Volume 11, Issue 17 April 30, 2019

CDC Science Clips: Volume 11, Issue 17, April 30, 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.
    • Chronic Diseases and Conditions
      • Oral health is important to general health, yet is often overlooked. During pregnancy, women may be more prone to periodontal (gum) disease and cavities, and research has shown an association between these conditions and adverse pregnancy outcomes. Additionally, a mother’s oral health status is a strong predictor of her children’s oral health status. Primary care providers often have an opportunity to influence their patients’ attitudes and behaviors regarding the importance of oral health during pregnancy. Through a cooperative agreement with the Centers for Disease Control and Prevention, the American Academy of Pediatrics worked to create Protect Tiny Teeth, an oral health communications resource that aims to facilitate conversations between pregnant women and their health care providers, as well as educate women and families about the importance of oral health.

      • Resurgence in diabetes-related complicationsexternal icon
        Gregg EW, Hora I, Benoit SR.
        Jama. 2019 Apr 15.

        [No abstract]

      • Progress toward improved cardiovascular health in the United Statesexternal icon
        Pahigiannis K, Thompson-Paul AM, Barfield W, Ochiai E, Loustalot F, Shero S, Hong Y.
        Circulation. 2019 Apr 16;139(16):1957-1973.
        The Healthy People Initiative has served as the leading disease prevention and health promotion roadmap for the nation since its inception in 1979. Healthy People 2020 (HP2020), the initiative’s current iteration, sets a national prevention agenda with health goals and objectives by identifying nationwide health improvement priorities and providing measurable objectives and targets from 2010 to 2020. Central to the overall mission and vision of Healthy People is an emphasis on achieving health equity, eliminating health disparities, and improving health for all population groups. The Heart Disease and Stroke (HDS) Work Group of the HP2020 Initiative aims to leverage advances in biomedical science and prevention research to improve cardiovascular health across the nation. The initiative provides a platform to foster partnerships and empower professional societies and nongovernmental organizations, governments at the local, state, and national levels, and healthcare professionals to strengthen policies and improve practices related to cardiovascular health. Disparities in cardiovascular disease burden are well recognized across, for example, race/ethnicity, sex, age, and geographic region, and improvements in cardiovascular health for the entire population are only possible if such disparities are addressed through efforts that target individuals, communities, and clinical and public health systems. This article summarizes criteria for creating and tracking the 50 HDS HP2020 objectives in 3 areas (prevention, morbidity/mortality, and systems of care), reports on progress toward the 2020 targets for these objectives based on the most recent data available, and showcases examples of relevant programs led by participating agencies. Although most of the measurable objectives have reached the 2020 targets ahead of time (n=14) or are on track to meet the targets (n=7), others may not achieve the decade’s targets if the current trends continue, with 3 objectives moving away from the targets. This summary illustrates the utility of HP2020 in tracking measures of cardiovascular health that are of interest to federal agencies and policymakers, professional societies, and other nongovernmental organizations. With planning for Healthy People 2030 well underway, stakeholders such as healthcare professionals can embrace collaborative opportunities to leverage existing progress and emphasize areas for improvement to maximize the Healthy People initiative’s positive impact on population-level health.

    • Communicable Diseases
      • Predictors of perinatal HIV transmission among women without prior antiretroviral therapy in a resource-limited setting: The Breastfeeding, Antiretrovirals and Nutrition Studyexternal icon
        Ewing AC, Ellington SR, Wiener JB, Chasela CS, Tegha G, Nelson JA, Jamieson DJ, van der Horst C, Kourtis AP.
        Pediatr Infect Dis J. 2019 May;38(5):508-512.
        BACKGROUND: To investigate potential risk factors for perinatal (intrauterine and intrapartum) mother-to-child transmission (MTCT) of HIV in women unexposed to antiretroviral therapy (ART) during pregnancy. METHODS: We compared factors according to perinatal MTCT outcome among 2275 ART-naive (until the onset of labor) HIV-infected women in the Breastfeeding, Antiretrovirals and Nutrition study (2004-2010) in Lilongwe, Malawi. Factors included HIV viral load during pregnancy, food security, demographic characteristics, hematologic and blood chemistry measures, medical history and physical factors. Associations with perinatal MTCT and interactions with maternal viral load were assessed using simple and multivariable logistic regression. RESULTS: There were 119 (115 intrauterine and 4 intrapartum) cases of perinatal MTCT, only one to a mother with <1000 HIV copies/mL. Maternal viral loads >10,000 copies/mL were common (63.1%). Lower maternal viral load (<1000 copies/mL and 1000.1-10,000 copies/mL) was associated with reduced odds of perinatal MTCT [adjusted odds ratio (aOR), 0.1; 95% confidence interval (CI): 0.01-0.4 and aOR, 0.2; 95% CI: 0.1-0.4, respectively), compared with maternal viral load >10,000 copies/mL. Low CD4+ T cell count (</=350 cells/muL) was only associated with perinatal MTCT in unadjusted models. Food shortage (aOR, 1.8; 95% CI: 1.2-2.6), sexually transmitted infection (STI) (past year; aOR, 1.9; 95% CI: 1.0-3.7), histories of herpes zoster (aOR, 3.0; 95% CI: 1.6-5.6) and tuberculosis (aOR, 2.5; 95% CI: 1.1-5.7) were associated with increased odds of perinatal MTCT. CONCLUSIONS: These findings confirm that lowering maternal HIV viral load is most important in preventing perinatal MTCT and support efforts to address food shortage, STI and tuberculosis prevention, while informing programs to improve ART coverage in pregnancy.

      • [No abstract]

      • Impact of abstinence and of reducing illicit drug use without abstinence on HIV viral loadexternal icon
        Nance RM, Trejo ME, Whitney BM, Delaney JA, Altice F, Beckwith CG, Chander G, Chandler R, Christopoulous K, Cunningham C, Cunningham WE, Del Rio C, Donovan D, Eron JJ, Fredericksen RJ, Kahana S, Kitahata MM, Kronmal R, Kuo I, Kurth A, Mathews WC, Mayer KH, Moore RD, Mugavero MJ, Ouellet LJ, Quan VM, Saag MS, Simoni JM, Springer S, Strand L, Taxman F, Young JD, Crane HM.
        Clin Infect Dis. 2019 Apr 17.
        BACKGROUND: Substance use is common among people living with HIV (PLWH) and a barrier to achieving viral suppression. OBJECTIVE: Among PLWH who report illicit drug use, we evaluated associations between HIV viral load (VL) and reduced use of illicit opioids, methamphetamine/crystal, cocaine/crack, and marijuana, regardless of whether or not abstinence was achieved. DESIGN: Longitudinal cohort studySetting/participantsPLWH in clinical care at 8 HIV clinics or 5 clinical studies. MEASUREMENTS: We used joint longitudinal and survival models to examine the impact of decreasing drug use and of abstinence for each drug on viral suppression. We repeated analyses using linear mixed models to examine associations between change in frequency of drug use and VL. RESULTS: The number of PLWH who were using each drug at baseline ranged from n=568 (illicit opioids) to n=4272 (marijuana). Abstinence was associated with higher odds of viral suppression (OR 1.4-2.2) and lower relative VL (ranging from 21-42% by drug) for all four drug categories. Reducing frequency of illicit opioid or methamphetamine/crystal use without abstinence was associated with VL suppression (OR 2.2, 1.6 respectively). Reducing frequency of illicit opioid or methamphetamine/crystal use without abstinence was associated with lower relative VL (47%, 38% respectively). LIMITATIONS: Observational data have limitations with causal inference. CONCLUSIONS: Abstinence was associated with viral suppression. In addition, reducing use of illicit opioids or methamphetamine/crystal, even without abstinence, was also associated with viral suppression. Findings highlight the impact of reducing substance use even when abstinence is not achieved and the potential benefits of medications, behavioral interventions, and harm-reduction interventions.

      • Utility of whole-genome sequencing to ascertain locally acquired cases of coccidioidomycosis, Washington, USAexternal icon
        Oltean HN, Etienne KA, Roe CC, Gade L, McCotter OZ, Engelthaler DM, Litvintseva AP.
        Emerg Infect Dis. 2019 Mar;25(3):501-506.
        Coccidioidomycosis is an emerging fungal infection in Washington, USA, and the epidemiology of the disease in this state is poorly understood. We used whole-genome sequencing to differentiate locally acquired cases in Washington on the basis of the previously identified phylogeographic population structure of Coccidioides spp. Clinical isolates from coccidioidomycosis cases involving possible Washington soil exposure were included. Of 17 human infections with epidemiologic evidence of possible local acquisition, 4 were likely locally acquired infections and 13 were likely acquired outside Washington. Isolates from locally acquired cases clustered within the previously established Washington clade of C. immitis. Genetic differences among these strains suggest multiple environmental reservoirs of C. immitis in the state.

