Volume 11, Issue 16 April 23, 2019

CDC Science Clips: Volume 11, Issue 16, April 23, 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 icon to track social and mainstream media mentions!

  1. Top Articles of the Week

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

    The names of CDC authors are indicated in bold text.
    • Communicable Diseases
      • Increased HIV diagnoses in West Virginia counties highly vulnerable to rapid HIV dissemination through injection drug use: a cautionary taleexternal icon
        Bradley H, Hogan V, Agnew-Brune C, Armstrong J, Broussard D, Buchacz K, Burton K, Cope S, Dawson E, De La Garza G, Gerard A, Granado M, Gupta R, Haddy L, Hoffman W, Johnson SD, Kirk N, Lee C, Lyss S, Mark-Carew M, Quilter L, Reynolds P, Rose B, Thompson A, Varella L, Weidle P, White B, Wills D, Young SA, Hoots BE.
        Ann Epidemiol. 2019 Mar 6.
        PURPOSE: To investigate HIV transmission potential from a cluster of HIV infections among men who have sex with men to persons who inject drugs in 15 West Virginia counties. These counties were previously identified as highly vulnerable to rapid HIV dissemination through injection drug use (IDU) associated with high levels of opioid misuse. METHODS: We interviewed persons with 2017 HIV diagnoses about past-year risk behaviors and elicited sexual, IDU, and social contacts. We tested contacts for HIV and assessed risk behaviors. To determine HIV transmission potential from persons with 2017 diagnoses to persons who inject drugs, we assessed viral suppression status, HIV status of contacts, and IDU risk behaviors of persons living with HIV and contacts. RESULTS: We interviewed 78 persons: 39 with 2017 diagnoses and 39 contacts. Overall, 13/78 (17%) injected drugs in the past year. Of 19 persons with 2017 diagnoses and detectable virus, 9 (47%) had more than or equal to 1 sexual or IDU contacts of negative or unknown HIV status. During the past year, 2/9 had injected drugs and shared equipment, and 1/9 had more than or equal to 1 partner who did so. CONCLUSIONS: We identified IDU risk behavior among persons with 2017 diagnoses and their contacts. West Virginia HIV prevention programs should continue to give high priority to IDU harm reduction.

      • Outlook for tuberculosis elimination in California: An individual-based stochastic modelexternal icon
        Goodell AJ, Shete PB, Vreman R, McCabe D, Porco TC, Barry PM, Flood J, Marks SM, Hill A, Cattamanchi A, Kahn JG.
        PLoS One. 2019 ;14(4):e0214532.
        RATIONALE: As part of the End TB Strategy, the World Health Organization calls for low-tuberculosis (TB) incidence settings to achieve pre-elimination (<10 cases per million) and elimination (<1 case per million) by 2035 and 2050, respectively. These targets require testing and treatment for latent tuberculosis infection (LTBI). OBJECTIVES: To estimate the ability and costs of testing and treatment for LTBI to reach pre-elimination and elimination targets in California. METHODS: We created an individual-based epidemic model of TB, calibrated to historical cases. We evaluated the effects of increased testing (QuantiFERON-TB Gold) and treatment (three months of isoniazid and rifapentine). We analyzed four test and treat targeting strategies: (1) individuals with medical risk factors (MRF), (2) non-USB, (3) both non-USB and MRF, and (4) all Californians. For each strategy, we estimated the effects of increasing test and treat by a factor of 2, 4, or 10 from the base case. We estimated the number of TB cases occurring and prevented, and net and incremental costs from 2017 to 2065 in 2015 U.S. dollars. Efficacy, costs, adverse events, and treatment dropout were estimated from published data. We estimated the cost per case averted and per quality-adjusted life year (QALY) gained. MEASUREMENTS AND MAIN RESULTS: In the base case, 106,000 TB cases are predicted to 2065. Pre-elimination was achieved by 2065 in three scenarios: a 10-fold increase in the non-USB and persons with MRF (by 2052), and 4- or 10-fold increase in all Californians (by 2058 and 2035, respectively). TB elimination was not achieved by any intervention scenario. The most aggressive strategy, 10-fold in all Californians, achieved a case rate of 8 (95% UI 4-16) per million by 2050. Of scenarios that reached pre-elimination, the incremental net cost was $20 billion (non-USB and MRF) to $48 billion. These had an incremental cost per QALY of $657,000 to $3.1 million. A more efficient but somewhat less effective single-lifetime test strategy reached as low as $80,000 per QALY. CONCLUSIONS: Substantial gains can be made in TB control in coming years by scaling-up current testing and treatment in non-USB and those with medical risks.

      • Factors associated with state variation in mortality among persons living with diagnosed HIV infectionexternal icon
        Krueger AL, Van Handel M, Dietz PM, Williams WO, Satcher Johnson A, Klein PW, Cohen S, Mandsager P, Cheever LW, Rhodes P, Purcell DW.
        J Community Health. 2019 Apr 4.
        In the United States, the all-cause mortality rate among persons living with diagnosed HIV infection (PLWH) is almost twice as high as among the general population. We aimed to identify amendable factors that state public health programs can influence to reduce mortality among PLWH. Using generalized estimating equations (GEE), we estimated age-group-specific models (24-34, 35-54, >/= 55 years) to assess the association between state-level mortality rates among PLWH during 2010-2014 (National HIV Surveillance System) and amendable factors (percentage of Ryan White HIV/AIDS Program (RWHAP) clients with viral suppression, percentage of residents with healthcare coverage, state-enacted anti-discrimination laws index) while controlling for sociodemographic nonamendable factors. Controlling for nonamendable factors, states with 5% higher viral suppression among RWHAP clients had a 3-5% lower mortality rates across all age groups [adjusted Risk Ratio (aRR): 0.95, 95% Confidence Interval (CI): 0.92-0.99 for 24-34 years, aRR: 0.97, 95%CI: 0.94-0.99 for 35-54 years, aRR: 0.96, 95%CI: 0.94-0.99 for >/= 55 years]; states with 5% higher health care coverage had 4-11% lower mortality rate among older age groups (aRR: 0.96, 95%CI: 0.93-0.99 for 34-54 years; aRR: 0.89, 95%CI: 0.81-0.97 for >/= 55 years); and having laws that address one additional area of anti-discrimination was associated with a 2-3% lower mortality rate among older age groups (aRR: 0.98, 95%CI: 0.95-1.00 for 34-54 years; aRR: 0.97, 95%CI: 0.94-0.99 for >/= 55 years). The mortality rate among PLWH was lower in states with higher levels of residents with healthcare coverage, anti-discrimination laws, and viral suppression among RWHAP clients. States can influence these factors through programs and policies.

    • Environmental Health
      • Communication channels for air quality alerts in the United Statesexternal icon
        Pennington AF, Sircar K, Hsu J, Zahran HS, Damon SA, Mirabelli MC.
        Prev Med Rep. 2019 ;14.
        Short-term exposure to air pollution can result in acute health effects, particularly for individuals with respiratory and cardiovascular disease. Air quality alert programs that notify the public about high air pollution days are critical for susceptible populations. We assessed how U.S. adults receive air quality alerts and whether it varies by demographic or health characteristics. We analyzed data from the summer 2014 wave of ConsumerStyles, a nationally representative survey of U.S. adults (n = 4269). We calculated the weighted proportion of individuals who received air quality alerts from seven communication channels, combining all individuals and stratifying by demographics. To assess whether the reach of communication channels varied by respiratory and cardiovascular disease status, we computed weighted prevalence ratios adjusted for sex, age, race, and education. Forty-eight percent of U.S. adults had heard about air quality alerts. Within every demographic category, television was the most common communication channel (76% among individuals aware of air quality alerts). Other common communication modes were radio (30%), newspaper (24%), and internet (20%). Less common communication modes were friend or family member, mobile phone or device app, and electronic highway sign. The reach of communication channels varied by demographic factors, such as age, but not by respiratory or cardiovascular disease status. Television is the most common communication channel for receiving air quality alerts. Expanding use of other communication channels might increase awareness of air quality alerts. These results can help decision-makers target communication channels that reach susceptible populations and will achieve the greatest impact.

    • Healthcare Associated Infections
      • Surgical site infection risk following cesarean deliveries covered by Medicaid or private insuranceexternal icon
        Yi SH, Perkins KM, Kazakova SV, Hatfield KM, Kleinbaum DG, Baggs J, Slayton RB, Jernigan JA.
        Infect Control Hosp Epidemiol. 2019 Apr 9:1-10.
        OBJECTIVE: To compare risk of surgical site infection (SSI) following cesarean delivery between women covered by Medicaid and private health insurance. STUDY DESIGN: Retrospective cohort. STUDY POPULATION: Cesarean deliveries covered by Medicaid or private insurance and reported to the National Healthcare Safety Network (NHSN) and state inpatient discharge databases by hospitals in California (2011-2013). METHODS: Deliveries reported to NHSN and state inpatient discharge databases were linked to identify SSIs in the 30 days following cesarean delivery, primary payer, and patient and procedure characteristics. Additional hospital-level characteristics were obtained from public databases. Relative risk of SSI by primary payer primary payer was assessed using multivariable logistic regression adjusting for patient, procedure, and hospital characteristics, accounting for facility-level clustering. RESULTS: Of 291,757 cesarean deliveries included, 48% were covered by Medicaid. SSIs were detected following 1,055 deliveries covered by Medicaid (0.75%) and 955 deliveries covered by private insurance (0.63%) (unadjusted odds ratio, 1.2; 95% confidence interval [CI], 1.1-1.3; P &lt; .0001). The adjusted odds of SSI following cesarean deliveries covered by Medicaid was 1.4 (95% CI, 1.2-1.6; P &lt; .0001) times the odds of those covered by private insurance. CONCLUSIONS: In this, the largest and only multicenter study to investigate SSI risk following cesarean delivery by primary payer, Medicaid-insured women had a higher risk of infection than privately insured women. These findings suggest the need to evaluate and better characterize the quality of maternal healthcare for and needs of women covered by Medicaid to inform targeted infection prevention and policy.

    • Laboratory Sciences
      • Antigenic drift of the influenza A(H1N1)pdm09 virus neuraminidase results in reduced effectiveness of A/California/7/2009 (H1N1pdm09)-specific antibodiesexternal icon
        Gao J, Couzens L, Burke DF, Wan H, Wilson P, Memoli MJ, Xu X, Harvey R, Wrammert J, Ahmed R, Taubenberger JK, Smith DJ, Fouchier RA, Eichelberger MC.
        MBio. 2019 Apr 9;10(2).
        The effectiveness of influenza vaccines against circulating A(H1N1)pdm09 viruses was modest for several seasons despite the absence of antigenic drift of hemagglutinin (HA), the primary vaccine component. Since antibodies against HA and neuraminidase (NA) contribute independently to protection against disease, antigenic changes in NA may allow A(H1N1)pdm09 viruses to escape from vaccine-induced immunity. In this study, analysis of the specificities of human NA-specific monoclonal antibodies identified antigenic sites that have changed over time. The impact of these differences on in vitro inhibition of enzyme activity was not evident for polyclonal antisera until viruses emerged in 2013 without a predicted glycosylation site at amino acid 386 in NA. Phylogenetic and antigenic cartography demonstrated significant antigenic changes that in most cases aligned with genetic differences. Typical of NA drift, the antigenic difference is observed in one direction, with antibodies against conserved antigenic domains in A/California/7/2009 (CA/09) continuing to inhibit NA of recent A(H1N1)pdm09 viruses reasonably well. However, ferret CA/09-specific antiserum that inhibited the NA of A/Michigan/45/2015 (MI/15) very well in vitro, protected mice against lethal MI/15 infection poorly. These data show that antiserum against the homologous antigen is most effective and suggest the antigenic properties of NA should not be overlooked when selecting viruses for vaccine production.IMPORTANCE The effectiveness of seasonal influenza vaccines against circulating A(H1N1)pdm09 viruses has been modest in recent years, despite the absence of antigenic drift of HA, the primary vaccine component. Human monoclonal antibodies identified antigenic sites in NA that changed early after the new pandemic virus emerged. The reactivity of ferret antisera demonstrated antigenic drift of A(H1N1)pdm09 NA from 2013 onward. Passive transfer of serum raised against A/California/7/2009 was less effective than ferret serum against the homologous virus in protecting mice against a virus with the NA of more recent virus, A/Michigan/45/2015. Given the long-standing observation that NA-inhibiting antibodies are associated with resistance against disease in humans, these data demonstrate the importance of evaluating NA drift and suggest that vaccine effectiveness might be improved by selecting viruses for vaccine production that have NAs antigenically similar to those of circulating influenza viruses.

