-290.

        [No abstract]

      5. Marburg virus disease outbreak in Kween District Uganda, 2017: Epidemiological and laboratory findingsExternal
        Nyakarahuka L, Shoemaker TR, Balinandi S, Chemos G, Kwesiga B, Mulei S, Kyondo J, Tumusiime A, Kofman A, Masiira B, Whitmer S, Brown S, Cannon D, Chiang CF, Graziano J, Morales-Betoulle M, Patel K, Zufan S, Komakech I, Natseri N, Chepkwurui PM, Lubwama B, Okiria J, Kayiwa J, Nkonwa IH, Eyu P, Nakiire L, Okarikod EC, Cheptoyek L, Wangila BE, Wanje M, Tusiime P, Bulage L, Mwebesa HG, Ario AR, Makumbi I, Nakinsige A, Muruta A, Nanyunja M, Homsy J, Zhu BP, Nelson L, Kaleebu P, Rollin PE, Nichol ST, Klena JD, Lutwama JJ.
        PLoS Negl Trop Dis. 2019 Mar;13(3):e0007257.
        INTRODUCTION: In October 2017, a blood sample from a resident of Kween District, Eastern Uganda, tested positive for Marburg virus. Within 24 hour of confirmation, a rapid outbreak response was initiated. Here, we present results of epidemiological and laboratory investigations. METHODS: A district task force was activated consisting of specialised teams to conduct case finding, case management and isolation, contact listing and follow up, sample collection and testing, and community engagement. An ecological investigation was also carried out to identify the potential source of infection. Virus isolation and Next Generation sequencing were performed to identify the strain of Marburg virus. RESULTS: Seventy individuals (34 MVD suspected cases and 36 close contacts of confirmed cases) were epidemiologically investigated, with blood samples tested for MVD. Only four cases met the MVD case definition; one was categorized as a probable case while the other three were confirmed cases. A total of 299 contacts were identified; during follow- up, two were confirmed as MVD. Of the four confirmed and probable MVD cases, three died, yielding a case fatality rate of 75%. All four cases belonged to a single family and 50% (2/4) of the MVD cases were female. All confirmed cases had clinical symptoms of fever, vomiting, abdominal pain and bleeding from body orifices. Viral sequences indicated that the Marburg virus strain responsible for this outbreak was closely related to virus strains previously shown to be circulating in Uganda. CONCLUSION: This outbreak of MVD occurred as a family cluster with no additional transmission outside of the four related cases. Rapid case detection, prompt laboratory testing at the Uganda National VHF Reference Laboratory and presence of pre-trained, well-prepared national and district rapid response teams facilitated the containment and control of this outbreak within one month, preventing nationwide and global transmission of the disease.

      6. Spatiotemporal incidence of Zika and associated environmental drivers for the 2015-2016 epidemic in ColombiaExternal
        Siraj AS, Rodriguez-Barraquer I, Barker CM, Tejedor-Garavito N, Harding D, Lorton C, Lukacevic D, Oates G, Espana G, Kraemer MU, Manore C, Johansson MA, Tatem AJ, Reiner RC, Perkins TA.
        Sci Data. 2018 Apr 24;5:180073.
        Despite a long history of mosquito-borne virus epidemics in the Americas, the impact of the Zika virus (ZIKV) epidemic of 2015-2016 was unexpected. The need for scientifically informed decision-making is driving research to understand the emergence and spread of ZIKV. To support that research, we assembled a data set of key covariates for modeling ZIKV transmission dynamics in Colombia, where ZIKV transmission was widespread and the government made incidence data publically available. On a weekly basis between January 1, 2014 and October 1, 2016 at three administrative levels, we collated spatiotemporal Zika incidence data, nine environmental variables, and demographic data into a single downloadable database. These new datasets and those we identified, processed, and assembled at comparable spatial and temporal resolutions will save future researchers considerable time and effort in performing these data processing steps, enabling them to focus instead on extracting epidemiological insights from this important data set. Similar approaches could prove useful for filling data gaps to enable epidemiological analyses of future disease emergence events.

      7. Chronic Q fever with vascular involvement: Progressive abdominal pain in a patient with aortic aneurysm repair in the United StatesExternal
        Wiley Z, Reddy S, Jacobs Slifka KM, Brandon DC, Jernigan J, Kersh GJ, Armstrong PA.
        Case Rep Infect Dis. 2019 ;2019:5369707.
        Q fever is a zoonotic bacterial infection caused by Coxiella burnetii. Chronic Q fever comprises less than five percent of all Q fever cases and, of those, endocarditis is the most common presentation (up to 78% of cases), followed by vascular involvement. Risk factors for chronic Q fever with vascular involvement include previous vascular surgery, preexisting valvular defects, aneurysms, and vascular prostheses. The most common symptoms of chronic Q fever with vascular involvement are nonspecific, including weight loss, fatigue, and abdominal pain. Criteria for diagnosis of chronic Q fever include clinical evidence of infection and laboratory criteria (antibody detection, detection of Coxiella burnetii DNA, or growth in culture). Treatment of chronic Q fever with vascular involvement includes a prolonged course of doxycycline and hydroxychloroquine (>/=18 months) as well as early surgical intervention, which has been shown to improve survival. Mortality is high in untreated chronic Q fever. We report a case of chronic Q fever with vascular involvement in a 77-year-old man with prior infrarenal aortic aneurysm repair, who lived near a livestock farm in the southeastern United States.

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

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