    • Healthcare Associated Infections
      • [No abstract]

      • Quantifying the risk of undetected HIV, hepatitis B virus, or hepatitis C virus infection in public health service increased risk donorsexternal icon
        Jones JM, Gurbaxani BM, Asher A, Sansom S, Annambhotla P, Moorman AC, Brooks JT, Basavaraju SV.
        Am J Transplant. 2019 Apr 13.
        To reduce the risk of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) transmission through organ transplantation, donors are universally screened for these infections by nucleic acid tests (NAT). Deceased organ donors are classified as “increased risk” if they engaged in specific behaviors during the 12 months before death. We developed a model to estimate the risk of undetected infection for HIV, HBV, and HCV among NAT-negative donors specific to the type and timing of donors’ potential risk behavior to guide revisions to the 12-month timeline. Model parameters were estimated, including risk of disease acquisition for increased-risk groups, number of virions that multiply to establish infection, virus doubling time, and limit of detection by NAT. Monte Carlo simulation was performed. The risk of undetected infection was <1/1,000,000 for HIV after 14 days, for HBV after 35 days, and for HCV after 7 days from the time of most recent potential exposure to the day of a negative NAT. The period during which reported donor risk behaviors result in an “increased risk” designation can be safely shortened. This article is protected by copyright. All rights reserved.

    • Zoonotic and Vectorborne Diseases
      • Using healthcare-seeking behaviour to estimate the number of Nipah outbreaks missed by hospital-based surveillance in Bangladeshexternal icon
        Hegde ST, Salje H, Sazzad HM, Hossain MJ, Rahman M, Daszak P, Klena JD, Nichol ST, Luby SP, Gurley ES.
        Int J Epidemiol. 2019 Apr 11.
        BACKGROUND: Understanding the true burden of emergent diseases is critical for assessing public-health impact. However, surveillance often relies on hospital systems that only capture a minority of cases. We use the example of Nipah-virus infection in Bangladesh, which has a high case-fatality ratio and frequent person-to-person transmission, to demonstrate how healthcare-seeking data can estimate true burden. METHODS: We fit logistic-regression models to data from a population-based, healthcare-seeking study of encephalitis cases to characterize the impact of distance and mortality on attending one of three surveillance hospital sites. The resulting estimates of detection probabilities, as a function of distance and outcome, are applied to all observed Nipah outbreaks between 2007 and 2014 to estimate the true burden. RESULTS: The probability of attending a surveillance hospital fell from 82% for people with fatal encephalitis living 10 km away from a surveillance hospital to 54% at 50 km away. The odds of attending a surveillance hospital are 3.2 (95% confidence interval: 1.6, 6.6) times greater for patients who eventually died (i.e. who were more severely ill) compared with those who survived. Using these probabilities, we estimated that 119 Nipah outbreaks (95% confidence interval: 103, 140)-an average of 15 outbreaks per Nipah season-occurred during 2007-14; 62 (52%) were detected. CONCLUSIONS: Our findings suggest hospital-based surveillance missed nearly half of all Nipah outbreaks. This analytical method allowed us to estimate the underlying burden of disease, which is important for emerging diseases where healthcare access may be limited.

  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. Poor accordance to a DASH dietary pattern is associated with higher risk of ESRD among adults with moderate chronic kidney disease and hypertensionexternal icon
        Banerjee T, Crews DC, Tuot DS, Pavkov ME, Burrows NR, Stack AG, Saran R, Bragg-Gresham J, Powe NR.
        Kidney Int. 2019 Mar 4.
        The Dietary Approaches to Stop Hypertension (DASH) diet lowers blood pressure, an important risk factor for chronic kidney disease (CKD) and end-stage renal disease (ESRD). However, it is unclear whether adherence to a DASH diet confers protection against future ESRD, especially among those with pre-existing CKD and hypertension. We examined whether a DASH diet is associated with lower risk of ESRD among 1,110 adults aged >/= 20 years with hypertension and CKD (estimated glomerular filtration rate, eGFR 30-59 ml/min/1.73 m(2)) enrolled in the National Health and Nutrition Examination Survey (1988-1994). Baseline DASH diet accordance score was assessed using a 24-hour dietary recall questionnaire. ESRD was ascertained by linkage to the U.S. Renal Data System registry. We used the Fine-Gray competing risks method to estimate the relative hazard (RH) for ESRD after adjusting for sociodemographics, clinical and nutritional factors, eGFR, and albuminuria. Over a median follow-up of 7.8 years, 18.4% of subjects developed ESRD. Compared to the highest quintile of DASH diet accordance, there was a greater risk of ESRD among subjects in quintiles 1 (RH=1.7; 95% CI 1.1-2.7) and 2 (RH 2.2; 95% CI 1.1-4.1). Significant interactions were observed with diabetes status and race/ethnicity, with the strongest association between DASH diet adherence and ESRD risk observed in individuals with diabetes and in non-Hispanic blacks. Low accordance to a DASH diet is associated with greater risk of ESRD in adults with moderate CKD and hypertension, particularly in non-Hispanic blacks and persons with diabetes.

      2. Cervical adenocarcinoma in situ: Human papillomavirus types and incidence trends in five states, 2008-2015external icon
        Cleveland AA, Gargano JW, Park IU, Griffin MR, Niccolai LM, Powell M, Bennett NM, Saadeh K, Pemmaraju M, Higgins K, Ehlers S, Scahill M, Johnson Jones ML, Querec T, Markowitz LE, Unger ER.
        Int J Cancer. 2019 Apr 13.
        Primary prevention through the use of human papillomavirus (HPV) vaccination is expected to impact both cervical intraepithelial neoplasia (CIN) and adenocarcinoma in situ (AIS). While CIN is well described, less is known about the epidemiology of AIS, a rare cervical precancer. We identified AIS and CIN grade 3 (CIN3) cases through population-based surveillance, and analyzed data on HPV types and incidence trends overall, and among women screened for cervical cancer. From 2008-2015, 470 AIS and 6,587 CIN3 cases were identified. The median age of women with AIS was older than those with CIN3 (35 vs 31 years; p<0.01). HPV16 was the most frequently detected type in both AIS and CIN3 (57% in AIS; 58% in CIN3), whereas HPV18 was the second most common type in AIS and less common in CIN3 (38% vs. 5%; p<0.01). AIS lesions were more likely than CIN3 lesions to be positive for high-risk types targeted by the bivalent and quadrivalent vaccines (HPV16/18, 92% vs. 63%; p<0.01), and nonavalent vaccine (HPV16/18/31/33/45/52/58, 95% vs. 87%; p<0.01). AIS incidence rates decreased significantly in the 21-24 year age group (annual percent change [APC] overall: -22.1%, 95% CI: -33.9 to -8.2; APC among screened: -16.1%, 95% CI: -28.8 to -1.2), but did not decrease significantly in any older age group. This report on the largest number of genotyped AIS cases to date suggests an important opportunity for vaccine prevention of AIS, and is the first to document a decline in AIS incidence rates among young women during the vaccine era. This article is protected by copyright. All rights reserved.

      3. Trends in high-grade cervical lesions and cervical cancer screening in 5 states, 2008-2015external icon
        Gargano JW, Park IU, Griffin MR, Niccolai LM, Powell M, Bennett NM, Johnson Jones ML, Whitney E, Pemmaraju M, Brackney M, Abdullah N, Scahill M, Dahl RM, Cleveland AA, Unger ER, Markowitz LE.
        Clin Infect Dis. 2019 Apr 8;68(8):1282-1291.
        BACKGROUND: We describe changes in rates of cervical intraepithelial neoplasia grades 2, 3 and adenocarcinoma in situ (CIN2+) during a period of human papillomavirus (HPV) vaccine uptake and changing cervical cancer screening recommendations. METHODS: We conducted population-based laboratory surveillance for CIN2+ in catchment areas in 5 states, 2008-2015. We calculated age-specific CIN2+ rates per 100000 women by age groups. We estimated incidence rate ratios (IRR) of CIN2+ for 2-year periods among all women and among screened women to evaluate changes over time. RESULTS: A total of 16572 CIN2+ cases were reported. Among women aged 18-20 and 21-24 years, CIN2+ rates declined in all sites, whereas in women aged 25-29, 30-34, and 35-39 years, trends differed across sites. The percent of women screened annually declined in all sites and age groups. Compared to 2008-2009, rates among screened women were significantly lower for all 3 periods in women aged 18-20 years (2010-2011: IRR 0.82, 95% confidence interval [CI] 0.67-0.99; 2012-2013: IRR 0.63, 95% CI 0.47-0.85; 2014-2015: IRR 0.44, 95% CI 0.28-0.68) and lower for the latter 2 time periods in women aged 21-24 years (2012-2013: IRR 0.86, 95% CI 0.79-0.94; 2014-2015: IRR 0.61, 95% CI 0.55-0.67). CONCLUSIONS: From 2008-2015, both CIN2+ rates and cervical cancer screening declined in women aged 18-24 years. The significant decreases in CIN2+ rates among screened women aged 18-24 years are consistent with a population-level impact of HPV vaccination.

