Volume 11, Issue 15 April 16, 2019

CDC Science Clips: Volume 11, Issue 15, April 16, 2019

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

This issue features scientific articles related to April’s CDC Public Health Grand Rounds, Building Local Response Capacity to Protect Families from Emerging Health Threats.

  1. CDC Public Health Grand Rounds
    • Disaster Control and Emergency Services – Building Local Response Capacity to Protect Families from Emerging Health Threats
      1. 2018 U.S. Virgin Islands Zika health brigade: Providing recommended pediatric health screenings for infants born to mothers with laboratory evidence of Zika virus exposure during pregnancyExternal
        Hillman B, Petersen DN, Galang RR, Godfred-Cato S, Mayers C, Thomas Y, Prosper A, Hawley J, Halbert M, Noe M, Reynolds M, Schoelles D, Brown-Shuler L, Fehrenbach N, Ellis EM.
        Birth Defects Res. 2019 Apr 15;111(7):360-362.

        [No abstract]

      2. Disaster Response 2.0: Noncommunicable Disease Essential Needs Still UnmetExternal
        Horn RB, Kirsch TD.
        Am J Public Health. 2018 Sep;108(S3):S202-s203.

        [No abstract]

      3. Public Health System Response to Extreme Weather EventsExternal
        Hunter MD, Hunter JC, Yang JE, Crawley AW, Aragon TJ.
        J Public Health Manag Pract. 2016 Jan-Feb;22(1):E1-10.
        CONTEXT: Extreme weather events, unpredictable and often far-reaching, constitute a persistent challenge for public health preparedness. OBJECTIVE: The goal of this research is to inform public health systems improvement through examination of extreme weather events, comparing across cases to identify recurring patterns in event and response characteristics. DESIGN: Structured telephone-based interviews were conducted with representatives from health departments to assess characteristics of recent extreme weather events and agencies’ responses. Response activities were assessed using the Centers for Disease Control and Prevention Public Health Emergency Preparedness Capabilities framework. Challenges that are typical of this response environment are reported. SETTING: Forty-five local health departments in 20 US states. RESULTS: Respondents described public health system responses to 45 events involving tornadoes, flooding, wildfires, winter weather, hurricanes, and other storms. Events of similar scale were infrequent for a majority (62%) of the communities involved; disruption to critical infrastructure was universal. Public Health Emergency Preparedness Capabilities considered most essential involved environmental health investigations, mass care and sheltering, surveillance and epidemiology, information sharing, and public information and warning. Unanticipated response activities or operational constraints were common. CONCLUSIONS: We characterize extreme weather events as a “quadruple threat” because (1) direct threats to population health are accompanied by damage to public health protective and community infrastructure, (2) event characteristics often impose novel and pervasive burdens on communities, (3) responses rely on critical infrastructures whose failure both creates new burdens and diminishes response capacity, and (4) their infrequency and scale further compromise response capacity. Given the challenges associated with extreme weather events, we suggest opportunities for organizational learning and preparedness improvements.

      4. INTRODUCTION: Research has shown that partnerships between public health agencies, service providers, and other key stakeholders can expand resources and facilitate focus on community health issues more effectively than can any agency or organization acting alone. There is, however, little empirical evidence drawn from actual public health emergency responses to support this claim. The US response to novel influenza A (H1N1) virus provided the Centers for Disease Control and Prevention (CDC) the opportunity to explore whether, and the extent to which, state, local and territorial health departments strengthened partnerships with key partner agencies and sectors. METHODS: Participants included the CDC Public Health Emergency Response (PHER) grantees comprised of 62 state, territorial and local health departments. PHER grantees completed an assessment instrument in May 2011, including questions asking them to rate their partnership strength (on a four-point ordinal scale) with six types of partners before and after the H1N1 response. Grantees additionally reported if and how PHER funding contributed to enhancing the strength of these partnerships. RESULTS: Sixty-one PHER grantees (61/62, 98%) completed the assessment instrument’s partnerships section. PHER grantees reported that their partnerships with retail pharmacies were most strengthened (mean increase = 1.11 (on a four-point ordinal scale), SD = .82). This was followed by schools (K-12) (mean increase = .90, SD = .58); private medical providers (mean increase = .81, SD = .68); immunization authorities (mean increase = .80, SD = .61); main education authorities (mean increase = .75, SD = .68); and businesses (mean increase = .74, SD = .61). Mean PHER grantee increases in the strength of each partner type were statistically significant for all partner types (P < .01). Grantees reported that PHER funding contributed to enhancing the strength of their partnerships with schools most frequently (46/46, 100%), and businesses least frequently (31/37, 83.8%). CONCLUSIONS: This inquiry provides evidence that state, territorial, and local health department partnerships with key sectors, agencies, and programs were strengthened after the H1N1 response. It further demonstrates that the CDC’s PHER funding contributed to the health departments’ reports of increased partnership strength.

      5. Like most public managers nowadays, local emergency managers operate within complex, uncertain environments. Rapid changes in the scope and severity of the issues increase the extent of intergovernmental collaboration necessary to address such challenges. Using a large data set of county emergency management agency directors, variations in intergovernmental collaboration reflect influences from problem severity, managerial capacity, and structural factors. The results demonstrate that public managers who perceive problems as severe, possess specific managerial skills, lead high-capacity organizations, and operate in less complex agency structures collaborate more often and more effectively across governmental boundaries.

      6. Assessment of State, Local, and Territorial Zika Planning and Preparedness Activities – United States, June 2016-July 2017External
        Murthy BP, Vagi S, Desamu-Thorpe R, Avchen R.
        MMWR Morb Mortal Wkly Rep. 2018 Sep 7;67(35):969-973.
        The emergency response to Zika virus disease required coordinated efforts and heightened collaboration among federal, state, local, and territorial public health jurisdictions. CDC activated its Emergency Operations Center on January 21, 2016, with seven task forces to support the national response. The State Coordination Task Force, which functions as a liaison between jurisdictions and federal operations during a response, coordinated the development of CDC Guidelines for Development of State and Local Risk-based Zika Action Plans, which included a Zika Preparedness Checklist (1). The checklist summarized recommendations covering topics from the seven task forces. In July 2016, CDC’s Office of Public Health Preparedness and Response (OPHPR) awarded $25 million in supplemental funding to 53 jurisdictions (41 states, eight territories, and four metropolitan areas) to support Zika preparedness and response activities. In December 2016, CDC awarded an additional $25 million to 21 of the 53 jurisdictions at the greatest risk for seeing Zika in their communities based on the presence of the mosquito responsible for spreading Zika, history of local transmission, or a high volume of travelers from Zika-affected areas. The additional $25 million was part of the $350 million in Zika supplemental funding provided to CDC by Congress in 2016* (2,3). Funded jurisdictions reported progress through the checklist at five quarterly points throughout the response. Data were analyzed to assess planning and response activities. Among the 53 jurisdictions, the percentage that reported having a Zika virus readiness, response, and recovery plan increased from 26% in June 2016 to 64% in July 2017. Overall, Zika planning and response activities increased among jurisdictions from June 2016 to July 2017. The recent Zika virus outbreak underscores the importance of strengthening state, local, and territorial health department capacity for rapid response to emerging threats.

      7. Application of the Incident Command System to the Hospital Biocontainment Unit SettingExternal
        Sauer LM, Romig M, Andonian J, Flinn JB, Hynes N, Maloney R, Maragakis LL, Garibaldi B.
        Health Secur. 2019 Jan/Feb;17(1):27-34.
        High-consequence pathogens create a unique problem. To provide effective treatment for infected patients while providing safety for the community, a series of 10 high-level isolation units have been created across the country; they are known as Regional Ebola and Special Pathogen Treatment Centers (RESPTCs). The activation of a high-level isolation unit is a highly resource-intensive activity, with effects that ripple across the healthcare system. The incident command system (ICS), a standard tool for command, control, and coordination in domestic emergencies, is a command structure that may be useful in a biocontainment event. A version of this system, the hospital emergency incident command system, provides an adaptable all-hazards approach in healthcare delivery systems. Here we describe its utility in an operational response to safely care for a patient(s) infected with a high-consequence pathogen on a high-level isolation unit. The Johns Hopkins Hospital created a high-level isolation unit to manage the comprehensive and complex needs of patients with high-consequence infectious diseases, including Ebola virus disease. The unique challenges of and opportunities for providing care in this high-level isolation unit led the authors to modify the hospital incident command system model for use during activation. This system has been tested and refined during full-scale functional and tabletop exercises. Lessons learned from the after-action reviews of these exercises led to optimization of the structure and implementation of ICS on the biocontainment unit, including improved job action sheets, designation of physical location of roles, and communication approaches. Overall, the adaptation of ICS for use in the high-level isolation unit setting may be an effective approach to emergency management during an activation.

      8. Community Assessment for Public Health Emergency Response (CASPER): An Innovative Emergency Management Tool in the United StatesExternal
        Schnall A, Nakata N, Talbert T, Bayleyegn T, Martinez D, Wolkin A.
        Am J Public Health. 2017 Sep;107(S2):S186-s192.
        OBJECTIVES: To demonstrate how inclusion of the Centers for Disease Control and Prevention’s Community Assessment for Public Health Emergency Response (CASPER) as a tool in Public Health Preparedness Capabilities: National Standards for State and Local Planning can increase public health capacity for emergency response. METHODS: We reviewed all domestic CASPER activities (i.e., trainings and assessments) between fiscal years 2012 and 2016. Data from these CASPER activities were compared with respect to differences in geographic distribution, type, actions, efficacy, and usefulness of training. RESULTS: During the study period, the Centers for Disease Control and Prevention conducted 24 domestic in-person CASPER trainings for 1057 staff in 38 states. On average, there was a marked increase in knowledge of CASPER. Ninety-nine CASPERs were conducted in the United States, approximately half of which (53.5%) assessed preparedness; the others were categorized as response or recovery (27.2%) or were unrelated to a disaster (19.2%). CONCLUSIONS: CASPER trainings are successful in increasing disaster epidemiology skills. CASPER can be used by Public Health Emergency Preparedness program awardees to help build and sustain preparedness and response capabilities.

      9. Identifying and Prioritizing Information Needs and Research Priorities of Public Health Emergency Preparedness and Response PractitionersExternal
        Siegfried AL, Carbone EG, Meit MB, Kennedy MJ, Yusuf H, Kahn EB.
        Disaster Med Public Health Prep. 2017 Oct;11(5):552-561.
        OBJECTIVE: This study describes findings from an assessment conducted to identify perceived knowledge gaps, information needs, and research priorities among state, territorial, and local public health preparedness directors and coordinators related to public health emergency preparedness and response (PHPR). The goal of the study was to gather information that would be useful for ensuring that future funding for research and evaluation targets areas most critical for advancing public health practice. METHODS: We implemented a mixed-methods approach to identify and prioritize PHPR research questions. A web survey was sent to all state, city, and territorial health agencies funded through the Public Health Emergency Preparedness (PHEP) Cooperative Agreement program and a sample of local health departments (LHDs). Three focus groups of state and local practitioners and subject matter experts from the Centers for Disease Control and Prevention (CDC) were subsequently conducted, followed by 3 meetings of an expert panel of PHPR practitioners and CDC experts to prioritize and refine the research questions. RESULTS: We identified a final list of 44 research questions that were deemed by study participants as priority topics where future research can inform PHPR programs and practice. We identified differences in perceived research priorities between PHEP awardees and LHD survey respondents; the number of research questions rated as important was greater among LHDs than among PHEP awardees (75%, n=33, compared to 24%, n=15). CONCLUSIONS: The research questions identified provide insight into public health practitioners’ perceived knowledge gaps and the types of information that would be most useful for informing and advancing PHPR practice. The study also points to a higher level of information need among LHDs than among PHEP awardees. These findings are important for CDC and the PHPR research community to ensure that future research studies are responsive to practitioners’ needs and provide the information required to enhance their capacity to meet the needs of the communities and jurisdictions they serve. (Disaster Med Public Health Preparedness. 2017;11:552-561).

      10. Acute Flaccid Myelitis of Unknown Etiology in California, 2012-2015External
        Van Haren K, Ayscue P, Waubant E, Clayton A, Sheriff H, Yagi S, Glenn-Finer R, Padilla T, Strober JB, Aldrovandi G, Wadford DA, Chiu CY, Xia D, Harriman K, Watt JP, Glaser CA.
        Jama. 2015 Dec 22-29;314(24):2663-71.
        IMPORTANCE: There has been limited surveillance for acute flaccid paralysis in North America since the regional eradication of poliovirus. In 2012, the California Department of Public Health received several reports of acute flaccid paralysis cases of unknown etiology. OBJECTIVE: To quantify disease incidence and identify potential etiologies of acute flaccid paralysis cases with evidence of spinal motor neuron injury. DESIGN, SETTING, AND PARTICIPANTS: Case series of acute flaccid paralysis in patients with radiological or neurophysiological findings suggestive of spinal motor neuron involvement reported to the California Department of Public Health with symptom onset between June 2012 and July 2015. Patients meeting diagnostic criteria for other acute flaccid paralysis etiologies were excluded. Cerebrospinal fluid, serum samples, nasopharyngeal swab specimens, and stool specimens were submitted to the state laboratory for infectious agent testing. MAIN OUTCOMES AND MEASURES: Case incidence and infectious agent association. RESULTS: Fifty-nine cases were identified. Median age was 9 years (interquartile range [IQR], 4-14 years; 50 of the cases were younger than 21 years). Symptoms that preceded or were concurrent included respiratory or gastrointestinal illness (n = 54), fever (n = 47), and limb myalgia (n = 41). Fifty-six patients had T2 hyperintensity of spinal gray matter on magnetic resonance imaging and 43 patients had cerebrospinal fluid pleocytosis. During the course of the initial hospitalization, 42 patients received intravenous steroids; 43, intravenous immunoglobulin; and 13, plasma exchange; or a combination of these treatments. Among 45 patients with follow-up data, 38 had persistent weakness at a median follow-up of 9 months (IQR, 3-12 months). Two patients, both immunocompromised adults, died within 60 days of symptom onset. Enteroviruses were the most frequently detected pathogen in either nasopharynx swab specimens, stool specimens, serum samples (15 of 45 patients tested). No pathogens were isolated from the cerebrospinal fluid. The incidence of reported cases was significantly higher during a national enterovirus D68 outbreak occurring from August 2014 through January 2015 (0.16 cases per 100,000 person-years) compared with other monitoring periods (0.028 cases per 100,000 person-years; P <.001). CONCLUSIONS AND RELEVANCE: In this series of patients identified in California from June 2012 through July 2015, clinical manifestations indicated a rare but distinct syndrome of acute flaccid paralysis with evidence of spinal motor neuron involvement. The etiology remains undetermined, most patients were children and young adults, and motor weakness was prolonged.