    • Occupational Safety and Health
      • Targeted GC-MS analysis of firefighters’ exhaled breath: Exploring biomarker response at the individual levelexternal icon
        Wallace MA, Pleil JD, Oliver KD, Whitaker DA, Mentese S, Fent KW, Horn GP.
        J Occup Environ Hyg. 2019 Apr 1:1-12.
        Biomarker measurements can provide unambiguous evidence of environmental exposures as well as the resultant biological responses. Firefighters have a high rate of occupational cancer incidence, which has been proposed to be linked in part to their increased environmental exposure to byproducts of combustion and contaminants produced during fire responses. In this article, the uptake and elimination of targeted volatile organic compounds were investigated by collecting the exhaled breath of firefighters on sorbent tubes before and after controlled structure burns and analyzing samples using automated thermal desorption-gas chromatography (ATD-GC/MS). Volatile organic compounds exposure was assessed by grouping the data according to firefighting job positions as well as visualizing the data at the level of the individual firefighter to determine which individuals had expected exposure responses. When data were assessed at the group level, benzene concentrations were found to be elevated post-exposure in both fire attack, victim search, and outside ventilation firefighting positions. However, the results of the data analysis at the individual level indicate that certain firefighters may be more susceptible to post-exposure volatile organic compounds increases than others, and this should be considered when assessing the effectiveness of firefighting protective gear. Although this work focuses on firefighting activity, the results can be translated to potential human health and ecological effects from building and forest fires.

    • Substance Use and Abuse
      • Exposure to secondhand smoke and secondhand e-cigarette aerosol among middle and high school studentsexternal icon
        Gentzke AS, Wang TW, Marynak KL, Trivers KF, King BA.
        Prev Chronic Dis. 2019 Apr 4;16:E42.
        INTRODUCTION: Youth exposure to secondhand smoke (SHS) and secondhand aerosol from e-cigarettes (SHA) may contribute to the renormalization of tobacco product use behaviors. Our study assessed self-reported SHS or SHA exposures in indoor or outdoor public places among US students. METHODS: Data came from the 2015 and 2017 National Youth Tobacco Survey, a school-based survey of US students in grades 6 through 12. Past 30-day exposure to SHS and SHA in indoor and outdoor public places was assessed. The prevalence of exposure was assessed overall and by covariates for each year. We used adjusted prevalence ratios (aPRs) to assess determinants of exposure. RESULTS: We observed no significant change from 2015 through 2017 in exposure to SHS (52.6% to 50.5%), SHA (25.2% to 25.6%), or either SHS or SHA (56.7% to 55.1%). Following multivariable adjustment, in 2017, exposure to either SHS or SHA in public was higher among female students versus male students (aPR = 1.29), high school students versus middle school students (aPR = 1.15), current e-cigarette users versus nonusers (aPR = 2.89), and current users of other tobacco product versus nonusers (aPR = 1.21). Exposure was higher for students who reported that a household member used tobacco products. CONCLUSION: In 2017, more than half (55.1%, 14.3 million) of US middle and high school students reported exposure to secondhand tobacco product emissions in indoor or outdoor public places. E-cigarette use may complicate the enforcement of existing smoke-free policies and contribute to the renormalization of tobacco use behaviors. Continued efforts are warranted to reduce the social acceptability of tobacco product use and protect bystanders from all tobacco product emissions.

      • During March-July 2018, the Illinois Department of Public Health responded to an acute outbreak of severe coagulopathy among patients with recent synthetic cannabinoid use. Toxicological testing indicated that cases were exposed to brodifacoum, a long-acting anticoagulant rodenticide. A total of 174 confirmed and probable cases, including 5 deaths, were linked to this outbreak. On the basis of the experience of responding to this complex outbreak, we recommend several steps for consideration to improve health department preparation for acute outbreaks involving illicit substances including strengthening communication between public health and law enforcement agencies, reviewing legal authority to investigate noninfectious acute disease outbreaks, continuing strong partnerships with state poison control centers, partnering with substance abuse and mental health agencies to provide services to patients, and determining health department ability to rapidly enter into public-private partnership agreements.

    • Zoonotic and Vectorborne Diseases

  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. Is it time for a patient-centered quality measure of asthma control?external icon
        Herman E, Beavers S, Hamlin B, Thaker K.
        J Allergy Clin Immunol Pract. 2019 Apr 3.
        Quality measures play a prominent role in the US health care system. They are used to monitor and report performance across health plans, providers, and health systems and are a foundational element of value-based payment. Measuring the quality of asthma care has been challenging because of a lack of reliable data to assess clinical processes and track patient-specific outcomes. Existing asthma Healthcare Effectiveness Data and Information Set measures rely on administrative claims-derived data on dispensed medications. These are proxy measures of appropriate prescribing but are not reflective of comprehensive asthma care. The increase in the volume and specificity of longitudinal clinical data in electronic health records, movement toward electronic quality measures, and advances in electronic clinical data systems enable the development of more meaningful measures. A patient-reported measure of asthma control would incorporate key clinical indicators such as a validated age- and culturally appropriate test, and would reflect the combined outcome of medical management, self-management education, reduction of environmental exposures, and appropriate support services. Although there is a current quality measure that includes a test of asthma control (the Optimal Asthma Control Measure), work is needed to address questions about usability, patient literacy, and the influence of setting on self-reported scores. Comprehensive reliability and validity testing of both clinical data and stratification across risk groups will be needed to determine whether a measure based on standardized assessments of asthma control indeed promote improved clinical outcomes.

      2. INTRODUCTION: Burden of disease is often defined by using epidemiologic measures. However, there may be latent aspects of disease burden that are not factored into these types of estimates. This study quantified environmental burden of disease by using population health indicators and exploratory factor analysis at the county level across the United States. METHODS: Ninety-nine variables drawn from public use data sets from 2010 to 2016 were used to create a multifactor index – the burden index. We applied principal components analysis with promax rotation to allow the factors to correlate. Correlation coefficients for each factor and the outcome of interest, age-adjusted cancer death rate, were calculated. We used both unadjusted and adjusted linear regression techniques. RESULTS: The final additive county-level index included 9 factors that explained 68.3% of the variance in the counties and county equivalents. The burden index had a moderate association with the age-adjusted cancer death rates (r =.48, P <.001), and adjusted linear regression with all 9 factors explained 34% of the variance in the age-adjusted cancer death rate. Results were mapped, and the geographic distribution of both the burden index and age-adjusted cancer mortality were assessed. There are distinct geospatial patterns for both. CONCLUSIONS: Results from this study show potential areas of need, as well as the importance of including environmental variables in the study of cancer etiology. Future studies can aim to validate these findings by quantifying burden as it relates to overall cancer mortality by using epidemiologic measures, along with other confirmatory statistical methods.

      3. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides breast and cervical cancer screening and diagnostic services to low-income, uninsured, and underinsured women across the nation. Although the program has provided services to more than 5 million women since 1991, there remains a significant burden of breast and cervical cancer with inequities among certain populations. To reduce this burden and improve health equity, the NBCCEDP is expanding its scope to include population-based strategies to increase screening in health systems and communities through the implementation of patient and provider evidence-based interventions, connecting women in communities to clinical services, increasing opportunities to access screening, and enhancing the targeting of women in need of services. The goal is to reach more women and make sure women are getting the right screening test at the right time.

    • Communicable Diseases
      1. Illness among US resident student travellers after return to the USA: a GeoSentinel analysis, 2007-17external icon
        Angelo KM, Haulman NJ, Terry AC, Leung DT, Chen LH, Barnett ED, Hagmann SH, Hynes NA, Connor BA, Anderson S, McCarthy A, Shaw M, Van Genderen PJ, Hamer DH.
        J Travel Med. 2018 Jan 1;25(1).
        Background: The number of US students studying abroad more than tripled during the past 20 years. As study abroad programmes’ destinations diversify, students increasingly travel to resource-limited countries, placing them at risk for infectious diseases. Data describing infections acquired by US students while travelling internationally are limited. We describe illnesses among students who returned from international travel and suggest how to prevent illness among these travellers. Methods: GeoSentinel is a global surveillance network of travel and tropical medicine providers that monitors travel-related morbidity. This study included the records of US resident student international travellers, 17-24 years old, who returned to the USA, had a confirmed travel-related illness at one of 15 US GeoSentinel sites during 2007-17 and had a documented exposure region. Records were analysed to describe demographic and travel characteristics and diagnoses. Results: The study included 432 students. The median age was 21 years; 69% were female. More than 70% had a pre-travel consultation with a healthcare provider. The most common exposure region was sub-Saharan Africa (112; 26%). Students were most commonly exposed in India (44; 11%), Ecuador (28; 7%), Ghana (25; 6%) and China (24; 6%). The median duration of travel abroad was 40 days (range: 1-469) and presented to a GeoSentinel site a median of 8 days (range: 0-181) after travel; 98% were outpatients. Of 581 confirmed diagnoses, the most common diagnosis category was gastrointestinal (45%). Acute diarrhoea was the most common gastrointestinal diagnosis (113 of 261; 43%). Thirty-one (7%) students had vector-borne diseases [14 (41%) malaria and 11 (32%) dengue]. Three had vaccine-preventable diseases (two typhoid; one hepatitis A); two had acute human immunodeficiency virus infection. Conclusions: Students experienced travel-related infections, despite the majority having a pre-travel consultation. US students should receive pre-travel advice, vaccinations and chemoprophylaxis to prevent gastrointestinal, vector-borne, sexually transmitted and vaccine-preventable infections.

      2. Notes from the field: Acute hepatitis A virus infection among previously vaccinated persons with HIV infection – Tennessee, 2018external icon
        Brennan J, Moore K, Sizemore L, Mathieson SA, Wester C, Dunn JR, Schaffner W, Jones TF.
        MMWR Morb Mortal Wkly Rep. 2019 Apr 12;68(14):328-329.