      4. Perceived risk of colorectal and breast cancers among women who are overweight or with obesityexternal icon
        Hall IJ, Soman A, Smith JL, White A, Crawford A.
        Prev Med Rep. 2019 June;14 (100845).
        Many overweight women or women with obesity do not acknowledge their high weight status and may be unaware of their elevated cancer risk. We explored the relationship between weight status and women’s perceived risk of colorectal (CRC) and breast cancers, overall and by race/ethnicity, in a nationally representative sample. Data was combined from NHIS 2005, 2010, and 2015 sample adult questionnaires and cancer control supplements. The analytic sample included females aged 18 years and over without reported history of cancer diagnosis. Multivariable logistic regression was performed and adjusted estimates for perceived risk of CRC and breast cancers were examined, stratified by body mass index and race/ethnicity. Data were reported using predicted marginal risk ratio (PMR). Colorectal cancer risk perception remained lowest among Non-Hispanic (NH) Black women regardless of weight status (PMR = 0.53 obesity, 0.65 overweight, 0.55 normal) compared to NH White women after adjustment for all covariates. Hispanic women who were overweight or had obesity also saw themselves at lower risk of CRC compared to NH White women, however these findings were statistically insignificant. Breast cancer risk perception also remained low for NH Blacks and Hispanics at any weight compared with NH Whites. Greater effort is needed to develop, disseminate, and widely adopt or institutionalize multilevel weight management interventions and programs. These programs increase awareness of excess weight as a risk factor for cancer and empower women in diverse communities to achieve and maintain a healthy weight by adopting healthy behaviors related to nutrition and physical activity.

      5. Public health approach to improve outcomes for congenital heart disease across the life spanexternal icon
        Jenkins KJ, Botto LD, Correa A, Foster E, Kupiec JK, Marino BS, Oster ME, Stout KK, Honein MA.
        J Am Heart Assoc. 2019 Apr 16;8(8):e009450.

        [No abstract]

    • Communicable Diseases
      1. Patterns of seasonal influenza activity in U.S. core-based statistical areas, described using prescriptions of oseltamivir in Medicare claims dataexternal icon
        Dahlgren FS, Shay DK, Izurieta HS, Forshee RA, Wernecke M, Chillarige Y, Lu Y, Kelman JA, Reed C.
        Epidemics. 2019 Mar;26:23-31.
        Using Medicare claims data on prescriptions of oseltamivir dispensed to people 65 years old and older, we present a descriptive analysis of patterns of influenza activity in the United States for 579 core-based statistical areas (CBSAs) from the 2010-2011 through the 2015-2016 influenza seasons. During this time, 1,010,819 beneficiaries received a prescription of oseltamivir, ranging from 45,888 in 2011-2012 to 380,745 in 2014-2015. For each season, the peak weekly number of prescriptions correlated with the total number of prescriptions (Pearson’s r >/= 0.88). The variance in peak timing decreased with increasing severity (p < 0.0001). Among these 579 CBSAs, neither peak timing, nor relative timing, nor severity of influenza seasons showed evidence of spatial autocorrelation (0.02 </= Moran’s I </= 0.23). After aggregating data to the state level, agreement between the seasonal severity at the CBSA level and the state level was fair (median Cohen’s weighted kappa = 0.32, interquartile range = 0.26-0.39). Based on seasonal severity, relative timing, and geographic place, we used hierarchical agglomerative clustering to join CBSAs into influenza zones for each season. Seasonal maps of influenza zones showed no obvious patterns that might assist in predicting influenza zones for future seasons. Because of the large number of prescriptions, these data may be especially useful for characterizing influenza activity and geographic distribution during low severity seasons, when other data sources measuring influenza activity are likely to be sparse.

      2. The objective of this qualitative study was to explore the perspectives of school and preparedness officials on the feasibility of implementing a range of social distancing practices to reduce influenza transmission during a pandemic. In the summer of 2017, we conducted 36 focus groups by teleconference and webinar lasting 90 min with school and preparedness stakeholders from across the United States. We identified and characterized 11 themes arising from the focus group protocol’s domains as well as unanticipated emergent themes. These themes were: the need for effective stakeholder communication, the importance of partnering for buy-in, the role of social distancing in heightening anxiety, ensuring student safety, how practices work in combination, challenges with enforcement, lack of funding for school nurses, differing views about schools’ role in protecting public health, the need for education and community engagement to ensure consistent implementation, the need for collaborative decision-making, and tension between standardizing public health guidance and adapting to local contexts. Addressing several crosscutting considerations can increase the likelihood that social distancing practices will be feasible and acceptable to school stakeholders.

      3. Implementing web-based interventions in HIV primary care clinics: Pilot implementation evaluation of Positive Health Checkexternal icon
        Harshbarger C, Burrus O, Zulkiewicz BA, Ortiz AM, Galindo CA, Garner BR, Furberg RD, Lewis MA.
        JMIR Form Res. 2019 Apr 18;3(2):e10688.
        BACKGROUND: Web-based interventions can help people living with HIV achieve better clinical outcomes and behaviors, but integrating them into clinical practice remains challenging. There is a gap in understanding the feasibility of implementing these interventions in HIV clinic settings from the clinicians’ perspective. OBJECTIVE: The goal of the research was to determine whether Positive Health Check (PHC)-a Web-based, tailored video counseling tool focused on increasing patient adherence and retention in care and reducing HIV risk among HIV-positive patients-was acceptable, appropriate, and feasible for HIV primary care clinic staff to implement in clinic workflows. METHODS: A multiple-case study design was used to evaluate the pilot implementation. Four primary care clinics located in the southeastern United States implemented PHC over a 1-month period. Nine clinic staff across the clinics participated in structured interviews before, during, and after the implementation. In total, 54 interviews were conducted. We used a framework analysis approach to code the data and identify themes related to implementation outcomes, including acceptability, appropriateness, and feasibility. We also analyzed patient intervention use metrics (n=104) to quantify patient intervention completion rates (n=68). RESULTS: Overall, clinicians viewed PHC as acceptable and appropriate. Themes that emerged related to these implementation outcomes include the ability for PHC to increase provider-patient communication and its ability to engage patients due to the tailored and interactive design. While generally feasible to implement, challenges to the clinic workflow and physical environment were areas that clinics needed to manage to make PHC work in their clinics. CONCLUSIONS: Findings from this pilot implementation suggest that clinical staff viewed PHC as acceptable and appropriate, especially as more patients used the intervention over the pilot period. Feasibility of implementation was challenging in some cases, and lessons learned from this pilot implementation can provide information for larger scale tests of the intervention that include assessment of both implementation outcomes and clinical outcomes.

      4. Evaluation of the impact of antimicrobial hand towels on hand contamination with Escherichia coli among mothers in Kisumu County, Kenya, 2011-2012external icon
        Kim S, Brown AC, Murphy J, Oremo J, Owuor M, Ouda R, Person B, Quick R.
        Water Res. 2019 Mar 29;157:564-571.
        Poor hand hygiene contributes to diarrhea in developing countries. Handwashing with soap reduces diarrhea risk, but drying hands on contaminated towels can compromise the benefits of handwashing. In response to the challenge of keeping hands clean, an antimicrobial hand towel was developed and shown to be promising in the laboratory, but has not been adequately tested in the field. We evaluated the effectiveness of an antimicrobial towel in two randomized, double-blinded crossover trials among mothers with children<5 years old in 125 households in western Kenya. In trial 1, we randomly assigned mothers to use either the treated towel or an identical untreated (placebo) towel and made surprise home visits at random times once a week for three weeks. At each visit, we tested hands for Escherichia coli using sterile hand rinses, then switched towel types in the two groups and repeated three weekly rounds of E. coli testing. In crossover trial 2, we compared E. coli contamination of maternal hands immediately following three different handwashing/drying procedures: soap and water + treated towel, water only + treated towel, and soap and water + air dry. There was no statistically significant difference in the level of E. coli contamination on maternal hands by type of towel used during trial 1 (odds ratio for treated vs untreated towel: 1.14, 95% confidence interval 0.83-1.56). In trial 2, there were no significant differences in E. coli contamination of maternal hands by handwashing/drying procedure. In these trials, use of antimicrobial hand towels did not prevent E. coli contamination of mothers’ hands in Kenyan households during random testing and offered no advantages over standard handwashing and drying practices. Handwashing with soap and clean water and drying with clean towels are recommended.

      5. Epidemiology of norovirus outbreaks reported to the Public Health Emergency Event Surveillance System, China, 2014(-)2017external icon
        Lian Y, Wu S, Luo L, Lv B, Liao Q, Li Z, Rainey JJ, Hall AJ, Ran L.
        Viruses. 2019 Apr 11;11(4).
        We conducted a retrospective analysis of norovirus outbreaks reported to the National Public Health Emergency Event Surveillance System (PHEESS) in China from January 1, 2014 to December 31, 2017. We reviewed all acute gastroenteritis outbreaks (n = 692) submitted to PHEESS to identify the frequency, seasonality, geographic distribution, setting, and transmission mode of outbreaks due to norovirus. A total of 616 norovirus outbreaks resulting in 30,848 cases were reported. Among these outbreaks, 571 (93%) occurred in school settings including 239 (39%) in primary schools, 136 (22%) in childcare facilities, and 121 (20%) in secondary schools. The majority of outbreaks (63%) were due to person-to-person transmission, followed by multiple modes of transmission (11%), foodborne (5%) and waterborne (3%) transmission. These findings highlight the importance of improving hand hygiene and environmental disinfection in high-risk settings. Developing a standard and quantitative outbreak reporting structure could improve the usefulness of PHEESS for monitoring norovirus outbreaks.