  2. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Chronic Diseases and Conditions
      1. Alternative waist-to-height ratios associated with risk biomarkers in youth with diabetes: comparative models in the SEARCH for Diabetes in Youth StudyExternal
        Kahn HS, Divers J, Fino NF, Dabelea D, Bell R, Liu LL, Zhong VW, Saydah S.
        Int J Obes (Lond). 2019 Mar 29.
        BACKGROUND/OBJECTIVES: The waist-to-height ratio (WHtR) estimates cardiometabolic risk in youth without need for growth charts by sex and age. Questions remain about whether waist circumference measured per protocol of the National Health and Nutrition Examination Survey (WNHAHtR) or World Health Organization (WWHOHtR) can better predict blood pressures and lipid parameters in youth. PARTICIPANTS/METHODS: WHtR was measured under both anthropometric protocols among participants in the SEARCH Study, who were recently diagnosed with diabetes (ages 5-19 years; N = 2 773). Biomarkers were documented concurrently with baseline anthropometry and again ~7 years later (ages 10-30 years; N = 1 712). For prediction of continuous biomarker outcomes, baseline WNHAHtR or WWHOHtR entered semiparametric regression models employing restricted cubic splines. To predict binary biomarkers (high-risk group defined as the most adverse quartile) linear WNHAHtR or WWHOHtR terms entered logistic models. Model covariates included demographic characteristics, pertinent medication use, and (for prospective predictions) the follow-up time since baseline. We used measures of model fit, including the adjusted-R(2) and the area under the receiver operator curves (AUC) to compare WNHAHtR and WWHOHtR. RESULTS: For the concurrent biomarkers, the proportion of variation in each outcome explained by full regression models ranged from 23 to 46%; for the prospective biomarkers, the proportions varied from 11 to 30%. Nonlinear relationships were recognized with the lipid outcomes, both at baseline and at follow-up. In full logistic models, the AUCs ranged from 0.75 (diastolic pressure) to 0.85 (systolic pressure) at baseline, and from 0.69 (triglycerides) to 0.78 (systolic pressure) at the prospective follow-up. To predict baseline elevations of the triglycerides/HDL cholesterol ratio, the AUC was 0.816 for WWHOHtR compared with 0.810 for WNHAHtR (p = 0.003), but otherwise comparisons between alternative WHtR protocols were not significantly different. CONCLUSIONS: Among youth with recently diagnosed diabetes, measurements of WHtR by either waist circumference protocol similarly helped estimate current and prospective cardiometabolic risk biomarkers.

      2. Population-based surveillance of haemophilia and patient outcomes in Indiana using multiple data sourcesExternal
        Okolo AI, Soucie JM, Grosse SD, Roberson C, Janson IA, Allen M, Shapiro AD.
        Haemophilia. 2019 Mar 29.
        INTRODUCTION: Epidemiological surveillance of haemophilia through linkage of medical records within a US state has not been conducted in 20 years. AIM: The Indiana Haemophilia Surveillance Project aims to identify all persons with haemophilia who resided in Indiana in 2011-2013 and to determine the percentage of patients in Indiana cared for at a federally recognized haemophilia treatment centre (HTC). METHODS: A retrospective review of medical charts was conducted to identify haemophilia cases during the surveillance years. Case-finding methods involved a variety of medical care resources including hospitals, administrative claims data and haematology/oncology clinic reports. RESULTS: In Indiana, 704 unique haemophilia cases were identified. Of those cases, 456 (64.8%) had factor VIII and 248 (35.2%) had factor IX deficiency. Among those with known severity levels (n = 685), 233 (34%) were severe, 185 (27%) were moderate, and 267 (39%) were mild. Overall, 81.7% of the haemophilia patients identified visited an HTC at least once during the three-year study period, which was the requirement for being considered an HTC patient. Age-adjusted prevalence for 2013 was 19.4 haemophilia cases per 100 000 males, 12.7 per 100 000 for factor VIII and 6.7 per 100 000 for factor IX. Incidence of haemophilia over the 10 years prior to the surveillance years was 1:3688 live male births in Indiana. During the surveillance years, 24 cases (3.4%) died. CONCLUSION: We observed higher incidence and prevalence of haemophilia in Indiana compared to previous national estimates, as well as higher HTC utilization among persons with haemophilia.

      3. The rate stabilizing tool: Generating stable local-level measures of chronic diseaseExternal
        Quick H, Tootoo J, Li R, Vaughan AS, Schieb L, Casper M, Miranda ML.
        Prev Chronic Dis. 2019 Mar 28;16:E38.
        Accurate and precise estimates of local-level epidemiologic measures are critical to informing policy and program decisions, but they often require advanced statistical knowledge, programming/coding skills, and extensive computing power. In response, we developed the Rate Stabilizing Tool (RST), an ArcGIS-based tool that enables users to input their own record-level data to generate more reliable age-standardized measures of chronic disease (eg, prevalence rates, mortality rates) or other population health outcomes at the county or census tract levels. The RST uses 2 forms of empirical Bayesian modeling (nonspatial and spatial) to estimate age-standardized rates and 95% credible intervals for user-specified geographic units. The RST also provides indicators of the reliability of point estimates. In addition to reviewing the RST’s statistical techniques, we present results from a simulation study that illustrates the key benefit of smoothing. We demonstrate the dramatic reduction in root mean-squared error (rMSE), indicating a better compromise between accuracy and stability for both smoothing approaches relative to the unsmoothed estimates. Finally, we provide an example of the RST’s use. This example uses heart disease mortality data for North Carolina census tracts to map the RST output, including reliability of estimates, and demonstrates a subsequent statistical test.

      4. Assessing the hereditary hemorrhagic telangiectasia algorithms in a community-based patient populationExternal
        Saparia T, Faughnan ME, Schneider JL, Almers LM, Chow N, Grosse SD, Kim H, Zaroff JG.
        Perm J. 2019 ;23.
        INTRODUCTION: Hereditary hemorrhagic telangiectasia (HHT) is a rare, genetic, and underdiagnosed disease that causes vascular malformations throughout the body. Two specific combinations of International Classification of Diseases, Ninth Revision-Clinical Modification diagnosis codes, the “HHT Algorithms” (HHTAs), were developed previously from a derivation cohort to help identify undiagnosed HHT cases. OBJECTIVES: To test these 2 algorithms, and a third, newly designed HHTA, in an independent population with available clinical records and thus identify people who might have undiagnosed HHT. METHODS: The HHTAs were applied to the patient population of Kaiser Permanente Northern California. The HHTAs produced 3 groups (A, B, and C) using different combinations of diagnosis codes reflecting clinical manifestations of HHT. First, the number of Kaiser Permanente Northern California patients with each code was determined by database programming. Next, detailed chart review was performed, and patients with a Curacao score of 2 or higher were considered to have possible HHT. RESULTS: Of 3,065,210 records queried, 163 patients met HHTA criteria. After chart review, the study identified 113 patients with possible undiagnosed HHT (Group A: n = 3, Group B: n = 3, Group C: n = 107). CONCLUSION: Employing the HHTAs in this community-based population resulted in a modest yield of patients with possible HHT. Further research is required to assess the utility of the HHTAs in identifying patients with actual HHT.

    • Communicable Diseases
      1. Noncommunicable disease burden among HIV patients in care: a national retrospective longitudinal analysis of HIV-treatment outcomes in Kenya, 2003-2013External
        Achwoka D, Waruru A, Chen TH, Masamaro K, Ngugi E, Kimani M, Mukui I, Oyugi JO, Mutave R, Achia T, Katana A, Ng’ang’a L, De Cock KM.
        BMC Public Health. 2019 Apr 3;19(1):372.
        BACKGROUND: Over the last decade, the Kenyan HIV treatment program has grown exponentially, with improved survival among people living with HIV (PLHIV). In the same period, noncommunicable diseases (NCDs) have become a leading contributor to disease burden. We sought to characterize the burden of four major NCDs (cardiovascular diseases, cancer, chronic respiratory diseases and diabetes mellitus) among adult PLHIV in Kenya. METHODS: We conducted a nationally representative retrospective medical chart review of HIV-infected adults aged >/=15 years enrolled in HIV care in Kenya from October 1, 2003 through September 30, 2013. We estimated proportions of four NCD categories among PLHIV at enrollment into HIV care, and during subsequent HIV care visits. We compared proportions and assessed distributions of co-morbidities using the Chi-Square test. We calculated NCD incidence rates and their confidence intervals in assessing cofactors for developing NCDs. RESULTS: We analyzed 3170 records of HIV-infected patients; 2115 (66.3%) were from women. Slightly over half (51.1%) of patient records were from PLHIVs aged above 35 years. Close to two-thirds (63.9%) of PLHIVs were on ART. Proportion of any documented NCD among PLHIV was 11.5% (95% confidence interval [CI] 9.3, 14.1), with elevated blood pressure as the most common NCD 343 (87.5%) among PLHIV with a diagnosed NCD. Despite this observation, only 17 (4.9%) patients had a corresponding documented diagnosis of hypertension in their medical record. Overall NCD incidence rates for men and women were (42.3 per 1000 person years [95% CI 35.8, 50.1] and 31.6 [95% CI 27.7, 36.1], respectively. Compared to women, the incidence rate ratio for men developing an NCD was 1.3 [95% CI 1.1, 1.7], p = 0.0082). No differences in NCD incidence rates were seen by marital or employment status. At one year of follow up 43.8% of PLHIV not on ART had been diagnosed with an NCD compared to 3.7% of patients on ART; at five years the proportions with a diagnosed NCD were 88.8 and 39.2% (p < 0.001), respectively. CONCLUSIONS: PLHIV in Kenya have a high prevalence of NCD diagnoses. In the absence of systematic, effective screening, NCD burden is likely underestimated in this population. Systematic screening and treatment for NCDs using standard guidelines should be integrated into HIV care and treatment programs in sub-Saharan Africa.

      2. Evaluation of diarrheal disease surveillance in the Minawao refugee camp, Cameroon, 2016External
        Amabo FC, Seukap EC, Mathieu E, Etoundi GA.
        Int J Infect Dis. 2019 Feb 26;82:9-14.
        BACKGROUND: Between 2013 and 2015, the Minawao refugee camp in Cameroon received about 51000 refugees fleeing Boko Haram. A rapid increase in population and inadequate sanitary installations increase the risk of diarrheal disease. This study was performed to assess the structure and attributes of the surveillance system in Minawao. METHODS: Updated US Centers for Disease Control and Prevention guidelines were used to evaluate the public health surveillance system. Information sources included health registers, surveillance reports, and key informant interviews. Scorecards were used to assess the simplicity, flexibility, data quality, acceptability, sensitivity, timeliness, stability, and usefulness of the system. RESULTS: Surveillance in Minawao is both passive and active, integrating four diseases reported weekly/immediately. All key informants agreed that surveillance was part of their routine work. Of 138 surveillance reports reviewed, all were complete; 91 (66%) were timely. Overall, 143 (100%) cases of diarrheal disease identified in health registers were reported to the next level. Only two (20%) surveillance personnel could correctly state standardized case definitions (SCD); three (30%) were unable to identify cases of diarrheal disease based on SCD. CONCLUSIONS: In Minawao, diarrheal disease surveillance is acceptable, flexible, sensitive, and useful. To improve timeliness and the use of SCD, we recommend the use of mobile phones to report and display SCD in health facilities.

      3. Capture-recapture among men who have sex with men and among female sex workers in 11 towns in UgandaExternal
        Apodaca K, Doshi RH, Ogwal M, Kiyingi H, Aluzimbi G, Musinguzi G, Lutalo I, Akello E, Hladik W.
        JMIR Public Health Surveill. 2019 Apr 3;5(2):e12316.
        BACKGROUND: Key populations at higher risk for HIV infection, including people who inject drugs, men who have sex with men (MSM), and female sex workers (FSWs), are disproportionately affected by the HIV/AIDS epidemic. Empirical estimates of their population sizes are necessary for HIV program planning and monitoring. Such estimates, however, are lacking for most of Uganda’s urban centers. OBJECTIVE: The aim of this study was to estimate the number of FSWs and MSM in select locations in Uganda. METHODS: We utilized conventional 2-source capture-recapture (CRC) to estimate the population of FSWs in Mbale, Jinja, Wakiso, Mbarara, Gulu, Kabarole, Busia, Tororo, Masaka, and Kabale and the population of MSM in Mbale, Jinja, Wakiso, Mbarara, Gulu, Kabarole, and Mukono from June to August 2017. Hand mirrors and key chains were distributed to FSWs and MSM, respectively, by peers during capture 1. A week later, different FSWs and MSM distributors went to the same towns to collect data for the second capture. Population size estimates and 95% CIs were calculated using the CRC Simple Interactive Statistical Analysis. RESULTS: We estimated the population of FSWs and MSM using 2 different recapture definitions: those who could present the object or identify the object from a set of photos. The most credible (closer to global estimates of MSM; 3%-5%) estimates came from those who presented the objects only. The FSW population in Mbale was estimated to be 693 (95% CI 474-912). For Jinja, Mukono, Busia, and Tororo, we estimated the number of FSWs to be 802 (95% CI 534-1069), 322 (95% CI 300-343), 961 (95% CI 592-1330), and 2872 (95% CI 0-6005), respectively. For Masaka, Mbarara, Kabale, and Wakiso, we estimated the FSWs population to be 512 (95% CI 384-639), 1904 (95% CI 1058-2749), 377 (95% CI 247-506), and 828 (95% CI 502-1152), respectively. For Kabarole and Gulu, we estimated the FSWs population to be 397 (95% CI 325-469) and 1425 (95% CI 893-1958), respectively. MSM estimates were 381 (95% CI 299-462) for Mbale, 1100 (95% CI 351-1849) for Jinja, 368 (95% CI 281-455) for Wakiso, 322 (95% CI 253-390) for Mbarara, 180 (95% CI 170-189) for Gulu, 335 (95% CI 258-412) for Kabarole, and 264 (95% CI 228-301) for Mukono. CONCLUSIONS: The CRC activity was one of the first to be carried out in Uganda to obtain small town-level population sizes for FSWs and MSM. We found that it is feasible to use FSW and MSM peers for this activity, but proper training and standardized data collection tools are essential to minimize bias.