        [No abstract]

      3. Adherence and viral suppression among participants of the Patient-centered HIV Care Model project-a collaboration between community-based pharmacists and HIV clinical providersexternal icon
        Byrd KK, Hou JG, Bush T, Hazen R, Kirkham H, Delpino A, Weidle PJ, Shankle MD, Camp NM, Suzuki S, Clay PG.
        Clin Infect Dis. 2019 Apr 6.
        BACKGROUND: HIV viral suppression (VS) decreases morbidity, mortality, and transmission risk. METHODS: The Patient-centered HIV Care Model (PCHCM) integrated community-based pharmacists with HIV medical providers and required them to share patient clinical information, identify therapy-related problems, and develop therapy-related action plans.Proportions of persons adherent to antiretroviral therapy (Proportion of Days Covered [PDC] >/=90%) and virally suppressed (HIV RNA <200 copies/mL), pre- and post-PCHCM implementation, were compared. Factors associated with post-implementation VS were determined using multivariable logistic regression. Participant demographics, baseline viral load (VL), and PDC were explanatory variables in the models. PDC was modified to account for time to last VL in the year post-implementation, and stratified as: >/=90%, <90-80%, <80-50%, <50%. RESULTS: The 765 enrolled participants were 43% non-Hispanic black, 73% male, with a median age of 48 years (interquartile range: 38-55); 421 and 649 were included in the adherence and VS analyses, respectively. Overall, proportions adherent to therapy remained unchanged. However, VS improved a relative 15% (75% to 86%, p<0.001). Persons with higher modified PDC (adjusted odds ratio [AOR] 1.74 per one-level increase in PDC category; 95% CI: 1.30-2.34) and those virally suppressed at baseline (AOR 7.69; CI: 3.96-15.7) had greater odds of post-implementation suppression. Although non-Hispanic black persons (AOR 0.29; CI: 0.12-0.62) had lower odds of suppression, VS improved a relative 23% (63% to 78%, p<0.001), pre- to post-implementation. CONCLUSION: Integrated care models between community-based pharmacists and primary medical providers may identify and address HIV therapy-related problems and improve overall VS among persons with HIV.

      4. Improving care and treatment for persons infected with hepatitis C virus (HCV) can reduce HCV-related morbidity and mortality. Our primary objective was to examine the HCV care continuum among patients receiving care at five federally qualified health centers (FQHCs) in Philadelphia, PA, where a testing and linkage to care program had been established. Among the five FQHCs, one served a homeless population, two served public housing residents, one served a majority Hispanic population, and the last, a “test and treat” site, also provided HCV treatment to patients. We analyzed data from electronic health records of patients tested for HCV antibody from 2012 to 2016 and calculated the percentage of patients across nine steps of the HCV care continuum ranging from diagnosis to cure. We further explored factors associated with successful patient navigation through two steps of the continuum using multivariable logistic regression. Of 885 chronically infected patients, 92.2% received their RNA-positive result, 82.7% were referred to an HCV provider, 69.4% were medically evaluated by the provider, 55.3% underwent liver disease staging, 15.0% initiated treatment, 12.0% completed treatment, 8.7% were assessed for sustained virologic response (SVR), and 8.0% achieved SVR. Regression results revealed that test and treat site patients were significantly more likely to be medically evaluated (adjusted odds ratio [aOR], 2.76; 95% confidence interval [CI], 1.82-4.17) and to undergo liver disease staging (aOR, 1.92; 95% CI, 1.02-2.86) than patients at the other FQHCs combined. Conclusion: In this US urban setting, over two thirds of HCV-infected patients were linked to care; although treatment uptake was low overall, it was highest at the test and treat site; scaling up treatment services in HCV testing settings will be vital to improve the HCV care continuum.

      5. Tuberculosis surveillance and control, Puerto Rico, 1898-2015pdf icon
        Dirlikov E, Thomas D, Yost D, Tejada-Vera B, Bermudez M, Joglar O, Chorba T.
        Emerg Infect Dis. 2019 March;25(3):538-546.
        The World Health Organization recognizes Puerto Rico as an area of low tuberculosis (TB) incidence, where TB elimination is possible by 2035. To describe the current low incidence of reported cases, provide key lessons learned, and detect areas that may affect progress, we systematically reviewed the literature about the history of TB surveillance and control in Puerto Rico and supplemented this information with additional references and epidemiologic data. We reviewed 3 periods: 1898-1946 (public health efforts before the advent of TB chemotherapy); 1947-1992 (control and surveillance after the introduction of TB chemotherapy); and 1993-2015 (expanded TB control and surveillance). Although sustained surveillance, continued care, and use of newly developed strategies occurred concomitantly with decreased incidence of reported TB cases and mortality rates, factors that may affect progress remain poorly understood and include potential delayed diagnosis and underreporting, the effects of government debt and Hurricane Maria, and poverty.

      6. We assessed disparities in viral suppression (VS) and antiretroviral therapy (ART) adherence among women of the HIV Outpatient Study to inform HIV treatment strategies. We used adjusted prevalence ratios (aPR) with 95% confidence intervals (CI) to assess VS by race/ethnicity and generalized estimating equations to investigate factors associated with not achieving VS and ART non-adherence. Among 426 women (median age = 46 years), at baseline, VS was less prevalent among black women (63%) compared with Hispanic women/Latinas (73%) and white women (78%). In the multivariable analysis, factors significantly associated with not achieving VS included the following social and behavioral determinants of care: using public insurance (aPR = 1.69, CI 1.01-2.82, p = 0.044) compared to using private insurance, seeking care in a public clinic (aPR = 1.60, CI 1.03-2.50, p = 0.037) compared to seeking care in a private clinic, and ART non-adherence (aPR = 2.79, CI 1.81-4.29), p < 0.001). Although race was not a significant factor in not achieving VS, race was associated with ART non-adherence; black women were more likely to miss a dose of ART medication (aPR = 2.07, CI 1.19-3.60, p = 0.010) when compared to white women and Hispanic women/Latinas. Interventions and resources disseminated to address social barriers to care and improve VS and ART adherence among HIV-positive women, particularly black women, are warranted.

      7. Neutralizing antibody against enterovirus D68 in children and adults before 2014 outbreak, Kansas City, Missouri, USAexternal icon
        Harrison CJ, Weldon WC, Pahud BA, Jackson MA, Oberste MS, Selvarangan R.
        Emerg Infect Dis. 2019 Mar;25(3):585-588.
        We evaluated enterovirus D68 seroprevalence in Kansas City, Missouri, USA, from samples obtained during 2012-2013. Neutralizing antibodies against Fermon and the dominant 2014 Missouri isolate were universally detected. Titers increased with age. Widespread circulation of enterovirus D68 occurred before the 2014 outbreak. Research is needed to determine a surrogate of protection.

      8. Response to isoniazid-resistant tuberculosis in homeless shelters, Georgia, USA, 2015-2017external icon
        Holland DP, Alexander S, Onwubiko U, Goswami ND, Yamin A, Mohamed O, Sales RM, Grant G, Talboy P, Ray S, Toomey KE.
        Emerg Infect Dis. 2019 Mar;25(3):593-595.
        In 2008, an outbreak of isoniazid-resistant tuberculosis was identified among residents of homeless shelters in Atlanta, Georgia, USA. When initial control efforts involving standard targeted testing failed, a comprehensive approach that involved all providers of services for the homeless successfully interrupted the outbreak.

      9. Active surveillance for norovirus in a US Veterans Affairs Patient Population, Houston, Texas, 2015-2016external icon
        Kambhampati AK, Vargas B, Mushtaq M, Browne H, Grytdal S, Atmar RL, Vinje J, Parashar UD, Lopman B, Hall AJ, Rodriguez-Barradas MC, Cardemil CV.
        Open Forum Infect Dis. 2019 Apr;6(4):ofz115.
        Background: Norovirus is a leading cause of acute gastroenteritis (AGE); however, few data exist on endemic norovirus disease burden among adults. Candidate norovirus vaccines are currently in development for all ages, and robust estimates of norovirus incidence among adults are needed to provide baseline data. Methods: We conducted active surveillance for AGE among inpatients at a Veterans Affairs (VA) hospital in Houston, Texas. Patients with AGE (>/=3 loose stools, >/=2 vomiting episodes, or >/=1 episode of both loose stool and vomiting, within 24 hours) within 10 days of enrollment and non-AGE control patients were enrolled. Demographic data and clinical characteristics were collected. Stool samples were tested using the FilmArray gastrointestinal panel; virus-positives were confirmed by real-time reverse transcription polymerase chain reaction and genotyped by sequencing. Results: From November 2, 2015 through November 30, 2016, 147 case patients and 19 control patients were enrolled and provided a stool specimen. Among case patients, 139 (95%) were male and 70 (48%) were aged >/=65 years. Norovirus was the leading viral pathogen detected (in 16 of 20 virus-positive case patients) and accounted for 11% of all AGE cases. No viral pathogens were detected among control patients. Incidence of norovirus-associated hospitalization was 20.3 cases/100 000 person-years and was similar among those aged <65 and >/=65 years. Conclusions: This active surveillance platform employed screening and enrollment of hospitalized VA patients meeting a standardized AGE case definition, as well as non-AGE control patients. Data from this study highlight the burden of norovirus in a VA inpatient population and will be useful in policy considerations of a norovirus vaccine.

      10. Diversity and characterization of HIV-1 subtypes in the United States, 2008-2016external icon
        Kline RL, Saduvala N, Zhang T, Oster AM.
        Ann Epidemiol. 2019 Mar 6.
        PURPOSE: This article describes subtype diversity among diagnosed HIV-1 infections in the United States during 2008-2016 by demographic or risk group and over time. METHODS: HIV-1 polymerase sequences reported to the National HIV Surveillance System for persons in 17 U.S. states with HIV infection diagnosed during 2008-2016 were subtyped using COMET, an automated subtyping tool, and National HIV Surveillance System demographic data were analyzed. RESULTS: Subtype B was identified in 93.6% of 121,793 reported sequences. The most common non-B subtypes and circulating recombinant forms (CRFs) were C, CRF02_AG, A, CRF01_AE, and G. Elevated percentages of non-B subtypes or CRFs were found in persons who were female, aged less than 13 years at diagnosis, Asian, or had transmission attributable to heterosexual contact (females only) or perinatal exposure. Foreign-born persons had a higher percentage of non-B subtypes. The prevalence of non-B subtypes and CRFs increased from 5.0% in 2008 to 8.5% in 2016; among specific subtypes and CRFs, subtype G and CRF01_AE increased. CONCLUSIONS: Subtype B remains the predominant strain in the United States. Non-B subtypes and CRFs were not widespread, but diversity and numbers increased from 2008 through 2016, which could have consequences for clinical management, diagnostic testing, and vaccine development.

      11. Hepatitis C virus infection among people who inject drugs in Bangkok, Thailand, 2005-2010external icon
        Martin M, Vanichseni S, Leelawiwat W, Anekvorapong R, Raengsakulrach B, Cherdtrakulkiat T, Sangkum U, Mock PA, Leethochawalit M, Chiamwongpaet S, McNicholl JM, Kittimunkong S, Curlin ME, Choopanya K.
        WHO South East Asia J Public Health. 2019 Apr;8(1):50-55.
        Background: Approximately 1% of adults in Thailand are infected with hepatitis C virus (HCV). New direct-acting antiviral agents achieve sustained virologic responses in >95% of HCV-infected patients and are becoming available in countries around the world. To prepare for new HCV treatment options in Thailand, this study characterized HCV infections among people who inject drugs (PWID) in Bangkok. Methods: The Bangkok Tenofovir Study (BTS) was a pre-exposure prophylaxis trial conducted among PWID, 2005-2013. Blood specimens were randomly selected from PWID screened for the BTS, to test for anti-HCV antibody and HCV RNA. The HVR1 region was amplified by polymerase chain reaction, using multiplex primer sets with unique identifier sequences; amplification products were pooled in sets of 25; and consensus sequencing was performed to characterize individual HCV genotypes. Results: The median age of 3679 participants tested for anti-HCV antibody was 31 years, 3016 (82.0%) were male and 447 (12.2%) were HIV infected. The prevalence of anti-HCV antibody was 44.3%. The adjusted odds of testing positive for anti-HCV antibody were higher in men (adjusted odds ratio [aOR] 3.2, 95% confidence interval [CI] 2.4-4.3), those aged 40 years or older (aOR 2.7, 95% CI 2.1-3.5), those who had more than a primary school education (aOR 1.7, 95% CI 1.4-2.1), and those who tested HIV positive (aOR 5.2, 95% CI 3.7-7.4). HCV RNA was detected in 644 (81.3%) of the 792 anti-HCV antibody-positive specimens, yielding an HCV RNA-positive prevalence of 36.0% (95% CI 33.8-38.2). Among a random sample of 249 of the 644 specimens, 218 could be characterized, and the most common HCV subtypes were 1a (30.3%), 1b (12.8%), 3a (35.8%), 3b (6.9%) and 6n (8.7%). Conclusion: The prevalence of anti-HCV antibody among PWID was 44.3% and more than one third (36.0%) were HCV RNA positive. Genotypes 1, 3 and 6 accounted for all typable infections. As the government of Thailand considers introduction of direct-acting antiviral medications for people with hepatitis C, it will be important to ensure that the medications target these subtypes.