      6. Notes from the field: Six cases of acute flaccid myelitis in children – Minnesota, 2018external icon
        Moline H, Kalaskar A, Pomputius WF, Lopez A, Routh J, Kenyon C, Griffith J.
        MMWR Morb Mortal Wkly Rep. 2019 Apr 19;68(15):356-358.

        [No abstract]

      7. BACKGROUND: Interventions to prevent HIV in women include screening, partner notification, promoting condoms, and pre-exposure prophylaxis (PrEP). Identifying a woman’s risk of acquiring HIV can help guide intervention recommendations. METHODS: We used data from Louisiana’s STI and HIV registries to study 13- to 59-year-old women following their first diagnosis of syphilis, (or if none) gonorrhea, or (if none) chlamydia during 2000-2015. We measured rates of HIV reported subsequent to their STI (through 2016). Rates for women without STI were estimated by subtracting women with STI from reported cases and from Census estimates for the population. PrEP cost was estimated as $11,000 per year, and effectiveness was estimated as 100%. RESULTS: First STI were: syphilis (6,574), gonorrhea (64,995), or chlamydia (140,034). These 211,603 women had 1,865,488 person-years of follow-up and 969 HIV diagnoses. Women with no STI had 5,186 HIV diagnoses over 24,359,397 person-years. Rates of HIV diagnosis (per 100,000 person-years) were higher for women after syphilis (177.3), gonorrhea (73.2), or chlamydia (35.4) compared to women with no STI (22.4). Providing PrEP to all women diagnosed with syphilis or gonorrhea would cost $7,371,111,000 and could have prevented 546 HIV diagnoses. Limiting PrEP to one year after syphilis or gonorrhea diagnosis would cost $963,847,334 but only 143 HIV diagnoses were within 2 years after a syphilis or gonorrhea diagnosis. CONCLUSIONS: Rates of HIV diagnosis were high after women had STI, but not high enough to make PrEP cost-effective for them. Most women diagnosed with HIV did not have previously reported STI.

      8. Estimation of the population size of men who have sex with men in Vietnam: Social app multiplier methodexternal icon
        Son VH, Safarnejad A, Nga NT, Linh VM, Tu LT, Manh PD, Long NH, Abdul-Quader A.
        JMIR Public Health Surveill. 2019 Apr 17;5(2):e12451.
        BACKGROUND: Although the prevalence of HIV among men who have sex with men (MSM) in Vietnam has been increasing in recent years, there are no estimates of the population size of MSM based on tested empirical methods. OBJECTIVE: This study aimed to estimate the size of the MSM population in 12 provinces in Vietnam and extrapolate from those areas to generate a national population estimate of MSM. A secondary aim of this study was to compare the feasibility of obtaining the number of users of a mobile social (chat and dating) app for MSM using 3 different approaches. METHODS: This study used the social app multiplier method to estimate the size of MSM populations in 12 provinces using the count of users on a social app popular with MSM in Vietnam as the first data source and a questionnaire propagated through the MSM community using respondent-driven sampling as the second data source. A national estimation of the MSM population is extrapolated from the results in the study provinces, and the percentage of MSM reachable through online social networks is clarified. RESULTS: The highest MSM population size among the 12 provinces is estimated in Hanoi and the lowest is estimated in Binh Dinh. On average, 37% of MSM in the provinces surveyed had used the social app Jack’d in the last 30 days (95% CI 27-48). Extrapolation of the results from the study provinces with reliable estimations results in an estimated national population of 178,000 MSM (95% CI 122,000-512,000) aged 15 to 49 years in Vietnam. The percentage of MSM among adult males aged 15 to 49 years in Vietnam is 0.68% (95% CI 0.46-1.95). CONCLUSIONS: This study is the first attempt to empirically estimate the population of MSM in Vietnam and highlights the feasibility of reaching a large proportion of MSM through a social app. The estimation reported in this study is within the bounds suggested by the Joint United Nations Programme on HIV/AIDS. This study provides valuable information on MSM population sizes in provinces where reliable estimates were obtained, which they can begin to work with in program planning and resource allocation.

    • Disease Reservoirs and Vectors
      1. BACKGROUND: Mosquito-borne diseases affect millions worldwide, with malaria alone killing over 400 thousand people per year and affecting hundreds of millions. To date, the best strategy to prevent the disease remains insecticide-based mosquito control. However, insecticide resistance as well as economic and social factors reduce the effectiveness of the current methodologies. Alternative control technologies are in development, including genetic control such as the sterile insect technique (SIT). The SIT is a pivotal tool in integrated agricultural pest management and could be used to improve malaria vector control. To apply the SIT and most other newer technologies against disease transmitting mosquitoes, it is essential that releases are composed of males with minimal female contamination. The removal of females is an essential requirement because released females can themselves contribute towards nuisance biting and disease transmission. Thus, females need to be eliminated from the cohorts prior to release. Manual separation of Anopheles gambiae pupae or adult mosquitoes based on morphology is time consuming, is not feasible on a large scale and has limited the implementation of the SIT technique. The doublesex (dsx) gene is one of the effector switches of sex determination in the process of sex differentiation in insects. Both males and females have specific splicing variants that are expressed across the different life stages. Using RNA interference (RNAi) to reduce expression of the female specific (dsxF) variant of this gene has proven to have detrimental effects to the females in other mosquito species, such as Aedes aegypti. We tested oral RNAi on dsx (AgdsxF) in An. gambiae. METHODS: We studied the expression pattern of the dsx gene in the An. gambiae G3 strain. We knocked down AgdsxF expression in larvae through oral delivery of double stranded RNA (dsRNA) produced by bacteria and observed its effects in adults. RESULTS: Our results show that feeding of AgdsxF dsRNA can effectively reduce (> 66%) the mRNA of female dsx transcript and that there is a concomitant reduction in the number of female larvae that achieve adulthood. Control groups produced 52% (+/- 3.9% SE) of adult males and 48% (+/- 4.0% SE) females, while AgdsxF dsRNA treated groups had 72.1% (+/- 4.0% SE) males vs 27.8% females (+/- 3.3% SE). In addition, the female adults produce fewer progeny, 37.1% (+/- 8.2% SE) less than the controls. The knockdown was sex-specific and had no impact on total numbers of viable male adults, in the male dsx transcripts or male fitness parameters such as longevity or body size. CONCLUSIONS: These findings indicate that RNAi could be used to improve novel mosquito control strategies that require efficient sex separation and male-only release of An. gambiae by targeting sex determination genes such as AgdsxF. The advantages of using RNAi in a controlled setting for mosquito rearing are numerous, as the dose and time of exposure are controlled, and the possibility of off-target effects and the waste of female production would be significantly reduced.

    • Environmental Health
      1. Environmental health indicators for China: Data resources for Chinese environmental public health trackingexternal icon
        Ban J, Du Z, Wang Q, Ma R, Zhou Y, Li T.
        Environ Health Perspect. 2019 Apr;127(4):44501.
        Many developed countries use environmental public health tracking to gain a better understanding of the link between environmental hazards and public health. To respond to complicated environmental health issues, the National Institute of Environmental Health (NIEH), Chinese Center for Disease Control and Prevention (China CDC), has begun to build a Chinese Environmental Public Health Tracking (CEPHT) system. On behalf of the CEPHT, authors provide insight into the CEPHT’s development, current status, and future plans. In the initial stage of CEPHT, an indicator framework linking environment and public health that included a list of publicly available data sources regarding environmental hazards, public health outcomes, and risk factors in China was developed. An analysis of data availability, along with a comparison between CEPHT’s indicator system and other tracking networks, revealed the existence of barriers and gaps in data integration that affect China’s ability to track environmental public health. The lack of access to data, combined with inadequate data quality, has led to difficulties linking environmental hazards to their effects on public health. Current CEPHT efforts will help integrate environmental factors and exposure data with public health outcomes. For the near future, CEPHT plans to focus on increasing collaboration among data tracking agencies, improving data quality, and expanding proper data sharing.

      2. Environmental health specialists often perform environmental assessments (EAs) when a suspected or confirmed foodborne illness outbreak is linked to a food establishment. Information from EAs helps officials determine the cause of the outbreak and develop strategies to prevent future outbreaks; however, EAs are not always conducted. To determine facilitators and barriers to conducting EAs, we analyzed openended responses reported to the National Environmental Assessment Reporting System about these assessments. We found that EAs were conducted most often when illness was identified, a jurisdiction had a policy to investigate illnesses, and there were resources for such a response. EAs were not conducted in instances such as limited resources, insufficient training, uncooperative facility personnel, or if the establishment fell outside of health department jurisdiction. Identifying the facilitators and barriers to conducting EAs can enable health departments to develop strategies that improve their ability to conduct EAs.