      4. Prevalence and genetic diversity of viral gastroenteritis viruses in children younger than 5 years of age in Guatemala, 2014-2015External
        Diez-Valcarce M, Lopez MR, Lopez B, Morales O, Sagastume M, Cadena L, Kaydos-Daniels S, Jarquin C, McCracken JP, Bryan JP, Vinje J.
        J Clin Virol. 2019 Mar 9;114:6-11.
        BACKGROUND: Acute diarrhea is an important cause of morbidity and mortality in children and is associated with approximately 500,000 deaths/year globally. Rotavirus and norovirus are leading causes of acute diarrhea accounting for more than half of this burden. OBJECTIVE/STUDY DESIGN: To determine the prevalence and genotype distribution of acute diarrhea caused by rotavirus, norovirus, sapovirus and astrovirus among children <5 years of age at two departments in Guatemala from January 2014 to December 2015, we tested 471 stool specimens (202 samples from hospitalized children and 269 samples from children in ambulatory clinics) by real-time reverse transcription-PCR and genotyped positive samples. RESULTS: Rotavirus was detected in 20.4%, norovirus in 18.5%, sapovirus in 7% and astrovirus in 4.2% of the samples. Co-infection of rotavirus and norovirus was found in 2.6% of the samples. Most norovirus (87.4%) and rotavirus (81.3%) infections were detected in children in the 6-12 months age group. The proportion of patients with rotavirus (34%) and norovirus (23%) was higher in hospitalized patients compared to ambulatory patients, whereas the prevalence of sapovirus and astrovirus was similar in both settings. Of the 40 genotyped norovirus strains, 62.5% were GII.4 and 15% GII.3. Sapovirus genotypes included GI.1 (15.4%), GII.2 (15.4%), GII.5 (38.5%) and GIV.1 (30.8%). CONCLUSIONS: Our data demonstrate that in 2014-2015, gastroenteritis viruses account for 50% of acute diarrhea in children younger than 5 years of age in Guatemala, highlighting the importance of continuous surveillance to guide impact of the current rotavirus vaccine and formulation of future norovirus vaccines.

      5. Feasibility of identifying household contacts of rifampin- and multidrug-resistant tuberculosis cases at high risk of progression to tuberculosis diseaseExternal
        Gupta A, Swindells S, Kim S, Hughes MD, Naini L, Wu X, Dawson R, Mave V, Sanchez J, Mendoza A, Gonzales P, Kumarasamy N, Comins K, Conradie F, Shenje J, Fontain SN, Garcia-Prats A, Asmelash A, Nedsuwan S, Mohapi L, Lalloo UG, Ferreira AC, Mugah C, Harrington M, Jones L, Cox S, Smith B, Shah NS, Hesseling AC, Churchyard G.
        Clin Infect Dis. 2019 Mar 28.
        BACKGROUND: We assessed multidrug-resistant tuberculosis (MDR-TB) cases and their household contacts (HHCs) to inform the development of an interventional clinical trial. METHODS: We conducted a cross-sectional study of adult MDR-TB cases and their HHCs in eight high-TB-burden countries. HHCs underwent symptom screening, chest radiography (CXR), sputum TB bacteriology, TB infection (TBI) testing (tuberculin skin test and interferon gamma release assay) and HIV testing. RESULTS: From October 2015 to April 2016, 1016 HHCs from 284 MDR-TB cases were enrolled. At diagnosis, 69% of MDR-TB cases were acid fast bacilli sputum smear-positive and 43% had cavitary disease; at study entry 35% remained smear-positive after a median MDR-TB treatment duration of 8.8 weeks. Nine HHCs were diagnosed with TB prior to entry and excluded. Of the remaining 1007 HHCs, 41% were male and the median age was 25 years. 121 (12%) HHC had new TB identified: 17 (2%) were confirmed; 33 (3%) probable; and 71 (7%) possible TB. TBI prevalence (defined as either TST or IGRA positivity) was 72% and varied by age, test used, and country. Of 1007 HHCs, 775 (77%) were considered high-risk per these mutually exclusive groups: 102 (10%) <5 years; 63 (6%) 5 and HIV-infected; and 610 (61%) 5 years, HIV-negative/unknown, and TBI positive. Only 21 (2%) HHCs were on preventive therapy. CONCLUSIONS: The majority of HHCs in these high-burden countries were at high risk of TB disease and infection, yet few were receiving routine preventive therapy. Trials of novel preventive therapies are urgently needed to inform treatment policy and practice.

      6. Undisclosed HIV infection among MSM in a behavioral surveillance studyExternal
        Hoots BE, Wejnert C, Martin A, Haaland R, Masciotra S, Sionean C, Smith A, Switzer WM, Paz-Bailey G.
        Aids. 2019 Apr 1;33(5):913-918.
        OBJECTIVE: As a proxy for undiagnosed HIV, the Centers for Disease Control and Prevention’s National HIV Behavioral Surveillance (NHBS) monitors participants who report being unaware of their infection, defined as self-reporting an HIV-negative or unknown status during the interview but testing positive for HIV infection. We validated the NHBS measure of awareness among MSM in 2014. DESIGN: We tested dried blood spots from MSM who reported being unaware of their infection for seven antiretrovirals (ARVs). MSM unaware with at least one ARV detected were defined as misreporters. METHODS: Weighted percentages and 95% confidence intervals were calculated to compare characteristics among misreporters, nonmisreporters, and those who self-reported as HIV-positive. Viral load was quantified with a validated assay using dried blood spots. RESULTS: Of 1818 HIV-positive MSM, 299 (16%) self-reported as HIV-negative or unknown infection status. Of these 299, 145 (49%) were considered misreporters based on ARV detection. Among the unaware, misreporters were more likely than nonmisreporters to be older and have health insurance. Compared with self-reported HIV-positive MSM, misreporters were more likely to be black, be bisexual, and have perceived discrimination. Of 138 misreporters with viral load data, 116 (84%) had an undetectable viral load. CONCLUSION: ARV testing revealed that half of MSM classified as unaware of their infection misreported their status. Although off-label preexposure prophylaxis use might explain the presence of ARVs, it is unlikely as many misreporters were virally suppressed, suggesting they were on HIV therapy. Biomarker validation of behavioral data can improve data quality and usefulness in NHBS and other studies.

      7. Estimating annual births to hepatitis B surface antigen-positive women in the United States by using data on maternal country of birthExternal
        Koneru A, Schillie S, Roberts H, Sirotkin B, Fenlon N, Murphy TV, Nelson NP.
        Public Health Rep. 2019 Apr 3:33354919836958.
        OBJECTIVE:: A national estimate of births to hepatitis B surface antigen (HBsAg)-positive women can help public health programs plan surveillance, educational, and outreach activities to improve identification and management of at-risk women and infants. Stratifying mothers by country of birth allows for the application of region-specific HBsAg prevalence estimates, which can more precisely estimate the number of at-risk infants. The objective of our study was to estimate the number of births to HBsAg-positive women in the United States with more granularity than previous models. METHODS:: We developed a model that incorporated maternal country of birth (MCOB) and updated HBsAg prevalence estimates. We assessed birth certificate data by MCOB, and we stratified US-born mothers by race/ethnicity, US territory-born mothers by territory, and non-US-born mothers by region. We multiplied and summed data in each subcategory by using HBsAg prevalence estimates calculated from the 2009-2014 National Health and Nutrition Examination Surveys or Perinatal Hepatitis B Prevention Program. We compared the findings of our MCOB model with a race/ethnicity model. RESULTS:: In 2015, an estimated 20 678 infants were born to HBsAg-positive women in the United States, representing 0.5% of all births. Births to US-born and non-US-born women comprised 77.2% and 21.5% of all births, respectively, and 40.1% and 57.9% of estimated births to HBsAg-positive women, respectively. The estimated contribution of births to HBsAg-positive women varied by MCOB region, from 4 (0.03%) infants born to women from Australia/Oceania to 5795 (28.0%) infants born to women from East Asia. Our MCOB model estimated 5666 fewer births to HBsAg-positive women than did the race/ethnicity model. CONCLUSIONS:: As global vaccine programs reduce HBsAg prevalence, the MCOB model can incorporate evolving HBsAg prevalence estimates for women from various regions of the world.

      8. Increase in infant measles deaths during a nationwide measles outbreak – Mongolia, 2015-2016External
        Lee CT, Hagan JE, Jantsansengee B, Tumurbaatar OE, Altanchimeg S, Yadamsuren B, Demberelsuren S, Tserendorj C, Munkhtogoo O, Badarch D, Gunregjav N, Baatarkhuu B, Ochir C, Berman L, Anderson R, Patel MK, Gregory CJ, Goodson JL.
        J Infect Dis. 2019 Mar 29.
        BACKGROUND: Surveillance data from a large measles outbreak in Mongolia suggested an increased case fatality ratio (CFR) in the second of two waves. To confirm the increase in CFR and identify risk factors for measles death, we enhanced mortality ascertainment and conducted a case-control study among infants hospitalized for measles. METHODS: We linked national vital records with surveillance data of clinically- or laboratory-confirmed infant (aged <12 months) measles cases with rash onset during March-September 2015 (wave 1) and October 2015-June 2016 (wave 2). We abstracted medical charts of 95 fatal cases and 273 nonfatal cases hospitalized for measles, matched by age and sex. We calculated adjusted matched odds ratios (amORs) and 95% confidence intervals (CIs) for risk factors. RESULTS: Infant measles deaths increased from 3 among 2,224 cases (CFR: 0.13%) in wave 1 to 113 among 4,884 cases (CFR: 2.31%) in wave 2 (p<0.001). Inpatient admission, 7-21 days before measles rash onset, for pneumonia or influenza (amOR: 4.5; CI 2.6-8.0), but not other diagnoses, was significantly associated with death. DISCUSSION: Measles infection among children hospitalized with respiratory infections likely increased deaths due to measles during wave 2. Preventing measles virus nosocomial transmission likely decreases measles mortality.

      9. Epidemics of plague past, present, and futureExternal
        Mead P.
        Lancet Infect Dis. 2019 Mar 28.

        [No abstract]

      10. Low rates of nucleoside reverse transcriptase inhibitor and nonnucleoside reverse transcriptase inhibitor drug resistance in BotswanaExternal
        Moyo S, Gaseitsiwe S, Zahralban-Steele M, Maruapula D, Nkhisang T, Mokaleng B, Mohammed T, Ditlhako TR, Bareng OT, Mokgethi TP, van Widenfelt E, Pretorius-Holme M, Mine MO, Raizes E, Yankinda EK, Wirth KE, Gaolathe T, Makhema JM, Lockman S, Essex M, Novitsky V.
        Aids. 2019 May 1;33(6):1073-1082.
        BACKGROUND: Scale-up of antiretroviral therapy (ART) and introduction of treat-all strategy necessitates population-level monitoring of acquired HIV drug resistance (ADR) and pretreatment drug resistance (PDR) mutations. METHODS: Blood samples were collected from 4973 HIV-positive individuals residing in 30 communities across Botswana who participated in the Botswana Combination Prevention Project (BCPP) in 2013-2018. HIV sequences were obtained by long-range HIV genotyping. Major drug-resistance mutations (DRMs) and surveillance drug resistance mutations (SDRMs) associated with nucleoside reverse transcriptase inhibitors (NRTI) and nonnucleoside reverse transcriptase inhibitors (NNRTI) were analyzed according to the Stanford University HIV Drug Resistance Database. Viral sequences were screened for G-to-A hypermutations. A threshold of 2% was used for hypermutation adjustment. Viral suppression was considered at HIV-1 RNA load </=400 copies/ml. RESULTS: Among 4973 participants with HIV-1C sequences, ART data were available for 4927 (99%) including 3858 (78%) on ART. Among those on ART, 3435 had viral load data and 3297 (96%) were virologically suppressed. Among 1069 (22%) HIV-infected individuals not on ART, we found NRTI-associated and NNRTI-associated SDRMs were found in 1.5% (95% confidence interval [CI] 1.0-2.5%) and 2.9% (95% CI 2.0-4.2%), respectively. Of the 138 (4%) of individuals who had detectable HIV-1 RNA, we found NRTI-associated and NNRTI-associated drug resistance mutations in 16% (95% CI 10-25%) and 33% (95% CI 25-42%), respectively. CONCLUSION: We found a low prevalence of NRTI-associated and NNRTI-associated PDR-resistance mutations among residents of rural and peri-urban communities across Botswana. However, individuals on ART with detectable virus had ADR NRTI and NNRTI mutations above 15%.