      12. The impact of HIV exposure on respiratory syncytial virus-associated severe respiratory illness in South African infants, 2011-2016external icon
        McMorrow ML, Tempia S, Walaza S, Treurnicht FK, Moyes J, Cohen AL, Pretorius M, Hellferscee O, Wolter N, von Gottberg A, Nguweneza A, McAnerney JM, Naby F, Mekgoe O, Venter M, Madhi SA, Cohen C.
        Clin Infect Dis. 2019 Apr 9.
        During 2011-2016, we conducted surveillance for severe respiratory illness in infants. HIV exposure statistically significantly increased the risk of RSV-associated hospitalization in infants aged <5 months. Over 60% of RSV-associated hospitalizations occurred in the first 4 months of life and may be preventable through maternal vaccination or birth-dose monoclonal antibody.

      13. HIV-related deaths in Nairobi, Kenya: Results from a HIV mortuary surveillance study, 2015external icon
        Nyagah LM, Young PW, Kim AA, Wamicwe J, Kimani M, Waruiru W, Rogena E, Oduor J, Walong E, Waruru A, Oyugi J, Downer M, De Cock KM, Sirengo M.
        J Acquir Immune Defic Syndr. 2019 May 1;81(1):18-23.
        BACKGROUND: Death is an important but often unmeasured endpoint in public health HIV surveillance. We sought to describe HIV among deaths using a novel mortuary-based approach in Nairobi, Kenya. METHODS: Cadavers aged 15 years and older at death at Kenyatta National Hospital (KNH) and City Mortuaries were screened consecutively from January 29 to March 3, 2015. Cause of death was abstracted from medical files and death notification forms. Cardiac blood was drawn and tested for HIV infection using the national HIV testing algorithm followed by viral load testing of HIV-positive samples. RESULTS: Of 807 eligible cadavers, 610 (75.6%) had an HIV test result available. Cadavers from KNH had significantly higher HIV positivity at 23.2% (95% CI: 19.3 to 27.7) compared with City Mortuary at 12.6% (95% CI: 8.8 to 17.8), P < 0.001. HIV prevalence was significantly higher among women than men at both City (33.3% vs. 9.2%, P = 0.008) and KNH Mortuary (28.8% vs. 19.0%, P = 0.025). Half (53.3%) of HIV-infected cadavers had no diagnosis before death, and an additional 22.2% were only diagnosed during hospitalization leading to death. Although not statistically significant, 61.9% of males had no previous diagnosis compared with 45.8% of females (P = 0.144). Half (52.3%) of 44 cadavers at KNH with HIV diagnosis before death were on treatment, and 1 in 5 (22.7%) with a previous diagnosis had achieved viral suppression. CONCLUSIONS: HIV prevalence was high among deaths in Nairobi, especially among women, and previous diagnosis among cadavers was low. Establishing routine mortuary surveillance can contribute to monitoring HIV-associated deaths among cadavers sent to mortuaries.

      14. University-based outbreaks of meningococcal disease caused by serogroup B, United States, 2013-2018external icon
        Soeters HM, McNamara LA, Blain AE, Whaley M, MacNeil JR, Hariri S, Mbaeyi SA.
        Emerg Infect Dis. 2019 Mar;25(3):434-440.
        We reviewed university-based outbreaks of meningococcal disease caused by serogroup B and vaccination responses in the United States in the years following serogroup B meningococcal (MenB) vaccine availability. Ten university-based outbreaks occurred in 7 states during 2013-2018, causing a total of 39 cases and 2 deaths. Outbreaks occurred at universities with 3,600-35,000 undergraduates. Outbreak case counts ranged from 2 to 9 cases; outbreak duration ranged from 0 to 376 days. All 10 universities implemented MenB vaccination: 3 primarily used MenB-FHbp and 7 used MenB-4C. Estimated first-dose vaccination coverage ranged from 14% to 98%. In 5 outbreaks, additional cases occurred 6-259 days following MenB vaccination initiation. Although it is difficult to predict outbreak trajectories and evaluate the effects of public health response measures, achieving high MenB vaccination coverage is crucial to help protect at-risk persons during outbreaks of meningococcal disease caused by this serogroup.

      15. Notes from the Field: Multistate coccidioidomycosis outbreak in U.S. residents returning from community service trips to Baja California, Mexico – July-August 2018external icon
        Toda M, Gonzalez FJ, Fonseca-Ford M, Franklin P, Huntington-Frazier M, Gutelius B, Kawakami V, Lunquest K, McCracken S, Moser K, Oltean H, Ratner AJ, Raybern C, Signs K, Zaldivar A, Chiller TM, Jackson BR, McCotter O.
        MMWR Morb Mortal Wkly Rep. 2019 Apr 12;68(14):332-333.

        [No abstract]

      16. Clinical manifestations of cryptosporidiosis and identification of a new Cryptosporidium subtype in patients from Sonora, Mexicoexternal icon
        Urrea-Quezada A, Gonzalez-Diaz M, Villegas-Gomez I, Durazo M, Hernandez J, Xiao L, Valenzuela O.
        Pediatr Infect Dis J. 2018 May;37(5):e136-e138.
        The aim of this study was to identify the clinical manifestations of cryptosporidiosis and the distribution of Cryptosporidium spp. and subtypes in children in Sonora, Mexico. Two subtypes of C. parvum, including IIaA15G2R1 and IIcA5G3a, and 6 subtypes of Cryptosporidium hominis, including IaA14R3, IaA15R3, IbA12G3, IdA23, IeA11G3T3, and a new subtype IaA14R11, were identified. Cryptosporidium as an etiologic agent for acute gastroenteritis is discussed.

      17. Surveillance for incidence and etiology of early-onset neonatal sepsis in Soweto, South Africaexternal icon
        Velaphi SC, Westercamp M, Moleleki M, Pondo T, Dangor Z, Wolter N, von Gottberg A, Shang N, Demirjian A, Winchell JM, Diaz MH, Nakwa F, Okudo G, Wadula J, Cutland C, Schrag SJ, Madhi SA.
        PLoS One. 2019 ;14(4):e0214077.
        BACKGROUND: Globally, over 400,000 neonatal deaths in 2015 were attributed to sepsis, however, the incidence and etiologies of these infections are largely unknown in low-middle income countries. We aimed to determine incidence and etiology of community-acquired early-onset (<72 hours age) sepsis (EOS) using culture and molecular diagnostics. METHODS: This was a prospective observational study, in which we conducted a surveillance for pathogens using a combination of blood culture and a polymerase chain reaction (PCR)-based test. Blood culture was performed on all neonates with suspected EOS. Among the subset fulfilling criteria for protocol-defined EOS, blood and nasopharyngeal (NP) respiratory swabs were tested by quantitative real-time reverse-transcriptase PCR using a Taqman Array Card (TAC) with 15 bacterial and 12 viral targets. Blood and NP samples from 312 healthy newborns were also tested by TAC to estimate background positivity rates. We used variant latent-class methods to attribute etiologies and calculate pathogen-specific proportions and incidence rates. RESULTS: We enrolled 2,624 neonates with suspected EOS and from these 1,231 newborns met criteria for protocol-defined EOS (incidence- 39.3/1,000 live-births). Using the partially latent-class modelling, only 26.7% cases with protocol-defined EOS had attributable etiology, and the largest pathogen proportion were Ureaplasma spp. (5.4%; 95%CI: 3.6-8.0) and group B Streptococcus (GBS) (4.8%; 95%CI: 4.1-5.8), and no etiology was attributable for 73.3% of cases. Blood cultures were positive in 99/1,231 (8.0%) with protocol-defined EOS (incidence- 3.2/1,000 live-births). Leading pathogens on blood culture included GBS (35%) and viridans streptococci (24%). Ureaplasma spp. was the most common organism identified on TAC among cases with protocol-defined EOS. CONCLUSION: Using a combination of blood culture and a PCR-based test the common pathogens isolated in neonates with sepsis were Ureaplasma spp. and GBS. Despite documenting higher rates of protocol-defined EOS and using a combination of tests, the etiology for EOS remains elusive.

      18. Notes from the field: Hepatitis A outbreak associated with drug use and homelessness – West Virginia, 2018external icon
        Wilson E, Hofmeister MG, McBee S, Briscoe J, Thomasson E, Olaisen RH, Augustine R, Duncan E, Bamrah Morris S, Haddy L.
        MMWR Morb Mortal Wkly Rep. 2019 Apr 12;68(14):330-331.

        [No abstract]

    • Disease Reservoirs and Vectors
      1. Impacts of Hurricanes Irma and Maria on Aedes aegypti populations, aquatic habitats, and mosquito infections with dengue, chikungunya, and Zika viruses in Puerto Ricoexternal icon
        Barrera R, Felix G, Acevedo V, Amador M, Rodriguez D, Rivera L, Gonzalez O, Nazario N, Ortiz M, Munoz JL, Waterman S, Hemme RR.
        Am J Trop Med Hyg. 2019 Apr 8.
        Puerto Rico was severely impacted by Hurricanes Irma and Maria in September 2017. The island has been endemic for dengue viruses (DENV) and recently suffered epidemics of chikungunya (CHIKV 2014) and Zika (ZIKV 2016) viruses. Although severe storms tend to increase the number of vector and nuisance mosquitoes, we do not know how they influence Aedes aegypti populations and arboviral transmission. We compared the abundance of female Ae. aegypti in autocidal gravid ovitraps (AGO traps), container habitats, and presence of RNA of DENV, CHIKV, and ZIKV in this vector before and after the hurricanes in Caguas city and in four communities in southern Puerto Rico. Two of these communities were under vector control using mass AGO trapping and the other two nearby communities were not. We also investigated mosquito species composition and relative abundance (females/trap) using BG-2 traps in 59 sites in metropolitan San Juan city after the hurricanes. Mosquitoes sharply increased 5 weeks after Hurricane Maria. Ensuing abundance of Ae. aegypti was higher in Caguas and in one of the southern communities without vector control. Aedes aegypti did not significantly change in the two areas with vector control. The most abundant mosquitoes among the 26 species identified in San Juan were Culex (Melanoconion) spp., Culex quinquefasciatus, Culex nigripalpus, and Ae. aegypti. No arboviruses were detected in Ae. aegypti following the hurricanes, in contrast with observations from the previous year, so that the potential for Aedes-borne arboviral outbreaks following the storms in 2017 was low.