      3. [No abstract]

      4. Exploring the science, safety, and benefits of air care products: perspectives from the inaugural air care summitexternal icon
        Johnson MB, Kingston R, Utell MJ, Wells JR, Singal M, Troy WR, Horenziak S, Dalton P, Ahmed FK, Herz RS, Osimitz TG, Prawer S, Yin S.
        Inhal Toxicol. 2019 Apr 18:1-13.
        Seventy-one percent of US households purchase air care products. Air care products span a diverse range of forms, including scented aerosol sprays, pump sprays, diffusers, gels, candles, and plug-ins. These products are used to eliminate indoor malodors and to provide pleasant scent experiences. The use of air care products can lead to significant benefits as studies have shown that indoor malodor can cause adverse effects, negatively impacting quality of life, hygiene, and the monetary value of homes and cars, while disproportionately affecting lower income populations. Additionally, studies have also shown that scent can have positive benefits related to mood, stress reduction, and memory enhancement among others. Despite the positive benefits associated with air care products, negative consumer perceptions regarding the safety of air care products can be a barrier to their use. During the inaugural Air Care Summit, held on 18 May 2018 in the Washington, DC, metropolitan area, multidisciplinary experts including industry stakeholders, academics, and scientific and medical experts were invited to share and assess the existing data related to air care products, focusing on ingredient and product safety and the benefits of malodor removal and scent. At the Summit’s completion, a panel of independent experts representing the fields of pulmonary medicine, medical and clinical toxicology, pediatric toxicology, basic science toxicology, occupational dermatology and experimental psychology convened to review the data presented, identify potential knowledge gaps, and suggest future research directions to further assess the safety and benefits of air care products.

      5. Maternal serum concentrations of perfluoroalkyl substances and birth size in British boysexternal icon
        Marks KJ, Cutler AJ, Jeddy Z, Northstone K, Kato K, Hartman TJ.
        Int J Hyg Environ Health. 2019 Apr 8.
        Per- and polyfluoroalkyl substances (PFAS) have been widely used in commercial and industrial manufacturing processes since the 1950s. Inverse associations between prenatal exposure to PFAS and birth size have been found in populations around the globe. This study examined the association of prenatal maternal serum concentrations of perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), perfluorohexane sulfonic acid (PFHxS), and perfluorononanoic acid (PFNA) and birth size in British boys. The study included 457 mother-son dyads participating in the Avon Longitudinal Study of Parents and Children (ALSPAC). Birth weight (g), crown to heel length (cm), and head circumference (cm) were collected at delivery. PFAS were detected in all maternal serum samples during pregnancy (median: 30 weeks gestation (interquartile range: 12-33)). Median concentrations (interquartile range) were 13.8ng/mL (11.0, 17.7), 3.0ng/mL (2.3, 3.8), 1.9ng/mL (1.4, 2.5), and 0.4ng/mL (0.3, 0.5) for PFOS, PFOA, PFHxS, and PFNA, respectively. In multivariable linear regression models, inverse associations were detected between PFOS (continuous) and birth weight (beta=-8.50g, 95% CI=-15.93, -1.07g), crown to heel length (beta=-0.04cm, 95% CI=-0.08, -0.01cm), and head circumference (beta=-0.02cm, 95% CI=-0.04, -0.002cm). In conclusion, prenatal exposure to high levels of PFOS may be associated with reduced birth size in male infants.

      6. Blood lead levels among resettled refugee children in select US states, 2010-2014external icon
        Pezzi C, Lee D, Kennedy L, Aguirre J, Titus M, Ford R, Cochran J, Smock L, Mamo B, Urban K, Morillo J, Hughes S, Payton C, Scott K, Montour J, Matheson J, Brown MJ, Mitchell T.
        Pediatrics. 2019 Apr 17.
        BACKGROUND: Elevated blood lead levels (EBLLs; >/=5 microg/dL) are more prevalent among refugee children resettled in the United States than the general US population and contribute to permanent health and neurodevelopmental problems. The Centers for Disease Control and Prevention recommends screening of refugee children aged 6 months to 16 years on arrival in the United States and retesting those aged 6 months to 6 years between 3- and 6-months postarrival. METHODS: We analyzed EBLL prevalence among refugee children aged 6 months to 16 years who received a domestic refugee medical examination between January 1, 2010 and September 30, 2014. We assessed EBLL prevalence by predeparture examination country and, among children rescreened 3 to 6 months after initial testing, we assessed EBLL changes during follow-up screening. RESULTS: Twelve sites provided data on 27 284 children representing nearly 25% of refugee children resettling during the time period of this analysis. The EBLL prevalence during initial testing was 19.3%. EBLL was associated with younger age, male sex, and overseas examination country. Among 1121 children from 5 sites with available follow-up test results, EBLL prevalence was 22.7%; higher follow-up BLLs were associated with younger age and predeparture examination country. CONCLUSIONS: EBLL decreased over the time period of our analysis in this population of refugee children. Refugee children may be exposed to lead before and after resettlement to the United States. Efforts to identify incoming refugee populations at high risk for EBLL can inform prevention efforts both domestically and overseas.

      7. Prevalence of blood lead among children living in battery recycling communities in greater Jakarta, Indonesiaexternal icon
        Prihartono NA, Djuwita R, Mahmud PB, Haryanto B, Helda H, Wahyono TY, Dignam T.
        Int J Environ Res Public Health. 2019 Apr 10;16(7).
        This study aimed to assess the prevalence of blood lead levels (BLLs) among children 1 to 5 years old who reside near and distant to informally used lead-acid battery (ULAB) recycling locations and examine risk factors for elevated BLLs. A cross-sectional study was conducted in three greater Jakarta neighborhoods where informal ULAB recycling occurs. Venous BLLs among 279 children were analyzed using portable blood lead testing machines. Demographic, child activities, and sources of lead exposure inside and outside homes were assessed. Multivariate analysis was performed to evaluate factors associated with the prevalence of BLLs. Forty-seven percent of children had BLLs >/= 5 microg/dL and 9% had BLLs >/= 10 microg/dL. No differences in geometric mean BLLs were observed between children who lived near and distant to ULAB locations. Older child age groups [Prevalence Ratio (PR) 2.14, 95% Confidence Interval (CI) 1.16, 4.18) and low household income (PR 1.58, 95% CI 1.03, 2.40) were associated with BLLs 5-9 microg/dL. Low educational attainment of the child’s father (PR 3.17, 95% CI 1.23, 8.16) and frequent outdoor child activity (PR 4.93, 95% CI 1.09, 22.21) were predictors of BLLs >/= 10 microg/dL. This study shows the association between lead exposure among children and environmental sources. Public health officials can consider expanded surveillance, health care provider education, and development of strategies to reduce lead exposure.

    • Food Safety
      1. The use of next generation sequencing for improving food safety: Translation into practiceexternal icon
        Jagadeesan B, Gerner-Smidt P, Allard MW, Leuillet S, Winkler A, Xiao Y, Chaffron S, Van Der Vossen J, Tang S, Katase M, McClure P, Kimura B, Ching Chai L, Chapman J, Grant K.
        Food Microbiol. 2019 Jun;79:96-115.
        Next Generation Sequencing (NGS) combined with powerful bioinformatic approaches are revolutionising food microbiology. Whole genome sequencing (WGS) of single isolates allows the most detailed comparison possible hitherto of individual strains. The two principle approaches for strain discrimination, single nucleotide polymorphism (SNP) analysis and genomic multi-locus sequence typing (MLST) are showing concordant results for phylogenetic clustering and are complementary to each other. Metabarcoding and metagenomics, applied to total DNA isolated from either food materials or the production environment, allows the identification of complete microbial populations. Metagenomics identifies the entire gene content and when coupled to transcriptomics or proteomics, allows the identification of functional capacity and biochemical activity of microbial populations. The focus of this review is on the recent use and future potential of NGS in food microbiology and on current challenges. Guidance is provided for new users, such as public health departments and the food industry, on the implementation of NGS and how to critically interpret results and place them in a broader context. The review aims to promote the broader application of NGS technologies within the food industry as well as highlight knowledge gaps and novel applications of NGS with the aim of driving future research and increasing food safety outputs from its wider use.

    • Health Disparities
      1. Social determinants of health: Family physicians’ leadership roleexternal icon
        Sherin K, Adebanjo T, Jani A.
        Am Fam Physician. 2019 Apr 15;99(8):476-477.