      11. An assessment of household water quality among Peace Corps volunteers in GuatemalaExternal
        Murphy DE, Poe SA, Murphy JL, Ferguson RW, Henderson SJ, Jung P.
        Trop Dis Travel Med Vaccines. 2019 ;5:2.
        Background: Gastrointestinal (GI) illness is the most commonly reported health concern among Peace Corps Volunteers (PCVs) serving in Guatemala. This project identified water types and treatment and storage practices used by PCVs and measured select water quality parameters in their household water. Methods: A survey about water types and practices was conducted of PCVs in Guatemala. The water type most frequently consumed in the household (“primary drinking water”) and other water types present in the household (“secondary water”) were tested for free chlorine residual (FCR) and for the presence of Escherichia coli and total coliforms. A negative binomial regression model was used to analyze data on incidence of self-reported GI illness. Results: Tambo (commercially purified water in a 5-gal bottle) was the water type most frequently (64%) reported as primary drinking water in 39 PCV households. Most (74%) PCVs reported drinking water other than primary drinking water >/=1 day per week; the incidence rate of GI illness per PCV per month was significantly lower among PCVs who reported never consuming water other than primary drinking water compared to those who did (0.4 and 1.6 GI illnesses per PCV per month, respectively) (p < 0.05). E. coli was not detected in any primary drinking water sample, but was detected in 35% of secondary water samples. Total coliforms were detected in more than two-thirds of primary drinking water and secondary water samples. Nearly all water samples had an FCR of < 0.2 mg/L. Conclusions: Consuming primary drinking water exclusively likely contributes to reducing the rate of GI illness among PCVs. However, most PCVs reported drinking multiple water types, which may include contaminated secondary water types in the household. All water intended for consumption, including secondary sources within and outside the household, should be properly treated and safely stored.

      12. Background:Violent crime rates are often correlated with the hard-to-measure social determinants of sexually transmissible infections (STIs). In this study, we examined whether including violent crime rate as an independent variable can improve the quality of ecological regression models of STIs. Methods: We obtained multiyear (2008-12) cross-sectional county-level data on violent crime and three STIs (chlamydia, gonorrhoea, and primary and secondary (P&S) syphilis) from counties in all the contiguous states in the US (except Illinois and Florida, due to lack of data). We used two measures of STI morbidity (one categorical and one continuous) and applied spatial regression with the spatial error model for each STI, with and without violent crime rate as an independent variable. We computed the associated Akaike’s information criterion (AIC) and Bayesian information criterion (BIC) as our measure of the relative goodness of fit of the models. Results: Including the violent crime rate as an independent variable improved the quality of the regression models after controlling for several sociodemographic factors. We found that the lower calculated AICs and BICs indicated more favourable goodness of fit in all the models that included violent crime rates, except for the categorical P&S syphilis model, in which the violent crime variable was not statistically significant. Conclusion: Because violent crime rates can account for the hard-to-measure social determinants of STIs, including violent crime rate as an independent variable can improve ecological regression models of STIs.

      13. Maternal and infant bone mineral density 1 year after delivery in a randomized, controlled trial of maternal tenofovir disoproxil fumarate to prevent mother-to-child transmission of hepatitis B virusExternal
        Salvadori N, Fan B, Teeyasoontranon W, Ngo-Giang-Huong N, Phanomcheong S, Luvira A, Puangsombat A, Suwannarat A, Srirompotong U, Putiyanun C, Cressey TR, Decker L, Khamduang W, Harrison L, Tierney C, Shepherd JA, Kourtis AP, Bulterys M, Siberry GK, Jourdain G.
        Clin Infect Dis. 2019 Mar 29.
        In a randomized, double-blind, placebo-controlled trial of tenofovir disoproxil fumarate (TDF) use from 28 weeks gestational age to 2 months postpartum to prevent mother-to-child transmission of hepatitis B virus, there was no significant effect of maternal TDF use on maternal or infant bone mineral density 1 year after delivery/birth. Clinical Trials Registration. NCT01745822.

      14. BACKGROUND: In 2016, the World Health Organization (WHO) recommended a shorter (9-12 month) multidrug-resistant tuberculosis (MDR-TB) treatment regimen (as compared to the conventional 18-24 month regimen) for patients without extrapulmonary TB, pregnancy, previous second-line TB medication exposure, or drug resistance to pyrazinamide, ethambutol, kanamycin, moxifloxacin, ethionamide, or clofazimine. The recommendation was based on successful clinical trials conducted in Asia and Africa, but studies, using mainly European data, have shown few patients in higher resource settings would meet WHO eligibility criteria. METHODS: We assessed eligibility for the shorter regimen among U.S. MDR-TB cases that had full drug susceptibility testing (DST) results and were reported during 2011-2016 to the U.S. National TB Surveillance System. We estimated costs by applying the eligibility criteria for the shorter regimen, and proportional inpatient/outpatient costs from a previous population-based study to all MDR-TB patients reported to NTSS. RESULTS: Of 586 reported MDR cases, 10% (59) were eligible for the shorter regimen. Of 527 ineligible patients, 386 had full DST, of which 246 were resistant to ethambutol and 217 resistant to pyrazinamide. Compared with conventional MDR-TB treatment, implementing the shorter regimen would reduce the U.S. annual societal MDR-TB cost burden by 4%, but the cost burden for eligible individuals would be reduced by 37-46%. CONCLUSIONS: Relying on full DST use, our analysis found a minority of U.S. MDR-TB patients would be eligible for the shorter regimen. Cost reductions would be minimal for society, but large for eligible individuals.

    • Disaster Control and Emergency Services
      1. An assessment of state laws providing gubernatorial authority to remove legal barriers to emergency responseExternal
        Sunshine G, Thompson K, Menon AN, Anderson N, Penn M, Koonin LM.
        Health Secur. 2019 Apr 3.
        Legal Perspectives is aimed at informing healthcare providers, emergency planners, public health practitioners, and other decision makers about important legal issues related to public health and healthcare preparedness and response. The articles describe these potentially challenging topics and conclude with the authors’ suggestions for further action. The articles do not provide legal advice. Therefore, those affected by the issues discussed in this column should seek further guidance from legal counsel. Readers may submit topics of interest to the column’s editor, Lainie Rutkow, JD, PhD, MPH, at Governors play a fundamental role in emergency preparedness and can help facilitate rapid responses to emergencies. However, laws that operate successfully under normal circumstances can inadvertently create barriers during emergencies, delaying a timely response. State laws could thus limit, or even prohibit, necessary response efforts. To combat this risk, legislatures have passed emergency powers laws in each state granting governors the authority to declare a state of emergency and to exercise certain emergency powers to meet the needs of the emergency. Researchers conducted a 50-state legal assessment, which identified and examined state laws that give governors the discretion to modify existing laws or create new laws to respond effectively to any type of declared emergency. This article outlines the findings of that assessment, which identified 35 states that explicitly permit governors to suspend or amend both statutes and regulations; 7 states in which governors are permitted to amend regulations during a declared emergency but are not explicitly authorized to modify or remove statutes; and 8 states and the District of Columbia that provide no explicit authority to governors to change statutes or regulations during a declared emergency. The article also provides examples of how this power has been used in the past to demonstrate the utility and scope of this authority in a variety of public health threats.

    • Disease Reservoirs and Vectors
      1. Seasonal malaria vector and transmission dynamics in western Burkina FasoExternal
        Epopa PS, Collins CM, North A, Millogo AA, Benedict MQ, Tripet F, Diabate A.
        Malar J. 2019 Apr 2;18(1):113.
        BACKGROUND: In the context of widespread mosquito resistance to currently available pesticides, novel, precise genetic vector control methods aimed at population suppression or trait replacement are a potentially powerful approach that could complement existing malaria elimination interventions. Such methods require knowledge of vector population composition, dynamics, behaviour and role in transmission. Here were characterized these parameters in three representative villages, Bana, Pala and Souroukoudingan, of the Sudano-Sahelian belt of Burkina Faso, a region where bed net campaigns have recently intensified. METHODS: From July 2012 to November 2015, adult mosquitoes were collected monthly using pyrethroid spray catches (PSC) and human landing catches (HLC) in each village. Larval habitat prospections assessed breeding sites abundance at each site. Mosquitoes collected by PSC were identified morphologically, and then by molecular technique to species where required, to reveal the seasonal dynamics of local vectors. Monthly entomological inoculation rates (EIR) that reflect malaria transmission dynamics were estimated by combining the HLC data with mosquito sporozoite infection rates (SIR) identified through ELISA-CSP. Finally, population and EIR fluctuations were fit to locally-collected rainfall data to highlight the strong seasonal determinants of mosquito abundance and malaria transmission in this region. RESULTS: The principal malaria vectors found were in the Anopheles gambiae complex. Mosquito abundance peaked during the rainy season, but there was variation in vector species composition between villages. Mean survey HLC and SIR were similar across villages and ranged from 18 to 48 mosquitoes/person/night and from 3.1 to 6.6% prevalence. The resulting monthly EIRs were extremely high during the rainy season (0.91-2.35 infectious bites/person/day) but decreased substantially in the dry season (0.03-0.22). Vector and malaria transmission dynamics generally tracked seasonal rainfall variations, and the highest mosquito abundances and EIRs occurred in the rainy season. However, despite low residual mosquito populations, mosquitoes infected with malaria parasites remained present in the dry season. CONCLUSION: These results highlight the important vector control challenge facing countries with high EIR despite the recent campaigns of bed net distribution. As demonstrated in these villages, malaria transmission is sustained for large parts of the year by a very high vector abundance and high sporozoite prevalence, resulting in seasonal patterns of hyper and hypo-endemicity. There is, therefore, an urgent need for additional vector control tools that can target endo and exophillic mosquito populations.

      2. Multistate survey of American dog ticks (Dermacentor variabilis) for Rickettsia speciesExternal
        Hecht JA, Allerdice ME, Dykstra EA, Mastel L, Eisen RJ, Johnson TL, Gaff HD, Varela-Stokes AS, Goddard J, Pagac BB, Paddock CD, Karpathy SE.
        Vector Borne Zoonotic Dis. 2019 Apr 3.
        Dermacentor variabilis, a common human-biting tick found throughout the eastern half and along the west coast of the United States, is a vector of multiple bacterial pathogens. Historically, D. variabilis has been considered a primary vector of Rickettsia rickettsii, the causative agent of Rocky Mountain spotted fever. A total of 883 adult D. variabilis, collected between 2012 and 2017 from various locations in 12 states across the United States, were screened for rickettsial DNA. Tick extracts were evaluated using three real-time PCR assays; an R. rickettsii-specific assay, a Rickettsia bellii-specific assay, and a Rickettsia genus-specific assay. Sequencing of ompA gene amplicons generated using a seminested PCR assay was used to determine the rickettsial species present in positive samples not already identified by species-specific real-time assays. A total of 87 (9.9%) tick extracts contained R. bellii DNA and 203 (23%) contained DNA of other rickettsial species, including 47 (5.3%) with Rickettsia montanensis, 11 (1.2%) with Rickettsia amblyommatis, 2 (0.2%) with Rickettsia rhipicephali, and 3 (0.3%) with Rickettsia parkeri. Only 1 (0.1%) tick extract contained DNA of R. rickettsii. These data support multiple other contemporary studies that indicate infrequent detection of R. rickettsii in D. variabilis in North America.

      3. Plasmodium falciparum (Haemosporodia: Plasmodiidae) and O’nyong-nyong virus development in a transgenic Anopheles gambiae (Diptera: Culicidae) strainExternal
        Mumford JD, Long CA, Weaver SC, Miura K, Wang E, Rotenberry R, Dotson EM, Benedict MQ.
        J Med Entomol. 2019 Mar 29.
        Transgenic Anopheles gambiae Giles (Diptera: Culicidae) mosquitoes have been developed that confer sexual sterility on males that carry a transgene encoding a protein which cuts ribosomal DNA. A relevant risk concern with transgenic mosquitoes is that their capacity to transmit known pathogens could be greater than the unmodified form. In this study, the ability to develop two human pathogens in these transgenic mosquitoes carrying a homing endonuclease which is expressed in the testes was compared with its nontransgenic siblings. Infections were performed with Plasmodium falciparum (Welch) and o’nyong-nyong virus (ONNV) and the results between the transgenic and nontransgenic sibling females were compared. There was no difference observed with ONNV isolate SG650 in intrathoracic infections or the 50% oral infectious dose measured at 14 d postinfection or in mean body titers. Some significant differences were observed for leg titers at the medium and highest doses for those individuals in which virus titer could be detected. No consistent difference was observed between the transgenic and nontransgenic comparator females in their ability to develop P. falciparum NF54 strain parasites. This particular transgene caused no significant effect in the ability of mosquitoes to become infected by these two pathogens in this genetic background. These results are discussed in the context of risk to human health if these transgenic individuals were present in the environment.