      2. Feeding success and host selection by Culex quinquefasciatus say mosquitoes in experimental trialsexternal icon
        McMillan JR, Marcet PL, Hoover CM, Mead D, Kitron U, Vazquez-Prokopec GM.
        Vector Borne Zoonotic Dis. 2019 Apr 9.
        Arthropod vector feeding preferences are defined as an overutilization of a particular host species given its abundance in relationship to other species in the community. Numerous methods exist to quantify vector feeding preferences; however, controlled host choice experiments are generally an underutilized approach. In this report, we present results from controlled vector host choice experiments using Culex quinquefasciatus Say (Diptera: Culicidae) mosquitoes and wild avian hosts identified as important contributors to West Nile virus (WNv) transmission in Atlanta, Georgia, United States. In each experiment, we allowed lab-reared F1 Cx. quinquefasciatus to feed freely overnight on two avian individuals of a different species (i.e., northern cardinals, American robins, blue jays, brown thrashers, and gray catbirds). We then estimated WNv transmission potential using vectorial capacity and R0. We found that mosquito blood feeding success was extremely variable among experimental replicates and that patterns of host choice only occasionally aggregated to a particular bird species. Vectorial capacity was highest for American robins and blue jays due to these species’ higher reservoir competence for WNv and greater probabilities of mosquito selection of these species. Despite species-specific differences in vectorial capacity, total community capacity was similar among species pairs. R0 estimates were qualitatively similar to capacity, and R0 was below and above unity across species pairs. Our results provide empirical evidence that C. quinquefasciatus is an opportunistic blood feeder and highlight how variability in vector-host contact rates as well as host community composition can influence the likelihood of WNv transmission in avian communities.

      3. Molecular phylogeny of Dermacentor parumapertus (Acari: Ixodidae) from two locations within its geographical rangeexternal icon
        Portugal JS, Allerdice M, Moraru GM, King J, Paddock CD, Becker T, Smith TC, Goddard J.
        J Med Entomol. 2019 Apr 5.
        Dermacentor parumapertus Neumann (Acari: Ixodidae) is a rather obscure tick found on jackrabbits in the western United States and parts of Canada and Mexico. Specimens from the northern part of their range are consistently different morphologically from ones found in southern and eastern parts of their range (particularly west Texas), leading some researchers to declare the southern form a variety or subspecies. This study examined field-collected adult D. parumapertus from two main locations-Utah and Texas-within its geographic distribution to ascertain the degree of genetic divergence in the two populations based upon both nuclear and mitochondrial DNA sequences. In total, 30 D. parumapertus were analyzed by PCR using both mtDNA and nDNA genes, and one D. nitens was included for comparison. Trees were constructed for all mtDNA genes individually, as well as after concatenating mtDNA (COI, COII, 12S) and nDNA (2 ITS2 primers), respectively. All constructed trees were exported to FigTree v1.4.3 and TreeGraph v2.14.1-771 beta for visualization. The majority of the Utah and Texas populations of D. parumapertus separated molecularly in both mtDNA and nDNA trees; however, analysis with mtDNA genes showed that 3/13 (23%) of Utah tick specimens were removed molecularly from other specimens collected at the same location. Thus, there was not enough evidence to declare these two disparate and morphologically different populations as distinct and separate species.

      4. Characterization of novel reoviruses [Wad Medani virus (Orbivirus) and Kundal (Coltivirus)] collected from Hyalomma antolicum ticks in India during CCHF surveillanceexternal icon
        Yadav PD, Whitmer SL, Sarkale P, Ng TF, Goldsmith CS, Nyayanit DA, Esona MD, Shrivastava-Ranjan P, Lakra R, Pardeshi P, Majumdar TD, Francis A, Klena JD, Nichol ST, Stroher U, Mourya D.
        J Virol. 2019 Apr 10.
        In 2011, ticks were collected from livestock following an outbreak of Crimean Congo Hemorrhagic fever (CCHF) in Gujarat state, India. CCHF-negative Hyalomma anatolicum tick pools were passaged for virus isolation, and two virus isolates were obtained, designated Karyana virus (KARYV) and Kundal virus (KUNDV) respectively. Traditional RT-PCR identification of known viruses was unsuccessful, but a next-generation sequencing approach identified KARYV and KUNDV as viruses in the Reoviridae family, Orbivirus, and Coltivirus genera, respectively. Viral genomes were de novo assembled, yielding 10 complete segments of KARYV and 12 nearly complete segments of KUNDV. The VP1 gene of KARYV shared a most recent common ancestor with Wad Medani virus (WMV), strain Ar495, and based on nucleotide identity we demonstrate that it is a novel WMV strain. The VP1 segment of KUNDV shares a common ancestor with Colorado tick fever virus, Eyach virus, Tai Forest reovirus and Tarumizu tick virus from the Coltivirus genus. Based on VP1, VP6, VP7, and VP12 nucleotide and amino acid identity, KUNDV is proposed to be a new species of Coltivirus Electron microscopy supported the classification of KARYV and KUNDV as reoviruses and identified replication morphology consistent with other Orbi- and Colti- viruses. The identification of novel tick-borne viruses carried by the CCHF vector is an important step in the characterization of their potential role in human and animal pathogenesis.Importance Ticks, mosquitoes, as well Culicoides, can transmit viruses in the Reoviridae family. With the help of next-generation sequencing (NGS), previously unreported reoviruses such as equine encephalosis virus, Wad Medani virus (WMV), Kammanvanpettai virus (KVPTV) and with this report, KARYV and KUNDV have been discovered and characterized in India. The isolation of KUNDV and KARYV from Hyalomma anatolicum, which is a known vector for zoonotic pathogens, such as Crimean Congo Hemorrhagic Fever virus, Babesia, Theileria and Anaplasma species, identifies arboviruses with the potential to transmit to humans. Characterization of these KUNDV and KARYV isolated from Hyalomma ticks is critical for the development of specific serological and molecular assays that can be used to determine the association of these viruses with disease in humans and livestock.

    • Environmental Health
      1. Age-specific associations of ozone and fine particulate matter with respiratory emergency department visits in the United Statesexternal icon
        Strosnider HM, Chang HH, Darrow LA, Liu Y, Vaidyanathan A, Strickland MJ.
        Am J Respir Crit Care Med. 2019 Apr 1;199(7):882-890.
        RATIONALE: Whereas associations between air pollution and respiratory morbidity for adults 65 years and older are well documented in the United States, the evidence for people under 65 is less extensive. To address this gap, the Centers for Disease Control and Prevention’s National Environmental Public Health Tracking Program collected respiratory emergency department (ED) data from 17 states. OBJECTIVES: To estimate age-specific acute effects of ozone and fine particulate matter (particulate matter </=2.5 mm in aerodynamic diameter [PM2.5]) on respiratory ED visits. METHODS: We conducted time-series analyses in 894 counties by linking daily respiratory ED visits with estimated ozone and PM2.5 concentrations during the week before the date of the visit. Overall effect estimates were obtained with a Bayesian hierarchical model to combine county estimates for each pollutant by age group (children, 0-18; adults, 19-64; adults >/= 65, and all ages) and by outcome group (acute respiratory infection, asthma, chronic obstructive pulmonary disease, pneumonia, and all respiratory ED visits). MEASUREMENTS AND MAIN RESULTS: Rate ratios (95% credible interval) per 10-mug/m(3) increase in PM2.5 and all respiratory ED visits were 1.024 (1.018-1.029) among children, 1.008 (1.004-1.012) among adults younger than 65 years, and 1.002 (0.996-1.007) among adults 65 and older. Per 20-ppb increase in ozone, rate ratios were 1.017 (1.011-1.023) among children, 1.051 (1.046-1.056) among adults younger than 65, and 1.033 (1.026-1.040) among adults 65 and older. Associations varied in magnitude by age group for each outcome group. CONCLUSIONS: These results address a gap in the evidence used to ensure adequate public health protection under national air pollution policies.

    • Genetics and Genomics
      1. Genotypes and population genetics of Cryptococcus neoformans and Cryptococcus gattii species complexes in Europe and the Mediterranean areaexternal icon
        Cogliati M, Desnos-Ollivier M, McCormick-Smith I, Rickerts V, Ferreira-Paim K, Meyer W, Boekhout T, Hagen F, Theelen B, Inacio J, Alonso B, Colom MF, Trilles L, Teresa Montagna M, De Donno A, Susever S, Ergin C, Velegraki A, Ellabib MS, Nardoni S, Macci C, Trovato L, Dipineto L, Akcaglar S, Mlinaric-Missoni E, Bertout S, Venca AC, Sampaio AC, Criseo G, Ranque S, Cerikcioglu N, Marchese A, Vezzulli L, Ilkit M, Pasquale V, Polacheck I, Lockhart SR.
        Fungal Genet Biol. 2019 Apr 3.
        A total of 476 European isolates (310 Cryptococcus neoformans var. grubii, 150 C. neoformans var. neoformans, and 16 C. gattii species complex) from both clinical and environmental sources were analyzed by multi-locus sequence typing. Phylogenetic and population genetic analyses were performed. Sequence analysis identified 74 sequence types among C. neoformans var. neoformans (VNIV), 65 among C. neoformans var. grubii (56 VNI, 8 VNII, 1 VNB), and 5 among the C. gattii species complex (4 VGI and 1 VGIV) isolates. ST23 was the most frequent genotype (22%) among VNI isolates which were mostly grouped in a large clonal cluster including 50% of isolates. Among VNIV isolates, a predominant genotype was not identified. A high percentage of autochthonous STs were identified in both VNI (71%) and VNIV (96%) group of isolates. The 16 European C. gattii species complex isolates analyzed in the present study originated all from the environment and all belonged to a large cluster endemic in the Mediterranean area. Population genetic analysis confirmed that VNI group of isolates were characterized by low variability and clonal expansion while VNIV by a higher variability and a number of recombination events. However, when VNI and VNIV environmental isolates were compared, they showed a similar population structure with a high percentage of shared mutations and the absence of fixed mutations. Also linkage disequilibrium analysis reveals differences between clinical and environmental isolates showing a key role of PLB1 allele combinations in host infection as well as the key role of LAC1 allele combinations for survival of the fungus in the environment. The present study shows that genetic comparison of clinical and environmental isolates represents a first step to understand the genetic characteristics that cause the shift of some genotypes from a saprophytic to a parasitic life style.

    • Health Behavior and Risk
      1. Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) adolescents face well-documented health disparities in suicide risk, substance use, and sexual health. These disparities are known to stem, in part, from stigma directed toward LGBTQ youth in the form of minority stressors such as violence, discrimination, and harassment. Given the proportion of time that LGBTQ students spend in school, schools provide a critical context within which protective factors may be developed and leveraged to improve the health and well-being of these populations. This article provides a summary of key findings from a discussion among researchers, practitioners, and community members who participated in “The State of LGBTQ Youth Health and Wellbeing: Strengthening Schools and Families to Build Resilience,” a public symposium held in June 2017. We detail emerging science on and future priorities for school-based research with LGBTQ youth which were identified by attendees at this meeting, with a particular focus on intersectionality, supportive adults in schools, and in-school programs. We call for more school-based research on priority gaps such as how LGBTQ students’ intersecting identities affect their in-school experiences, how to design professional development programs that cultivate supportive educators, and how to leverage gay-straight alliances/gender and sexuality alliances as sites of health programming for LGBTQ students.