        [No abstract]

      2. BACKGROUND: In 2016, black women with HIV infection attributed to heterosexual contact accounted for 47% of all women living with diagnosed HIV, and 41% of deaths that occurred among women with diagnosed HIV in the USA that year. Social determinants of health have been found to be associated with mortality risk among people with HIV. We analyzed the role social determinants of health may have on risk of mortality among black women with HIV attributed to heterosexual contact. METHODS: Data from the Center for Disease Control and Prevention’s National HIV Surveillance System were merged at the county level with three social determinants of health (SDH) variables from the U.S. Census Bureau’s American Community Survey for black women aged >/= 18 years with HIV infection attributed to heterosexual contact that had been diagnosed by 2011. SDH variables were categorized into four empirically derived quartiles, with the highest quartile in each category serving as the reference variable. For black women whose deaths occurred during 2012-2016, mortality rate ratios (MRR) were calculated using age-stratified multivariate logistic regressions to evaluate associations between SDH variables and all-cause mortality risk. RESULTS: Risk of mortality was lower for black women aged 18-34 years and 35-54 years who lived in counties with the lowest quartile of poverty (adjusted mortality rate ratio aMRR = 0.56, 95% confidence interval CI [0.39-0.83], and aMRR = 0.67, 95% CI [0.58-0.78], respectively) compared to those who lived in counties with the highest quartile of poverty (reference group). Compared to black women who lived in counties with the highest quartile of health insurance coverage (reference group), the mortality risk was lower for black women aged 18-34 years and black women aged 35-54 who lived in counties with the lowest 2 quartiles of health insurance coverage. Unemployment status was not associated with mortality risk. CONCLUSIONS: This ecological analysis found poverty and lack of health insurance to be predictors of mortality, suggesting a need for increased prevention, care, and policy efforts targeting black women with HIV who live in environments characterized by increased poverty and lack of health insurance.

    • Healthcare Associated Infections
      1. Hospital epidemiologists’ and infection preventionists’ opinions regarding hospital-onset bacteremia and fungemia as a potential healthcare-associated infection metricexternal icon
        Dantes RB, Abbo LM, Anderson D, Hall L, Han JH, Harris AD, Leekha S, Milstone AM, Morgan DJ, Safdar N, Schweizer ML, Sengupta S, Seo SK, Rock C.
        Infect Control Hosp Epidemiol. 2019 Apr 1:1-5.
        OBJECTIVE: To ascertain opinions regarding etiology and preventability of hospital-onset bacteremia and fungemia (HOB) and perspectives on HOB as a potential outcome measure reflecting quality of infection prevention and hospital care. DESIGN: Cross-sectional survey. PARTICIPANTS: Hospital epidemiologists and infection preventionist members of the Society for Healthcare Epidemiology of America (SHEA) Research Network. METHODS: A web-based, multiple-choice survey was administered via the SHEA Research Network to 133 hospitals. RESULTS: A total of 89 surveys were completed (67% response rate). Overall, 60% of respondents defined HOB as a positive blood culture on or after hospital day 3. Central line-associated bloodstream infections and intra-abdominal infections were perceived as the most frequent etiologies. Moreover, 61% thought that most HOB events are preventable, and 54% viewed HOB as a measure reflecting a hospital’s quality of care. Also, 29% of respondents’ hospitals already collect HOB data for internal purposes. Given a choice to publicly report central-line-associated bloodstream infections (CLABSIs) and/or HOB, 57% favored reporting either HOB alone (22%) or in addition to CLABSI (35%) and 34% favored CLABSI alone. CONCLUSIONS: Among the majority of SHEA Research Network respondents, HOB is perceived as preventable, reflective of quality of care, and potentially acceptable as a publicly reported quality metric. Further studies on HOB are needed, including validation as a quality measure, assessment of risk adjustment, and formation of evidence-based bundles and toolkits to facilitate measurement and improvement of HOB rates.

    • Immunity and Immunization
      1. The MMR vaccine and autismexternal icon
        DeStefano F, Shimabukuro TT.
        Annu Rev Virol. 2019 Apr 15.
        Autism is a developmental disability that can cause significant social, communication, and behavioral challenges. A report published in 1998, but subsequently retracted by the journal, suggested that measles, mumps, and rubella (MMR) vaccine causes autism. However, autism is a neurodevelopmental condition that has a strong genetic component with genesis before one year of age, when MMR vaccine is typically administered. Several epidemiologic studies have not found an association between MMR vaccination and autism, including a study that found that MMR vaccine was not associated with an increased risk of autism even among high-risk children whose older siblings had autism. Despite strong evidence of its safety, some parents are still hesitant to accept MMR vaccination of their children. Decreasing acceptance of MMR vaccination has led to outbreaks or resurgence of measles. Health-care providers have a vital role in maintaining confidence in vaccination and preventing suffering, disability, and death from measles and other vaccine-preventable diseases. Expected final online publication date for the Annual Review of Virology Volume 6 is September 30, 2019. Please see for revised estimates.

      2. Evaluating vaccination policies to accelerate measles elimination in China: a meta-population modelling studyexternal icon
        Hao L, Glasser JW, Su Q, Ma C, Feng Z, Yin Z, Goodson JL, Wen N, Fan C, Yang H, Rodewald LE, Feng Z, Wang H.
        Int J Epidemiol. 2019 Apr 11.
        BACKGROUND: Measles is among the most highly infectious human diseases. By virtue of increasingly effective childhood vaccination, together with targeted supplemental immunization activities (SIAs), health authorities in the People’s Republic of China have reduced measles’ reproduction number from about 18 to 2.3. Despite substantial residual susceptibility among young adults, more in some locales than others, sustained routine childhood immunization likely would eliminate measles eventually. To support global eradication efforts, as well as expedite morbidity and mortality reductions in China, we evaluated alternative SIAs via mechanistic mathematical modelling. METHODS: Our model Chinese population is stratified by immune status (susceptible to measles infection; infected, but not yet infectious; infectious; and recovered or immunized), age (0, 1-4, 5-9, …, 65+ years) and location (31 provinces). Contacts between sub-populations are either empirical or a mixture of preferential and proportionate with respect to age and decline exponentially with distance between locations at age-dependent rates. We estimated initial conditions and most parameters from recent cross-sectional serological surveys, disease surveillance and demographic observations. Then we calculated the reproduction numbers and gradient of the effective number with respect to age- and location-specific immunization rates. We corroborated these analytical results by simulating adolescent and young adult SIAs using a version of our model in which the age-specific contact rates vary seasonally. RESULTS: Whereas the gradient indicates that vaccinating young adults generally is the optimal strategy, simulations indicate that a catch-up campaign among susceptible adolescent schoolchildren would accelerate elimination, with timing dependent on uptake. CONCLUSIONS: These results are largely due to indirect effects (i.e. fewer infections than immunized people might otherwise cause), which meta-population models with realistic mixing are uniquely capable of reproducing accurately.

      3. Trends in anogenital wart incidence among Tennessee Medicaid enrollees, 2006-2014: The impact of human papillomavirus vaccinationexternal icon
        Shing JZ, Hull PC, Zhu Y, Gargano JW, Markowitz LE, Cleveland AA, Pemmaraju M, Park IU, Whitney E, Mitchel EF, Griffin MR.
        Papillomavirus Res. 2019 Apr 10;7:141-149.
        INTRODUCTION: Evidence of human papillomavirus (HPV) vaccine impact on anogenital warts (AGWs) by race or urbanicity in the US is lacking. We evaluated HPV vaccine impact in Tennessee by assessing AGW trends among Tennessee Medicaid (TennCare) enrollees aged 15-39 years from 2006-2014. METHODS: Persons with incident AGWs were identified using diagnosis/pharmacy codes from TennCare billing claims. We calculated sex-specific annual AGW incidence by age group, race, and urbanicity; estimated annual percent changes (APCs) using log-linear models; and performed pairwise comparisons by race and urbanicity. RESULTS: AGW incidence decreased among females aged 15-19 (APC=-10.6; P<0.01) and 20-24 years (APC=-3.9; P=0.02). Overall trends were similar between Whites and Blacks, and between those living in metropolitan statistical areas (MSAs) and non-MSAs. Rates among males aged 15-19 years began decreasing after 2010. Among enrollees aged 25-39 years, rates increased or were stable. CONCLUSIONS: Following introduction of the HPV vaccine in 2006, AGWs decreased among age groups most likely to be vaccinated. The change in trend among young males after 2010 suggests early herd effects. Our findings indicate vaccine effects and support the importance of improving adherence to current vaccination recommendations for preventing AGWs and other HPV-related diseases.