    • Environmental Health
      1. A repeated measures study of phenol, paraben and triclocarban urinary biomarkers and circulating maternal hormones during gestation in the Puerto Rico PROTECT cohortExternal
        Aker AM, Ferguson KK, Rosario ZY, Mukherjee B, Alshawabkeh AN, Calafat AM, Cordero JF, Meeker JD.
        Environ Health. 2019 Apr 2;18(1):28.
        INTRODUCTION: Prenatal exposure to some phenols and parabens has been associated with adverse birth outcomes. Hormones may play an intermediate role between phenols and adverse outcomes. We examined the associations of phenol and paraben exposures with maternal reproductive and thyroid hormones in 602 pregnant women in Puerto Rico. Urinary triclocarban, phenol and paraben biomarkers, and serum hormones (estriol, progesterone, testosterone, sex-hormone-binding globulin (SHBG), corticotropin-releasing hormone (CRH), total triiodothyronine (T3), total thyroxine (T4), free thyroxine (FT4) and thyroid-stimulating hormone (TSH)) were measured at two visits during pregnancy. METHODS: Linear mixed models with a random intercept were constructed to examine the associations between hormones and urinary biomarkers. Results were additionally stratified by study visit. Results were transformed to hormone percent changes for an inter-quartile-range difference in exposure biomarker concentrations (%Delta). RESULTS: Bisphenol-S was associated with a decrease in CRH [(%Delta -11.35; 95% CI: -18.71, – 3.33), and bisphenol-F was associated with an increase in FT4 (%Delta: 2.76; 95% CI: 0.29, 5.22). Butyl-, methyl- and propylparaben were associated with decreases in SHBG [(%Delta: -5.27; 95% CI: -9.4, – 1.14); (%Delta: -3.53; 95% CI: -7.37, 0.31); (%Delta: -3.74; 95% CI: -7.76, 0.27)]. Triclocarban was positively associated with T3 (%Delta: 4.08; 95% CI: 1.18, 6.98) and T3/T4 ratio (%Delta: 4.67; 95% CI: -1.37, 6.65), and suggestively negatively associated with TSH (%Delta: -10.12; 95% CI: -19.47, 0.32). There was evidence of susceptible windows of vulnerability for some associations. At 24-28 weeks gestation, there was a positive association between 2,4-dichlorophenol and CRH (%Delta: 9.66; 95% CI: 0.67, 19.45) and between triclosan and estriol (%Delta: 13.17; 95% CI: 2.34, 25.2); and a negative association between triclocarban and SHBG (%Delta: -9.71; 95% CI:-19.1, – 0.27) and between bisphenol A and testosterone (%Delta: -17.37; 95% CI: -26.7, – 6.87). CONCLUSION: Phenols and parabens are associated with hormone levels during pregnancy. Further studies are required to substantiate these findings.

      2. Radon is a leading cause of lung cancer. Recommendations for radon testing in multi-family housing focus on testing a percentage of all units. There is considerable variability among recommendations as well as their implementation. I used the hypergeometric distribution to determine the probability of identifying one or more units with radon at or above 4.0 pCi/L for two prevalences (1:15, the U.S. average) and 1:3 (for states with many homes with radon >/=4.0 pCi/L) using two approaches. First, the distribution was used to evaluate the probability of finding one or more units with radon at or above 4.0 pCi/L when: (1) testing 10% or 25% of a range of ground-floor units; or (2) testing a varying percentage of units in 10-, 20-, or 30- ground-floor unit buildings. Second, the method was used to determine the number of units to be tested to identify one or more units with radon at or above 4.0 pCi/L with 95% probability, given a range of total ground-floor units. Analyses identified that testing 10% or 25% of ground-floor units had low probability of identifying at least one unit with radon at or above 4.0 pCi/L, especially at low prevalence. At low prevalence (1:15), at least 10 units need to be tested in structures with 20 or fewer total units; at high prevalence (1:3), at least 5 units need to be tested in units with structures having 10 or fewer units to achieve 95% probability of identifying at least one unit with radon at or above 4.0 pCi/L. These findings indicate that recommendations for radon testing in multi-family housing may be improved by applying a well-established and more rigorous statistical approach than percentage-based testing to more accurately characterize exposure to radon in multi-family housing units, which could improve lung cancer prevention efforts.

      3. Phthalates and phthalate alternatives have diverse associations with oxidative stress and inflammation in pregnant womenExternal
        van TE, Rosen EM, Barrett ES, Nguyen RH, Sathyanarayana S, Milne GL, Calafat AM, Swan SH, Ferguson KK.
        Environ Sci Technol. 2019 Mar 19;53(6):3258-3267.
        Exposure to environmental chemicals such as phthalates has been linked to numerous adverse pregnancy outcomes, potentially through an oxidative stress mediated mechanism. Most research examined urinary 8-iso-prostaglandin F2alpha (8-iso-PGF2alpha) as the oxidative stress biomarker. However, 8-iso-PGF2alpha also originates from enzymatic sources linked to inflammation. Therefore, associations between phthalates and 8-iso-PGF2alpha could have been misinterpreted. To clarify this, the 8-iso-PGF2alpha/prostaglandin F2alpha ratio approach was used to quantitatively distinguish between inflammation or oxidative stress derived 8-iso-PGF2alpha and estimate their associations with phthalate metabolites in a cohort of 758 pregnant women from The Infant Development and Environment Study (TIDES). Most urinary phthalate metabolites were associated with a significant increase in 8-iso-PGF2alpha. For example, a 22.4% higher 8-iso-PGF2alpha concentration (95% confidence interval = 14.4, 30.9) was observed with an interquartile range increase in mono- n-butyl phthalate. For most metabolites, associations were observed solely with oxidative stress derived 8-iso-PGF2alpha. In contrast, monocarboxy-isononyl phthalate and monoisononyl phthalate (MNP) were associated with both sources of 8-iso-PGF2alpha. Metabolites of the phthalate alternative 1,2-cyclohexane dicarboxylic acid, diisononyl ester (DINCH), were only associated with inflammation-derived 8-iso-PGF2alpha, which is interesting because DINCH metabolites and MNP have structural similarities.In conclusion, phthalates metabolites are not exclusively associated with oxidative stress derived 8-iso-PGF2alpha. Depending on the metabolite structure, some are also associated with inflammation derived sources, which provides interesting insights in the toxicology of phthalates.

    • Food Safety
      1. Outbreak of cyanide poisoning caused by consumption of cassava flour – Kasese District, Uganda, September 2017External
        Alitubeera PH, Eyu P, Kwesiga B, Ario AR, Zhu BP.
        MMWR Morb Mortal Wkly Rep. 2019 Apr 5;68(13):308-311.
        Cassava (Manihot esculenta), an edible tuberous root that is resistant to drought, diseases, and pests, is a major source of carbohydrates in tropical areas, the second most widely grown and consumed food in Uganda after bananas, and a staple in the diet for approximately 57% of the Uganda population (Figure 1) (1). On September 5, 2017, a funeral was held in Kasese District in western Uganda. Following the funeral, 33 persons with symptoms that included diarrhea, vomiting, and abdominal pains were admitted to Bwera Hospital in Kasese District. On September 8, the Uganda Ministry of Health received notification from the Kasese District health team regarding this outbreak of suspected food poisoning. An investigation to determine the cause of the outbreak and recommend control measures revealed that the outbreak resulted from consumption of a cassava dish made by combining hot water with cassava flour. The implicated batch of cassava flour was traced back to a single wholesaler and found to contain high cyanogenic content. Informed by the investigation findings, police confiscated all cassava flour from retailers identified as the patients’ source of the flour. Health education about cyanide poisoning from cassava and the need to adequately process cassava to reduce cyanogenic content was conducted by public health officials.

      2. The population-level impacts of excluding norovirus-infected food workers from the workplace: A mathematical modeling studyExternal
        Yang W, Steele M, Lopman B, Leon JS, Hall AJ.
        Am J Epidemiol. 2019 Jan 1;188(1):177-187.
        Norovirus is the leading cause of acute gastroenteritis and foodborne disease in the United States. The Food and Drug Administration recommends that food workers infected with norovirus be excluded from the workplace while symptomatic and for 48 hours after their symptoms subside. Compliance with this recommendation is not ideal, and the population-level impacts of changes in food-worker compliance have yet to be quantified. We aimed to assess the population impacts of varying degrees of compliance with the current recommendation through the use of a compartmental model. We modeled the number and proportion of symptomatic norovirus cases averted annually in the US population (using data from 1983-2014) in specific age groups (children aged <5 years, children aged 5-17 years, adults aged 18-64 years, and adults aged >/=65 years) under various scenarios of food-worker exclusion (i.e., proportion compliant and days of postsymptomatic exclusion) in comparison with a referent scenario which assumed that 66.6 % of norovirus-symptomatic food workers and 0% of postsymptomatic food workers were excluded from work. Overall, we estimated that 6.0 million cases of norovirus have already been avoided annually under the referent scenario and that 6.7 million (28%) more cases might be avoided through 100% compliance with the current recommendations. Substantial population-level benefits were predicted from improved compliance in exclusion of norovirus-infected food workers from the workplace-benefits that may be realized through policies or programs incentivizing self-exclusion.

    • Healthcare Associated Infections
      1. Transfusion-transmitted infections reported to the National Healthcare Safety Network Hemovigilance ModuleExternal
        Haass KA, Sapiano MR, Savinkina A, Kuehnert MJ, Basavaraju SV.
        Transfus Med Rev. 2019 Jan 25.
        Transfusion-transmitted infections (TTIs) can be severe and result in death. Transfusion-transmitted viral pathogen transmission has been substantially reduced, whereas sepsis due to bacterial contamination of platelets and transfusion-transmitted babesiosis may occur more frequently. Quantifying the burden of TTI is important to develop targeted interventions. From January 1, 2010, to December 31, 2016, health care facilities participating in the National Healthcare Safety Network Hemovigilance Module monitored transfusion recipients for evidence of TTI and recorded the total number of units transfused. Facilities use standard criteria to report TTIs. Incidence rates of TTIs, including for bacterial contamination of platelets and transfusion-transmitted babesiosis, are presented. One hundred ninety-five facilities reported 111 TTIs and 7.9 million transfused components to the National Healthcare Safety Network Hemovigilance Module. Of these 111 reports, 54 met inclusion criteria. The most frequently reported pathogens were Babesia spp in RBCs (16/23, 70%) and Staphylococcus aureus in platelets (12/30, 40%). There were 1.95 (26 apheresis, 4 whole blood derived) TTIs per 100000 transfused platelet units and 0.53 TTI per 100000 transfused RBC components, compared to 0.68 TTI per 100000 all transfused components. Bacterial contamination of platelets and transfusion-transmitted babesiosis were the most frequently reported TTIs. Interventions that reduce the burden of bacterial contamination of platelets, particularly collected by apheresis, and Babesia transmission through RBC transfusion would reduce transfusion recipient morbidity and mortality. These analyses demonstrate the value and importance of facility participation in national recipient hemovigilance using standard reporting criteria.

      2. In 2016, 42% of nursing homes enrolled in the National Healthcare Safety Network reported meeting all 7 of the Centers for Disease Control and Prevention’s Core Elements of Antibiotic Stewardship. Bivariate analyses suggested that implementation of all core elements differed by ownership type and amount of infection prevention staff hours.

      3. Investigation of healthcare infection risks from water-related organisms: Summary of CDC consultations, 2014-2017External
        Perkins KM, Reddy SC, Fagan R, Arduino MJ, Perz JF.
        Infect Control Hosp Epidemiol. 2019 Apr 3:1-6.
        OBJECTIVE: Water exposures in healthcare settings and during healthcare delivery can place patients at risk for infection with water-related organisms and can potentially lead to outbreaks. We aimed to describe Centers for Disease Control and Prevention (CDC) consultations involving water-related organisms leading to healthcare-associated infections (HAIs). DESIGN: Retrospective observational study. METHODS: We reviewed internal CDC records from January 1, 2014, through December 31, 2017, using water-related terms and organisms, excluding Legionella, to identify consultations that involved potential or confirmed transmission of water-related organisms in healthcare. We determined plausible exposure pathways and routes of transmission when possible. RESULTS: Of 620 consultations during the study period, we identified 134 consultations (21.6%), with 1,380 patients, that involved the investigation of potential water-related HAIs or infection control lapses with the potential for water-related HAIs. Nontuberculous mycobacteria were involved in the greatest number of investigations (n = 40, 29.9%). Most frequently, investigations involved medical products (n = 48, 35.8%), and most of these products were medical devices (n = 40, 83.3%). We identified a variety of plausible water-exposure pathways, including medication preparation near water splash zones and water contamination at the manufacturing sites of medications and medical devices. CONCLUSIONS: Water-related investigations represent a substantial proportion of CDC HAI consultations and likely represent only a fraction of all water-related HAI investigations and outbreaks occurring in US healthcare facilities. Water-related HAI investigations should consider all potential pathways of water exposure. Finally, healthcare facilities should develop and implement water management programs to limit the growth and spread of water-related organisms.

      4. Elizabethkingia anophelis is an emerging global multidrug-resistant opportunistic pathogen. We assessed the diversity among 13 complete genomes and 23 draft genomes of E. anophelis strains derived from various environmental settings and human infections from different geographic regions around the world from 1950s to the present. Putative integrative and conjugative elements (ICEs) were identified in 31/36 (86.1%) strains in the study. A total of 52 putative ICEs (including eight degenerated elements lacking integrases) were identified and categorized into three types based on the architecture of the conjugation module and the phylogeny of the relaxase, coupling protein, TraG, and TraJ protein sequences. The type II and III ICEs were found to integrate adjacent to tRNA genes, while type I ICEs integrate into intergenic regions or into a gene. The ICEs carry various cargo genes, including transcription regulator genes and genes conferring antibiotic resistance. The adaptive immune CRISPR-Cas system was found in nine strains, including five strains in which CRISPR-Cas machinery and ICEs coexist at different locations on the same chromosome. One ICE-derived spacer was present in the CRISPR locus in one strain. ICE distribution in the strains showed no geographic or temporal patterns. The ICEs in E. anophelis differ in architecture and sequence from CTnDOT, a well-studied ICE prevalent in Bacteroides spp. The categorization of ICEs will facilitate further investigations of the impact of ICE on virulence, genome epidemiology, and adaptive genomics of E. anophelis IMPORTANCE Elizabethkingia anophelis is an opportunistic human pathogen, and the genetic diversity between strains from around the world becomes apparent as more genomes are sequenced. Genome comparison identified three types of putative ICEs in 31 of 36 strains. The diversity of ICEs suggests that they had different origins. One of the ICEs was discovered previously from a large E. anophelis outbreak in Wisconsin in the United States; this ICE has integrated into the mutY gene of the outbreak strain, creating a mutator phenotype. Similar to ICEs found in many bacterial species, ICEs in E. anophelis carry various cargo genes that enable recipients to resist antibiotics and adapt to various ecological niches. The adaptive immune CRISPR-Cas system is present in nine of 36 strains. An ICE-derived spacer was found in the CRISPR locus in a strain that has no ICE, suggesting a past encounter and effective defense against ICE.