    • Health Disparities
      1. [No abstract]

    • Health Economics
      1. Spillover effects on the welfare of family members may refer to caregiver health effects, informal care time costs, or both. This review focuses on methods that have been used to measure and value informal care time and makes suggestions for their appropriate use in cost-of-illness and cost-effectiveness analyses. It highlights the importance of methods to value informal care time that are independent of caregiver health effects in order to minimize double counting of spillover effects. Although the concept of including caregiver time costs in economic evaluations is not new, relatively few societal perspective cost-effectiveness analyses have included informal care, with the exception of dementia. This is due in part to challenges in measuring and valuing time costs. Analysts can collect information on time spent in informal care or can assess its impact in displacing other time use, notably time in paid employment. A key challenge is to ensure appropriate comparison groups that do not require informal care to be able to correctly estimate attributable informal care time or foregone market work. To value informal care time, analysts can use estimates of hourly earnings in either opportunity cost or replacement cost approaches. Researchers have used widely varying estimates of hourly earnings. Alternatively, stated-preference methods (i.e. contingent valuation, conjoint analysis) can be used to value the effect of informal care on utility, but this can entail double counting with health effects. Lack of consensus and standardization of methods makes it difficult to compare estimates of informal care costs.

      2. Despite the prominence of episode groupers for analysis and reimbursement in US payer settings, peer-reviewed articles using episode groupers for cost-of-illness analysis that informs public health research and decision-making are uncommon. This article provides a brief practical guide to episode-based cost analysis and offers some examples of episode grouper products. It is intended for an audience of health services researchers and managers in public health settings who perform or commission cost-of-illness studies with the US healthcare claims fee-for-service data but lack familiarity with episode groupers.

    • Healthcare Associated Infections
      1. Genomic analysis of cardiac surgery-associated Mycobacterium chimaera infections, United Statesexternal icon
        Hasan NA, Epperson LE, Lawsin A, Rodger RR, Perkins KM, Halpin AL, Perry KA, Moulton-Meissner H, Diekema DJ, Crist MB, Perz JF, Salfinger M, Daley CL, Strong M.
        Emerg Infect Dis. 2019 Mar;25(3):559-563.
        A surgical heater-cooler unit has been implicated as the source for Mycobacterium chimaera infections among cardiac surgery patients in several countries. We isolated M. chimaera from heater-cooler units and patient infections in the United States. Whole-genome sequencing corroborated a risk for these units acting as a reservoir for this pathogen.

      2. Impact of U.S. Public Health Service increased risk deceased donor designation on organ utilizationexternal icon
        Sapiano MR, Jones JM, Bowman J, Levi ME, Basavaraju SV.
        Am J Transplant. 2019 Apr 8.
        Under U.S. Public Health Service (PHS) guidelines, organ donors with risk factors for human immunodeficiency virus (HIV), hepatitis B virus (HBV) or hepatitis C virus (HCV) are categorized as Increased Risk Donors (IRD). Previous studies have suggested that IRD organs are utilized at lower rates than organs from standard risk donors (SRD), but these studies were conducted prior to universal donor nucleic acid test screening. We conducted risk-adjusted analyses to determine the effect of IRD designation on organ utilization using 2010-2017 data (21,626 heart, 101,160 kidney, 52,714 liver and 16,219 lung recipients in the United States) from the Organ Procurement and Transplantation Network. There was no significant difference (p<0.05) between risk-adjusted utilization rates for IRD versus SRD organs for adult hearts and livers and pediatric kidneys, livers, and lungs. Significantly lower utilization was found among IRD adult kidneys, lungs and pediatric hearts. Analysis of the proportion of transplanted organs recovered from IRD by facility suggests that a subset of facilities contribute to the underutilization of adult IRD kidneys. Along with revised criteria and nomenclature to identify donors with HIV, HBV, or HCV risk factors, educational efforts to standardize informed consent discussions might improve organ utilization. This article is protected by copyright. All rights reserved.

      3. Conjugal transfer, whole-genome sequencing, and plasmid analysis of four mcr-1-bearing isolates from U.S. patientsexternal icon
        Zhu W, Lawsin A, Lindsey RL, Batra D, Knipe K, Yoo BB, Perry KA, Rowe LA, Lonsway D, Walters MS, Rasheed JK, Halpin AL.
        Antimicrob Agents Chemother. 2019 Apr;63(4).
        Four Enterobacteriaceae clinical isolates bearing mcr-1 gene-harboring plasmids were characterized. All isolates demonstrated the ability to transfer colistin resistance to Escherichia coli; plasmids were stable in conjugants after multiple passages on nonselective media. mcr-1 was located on an IncX4 (n = 3) or IncN (n = 1) plasmid. The IncN plasmid harbored 13 additional antimicrobial resistance genes. Results indicate that the mcr-1-bearing plasmids in this study were highly transferable in vitro and stable in the recipients.

    • Immunity and Immunization
      1. BACKGROUND: High quality data are needed for decision-making at all levels of the public health system, from guiding public health activities at the local level, to informing national policy development, to monitoring the impact of global initiatives. Although a number of approaches have been developed to evaluate the underlying quality of routinely collected vaccination administrative data, there remains a lack of consensus around how data quality is best defined or measured. DISCUSSION: We present a definitional framework that is intended to disentangle many of the elements that have confused discussions of vaccination data quality to date. The framework describes immunization data in terms of three key characteristics: data quality, data usability, and data utilization. The framework also offers concrete suggestions for a specific set of indicators that could be used to better understand immunization those key characteristics, including Trueness, Concurrence, Relevancy, Efficiency, Completeness, Timeliness, Integrity, Consistency, and Utilization. CONCLUSION: Being deliberate about the choice of indicators; being clear on their definitions, limitations, and methods of measurement; and describing how those indicators work together to give a more comprehensive and practical understanding of immunization data quality, usability, and use, should yield more informed, and therefore better, programmatic decision-making.

      2. Comparison of micro-census results for Magarya Ward, Wurno local government area of Sokoto State, Nigeria, with other sources of denominator dataexternal icon
        Ghiselli ME, Wilson IN, Kaplan B, Waziri NE, Sule A, Ayanleke HB, Namalam F, Tambuwal SA, Aliyu N, Kadi U, Bolu O, Barau N, Yahaya M, Ugbenyo G, Osigwe U, Oguji C, Usifoh N, Seaman V.
        Data (Basel). 2019 ;4(1):20.
        Routine immunization coverage in Nigeria is suboptimal. In the northwestern state of Sokoto, an independent population-based survey for 2016 found immunization coverage with the third dose of Pentavalent vaccine to be 3%, whereas administrative coverage in 2016 was reported to be 69%. One possibility driving this large discrepancy is that administrative coverage is calculated using an under-estimated target population. Official population projections from the 2006 Census are based on state-specific standard population growth rates. Immunization target population estimates from other sources have not been independently validated. We conducted a micro-census in Magarya ward, Wurno Local Government Area of Sokoto state to obtain an accurate count of the total population living in the ward, and to compare these results with other sources of denominator data. We developed a precise micro-plan using satellite imagery, and used the navigation tool EpiSample v1 in the field to guide teams to each building, without duplications or omissions. The particular characteristics of the selected ward underscore the importance of using standardized shape files to draw precise boundaries for enumeration micro-plans. While the use of this methodology did not resolve the discrepancy between independent and administrative vaccination coverage rates, a simplified application can better define the target population for routine immunization services and estimate the number of children still unprotected from vaccine-preventable diseases.

      3. Preemptive tecovirimat use in an active duty member presenting with acute myeloid leukemia after smallpox vaccinationexternal icon
        Lindholm DA, Fisher RD, Montgomery JR, Davidson W, Yu PA, Yu YC, Burgado J, Wilkins K, Petersen BW, Okulicz JF.
        Clin Infect Dis. 2019 Apr 9.
        Smallpox vaccine is contraindicated in immunosuppression due to increased risk for adverse reactions (e.g., progressive vaccinia). We describe the first-ever use of tecovirimat as a preemptive vaccinia virus treatment strategy during induction chemotherapy in an active duty member who presented with acute leukemia and inadvertent auto-inoculation after smallpox vaccination.

      4. [No abstract]

    • Injury and Violence
      1. Adapting a global gender-transformative violence prevention program for the U.S. community-based setting for work with young menexternal icon
        Kato-Wallace J, Barker G, Garg A, Feliz N, Levack A, Ports K, Miller E.
        Glob Soc Welf. 2019 ;2019.
        Extensive practice-based evidence from international settings, as well as in-depth evaluations of programs promoting gender equity, have demonstrated effectiveness in reducing perpetration of violence against women and girls. Such “gender-transfor-mative programs” encourage critical analysis of gender norms, challenge homophobia and gender-based harassment, build skills to question harmful masculine norms, interrupt harmful and disrespectful behaviors, and encourage more equitable behaviors. Here we describe the history of a gender-transformative program, “Program H,” first developed in Brazil and Mexico, the rationale for and evaluation of this original program, and the processes of adaptation for the US urban community-based setting, and highlight the risks as well as opportunities on the work with young men and boys in the future.

      2. PURPOSE: The purpose of this study was to examine multiple ways youth may access firearms among a sample of urban, mountain west youth, and explore whether youth reporting various types of violence involvement and other behavioral or mental health factors have differential access to firearms compared with youth who do not report these issues. METHODS: A cross-sectional community-based survey was conducted among adolescents aged 10-17 years and one of their parents. The main outcomes were youth firearm access and possession and associated violence and behavioral and mental health factors. Bivariate and binomial logistic regression, controlling for demographic factors, was used to determine associations and predictors. RESULTS: One thousand one hundred youth and 730 parents participated. Nearly half of youth were male; 58.2% were Hispanic, 24.7% non-Hispanic black, 10.5% multiracial, 3.9% other, and 2.5% white. About 20% were categorized as having potential access to firearms (i.e., youth knows how and/or where to access firearms); 1.9% possessed a firearm. Analyses revealed that being physically aggressive (odds ratio [OR] 2.7), risk for future violence perpetration (OR 2.6), using alcohol (OR 2.0), having internalizing symptoms (OR 1.9), peer problems (OR 1.9), and older age (OR 1.26) predicted youth’s possible access to firearms. Marijuana use (OR 9.9), parental gun ownership (OR 6.5), and reported delinquency (OR 8.3) predicted youth’s firearm possession. CONCLUSIONS: Youth with potential firearm access demonstrate more violence risk and involvement, and other behavioral or mental health issues than youth without potential firearm access. Parental firearm ownership predicts youth firearm possession. It is important for both health-care providers and parents to recognize these potentially lethal associations to provide appropriate counseling.

    • Laboratory Sciences
      1. Development of an occupational risk assessment tool for laboratory animal facilitiesexternal icon
        Clayton AM, Hayes J, Lathrop GW, Powell N.
        Applied Biosafety. 2019 .
        Introduction: Laboratory animal facilities aim to provide excellence in animal care and welfare and support scientific research. Critical to these goals is to ensure a safe work environment for personnel comprising veterinary and animal care, laboratory research, and maintenance staff. Objective: Thus, performing occupational risk assessments allows for evaluation of risks from identified hazards associated with a variety of tasks ongoing in laboratory animal facilities. Methods: Herein, we present the development of an occupational risk assessment tool purposed to capture the dynamics of work performed in laboratory animal facilities, calculate and prioritize identified risks associated with procedures and processes, and inform and evaluate risk mitigations. Results: We also discuss a risk assessment for refining sharps use in nonhuman primate husbandry and care to demonstrate the utility of this tool to improve occupational safety in our animal facility. Conclusion: This tool and framework evolve into a holistic occupational risk management system that identifies, evaluates, and mitigates occupational risks; determines risk acceptability; consistently ensures communication and consultation with frontline personnel, stakeholders, senior leadership, and subject matter experts in biosafety, science, and animal care and welfare; and continuously strives to improve and enhance the operations of laboratory animal facilities.