    • Injury and Violence
      1. The need to improve information on road user type in National Vital Statistics System mortality dataexternal icon
        Mack KA, Hedegaard H, Ballesteros MF, Warner M, Eames J, Sauber-Schatz E.
        Traffic Inj Prev. 2019 Apr 15:1-6.
        OBJECTIVES: Both the National Vital Statistics System (NVSS) and the Fatality Analysis Reporting System (FARS) can be used to examine motor vehicle crash (MVC) deaths. These 2 data systems operate independently, using different methods to collect and code information about the type of vehicle (e.g., car, truck, bus) and road user (e.g., occupant, motorcyclist, pedestrian) involved in an MVC. A substantial proportion of MVC deaths in NVSS are coded as “unspecified” road user, which reduces the utility of the NVSS data for describing burden and identifying prevention measures. This study aimed to describe characteristics of unspecified road user deaths in NVSS to further our understanding of how these groups may be similar to occupant road user deaths. METHODS: Using data from 1999 to 2015, we compared NVSS and FARS MVC death counts by road user type, overall and by age group, gender, and year. In addition, we examined factors associated with the categorization of an MVC death as unspecified road user such as state of residence of decedent, type of medical death investigation system, and place of death. RESULTS: The number of MVC occupant deaths in NVSS was smaller than that in FARS in each year and the number of unspecified road user deaths in NVSS was greater than that in FARS. The sum of the number of occupant and unspecified road user deaths in NVSS, however, was approximately equal to the number of FARS occupant deaths. Age group and gender distributions were roughly equivalent for NVSS and FARS occupants and NVSS unspecified road users. Within NVSS, the number of MVC deaths listed as unspecified road user varied across states and over time. Other categories of road users (motorcyclists, pedal cyclists, and pedestrians) were consistent when comparing NVSS and FARS. CONCLUSIONS: Our findings suggest that the unspecified road user MVC deaths in NVSS look similar to those of MVC occupants according to selected characteristics. Additional study is needed to identify documentation and reporting challenges in individual states and over time and to identify opportunities for improvement in the coding of road user type in NVSS.

      2. Building capacity for injury prevention: a process evaluation of a replication of the Cardiff Violence Prevention Programme in the Southeastern USAexternal icon
        Mercer Kollar LM, Sumner SA, Bartholow B, Wu DT, Moore JC, Mays EW, Atkins EV, Fraser DA, Flood CE, Shepherd JP.
        Inj Prev. 2019 Apr 16.
        OBJECTIVES: Violence is a major public health problem in the USA. In 2016, more than 1.6 million assault-related injuries were treated in US emergency departments (EDs). Unfortunately, information about the magnitude and patterns of violent incidents is often incomplete and underreported to law enforcement (LE). In an effort to identify more complete information on violence for the development of prevention programme, a cross-sectoral Cardiff Violence Prevention Programme (Cardiff Model) partnership was established at a large, urban ED with a level I trauma designation and local metropolitan LE agency in the Atlanta, Georgia metropolitan area. The Cardiff Model is a promising violence prevention approach that promotes combining injury data from hospitals and LE. The objective was to describe the Cardiff Model implementation and collaboration between hospital and LE partners. METHODS: The Cardiff Model was replicated in the USA. A process evaluation was conducted by reviewing project materials, nurse surveys and interviews and ED-LE records. RESULTS: Cardiff Model replication centred around four activities: (1) collaboration between the hospital and LE to form a community safety partnership locally called the US Injury Prevention Partnership; (2) building hospital capacity for data collection; (3) data aggregation and analysis and (4) developing and implementing violence prevention interventions based on the data. CONCLUSIONS: The Cardiff Model can be implemented in the USA for sustainable violent injury data surveillance and sharing. Key components include building a strong ED-LE partnership, communicating with each other and hospital staff, engaging in capacity building and sustainability planning.

      3. Prevalence of violence victimization and perpetration among persons aged 13-24 years – four Sub-Saharan African countries, 2013-2015external icon
        Swedo EA, Sumner SA, Hillis SD, Aluzimbi G, Apondi R, Atuchukwu VO, Auld AF, Chipimo PJ, Conkling M, Egbe OE, Kalanda MS, Mapoma CC, Phiri E, Wasula LN, Massetti GM.
        MMWR Morb Mortal Wkly Rep. 2019 Apr 19;68(15):350-355.
        Violence is a major public health and human rights concern, claiming over 1.3 million lives globally each year (1). Despite the scope of this problem, population-based data on physical and sexual violence perpetration are scarce, particularly in low-income and middle-income countries (2,3). To better understand factors driving both children becoming victims of physical or sexual violence and subsequently (as adults) becoming perpetrators, CDC collaborated with four countries in sub-Saharan Africa (Malawi, Nigeria, Uganda, and Zambia) to conduct national household surveys of persons aged 13-24 years to measure experiences of violence victimization in childhood and subsequent perpetration of physical or sexual violence. Perpetration of physical or sexual violence was prevalent among both males and females, ranging among males from 29.5% in Nigeria to 51.5% in Malawi and among females from 15.3% in Zambia to 28.4% in Uganda. Experiencing physical, sexual, or emotional violence in childhood was the strongest predictor for perpetrating violence; a graded dose-response relationship emerged between the number of types of childhood violence experienced (i.e., physical, sexual, and emotional) and perpetration of violence. Efforts to prevent violence victimization need to begin early, requiring investment in the prevention of childhood violence and interventions to mitigate the negative effects of violence experienced by children.

    • Laboratory Sciences
      1. Performance and workflow assessment of six nucleic acid extraction technologies for use in resource limited settingsexternal icon
        Beall SG, Cantera J, Diaz MH, Winchell JM, Lillis L, White H, Kalnoky M, Gallarda J, Boyle DS.
        PLoS One. 2019 ;14(4):e0215753.
        Infectious disease nucleic acid amplification technologies (NAAT) have superior sensitivity, specificity, and rapid time to result compared to traditional microbiological methods. Recovery of concentrated, high quality pathogen nucleic acid (NA) from complex specimen matrices is required for optimal performance of several NA amplification/detection technologies such as polymerase chain reaction (PCR). Fully integrated NAAT platforms that enable rapid sample-to-result workflows with minimal user input are generally restricted to larger reference lab settings, and their complexity and cost are prohibitive to widespread implementation in resource limited settings (RLS). Identification of component technologies for incorporation of reliable and affordable sample preparation with pathogen NA amplification/detection into an integrated platform suitable for RLS, is a necessary first step toward achieving the overarching goal of reducing infectious disease-associated morbidity and mortality globally. In the current study, we evaluate the performance of six novel NA extraction technologies from different developers using blinded panels of stool, sputum and blood spiked with variable amounts of quality-controlled DNA- and/or RNA-based microbes. The extraction efficiencies were semi-quantitatively assessed using validated real-time reverse transcription (RT)-PCR assays specific for each microbe and comparing target-specific RT-PCR results to those obtained with reference NA extraction methods. The technologies were ranked based on overall diagnostic accuracy (analytical sensitivity and specificity). Sample input and output volumes, total processing time, user-required manual steps and cost estimates were also examined for suitability in RLS. Together with the performance analysis, these metrics were used to select the more suitable candidate technologies for further optimization of integrated NA amplification and detection technologies for RLS.

      2. The analysis of degradation products from the classic chemical warfare nerve agents by high-performance liquid chromatography-mass spectrometry has been of much interest in recent years owing to the possible use as a terrorist weapon, and the incidents of chemical weapon usage in recent years in war torn countries. The alkyl methylphosphonic acid degradation products are of a particular interest, and they represent a specific chromatographic technical challenge for use in typical separation systems. Various published methods are summarized in this review and some of the problems associated with the analysis of these compounds are discussed. Future trends of the analysis in this area of research are also considered.

      3. Zika virus (ZIKV) infection during pregnancy can cause adverse fetal outcomes and severe irreversible congenital birth defects including microcephaly. Immunohistochemistry (IHC) is a valuable diagnostic tool for detecting ZIKV antigens in tissues from cases of fetal loss in women infected with ZIKV, and for providing insights into disease pathogenesis. As a result, there is increasing demand for commercially available ZIKV antibodies for use in IHC assays. ZIKV antibodies were selected and obtained from commercial sources to include both mouse and rabbit hosts, and a variety of antigenic targets. Pretreatment conditions and antibody concentrations resulting in optimal immunohistochemical staining were determined using ZIKV cell control and polymerase chain reaction (PCR)-confirmed ZIKV case control material (fetal brain tissue). Cross-reactivity of the antibodies against other flaviviruses (dengue virus serogroups 1-4, yellow fever virus, Japanese encephalitis virus, West Nile virus) and chikungunya virus was also evaluated. Immunostaining using the commercially available antibodies was compared to a previously validated ZIKV IHC assay used for primary diagnosis. Four antibodies demonstrated optimal staining similar to the previously validated ZIKV IHC assay. Two of the four antibodies cross-reacted with dengue virus, while the other two antibodies showed no cross-reactivity with dengue, other flaviviruses, or chikungunya virus. Differences in the cross-reactivity profiles could not be entirely explained by the antigenic target. Commercially available ZIKV antibodies can be optimized for use in IHC testing to aid in ZIKV diagnostic testing and an evaluation of tissue tropism.