    • Immunity and Immunization
      1. BACKGROUND: Rotavirus disease rates dramatically declined among children <5 years of age since the rotavirus vaccine was introduced in 2006; population-level impacts remain to be fully elucidated. METHODS: Data from the Healthcare Cost and Utilization Project State Inpatient Databases were used to conduct a time-series analysis of monthly hospital discharges across age groups for acute gastroenteritis and rotavirus from 2000 to 2013. Rate ratios were calculated comparing prevaccine and postvaccine eras. RESULTS: Following vaccine introduction, a decrease in rotavirus hospitalizations occurred with a shift toward biennial patterns across all ages. The 0-4-year age group experienced the largest decrease in rotavirus hospitalizations (rate ratio, 0.14; 95% confidence interval, .09-.23). The 5-19-year and 20-59-year age groups experienced significant declines in rotavirus hospitalization rates overall; the even postvaccine calendar years were characterized by progressively lower rates, and the odd postvaccine years were associated with reductions in rates that diminished over time. Those aged >/=60 years experienced the smallest change in rotavirus hospitalization rates overall, with significant reductions in even postvaccine years compared with prevaccine years (rate ratio, 0.51; 95% confidence interval, .39-.66). CONCLUSIONS: Indirect impacts of infant rotavirus vaccination are apparent in the emergence of biennial patterns in rotavirus hospitalizations that extend to all age groups ineligible for vaccination. These observations are consistent with the notion that young children are of primary importance in disease transmission and that the initial postvaccine period of dramatic population-wide impacts will be followed by more complex incidence patterns across the age range in the long term.

      2. Economic value of vaccinating geographically hard-to-reach populations with measles vaccine: A modeling application in KenyaExternal
        Lee BY, Brown ST, Haidari LA, Clark S, Abimbola T, Pallas SE, Wallace AS, Mitgang EA, Leonard J, Bartsch SM, Yemeke TT, Zenkov E, Ozawa S.
        Vaccine. 2019 Mar 25.
        BACKGROUND: Since special efforts are necessary to vaccinate people living far from fixed vaccination posts, decision makers are interested in knowing the economic value of such efforts. METHODS: Using our immunization geospatial information system platform and a measles compartment model, we quantified the health and economic value of a 2-dose measles immunization outreach strategy for children <24months of age in Kenya who are geographically hard-to-reach (i.e., those living outside a specified catchment radius from fixed vaccination posts, which served as a proxy for access to services). FINDINGS: When geographically hard-to-reach children were not vaccinated, there were 1427 total measles cases from 2016 to 2020, resulting in $9.5million ($3.1-$18.1million) in direct medical costs and productivity losses and 7504 (3338-12,903) disability-adjusted life years (DALYs). The outreach strategy cost $76 ($23-$142)/DALY averted (compared to no outreach) when 25% of geographically hard-to-reach children received MCV1, $122 ($40-$226)/DALY averted when 50% received MCV1, and $274 ($123-$478)/DALY averted when 100% received MCV1. CONCLUSION: Outreach vaccination among geographically hard-to-reach populations was highly cost-effective in a wide variety of scenarios, offering support for investment in an effective outreach vaccination strategy.

      3. Implementing a birth dose of hepatitis B vaccine in Africa: Findings from assessments in 5 countriesExternal
        Moturi E, Tevi-Benissan C, Hagan JE, Shendale S, Mayenga D, Murokora D, Patel M, Hennessey K, Mihigo R.
        J Immunol Sci. 2018 Aug 2;Suppl(5):31-40.
        Introduction: Few African countries have introduced a birth dose of hepatitis B vaccine (HepB-BD) despite a World Health Organization (WHO) recommendation. HepB-BD given within 24 hours of birth, followed by at least two subsequent doses, is 90% effective in preventing perinatal transmission of hepatitis B virus. This article describes findings from assessments conducted to document the knowledge, attitudes, and practices surrounding HepB-BD implementation among healthcare workers in five African countries. Methods: Between August 2015 and November 2016, a series of knowledge, attitude and practices assessments were conducted in a convenience sample of public and private health facilities in Botswana, the Gambia, Namibia, Nigeria, and Sao Tome and Principe (STP). Data were collected from immunization and maternity staff through interviewer-administered questionnaires focusing on HepB-BD vaccination knowledge, practices and barriers, including those related to home births. HepB-BD coverage was calculated for each visited facility. Results: A total of 78 health facilities were visited: STP 5 (6%), Nigeria 23 (29%), Gambia 9 (12%), Botswana 16 (21%), and Namibia 25 (32%). Facilities in the Gambia attained high total coverage of 84% (range: 60-100%) but low timely estimates 7% (16-28%) with the median days to receiving HepB-BD of 11 days (IQR: 6-16 days). Nigeria had low total (23% [range: 12-40%]), and timely (13% [range: 2-21%]) HepB-BD estimates. Facilities in Botswana had high total (94% [range: 80-100%]), and timely (74% [range: 57-88%]) HepB-BD coverage. Coverage rates were not calculated for STP because the maternal Hepatitis B virus (HBV) status was not recorded in the delivery registers. The study in Namibia did not include a coverage assessment component. Barriers to timely HepB-BD included absence of standard operating procedures delineating staff responsible for HepB-BD, not integrating HepB-BD into essential newborn packages, administering HepB-BD at the point of maternal discharge from facilities, lack of daily vaccination services, sub-optimal staff knowledge about HepB-BD contraindications and age-limits, lack of outreach programs to reach babies born outside facilities, and reporting tools that did not allow for recording the timeliness of HepB-BD doses. Discussion: These assessments demonstrate how staff perceptions and lack of outreach programs to reach babies born outside health facilities with essential services are barriers for implementing timely delivery of HepB-BD vaccine. Addressing these challenges may accelerate HepB-BD implementation in Africa.

      4. Surveillance to track progress toward polio eradication – worldwide, 2017-2018External
        Patel JC, Diop OM, Gardner T, Chavan S, Jorba J, Wassilak SG, Ahmed J, Snider CJ.
        MMWR Morb Mortal Wkly Rep. 2019 Apr 5;68(13):312-318.
        When the Global Polio Eradication Initiative (GPEI) began in 1988, cases of poliomyelitis were reported from 125 countries. Since then, only Afghanistan, Nigeria, and Pakistan have experienced uninterrupted transmission of wild poliovirus (WPV). The primary means of detecting poliovirus is through surveillance for acute flaccid paralysis (AFP) among children aged <15 years with testing of stool specimens for WPV and vaccine-derived polioviruses (VDPVs) in World Health Organization (WHO)-accredited laboratories of the Global Polio Laboratory Network (GPLN) (1,2). AFP surveillance is supplemented by environmental surveillance for polioviruses in sewage at selected locations. Analysis of genomic sequences of isolated polioviruses enables assessment of transmission by time and place, potential gaps in surveillance, and emergence of VDPVs (3). This report presents 2017-2018 poliovirus surveillance data, focusing on 31 countries* identified as high-priority countries because of a “high risk of poliovirus transmission and limited capacity to adequately address those risks” (4). Some of these countries are located within WHO regions with endemic polio, and others are in regions that are polio-free. In 2018, 26 (84%) of the 31 countries met AFP surveillance indicators nationally; however, subnational variation in surveillance performance was substantial. Surveillance systems need continued strengthening through monitoring, supervision, and improvements in specimen collection and transport to provide sufficient evidence for interruption of poliovirus circulation.

    • Informatics
      1. Chief complaint classification with recurrent neural networksExternal
        Lee SH, Levin D, Finley PD, Heilig CM.
        J Biomed Inform. 2019 Mar 26:103158.
        Syndromic surveillance detects and monitors individual and population health indicators through sources such as emergency department records. Automated classification of these records can improve outbreak detection speed and diagnosis accuracy. Current syndromic systems rely on hand-coded keyword-based methods to parse written fields and may benefit from the use of modern supervised-learning classifier models. In this paper, we implement two recurrent neural network models based on long short-term memory (LSTM) and gated recurrent unit (GRU) cells and compare them to two traditional bag-of-words classifiers: multinomial naive Bayes (MNB) and a support vector machine (SVM). The MNB classifier is one of only two machine learning algorithms currently being used for syndromic surveillance. All four models are trained to predict diagnostic code groups as defined by Clinical Classification Software, first to predict from discharge diagnosis, and then from chief complaint fields. The classifiers are trained on 3.6 million de-identified emergency department records from a single United States jurisdiction. We compare performance of these models primarily using the F1 score, and we measure absolute model performance to determine which conditions are the most amenable to surveillance based on chief complaint alone. Using discharge diagnoses, the LSTM classifier performs best, though all models exhibit an F1 score above 96.00. Using chief complaints, the GRU performs best (F1=47.38), and MNB with bigrams performs worst (F1=39.40). We also note that certain syndrome types are easier to detect than others. For example, chief complaints using the GRU model predicts alcohol-related disorders well (F1=78.91) but predicts influenza poorly (F1=14.80). In all instances, the RNN models outperformed the bag-of-words classifiers suggesting deep learning models could substantially improve the automatic classification of unstructured text for syndromic surveillance.

    • Injury and Violence
      1. Spatial clustering of suicide and associated community characteristics, Idaho, 2010-2014External
        Kassem AM, Carter KK, Johnson CJ, Hahn CG.
        Prev Chronic Dis. 2019 Mar 28;16:E37.
        INTRODUCTION: In 2015, Idaho had the fifth highest suicide rate in the United States. Little is known about the characteristics of areas in Idaho with high suicide rates. To aid suicide prevention efforts in the state, we sought to identify and characterize spatial clusters of suicide. METHODS: We obtained population data from the 2010 US Census and the 2010-2014 American Community Survey, analyzed data on suicides from death certificates, and used a discrete Poisson model in SaTScan to identify spatial clusters of suicide. We used logistic regression to examine associations between suicide clustering and population characteristics. RESULTS: We found 2 clusters of suicide during 2010-2014 that accounted for 70 (4.7%) of 1,501 suicides in Idaho. Areas within clusters were positively associated with the following population characteristics: median age </=31.1 years versus >31.1 years (multivariable-adjusted odds ratio [aOR] = 2.4; 95% confidence interval [CI], 1.04-5.6), >53% female vs </=53% female (aOR = 2.7; 95% CI, 1.3-5.8; P = .01), >1% American Indian/Alaska Native vs </=1% American Indian/Alaska Native (aOR = 2.9; 95% CI, 1.4-6.3), and >30% never married vs </=30% never married (aOR = 3.4; 95% CI, 1.5-8.0; P = .004). CONCLUSION: Idaho suicide prevention programs should consider using results to target prevention efforts to communities with disproportionately high suicide rates.

      2. Nonfatal assaults and homicides among adults aged >/=60 years – United States, 2002-2016External
        Logan JE, Haileyesus T, Ertl A, Rostad WL, Herbst JH.
        MMWR Morb Mortal Wkly Rep. 2019 Apr 5;68(13):297-302.
        Since interpersonal violence was recognized as a public health problem in the 1970s, much attention has focused on preventing violence among young persons and intimate partners (1). Violence directed against older adults (>/=60 years) has received less attention, despite the faster growth of this population than that of younger groups (2). Using data from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) and the National Vital Statistics System (NVSS), CDC analyzed rates of nonfatal assaults and homicides against older adults during 2002-2016. Across the 15-year period, the nonfatal assault rate increased 75.4% (from 77.7 to 136.3 per 100,000) among men, and from 2007 to 2016, increased 35.4% (from 43.8 to 59.3) among women. From 2010 to 2016, the homicide rate increased among men by 7.1%, and a 19.3% increase was observed from 2013 to 2016 among men aged 60-69 years. Growth in both the older adult population and the rates of violence against this group, especially among men, suggests an important need for violence prevention strategies (3). Focusing prevention efforts for this population will require improved understanding of magnitude and trends in violence against older adults.

    • Laboratory Sciences
      1. Development and validation of a clinical laboratory improvement amendments-compliant multiplex real-time PCR assay for detection of mcr genesExternal
        Daniels JB, Campbell D, Boyd S, Ansari U, Lutgring J, Rasheed JK, Halpin AL, Sjolund-Karlsson M.
        Microb Drug Resist. 2019 Apr 3.
        Increased use of colistin in both human and veterinary medicine has led to the emergence of plasmid-mediated colistin resistance (mcr genes). In this study, we report the development of a real-time PCR assay using TaqMan probe-based chemistry for detection of mcr genes from bacterial isolates. Positive control isolates harboring mcr-1 and mcr-2 yielded exponential amplification curves with the assay, and the amplification efficiency was 98% and 96% for mcr-1 and mcr-2, respectively. Each target gene could be reproducibly detected from a sample containing 10(3) cfu/mL of mcr-harboring bacteria, and there was no cross-reactivity with DNA extracted from several multidrug-resistant bacteria harboring other resistance genes, but lacking mcr genes. Both sensitivity and specificity of the mcr real-time PCR assay were 100% in a method validation performed with a set of 25 previously well-characterized bacterial isolates containing mcr-positive and -negative bacteria. This newly developed assay is a rapid and sensitive tool for detecting emerging mcr genes in cultured bacterial isolates. The assay was successfully validated according to quality standards of the Clinical Laboratory Improvement Amendments (CLIA).