      2. Single-dose replicon particle vaccine provides complete protection against Crimean-Congo hemorrhagic fever virus in miceexternal icon
        Scholte FE, Spengler JR, Welch SR, Harmon JR, Coleman-McCray JD, Freitas BT, Kainulainen MH, Pegan SD, Nichol ST, Bergeron E, Spiropoulou CF.
        Emerg Microbes Infect. 2019 ;8(1):575-578.

        [No abstract]

      3. Toxicological assessment of dust from sanding micronized copper-treated lumber in vivoexternal icon
        Sisler JD, Mandler WK, Shaffer J, Lee T, McKinney WG, Battelli LA, Orandle MS, Thomas TA, Castranova VC, Qi C, Porter DW, Andrew ME, Fedan JS, Mercer RR, Qian Y.
        J Hazard Mater. 2019 Mar 31;373:630-639.
        Micronized copper azole (MCA) is a lumber treatment improve longevity. In this study, the in vivo response to PM2.5 sanding dust generated from MCA-treated lumber was compared to that of untreated yellow pine (UYP) or soluble copper azole-treated (CA-C) lumber to determine if the MCA was more bioactive than CA-C. Mice were exposed to doses (28, 140, or 280 mug/mouse) of UYP, MCA, or CA-C sanding dust using oropharyngeal aspiration. Bronchoalveolar lavage fluid (BALF) lactate dehydrogenase activity was increased at 1 day post-exposure to 280 mug/mouse of MCA and CA-C compared to UYP. BALF polymorphonuclear cells were increased by MCA and CA-C. There were increases in BALF cytokines in MCA and CA-C-exposed groups at 1 day post-exposure. Lung histopathology indicated inflammation with infiltration of neutrophils and macrophages. Pulmonary responses were more severe in MCA and CA-C-exposed groups at 1 day post-exposure. MCA caused more severe inflammatory responses than CA-C at 1 day post-exposure. These findings suggest that the MCA and CA-C sanding dusts are more bioactive than the UYP sanding dust, and, moreover, the MCA sanding dust is more bioactive in comparison to the CA-C sanding dust. No chronic toxic effects were observed among all observed sanding dusts.

    • Maternal and Child Health
      1. The prevalence of histologic acute chorioamnionitis among HIV infected pregnant women in Uganda and its association with adverse birth outcomesexternal icon
        Ategeka J, Wasswa R, Olwoch P, Kakuru A, Natureeba P, Muehlenbachs A, Kamya MR, Dorsey G, Rizzuto G.
        PLoS One. 2019 ;14(4):e0215058.
        BACKGROUND: Preterm birth (PTB) is a leading cause of neonatal mortality and longer-term morbidity. Acute chorioamnionitis (ACA) is a common cause of PTB, however, there are limited data on the prevalence of ACA and its association with PTB in resource limited settings. METHODS: Data and samples came from a clinical trial evaluating novel strategies for the prevention of malaria in HIV infected pregnant women in Uganda. Women were enrolled between 12-28 weeks of gestation and followed through delivery. For each placenta delivered, three placental tissue types (membrane roll, umbilical cord and chorionic plate/villous parenchyma) were collected. Slides were assessed for diagnosis of maternal and fetal ACA by microscopic evaluation of neutrophilic infiltration using a standardized grading scale. The primary outcomes were PTB (<37 weeks), low birth weight (LBW, <2500 grams), and small-for-gestational age (SGA, birth weight <10th percentile for age). Univariate and multivariate logistic regression were used to estimate associations between 1) maternal characteristics (age, education, wealth, gravidity, gestational age at enrollment, placental malaria, anti-malarial prophylaxis treatment regimen, HIV disease parameters) and ACA, and 2) associations between ACA and adverse birth outcomes. FINDINGS: A total of 193 placentas were included in the analysis. The prevalence of maternal and fetal ACA was 44.5% and 28.0%, respectively. HIV infected women between 28-43 years of age had a higher risk of maternal ACA compared to those between 17-21 years of age (50.9% vs. 19.1%; aOR = 4.00 (1.10-14.5), p = 0.04) and the diagnosis of severe maternal ACA was associated with a significantly higher risk of PTB (28.6% vs. 6.0%; aOR = 6.04 (1.87-19.5), p = 0.003), LBW (33.3% vs. 9.4%; aOR = 4.86 (1.65-14.3); p = 0.004), and SGA (28.6% vs. 10.1%; aOR = 3.70 (1.20-11.4), p = 0.02). No maternal characteristics were significantly associated with fetal ACA and the diagnosis of fetal ACA was not associated with adverse birth outcomes. CONCLUSIONS: Histological evidence of severe maternal ACA was associated with an increased risk of PTB, LBW, and SGA in HIV infected, pregnant Ugandan women.

      2. Prevalence and characteristics of autism spectrum disorder among children aged 4 years – Early Autism and Developmental Disabilities Monitoring Network, seven sites, United States, 2010, 2012, and 2014external icon
        Christensen DL, Maenner MJ, Bilder D, Constantino JN, Daniels J, Durkin MS, Fitzgerald RT, Kurzius-Spencer M, Pettygrove SD, Robinson C, Shenouda J, White T, Zahorodny W, Pazol K, Dietz P.
        MMWR Surveill Summ. 2019 Apr 12;68(2):1-19.
        PROBLEM/CONDITION: Autism spectrum disorder (ASD) is estimated to affect up to 3% of children in the United States. Public health surveillance for ASD among children aged 4 years provides information about trends in prevalence, characteristics of children with ASD, and progress made toward decreasing the age of identification of ASD so that evidence-based interventions can begin as early as possible. PERIOD COVERED: 2010, 2012, and 2014. DESCRIPTION OF SYSTEM: The Early Autism and Developmental Disabilities Monitoring (Early ADDM) Network is an active surveillance system that provides biennial estimates of the prevalence and characteristics of ASD among children aged 4 years whose parents or guardians lived within designated sites. During surveillance years 2010, 2012, or 2014, data were collected in seven sites: Arizona, Colorado, Missouri, New Jersey, North Carolina, Utah, and Wisconsin. The Early ADDM Network is a subset of the broader ADDM Network (which included 13 total sites over the same period) that has been conducting ASD surveillance among children aged 8 years since 2000. Each Early ADDM site covers a smaller geographic area than the broader ADDM Network. Early ADDM ASD surveillance is conducted in two phases using the same methods and project staff members as the ADDM Network. The first phase consists of reviewing and abstracting data from children’s records, including comprehensive evaluations performed by community professionals. Sources for these evaluations include general pediatric health clinics and specialized programs for children with developmental disabilities. In addition, special education records (for children aged >/=3 years) were reviewed for Arizona, Colorado, New Jersey, North Carolina, and Utah, and early intervention records (for children aged 0 to <3 years) were reviewed for New Jersey, North Carolina, Utah, and Wisconsin; in Wisconsin, early intervention records were reviewed for 2014 only. The second phase involves a review of the abstracted evaluations by trained clinicians using a standardized case definition and method. A child is considered to meet the surveillance case definition for ASD if one or more comprehensive evaluations of that child completed by a qualified professional describes behaviors consistent with the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) diagnostic criteria for any of the following conditions: autistic disorder, pervasive developmental disorder-not otherwise specified (PDD-NOS, including atypical autism), or Asperger disorder (2010, 2012, and 2014). For 2014 only, prevalence estimates based on surveillance case definitions according to DSM-IV-TR and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) were compared. This report provides estimates of overall ASD prevalence and prevalence by sex and race/ethnicity; characteristics of children aged 4 years with ASD, including age at first developmental evaluation, age at ASD diagnosis, and cognitive function; and trends in ASD prevalence and characteristics among Early ADDM sites with data for all 3 surveillance years (2010, 2012, and 2014), including comparisons with children aged 8 years living in the same geographic area. Analyses of time trends in ASD prevalence are restricted to the three sites that contributed data for all 3 surveillance years with consistent data sources (Arizona, Missouri, and New Jersey). RESULTS: The overall ASD prevalence was 13.4 per 1,000 children aged 4 years in 2010, 15.3 in 2012, and 17.0 in 2014 for Early ADDM sites with data for the specific years. ASD prevalence was determined using a surveillance case definition based on DSM-IV-TR. Within each surveillance year, ASD prevalence among children aged 4 years varied across surveillance sites and was lowest each year for Missouri (8.5, 8.1, and 9.6 per 1,000, for 2010, 2012, and 2014, respectively) and highest each year for New Jersey (19.7, 22.1, and 28.4 per 1,000, for the same years, respectively). Aggregated prevalence estimates were higher for sites that reviewed education and health care records than for sites that reviewed only health care records. Among all participating sites and years, ASD prevalence among children aged 4 years was consistently higher among boys than girls; prevalence ratios ranged from 2.6 (Arizona and Wisconsin in 2010) to 5.2 boys per one girl (Colorado in 2014). In 2010, ASD prevalence was higher among non-Hispanic white children than among Hispanic children in Arizona and non-Hispanic black children in Missouri; no other differences were observed by race/ethnicity. Among four sites with >/=60% data on cognitive test scores (Arizona, New Jersey, North Carolina, and Utah), the frequency of co-occurring intellectual disabilities was significantly higher among children aged 4 years than among those aged 8 years for each site in each surveillance year except Arizona in 2010. The percentage of children with ASD who had a first evaluation by age 36 months ranged from 48.8% in Missouri in 2012 to 88.9% in Wisconsin in 2014. The percentage of children with a previous ASD diagnosis from a community provider varied by site, ranging from 43.0% for Arizona in 2012 to 86.5% for Missouri in 2012. The median age at earliest known ASD diagnosis varied from 28 months in North Carolina in 2014 to 39.0 months in Missouri and Wisconsin in 2012. In 2014, the ASD prevalence based on the DSM-IV-TR case definition was 20% higher than the prevalence based on the DSM-5 (17.0 versus 14.1 per 1,000, respectively). Trends in ASD prevalence and characteristics among children aged 4 years during the study period were assessed for the three sites with data for all 3 years and consistent data sources (Arizona, Missouri, and New Jersey) using the DSM-IV-TR case definition; prevalence was higher in 2014 than in 2010 among children aged 4 years in New Jersey and was stable in Arizona and Missouri. In Missouri, ASD prevalence was higher among children aged 8 years than among children aged 4 years. The percentage of children with ASD who had a comprehensive evaluation by age 36 months was stable in Arizona and Missouri and decreased in New Jersey. In the three sites, no change occurred in the age at earliest known ASD diagnosis during 2010-2014. INTERPRETATION: The findings suggest that ASD prevalence among children aged 4 years was higher in 2014 than in 2010 in one site and remained stable in others. Among children with ASD, the frequency of cognitive impairment was higher among children aged 4 years than among those aged 8 years and suggests that surveillance at age 4 years might more often include children with more severe symptoms or those with co-occurring conditions such as intellectual disability. In the sites with data for all years and consistent data sources, no change in the age at earliest known ASD diagnosis was found, and children received their first developmental evaluation at the same or a later age in 2014 compared with 2010. Delays in the initiation of a first developmental evaluation might adversely affect children by delaying access to treatment and special services that can improve outcomes for children with ASD. PUBLIC HEALTH ACTION: Efforts to increase awareness of ASD and improve the identification of ASD by community providers can facilitate early diagnosis of children with ASD. Heterogeneity of results across sites suggests that community-level differences in evaluation and diagnostic services as well as access to data sources might affect estimates of ASD prevalence and age of identification. Continuing improvements in providing developmental evaluations to children as soon as developmental concerns are identified might result in earlier ASD diagnoses and earlier receipt of services, which might improve developmental outcomes.