    • Maternal and Child Health
      1. We aimed to investigate associations between individual and concurrent (>/=2) intakes of one-carbon cofactors vitamins B6 and B12, choline, betaine, and methionine and neural tube defect (NTD) outcomes among mothers meeting the folic acid recommendations. In the Slone Birth Defects Study (case-control design; North America, 1998-2015), mothers of 164 NTD cases and 2,831 nonmalformed controls completed food frequency questionnaires and structured interviews. Estimated intakes of one-carbon cofactors were dichotomized (high vs. low) for all except betaine (low or middle vs. high). We used logistic regression models to estimate odds ratios and 95% confidence intervals adjusted for center, age, and race. The analysis was restricted to mothers with estimated daily total folate intake of >/=400 mug during periconception. Fewer cases, compared with controls, had high intakes for each one-carbon cofactor except betaine, where the starkest contrast occurred in the middle group. Women with concurrent high intakes of B6, B12, choline, and methionine and moderate intake of betaine had approximately half the risk of an NTD-affected pregnancy (odds ratio = 0.49, 95% confidence interval: 0.23, 1.08). These findings suggest that, in the presence of folic acid, one-carbon cofactors-notably when consumed together-might reduce NTD risk. Additional research should inform any changes to clinical recommendations.

    • Occupational Safety and Health
      1. ‘Internet of ears’ and hearables for hearing loss preventionexternal icon
        Themann CL, Kardous CA, Beamer BR, Morata TC.
        Hear J. 2019 ;72(4):32-34.

        [No abstract]

    • Occupational Safety and Health – Mining
      1. Typcial monitoring procedures for diesel particulate matter (DPM) in mines include the collection of filter samples using particle size selectors. The size selectors are meant to separate the DPM, which is generally considered to occur in the submicron range (i.e., < 0.8 ?m), from larger dust particles that could present analytical interferences. However, previous studies have demonstrated that this approach can sometimes result in undersampling, therefore, excluding significant fractions of the DPM mass. The excluded fraction may represent oversized DPM particles, but another possibility is that submicron DPM attaches to supramicron dust particles such that it is effectively oversized. To gain insights into this possibility, a field study was conducted in an underground stone mine. Submicron, respirable, and total airborne particulate filter samples were collected in three locations to determine elemental carbon (EC) and total carbon (TC), which are commonly used as analytical surrogates for DPM. Concurrent with the collection of the filter samples, a low-flow sampler with an electrostatic precipitator was also used to collect airborne particulates onto 400-mesh copper grids for analysis by transmission electron microscope (TEM). Results indicated that, while typical submicron sampling did account for the majority of DPM mass in the study mine, DPM-dust attachment can indeed occur. The effect of exposure to such attached particulates has not been widely investigated.

    • Reproductive Health
      1. Spatial and temporal trends of cesarean deliveries in Uganda: 2012-2016external icon
        Atuheire EB, Opio DN, Kadobera D, Ario AR, Matovu JK, Harris J, Bulage L, Nakiganda B, Tumwesigye NM, Zhu BP, Kaharuza F.
        BMC Pregnancy Childbirth. 2019 Apr 16;19(1):132.
        BACKGROUND: Cesarean section (CS) is an important intervention in complicated births when the safety of the mother or baby is compromised. Despite worldwide concerns about the overutilization of CS in recent years, many African women and their newborns still die because of limited or no access to CS services. We evaluated temporal and spatial trends in CS births in Uganda and modeled future trends to inform programming. METHODS: We performed secondary analysis of total births data from the Uganda National Health Management Information System (HMIS) reports during 2012-2016. We reviewed data from 3461 health facilities providing basic, essential obstetric and emergency obstetric care services in all 112 districts. We defined facility-based CS rate as the proportion of cesarean deliveries among total live births in facilities, and estimated the population-based CS rate using the total number of cesarean deliveries as a proportion of annual expected births (including facility-based and non-facility-based) for each district. We predicted CS rates for 2021 using Generalised Linear Models with Poisson family, Log link and Unbiased Sandwich Standard errors. We used cesarean deliveries as the dependent variable and calendar year as the independent variable. RESULTS: Cesarean delivery rates increased both at facility and population levels in Uganda. Overall, the CS rate for live births at facilities was 9.9%, increasing from 8.5% in 2012 to 11% in 2016. The overall population-based CS rate was 4.7%, and increased from 3.2 to 5.9% over the same period. Health Centre IV level facilities had the largest annual rate of increase in CS rate between 2012 and 2016. Among all 112 districts, 80 (72%) had a population CS rate below 5%, while 38 (34%) had a CS rate below 1% over the study period. Overall, Uganda’s facility-based CS rate is projected to increase by 36% (PRR 1.36, 95% CI 1.35-1.36) in 2021 while the population-based CS rate is estimated to have doubled (PRR 2.12, 95% CI 2.11-2.12) from the baseline in 2016. CONCLUSION: Cesarean deliveries are increasing in Uganda. Health center IVs saw the largest increases in CS, and while there was regional heterogeneity in changes in CS rates, utilization of CS services is inadequate in most districts. We recommend expansion of CS services to improve availability.

    • Substance Use and Abuse
      1. Waterpipe tobacco smoke: Characterization of toxicants and exposure biomarkers in a cross-sectional study of waterpipe employeesexternal icon
        Kaplan B, Sussan T, Rule A, Moon K, Grau-Perez M, Olmedo P, Chen R, Carkoglu A, Levshin V, Wang L, Watson C, Blount B, Calafat AM, Jarrett J, Caldwell K, Wang Y, Breysse P, Strickland P, Cohen J, Biswal S, Navas-Acien A.
        Environ Int. 2019 Apr 10;127:495-502.
        INTRODUCTION: Few studies have comprehensively characterized toxic chemicals related to waterpipe use and secondhand waterpipe exposure. This cross-sectional study investigated biomarkers of toxicants associated with waterpipe use and passive waterpipe exposure among employees at waterpipe venues. METHOD: We collected urine specimens from employees in waterpipe venues from Istanbul, Turkey and Moscow, Russia, and identified waterpipe and cigarette smoking status based on self-report. The final sample included 110 employees. Biomarkers of exposure to sixty chemicals (metals, volatile organic compounds (VOCs), polycyclic aromatic hydrocarbons (PAHs), nicotine, and heterocyclic aromatic amines (HCAAs)) were quantified in the participants’ urine. RESULTS: Participants who reported using waterpipe had higher urinary manganese (geometric mean ratio (GMR): 2.42, 95% confidence interval (CI): 1.16, 5.07) than never/former waterpipe or cigarette smokers. Being exposed to more hours of secondhand smoke from waterpipes was associated with higher concentrations of cobalt (GMR: 1.38, 95% CI: 1.10, 1.75). Participants involved in lighting waterpipes had higher urinary cobalt (GMR: 1.43, 95% CI: 1.10, 1.86), cesium (GMR: 1.21, 95% CI: 1.00, 1.48), molybdenum (GMR: 1.45, 95% CI: 1.08, 1.93), 1-hydroxypyrene (GMR: 1.36, 95% CI: 1.03, 1.80), and several VOC metabolites. CONCLUSION: Waterpipe tobacco users and nonsmoking employees of waterpipe venues had higher urinary concentrations of several toxic metals including manganese and cobalt as well as of VOCs, in a distinct signature compared to cigarette smoke. Employees involved in lighting waterpipes may have higher exposure to multiple toxic chemicals compared to other employees.

      2. BACKGROUND: Fetal alcohol syndrome (FAS) typically is observed among individuals with high prenatal alcohol exposures (PAE), but exposure histories obtained in clinical diagnostic settings are often inaccurate. The present analysis used the Lifestyle During Pregnancy Study (LDPS) to assess the potential effects of low to moderate average weekly alcohol consumption and binge drinking in early pregnancy on facial features associated with FAS among children five years of age. METHODS: The analysis is a prospective follow-up study of 670 women and their children sampled from the LDPS cohort based on maternal alcohol consumption during pregnancy. The 4-Digit Code FAS Facial Photographic software was used to measure the magnitude of expression of the three diagnostic facial features of FAS from standardized digital photographs. Logistic regression was used to estimate the odds of presenting with the FAS/Partial FAS (PFAS) facial phenotypes relative to different patterns of prenatal alcohol exposure. RESULTS: Ten children presented with the FAS/PFAS facial phenotypes. None of the children sampled met the central nervous system (CNS) criteria for FAS or PFAS at age 5 years. All remained at risk for PFAS since some types of CNS dysfunction associated with this diagnosis may only be assessed at older ages. The FAS/PFAS facial phenotypes were 8.5-fold more likely among children exposed to an average of 1-4 drinks per week, and 2.5-fold more likely among children with a single binge exposure in gestational weeks 3-4 compared to children with no such exposures. The magnitude of expression of the FAS facial phenotype was significantly correlated with all other diagnostic features of FAS: growth deficiency, microcephaly, and measures of CNS dysfunction. CONCLUSIONS: These findings suggest that low to moderate levels of PAE or isolated binge exposures may place some fetuses at risk for FAS/PFAS. Thus, conservative advice is still for women to abstain from alcohol consumption during pregnancy. This article is protected by copyright. All rights reserved.

    • Zoonotic and Vectorborne Diseases
      1. Notes from the field: Identification of a Triatoma sanguisuga “kissing bug” – Delaware, 2018external icon
        Eggers P, Offutt-Powell TN, Lopez K, Montgomery SP, Lawrence GG.
        MMWR Morb Mortal Wkly Rep. 2019 Apr 19;68(15):359.

        [No abstract]

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

Page last reviewed: May 3, 2019, 12:00 AM