      2. Evaluation of the performance of three biomarker assays for recent HIV infection using a well-characterized HIV-1 subtype C incidence cohortExternal
        Gonese E, Kilmarx P, van Schalkwyk C, Grebe E, Mutasa K, Ntozini R, Parekh B, Dobbs T, Duong Pottinger Y, Masciotra S, Owen M, Nachega J, van Zyl G, Hargrove J.
        AIDS Res Hum Retroviruses. 2019 Apr 2.
        BACKGROUND: Biomarkers for detecting early HIV infection and estimating HIV incidence should minimise False-Recent Rates (FRRs) while maximising Mean Duration of Recent Infection (MDRIs). We compared BED capture enzyme immunoassay (BED), Sedia Limiting Antigen Avidity EIA (LAg) and Bio-Rad avidity incident incidence (BRAI) assays using samples from Zimbabwean postpartum women infected with clade C HIV. METHODS: We calculated MDRIs using 590 samples from 351 seroconverting postpartum women, and FRRs using samples from 2,825 women known to be HIV-positive for >12 months. RESULTS: Antibody kinetics were more predictable with LAg and had higher precision compared to BED or BRAI. BRAI also exhibited more variability, and avidity reversal in some cases. For BED, LAg and BRAI, used alone or with viral load (VL), MDRI values in days were: BED – 188 and 170 at normalized optical density (ODn) 0.8; LAg – 104 and 100 at ODn cut-off 1.5; BRAI – 135 and 134 at Avidity Index cut-off 30%. Corresponding FRRs were: BRAI 1.1% and 1.0% and LAg 0.57% and 0.35%: these were 3.8 – 10.9 times lower than BED values of 4.8% and 3.8 Conclusion: BRAI and LAg have significantly lower FRRs and MDRIs than in published studies, and much lower than BED and could be used to estimate incidence in perinatal women and to measure population level HIV incidence in HIV control operations in Africa. BRAI and LAg have significantly lower FRRs and MDRIs than in published studies, and much lower than BED. These improved methods could be used to estimate incidence in perinatal women and to measure population level HIV incidence in HIV control operations in Africa.

      3. Molecular characterization of Clostridium botulinum harboring the bont/B7 geneExternal
        Halpin JL, Dykes JK, Katz L, Centurioni DA, Perry MJ, Egan CT, Luquez C.
        Foodborne Pathog Dis. 2019 Mar 30.
        Clostridium botulinum produces botulinum neurotoxin (BoNT), which is the causative agent of botulism, a rare but serious disease that can result in death if not treated. Infant botulism occurs when C. botulinum colonizes the intestinal tract of infants and produces BoNT. It has been proposed that infants under the age of 1 year are uniquely susceptible to colonization by C. botulinum as their intestinal microbiota is not fully developed and provides little competition, allowing C. botulinum to thrive and produce BoNT in the gut. There are seven well-characterized serotypes (A-G) of BoNT identified by the ability of specific antitoxins to neutralize BoNTs. Molecular technology has allowed researchers to narrow these further into subtypes based on nucleic acid sequences of the botulinum toxin (bont) gene. One of the most recently recognized subtypes for bont/B is subtype bont/B7. We identified through whole genome sequencing five C. botulinum isolates harboring bont/B7 from CDC’s strain collection, including patient isolates and an epidemiologically linked isolate from an opened infant formula container. In this study, we report the results of whole genome sequencing analysis of these C. botulinum subtype bont/B7 isolates. Average nucleotide identity and high quality single nucleotide polymorphism (hqSNP) analysis resulted in two major clades. The epidemiologically linked isolates differed from each other by 2-6 hqSNPs, and this clade separated from the other isolates by 95-119 hqSNPs, corroborating available epidemiological evidence.

      4. Multi-walled carbon nanotubes inhibit estrogen receptor expression in vivo and in vitro through transforming growth factor beta1External
        Smith LC, Moreno S, Robinson S, Orandle M, Porter DW, Das D, Saleh NB, Sabo-Attwood T.
        NanoImpact. 2019 ;14.
        Exposure to multi-walled carbon nanotubes (MWCNTs) is suspected to contribute to pulmonary fibrosis through modulation of transforming growth factor beta1 (TGF-1). There is growing evidence that estrogen signaling is important in pulmonary function and modulates pro-fibrogenic signaling in multiple models of pulmonary fibrosis, however an interaction between MWCNT exposure and estrogen signaling in the lung is not known. The purpose of this work was to determine whether estrogen signaling in the lung is a target for MWCNTs and to identify potential signaling mechanisms mediating MWCNT-induced responses using a whole-body inhalation mouse model and an in vitro human lung cell model. Mice exposed to MWCNTs had reduced mRNA expression of estrogen receptor alpha and beta (Esr1 and Esr2, respectively) in lung tissue at multiple time-points post exposure, whereas expression of G-protein coupled estrogen receptor 1 (Gper1) was more variable. We localized ESR1 protein expression as primarily associated with bronchioles and within inflammatory macrophages. The reduction in estrogen receptor expression was concomitant to an increase in TGF-1 levels in the bronchoalveolar lavage fluid (BALF) of MWCNT-exposed animals. We confirmed a role for TGF-1 in mediating MWCNT-induced repression of ESR1 mRNA expression using a TGF- type-I receptor inhibitor in bronchial epithelial cells in vitro. Overall these results highlight a novel mechanism of MWCNT-induced signaling where MWCNT-induced regulation of TGF-1 represses estrogen receptor expression. Dysregulated estrogen signaling through altered receptor expression may have potential consequences on lung function.

      5. Influence of welding fume metal composition on lung toxicity and tumor formation in experimental animal modelsExternal
        Zeidler-Erdely PC, Falcone LM, Antonini JM.
        J Occup Environ Hyg. 2019 Apr 1:1-6.

        [No abstract]

      6. Impact of testosterone assay standardization efforts assessed via accuracy-based proficiency testingExternal
        Zhimin C, Botelho JC, Rej R, Vesper H, Astles JR.
        Clin Biochem. 2019 Mar 27.
        BACKGROUND: We reported observations on analytical performance in testosterone measurements of various methods/assays from the study carried out using accuracy-based proficiency testing (PT) during 2012-2013. In 2016, we re-evaluated analytical performance of testosterone assays using accuracy-based PT to assess effectiveness of CDC efforts toward standardization. METHODS: Five single-donor human serum samples from female and male adult donors were analyzed for testosterone by New York State Department of Health-certified clinical laboratories using 16 immunoassays and LC-MS/MS methods. Target values were determined using the CDC reference measurement procedure. RESULTS: Testosterone targets for the 5 samples were 43.5, 160, 294, 457, and 534ng/dL. The biases of individual result of the 65 participant laboratories against the target for each sample were calculated. Of participants, 87.7% had >/=4 of the 5 results within the minimum allowable total error limits (+/- 25.1%), a 14.7% increase from the previous study. The improved PT scores were attributed to better analytical accuracy and precision, and laboratories’ selection of more accurate assays/methods. CONCLUSIONS: Improved analytical accuracy and precision for testosterone assays were demonstrated over a 3.5-year period after the first CDC-directed accuracy-based proficiency testing. Additional effort is needed to improve accuracy/precision of measurements, especially at low concentrations.

    • Maternal and Child Health
      1. Venous thromboembolism as a cause of severe maternal morbidity and mortality in the United StatesExternal
        Abe K, Kuklina EV, Hooper WC, Callaghan WM.
        Semin Perinatol. 2019 Mar 9.
        In the U.S., deaths due to pulmonary embolism (PE) account for 9.2% of all pregnancy-related deaths or approximately 1.5 deaths per 100,000 live births. Maternal deaths and maternal morbidity due to PE are more common among women who deliver by cesarean section. In the past decade, the clinical community has increasingly adopted venous thromboembolism (VTE) guidelines and thromboprophylaxis recommendations for pregnant women. Although deep vein thrombosis rates have decreased during this time-period, PE rates have remained relatively unchanged in pregnancy hospitalizations and as a cause of maternal mortality. Changes in the health profile of women who become pregnant, particularly due to maternal age and co-morbidities, needs more attention to better understand the impact of VTE risk during pregnancy and the postpartum period.

      2. Improving developmental screening, discussion, and referral in pediatric practiceExternal
        Bright MA, Zubler J, Boothby C, Whitaker TM.
        Clin Pediatr (Phila). 2019 Apr 2:9922819841017.
        OBJECTIVE: Although pediatricians’ use of standardized screening tools for identifying developmental delays has increased, only 63% of pediatricians report performing standardized screening as recommended. The purpose of the current quality improvement project was to improve developmental monitoring, screening, and referral for developmental concerns by pediatricians. METHOD: Twenty-eight pediatricians completed an in-person meeting, monthly webinars, and individualized feedback from an Expert Work Group on progress across a 3-month action period. RESULTS: Statistically significant increases were observed in rates of autism screening, discussions of screening results with families, and referral following abnormal results. There was no statistically significant change in rates of general developmental screening. Comparing self-report with record review, pediatricians overestimated the extent to which they conducted discussion and referral. CONCLUSIONS: Universal screening for all children has yet to be achieved. The current project supports that practice-based improvements can be made and delineates some of the routes to success.

      3. Risk of gastroschisis with maternal genitourinary infections: the US National Birth Defects Prevention Study 1997-2011External
        Feldkamp ML, Arnold KE, Krikov S, Reefhuis J, Almli LM, Moore CA, Botto LD.
        BMJ Open. 2019 Mar 30;9(3):e026297.
        OBJECTIVE: To assess the association between occurrence and timing of maternal self-reported genitourinary tract infection (urinary tract infections [UTIs] and/or sexually transmitted infection [STI]) and risk for gastroschisis in the offspring. DESIGN: Population-based case-control study. SETTING: National Birth Defects Prevention Study, a multisite study in the USA. PARTICIPANTS: Mothers of 1366 gastroschisis cases and 11 238 healthy controls. MAIN OUTCOME MEASURES: Crude and adjusted ORs (aORs) with 95% CIs. RESULTS: Genitourinary infections were frequent in case (19.3%) and control women (9.9%) during the periconceptional period (defined as 3 months prior to 3 months after conception). UTI and/or STI in the periconceptional period were associated with similarly increased risks for gastroschisis (aOR 1.5, 95% CI 1.3 to 1.8; aOR 1.6, 95% CI 1.2 to 2.3, respectively). The risk was increased with a UTI before (aOR 2.5; 95% CI 1.4 to 4.5) or after (aOR 1.7; 95% CI 1.1 to 2.6) conception only among women >/=25 years of age. The risk was highest among women <20 years of age with an STI before conception (aOR 3.6; 95% CI 1.5 to 8.4) and in women >/=25 years of age, the risk was similar for before (aOR 2.9; 95% CI 1.0 to 8.5) and after (aOR 2.8; 95% CI 1.3 to 6.1) conception. A specific STI pathogen was reported in 89.3% (50/56) of cases and 84.3% (162/191) of controls with Chlamydia trachomatis the most common (25/50 cases, 50%; 58/162 controls, 36%) and highest among women <20 years of age (16/25 cases, 64%; 22/33 controls, 67%). CONCLUSIONS: UTI and/or STI were associated with an increased risk for gastroschisis, with the strength of the association varying by maternal age and timing of infection.

    • Medicine
      1. Radiation protection professionals benefit from using and applying a robust system of radiological protection that has evolved and matured through decades of research and experience. Nevertheless, uncertainties in potential health effects from low doses and low dose rates of radiation continue to remain. This uncertainty, coupled with complex jargon and nuances, has created an environment where the system of radiological protection can be misrepresented, even by radiation safety professionals, and by extension, misunderstood by the public. While it is universally agreed that the linear-no-threshold model cannot adequately explain or predict health effects of low dose radiation for all cancers, all individuals, or all exposure situations, the recommendation of authoritative scientific bodies to use this model for managing risks of radiation exposure is unequivocal. The role of individual radiation protection professionals in communicating radiation health and risk information is critical and consistent with the primary objective of professional organizations that represent them, mainly to promote best science and practice of radiation protection. If radiation protection professionals provide advice contrary to the recommendations and advice of regulatory and authoritative scientific bodies, it can erode public confidence in the system of radiological protection and harm the credibility of our profession.

    • Military Medicine and Health
      1. Prevalence and covariates of problematic gambling among a US military cohortExternal
        Gallaway MS, Fink DS, Sampson L, Cohen GH, Tamburrino M, Liberzon I, Calabrese J, Galea S.
        Addict Behav. 2019 Mar 21;95:166-171.
        The availability of and participation in gambling has increased substantially the past several decades, however studies of military members’ gambling behaviors are limited. The present study aimed to investigate potential problematic gambling and its association with demographics and behavioral characteristics in a US military cohort. We analyzed cohort data from a telephone survey during 2015-2016 of 1553 Ohio Army National Guard members. We assessed potential problematic gambling by using the 3-item National Opinion Research Center Diagnostic Screen-Loss of Control, Lying, and Preoccupation Screen (NODS-CLiP). Potential correlates examined were demographics, depression, suicidal ideation, smoking status, alcohol use, legal and financial problems, perceived general health status, pain, and impulsivity. Results indicated past-year frequent gambling (at least once per week) and lifetime potential problematic gambling was reported by 13% and 8% of respondents, respectively. Problematic gambling and past-year gambling behaviors were associated in a dose-response relationship from 18% among soldiers gambling once per week to 44% among those gambling 4 or more times per week. Correlates of screening positive for potential problematic gambling included the following: being male, currently unmarried, having left the Guard or retired, minor depression, alcohol dependence, legal problems, and increased pain. Given the higher prevalence of frequent gambling in this military cohort (8%), nearly twice the US prevalence (5%), and the association with negative psychological and behavioral outcomes, routine screening of gambling frequency and problem gambling may be needed to ensure military and veteran populations live the healthiest lives possible.