      3. Maternal diabetes and hypertensive disorders in association with autism spectrum disorderexternal icon
        Cordero C, Windham GC, Schieve LA, Fallin MD, Croen LA, Siega-Riz AM, Engel SM, Herring AH, Stuebe AM, Vladutiu CJ, Daniels JL.
        Autism Res. 2019 Apr 10.
        Previous studies have shown complications of pregnancy, often examined in aggregate, to be associated with autism spectrum disorder (ASD). Results for specific complications, such as maternal diabetes and hypertension, have not been uniformly consistent and should be investigated independently in relation to ASD in a large community-based sample. The Study to Explore Early Development (SEED), a US multisite case-control study, enrolled children born in 2003-2006 at 2-5 years of age. Children were classified into three groups based on confirmation of ASD (n = 698), non-ASD developmental delay (DD; n = 887), or controls drawn from the general population (POP; n = 979). Diagnoses of any diabetes or hypertensive disorder during pregnancy were identified from prenatal medical records and maternal self-report. Logistic regression models estimated adjusted odds ratios (aOR) and confidence intervals (CI) adjusting for maternal age, race/ethnicity, education, smoking during pregnancy, and study site. Models for hypertension were additionally adjusted for parity and plurality. Among 2,564 mothers, we identified 246 (9.6%) with any diabetes and 386 (15.1%) with any hypertension in pregnancy. After adjustment for covariates, any diabetes during pregnancy was not associated with ASD (aOR = 1.10 [95% CI 0.77, 1.56]), but any hypertension was associated with ASD (aOR = 1.69 [95% CI 1.26, 2.26]). Results were similar for DD, and any diabetes (aOR = 1.29 [95% CI 0.94, 1.78]) or any hypertension (aOR = 1.71 [95% CI 1.30, 2.25]). Some pregnancy complications, such as hypertension, may play a role in autism etiology and can possibly serve as a prompt for more vigilant ASD screening efforts. Autism Res 2019. (c) 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: We studied if common complications in pregnancy are associated with autism spectrum disorder (ASD) in a large sample of mothers and children. Our results show an association between conditions marked by high blood pressure and ASD, but no association with conditions marked by high blood sugar and ASD. Associations were similar for children who had a developmental disorder that was not ASD, suggesting that this relationship may not be specific to ASD.

    • Occupational Safety and Health
      1. Immunological methods for diagnosis and monitoring of IgE-mediated allergy caused by industrial sensitizing agents (IMExAllergy)external icon
        Baur X, Akdis CA, Budnik LT, Cruz MJ, Fischer A, Forster-Ruhrmann U, Goen T, Goksel O, Heutelbeck AR, Jones M, Lux H, Maestrelli P, Munoz X, Nemery B, Schlunssen V, Sigsgaard T, Traidl-Hoffmann C, Siegel P.
        Allergy. 2019 Apr 6.
        Industrial sensitizing agents (allergens) in living and working environments play an important role in eliciting type I allergic disorders including asthma and allergic rhinitis. Successful management of allergic diseases necessitates identifying their specific causes (i.e. identify the causative agent(s) and the route of contact to allergen: airborne, or skin contact) to avoid further exposure. Identification of sensitization by a sensitive and validated measurement of specific-IgE is an important step in the diagnosis. However, only a limited number of environmental and occupational allergens are available on the market for use in sIgE testing. Accordingly, specific in-house testing by individual diagnostic and laboratory centers is often required. Currently, different immunological tests are in use at various diagnostic centers that often produce considerably divergent results, mostly due to lack of standardized allergen preparation and standardized procedures as well as inadequate quality control. Our review and meta-analysis exhibited satisfactory performance of s IgE detection test for most high molecular weight (HMW) allergens with a pooled sensitivity of 0.74 and specificity of 0.71. However, for low molecular weight (LMW) allergens, pooled sensitivity is generally lower (0.28) and specificity higher (0.89) than for HMW tests. Major recommendations based on the presented data include diagnostic use of sIgE to HMW allergens. A negative sIgE results for LMW agents does not exclude sensitization. In addition, the requirements for full transparency of the content of allergen preparations with details on standardization and quality control is underlined. Development of standard operating procedures for in-house sIgE assays, and clinical validation, centralized quality control and audits are emphasized. There is also a need for specialized laboratories to provide a custom service for the development of tests for the measurement of putative novel occupational allergens that are not commercially available. This article is protected by copyright. All rights reserved.

      2. Firefighter and fire instructor’s physiological responses and safety in various training fire environmentsexternal icon
        Horn GP, Stewart JW, Kesler RM, DeBlois JP, Kerber S, Fent KW, Scott WS, Fernhall B, Smith DL.
        Safety Science. 2019 July;116:287-294.
        For firefighters around the world, fire training is necessary to ensure operational readiness, but can be hazardous. Fire instructors routinely attempt to design safe but realistic scenarios and may do so in very different thermal environments. Yet, the physiological burden (and presumed physiological benefits) of different training has rarely been investigated. We studied the impact of three training fire environments: (a) pallets (Pallet), (b) oriented strand board (OSB) and simulated fire/smoke (Fog) on firefighters’ and fire instructors’ physiological responses. Peak ambient temperatures exceeded 420 degreeC in Pallet and OSB scenarios, but were less than 40 degreeC for Fog. Firefighters’ peak core temperatures, heart rates and hemostatic responses were not statistically different among the training environments despite the large differences in ambient conditions. Instructors’ heart rate and hemostatic responses were significantly blunted compared to the firefighters’ despite similar peak core temperatures, suggesting instructors performed less work or were less stressed. It is important that physiological responses experienced by firefighters and instructors working in fully encapsulating personal protective equipment be considered based on intensity and duration of work, regardless of the apparent risk from ambient conditions.

      3. Characteristics associated with negative attitudes toward mental illness among US veterinariansexternal icon
        Kassem AM, Witte TK, Nett RJ, Carter KK.
        J Am Vet Med Assoc. 2019 Apr 15;254(8):979-985.
        OBJECTIVE: To explore associations between demographic, occupational, and mental health characteristics and negative attitudes toward mental illness among veterinarians. DESIGN: Cross-sectional survey. SAMPLE: 9,522 veterinarians employed in the United States. PROCEDURES: Data from a previously conducted voluntary, anonymous, web-based survey were used. Negative attitude was defined as slight or strong disagreement with 2 statements: “Treatment can help people with mental illness lead normal lives” (treatment effectiveness) and “People are generally caring and sympathetic to people with mental illness” (social support). Multivariable logistic regression was used to identify variables associated with negative attitudes. RESULTS: Of the 9,522 respondents, 6,585 (69.2%) were female, 4,523 (47.5%) were 40 to 59 years old, 291 (3.1%) had a negative attitude toward treatment effectiveness, and 4,504 (47.3%) had a negative attitude toward social support. After adjusting for other variables, negative attitude toward treatment effectiveness was significantly more likely in males, those with 10 to 19 (vs 1 to 9) years of practice experience, solo practitioners, those in government (vs “other”) practice, those with evidence of serious psychological distress, and those reporting suicidal ideation after veterinary school and significantly less likely in those receiving mental health treatment. A negative attitude toward social support was significantly less likely in males and significantly more likely in 40 to 59 (vs 20 to 39) year olds, childless respondents, solo practitioners, those without membership in a veterinary association, those with evidence of serious psychological distress, those reporting depression during or after veterinary school, and those reporting suicidal ideation after veterinary school. CONCLUSIONS AND CLINICAL RELEVANCE: Characteristics such as age, sex, practice setting, and mental illness history might be useful to consider when targeting interventions to support and educate veterinarians about mental illness.

      4. ASTM F48 formation and standards for industrial exoskeletons and exosuitsexternal icon
        Lowe BD, Billotte WG, Peterson DR.
        IISE Trans Occup Ergon Hum Factors. 2019 :1-7.
        OCCUPATIONAL APPLICATIONSThis paper provides an overview of a new consensus standards committee for exoskeletons, ASTM International F48, and describes the organization and current activities of this committee. Lack of product standards and certifications have been described as barriers to adoption of exoskeleton technologies in industry practice. While exoskeletons are not considered a traditional form of personal protective equipment (PPE), they are similarly wearable, and much of the interest in their application in the industrial/workplace domain is motivated by injury prevention. ASTM F48 believes that standards and certifications for exoskeletons in their manufacture, deployment, and use would enhance their adoption and effective application in the workplace.

      5. Drug overdose deaths at work, 2011-2016external icon
        Tiesman HM, Konda S, Cimineri L, Castillo DN.
        Inj Prev. 2019 Apr 10.
        Drug overdose fatalities have risen sharply and the impact on US workplaces has not been described. This paper describes US workplace overdose deaths between 2011 and 2016. Drug overdose deaths were identified from the Census of Fatal Occupational Injuries and fatality rates calculated using denominators from the Current Population Survey. Fatality rates were compared among demographic groups and industries. Negative binomial regression was used to analyse trends. Between 2011 and 2016, 760 workplace drug overdoses occurred for a fatality rate of 0.9 per 1 000 000 full-time equivalents (FTEs). Workplace overdose fatality rates significantly increased 24% annually. Workplace overdose fatality rates were highest in transportation and mining industries (3.0 and 2.6 per 1 000 000 FTEs, respectively). One-third of workplace overdose fatalities occurred in workplaces with fewer than 10 employees. Heroin was the single most frequent drug documented in workplace overdose deaths (17%). Workplace overdose deaths were low, but increased considerably over the six-year period. Workplaces are impacted by the national opioid overdose epidemic.

    • Substance Use and Abuse
      1. Notes from the field: Unintentional drug overdose deaths with kratom detected – 27 states, July 2016-December 2017external icon
        Olsen EO, O’Donnell J, Mattson CL, Schier JG, Wilson N.
        MMWR Morb Mortal Wkly Rep. 2019 Apr 12;68(14):326-327.

        [No abstract]

      2. Effects of mandatory prescription drug monitoring program (PDMP) use laws on prescriber registration and use and on risky prescribingexternal icon
        Strickler GK, Zhang K, Halpin JF, Bohnert AS, Baldwin GT, Kreiner PW.
        Drug Alcohol Depend. 2019 Mar 22;199:1-9.
        BACKGROUND: Comprehensive mandatory use laws for prescription drug monitoring programs (PDMPs) have been implemented in a number of states to help address the opioid overdose epidemic. These laws may reduce opioid-related overdose deaths by increasing prescribers’ use of PDMPs and reducing high-risk prescribing behaviors. METHODS: We used state PDMP data to examine the effect of these mandates on prescriber registration, use of the PDMP, and on prescription-based measures of patient risk in three states-Kentucky, Ohio, and West Virginia-that implemented mandates between 2010 and 2015. We conducted comparative interrupted time series analyses to examine changes in outcome measures after the implementation of mandates in the mandate states compared to control states. RESULTS: Mandatory use laws increased prescriber registration and utilization of the PDMP in the mandate states compared to controls. The multiple provider episode rate, rate of opioid prescribing, rate of overlapping opioid prescriptions, and rate of overlapping opioid/benzodiazepine prescriptions decreased in Kentucky and Ohio. Nevertheless, the magnitude of changes in these measures varied among mandates states. CONCLUSIONS: These findings indicate that PDMP mandates have the potential to reduce risky opioid prescribing practices. Variation in the laws may explain why the effectiveness varied between states.

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

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