    • Occupational Safety and Health
      1. Survival of Staphylococcus aureus on the outer shell of fire fighter turnout gear after sanitation in a commercial washer/extractorExternal
        Farcas D, Blachere FM, Kashon ML, Sbarra D, Schwegler-Berry D, Stull JO, Noti JD.
        J Occup Med Toxicol. 2019 ;14(1).
        Background: Methicillin-resistant Staphylococcus aureus contamination on surfaces including turnout gear had been found throughout a number of fire stations. As such, the outer shell barrier of turnout gear jackets may be an indirect transmission source and proper disinfection is essential to reduce the risk of exposure to fire fighters. Cleaning practices vary considerably among fire stations, and a method to assess disinfection of gear washed in commercial washer/extractors is needed. Methods: Swatches (1 in. x 1.5 in.) of the outer shell fabrics, Gemini, Advance, and Pioneer, of turnout gear were inoculated with S. aureus, and washed with an Environmental Protection Agency-registered sanitizer commonly used to wash turnout gear. To initially assess the sanitizer, inoculated swatches were washed in small tubes according to the American Society for Testing Materials E2274 Protocol for evaluating laundry sanitizers. Inoculated swatches were also pinned to turnout gear jackets and washed in a Milnor commercial washer/extractor. Viable S. aureus that remained attached to fabric swatches after washing were recovered and quantified. Scanning Electron Microscopy was used to characterize the stages of S. aureus biofilm formation on the swatches that can result in resistance to disinfection. Results: Disinfection in small tubes for only 10 s reduced the viability of S. aureus on Gemini, Advance, and Pioneer by 73, 99, and 100%, respectively. In contrast, disinfection of S. aureus-contaminated Gemini swatches pinned to turnout gear and washed in the washer/extractor was 99.7% effective. Scanning Electron Microscopy showed that biofilm formation begins as early as 5 h after attachment of S. aureus. Conclusion: This sanitizer and, likely, others containing the anti-microbial agent didecyl dimethyl ammonium chloride, is an effective disinfectant of S. aureus. Inclusion of contaminated outer shell swatches in the wash cycle affords a simple and quantitative method to assess sanitization of gear by commercial gear cleaning facilities. This methodology can be extended to assess for other bacterial contaminants. Sanitizer-resistant strains will continue to pose problems, and biofilm formation may affect the cleanliness of the washed turnout gear. Our methodology for assessing effectiveness of disinfection may help reduce the occupational exposure to fire fighters from bacterial contaminants.

      2. The process industry has made major advancements and is a leader in near-miss safety management, with several validated models and databases to track close call reports. However, organizational efforts to develop safe work procedures and rules do not guarantee that employees will behaviorally comply with them. Assuming that at some point, every safety management system will need to be examined and realigned to help prevent incidents on the job, it is important to understand how personality traits can impact workers? risk-based decisions. Such work has been done in the mining industry due to its characteristically high risks and the results can be gleaned to help the process industry realign goals and values with their workforce. In the current study, researchers cross-sectionally surveyed 1,334 miners from 20 mine sites across the United States, varying in size and commodity. The survey sought to understand how mineworkers’ risk avoidance could impact their near miss incidents on the job – a common precursor to lost-time incidents. Multiple regressions showed that as a miner’s level of risk avoidance increased by 1 unit in the 6-point response scale, the probability of experiencing a near miss significantly decreased by 30% when adjusting for relevant control variables. Additionally, a significant interaction between risk avoidance and locus of control suggested that the effect of risk avoidance on near misses is enhanced as a miner’s locus of control increases. A one-unit increase in locus of control appends the base effect of risk avoidance on near misses with an additional 8% decrease in the probability. Findings are discussed from a near-miss safety management system perspective in terms of methods to foster both risk avoidance and locus of control in an effort to reduce the probability of near misses and lost time at the organizational level within the process industry and other high-hazard industries.

      3. Anti-Mullerian hormone levels in nurses working night shiftsExternal
        Johnson CY, Tanz LJ, Lawson CC, Howards PP, Bertone-Johnson ER, Eliassen AH, Schernhammer ES, Rich-Edwards JW.
        Arch Environ Occup Health. 2019 Apr 4:1-8.
        Our objective was to examine associations between night shift work and serum anti-Mullerian hormone (AMH) levels. We analyzed 1,537 blood samples from premenopausal female nurses in the Nurses’ Health Study II, assayed for AMH. Rotating or permanent night shifts worked in the two weeks before blood collection and years of rotating night shift work were obtained via questionnaire. We found no associations between recent night shifts or rotating night shift work and AMH. The median difference in AMH was 0.3 (95% CI: -0.4, 0.8) ng/mL for >/=5 versus 0 recent night shifts and -0.1 (95% CI: -0.4, 0.3) ng/mL for >/=6 versus 0 years of rotating night shift work. Although we found no associations between night shift work and AMH, this does not preclude associations between night shift work and fertility operating through other mechanisms.

      4. A control banding framework for protecting the US workforce from aerosol transmissible infectious disease outbreaks with high public health consequencesExternal
        Sietsema M, Radonovich L, Hearl FJ, Fisher EM, Brosseau LM, Shaffer RE, Koonin LM.
        Health Secur. 2019 Apr 3.
        Recent high-profile infectious disease outbreaks illustrate the importance of selecting appropriate control measures to protect a wider range of employees, other than those in healthcare settings. In such settings, where routine exposure risks are often high, control measures may be more available, routinely implemented, and studied for effectiveness. In the absence of evidence-based guidelines or established best practices for selecting appropriate control measures, employers may unduly rely on personal protective equipment (PPE) because of its wide availability and pervasiveness as a control measure, circumventing other effective options for protection. Control banding is one approach that may be used to assign job tasks into risk categories and prioritize the application of controls. This article proposes an initial control banding framework for workers at all levels of risk and incorporates a range of control options, including PPE. Using the National Institutes of Health (NIH) risk groups as a surrogate for toxicity and combining the exposure duration with the exposure likelihood, we can generate the risk of a job task to the worker.

      5. Tobacco smoking is a major risk factor for chronic obstructive pulmonary disease (COPD), a debilitating respiratory condition with high mortality and morbidity (1,2). However, an estimated 24% of adults with COPD have never smoked (3,4). Among these persons, 26%-53% of COPD can be attributed to workplace exposures, including dust, fumes, gases, vapors, and secondhand smoke exposure (4-6). To assess industry-specific and occupation-specific COPD prevalence among adults aged >/=18 years who have never smoked and who were employed any time during the past 12 months, CDC analyzed 2013-2017 National Health Interview Survey (NHIS) data. Among an estimated 106 million workers who had never smoked, 2.2% (2.4 million) have COPD. Highest prevalences were among workers aged >/=65 years (4.6%), women (3.0%), and those reporting fair/poor health (6.7%). Among industries and occupations, the highest COPD prevalences were among workers in the information industry (3.3%) and office and administrative support occupations (3.3%). Among women, the highest prevalences were among those employed in the information industry (5.1%) and in the transportation and material moving occupation (4.5%), and among men, among those employed in the agriculture, forestry, fishing, and hunting industry (2.3%) and the administrative and support, waste management, and remediation services industry (2.3%). High COPD prevalences in certain industries and occupations among persons who have never smoked underscore the importance of continued surveillance, early identification of COPD, and reduction or elimination of COPD-associated risk factors, such as the reduction of workplace exposures to dust, vapors, fumes, chemicals, and exposure to indoor and outdoor air pollutants.

      6. [No abstract]

    • Parasitic Diseases
      1. Comparison of msp genotyping and a 24 SNP molecular assay for differentiating Plasmodium falciparum recrudescence from reinfectionExternal
        Fulakeza J, McNitt S, Vareta J, Saidi A, Mvula G, Taylor T, Mathanga DP, Small DS, Skarbinski J, Gutman JR, Seydel K.
        Malar J. 2019 Mar 18;18(1):84.
        BACKGROUND: Current World Health Organization guidelines for conducting anti-malarial drug efficacy clinical trials recommend genotyping Plasmodium falciparum genes msp1 and msp2 to distinguish recrudescence from reinfection. A more recently developed potential alternative to this method is a molecular genotyping assay based on a panel of 24 single nucleotide polymorphism (SNP) markers. METHODS: Performance parameters of these two genotyping methods were compared using data from two recently completed drug efficacy trials. Blood samples from two anti-malarial therapeutic trials were analysed by both msp genotyping and the 24 SNP assay. Additionally, to conserve time and resources, the statistical program R was used to select the most informative SNPs for a set of unrelated Malawian samples to develop a truncated SNP-based assay for the region surrounding Blantyre, Malawi. The ability of this truncated assay to distinguish reinfection from recrudescence when compared to the full 24 SNP assay was then analysed using data from the therapeutic trials. RESULTS: A total of 360 samples were analysed; 66 for concordance of msp and SNP barcoding methodologies, and 294 for assessing the most informative of the 24 SNP markers. SNP genotyping performed comparably to msp genotyping, with only one case of disagreement among the 50 interpretable results, where the SNP assay identified the sample as reinfection and the msp typing as recrudescence. Furthermore, SNP typing was more robust; only 6% of samples were uninterpretable by SNP typing, compared to 19.7% when msp genotyping was used. For discriminating reinfection from recrudescence, a truncated 6 SNP assay was found to perform at 95.1% the accuracy of the full 24 SNP bar code. CONCLUSIONS: The use of SNP analysis has similar sensitivity to the standard msp genotyping in determining recrudescence from reinfection. Although more expensive, SNP typing is faster and less work intensive. Limiting the assay to those SNPs most informative in the geographical region of interest may further decrease the workload and the cost, making this technique a feasible and affordable alternative in drug efficacy trials.

      2. [No abstract]

      3. The temporal dynamics and infectiousness of subpatent Plasmodium falciparum infections in relation to parasite densityExternal
        Slater HC, Ross A, Felger I, Hofmann NE, Robinson L, Cook J, Goncalves BP, Bjorkman A, Ouedraogo AL, Morris U, Msellem M, Koepfli C, Mueller I, Tadesse F, Gadisa E, Das S, Domingo G, Kapulu M, Midega J, Owusu-Agyei S, Nabet C, Piarroux R, Doumbo O, Doumbo SN, Koram K, Lucchi N, Udhayakumar V, Mosha J, Tiono A, Chandramohan D, Gosling R, Mwingira F, Sauerwein R, Riley EM, White NJ, Nosten F, Imwong M, Bousema T, Drakeley C, Okell LC.
        Nat Commun. 2019 Mar 29;10(1):1433.
        Malaria infections occurring below the limit of detection of standard diagnostics are common in all endemic settings. However, key questions remain surrounding their contribution to sustaining transmission and whether they need to be detected and targeted to achieve malaria elimination. In this study we analyse a range of malaria datasets to quantify the density, detectability, course of infection and infectiousness of subpatent infections. Asymptomatically infected individuals have lower parasite densities on average in low transmission settings compared to individuals in higher transmission settings. In cohort studies, subpatent infections are found to be predictive of future periods of patent infection and in membrane feeding studies, individuals infected with subpatent asexual parasite densities are found to be approximately a third as infectious to mosquitoes as individuals with patent (asexual parasite) infection. These results indicate that subpatent infections contribute to the infectious reservoir, may be long lasting, and require more sensitive diagnostics to detect them in lower transmission settings.

    • Physical Activity
      1. Physical activity: Cornucopia and conundrumsExternal
        Powell KE, Blair SN.
        Kinesiol Rev (Champaign). 2019 ;8(1):4-10.
        The number and scope of established health-related benefits from physical activity continue to expand. Notable recent additions include improved weight status and bone health in children 3-5 years of age, prevention of excessive weight gain among adults, reduced risk of dementia, and improved cognition and a variety of other brain-health benefits. Greater flexibility in receiving health benefits is also apparent. No threshold of moderate to vigorous physical activity (MVPA) must be exceeded for benefits to accrue; small increments by individuals performing little to no MVPA produce larger reductions in risk than similarly sized increments in individuals already performing greater amounts of MVPA, bouts of MVPA < 10 min in duration contribute to the accumulation of MVPA, and light-intensity physical activity can benefit individuals currently doing little or no MVPA. MVPA is indirectly related to the adverse effects of sedentary behavior. The definition of physical activity continues to be debated.

    • Zoonotic and Vectorborne Diseases
      1. New filovirus disease classification and nomenclatureExternal
        Kuhn JH, Adachi T, Adhikari NK, Arribas JR, Bah IE, Bausch DG, Bhadelia N, Borchert M, Brantsaeter AB, Brett-Major DM, Burgess TH, Chertow DS, Chute CG, Cieslak TJ, Colebunders R, Crozier I, Davey RT, de Clerck H, Delgado R, Evans L, Fallah M, Fischer WA, Fletcher TE, Fowler RA, Grunewald T, Hall A, Hewlett A, Hoepelman AI, Houlihan CF, Ippolito G, Jacob ST, Jacobs M, Jakob R, Jacquerioz FA, Kaiser L, Kalil AC, Kamara RF, Kapetshi J, Klenk HD, Kobinger G, Kortepeter MG, Kraft CS, Kratz T, Bosa HS, Lado M, Lamontagne F, Lane HC, Lobel L, Lutwama J, Lyon GM, Massaquoi MB, Massaquoi TA, Mehta AK, Makuma VM, Murthy S, Musoke TS, Muyembe-Tamfum JJ, Nakyeyune P, Nanclares C, Nanyunja M, Nsio-Mbeta J, O’Dempsey T, Paweska JT, Peters CJ, Piot P, Rapp C, Renaud B, Ribner B, Sabeti PC, Schieffelin JS, Slenczka W, Soka MJ, Sprecher A, Strong J, Swanepoel R, Uyeki TM, van Herp M, Vetter P, Wohl DA, Wolf T, Wolz A, Wurie AH, Yoti Z.
        Nat Rev Microbiol. 2019 Mar 29.

        [No abstract]

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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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