Volume 11, Issue 18 May 7, 2019

CDC Science Clips: Volume 11, Issue 18, May 7, 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!

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

  1. CDC Vital Signs
    • Maternal and Child Health – Maternal Mortality
      1. *What we can do about maternal mortality – and how to do it quicklyexternal icon
        Mann S, Hollier LM, McKay K, Brown H.
        N Engl J Med. 2018 Nov 1;379(18):1689-1691.

        [No abstract]

      2. *Challenges and opportunities in identifying, reviewing, and preventing maternal deathsexternal icon
        St Pierre A, Zaharatos J, Goodman D, Callaghan WM.
        Obstet Gynecol. 2018 Jan;131(1):138-142.
        Despite many efforts at the state, city, and national levels over the past 70 years, a nationwide consensus on how best to identify, review, and prevent maternal deaths remains challenging. We present a brief history of maternal death surveillance in the United States and compare the three systems of national surveillance that exist today: the National Vital Statistics System, the Pregnancy Mortality Surveillance System, and maternal mortality review committees. We discuss strategies to address the perennial challenges of shared terminology and accurate, comparable data among maternal mortality review committees. Finally, we propose that with the opportunity presented by a systematized shared data system that can accurately account for all maternal deaths, state and local-level maternal mortality review committees could become the gold standard for understanding the true burden of maternal mortality at the national level.

      3. ACOG Committee Opinion No. 736: Optimizing Postpartum Careexternal icon
        ACOG .
        Obstet Gynecol. 2018 May;131(5):e140-e150.
        The weeks following birth are a critical period for a woman and her infant, setting the stage for long-term health and well-being. To optimize the health of women and infants, postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs. It is recommended that all women have contact with their obstetrician-gynecologists or other obstetric care providers within the first 3 weeks postpartum. This initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth. The comprehensive postpartum visit should include a full assessment of physical, social, and psychological well-being, including the following domains: mood and emotional well-being; infant care and feeding; sexuality, contraception, and birth spacing; sleep and fatigue; physical recovery from birth; chronic disease management; and health maintenance. Women with chronic medical conditions such as hypertensive disorders, obesity, diabetes, thyroid disorders, renal disease, and mood disorders should be counseled regarding the importance of timely follow-up with their obstetrician-gynecologists or primary care providers for ongoing coordination of care. During the postpartum period, the woman and her obstetrician-gynecologist or other obstetric care provider should identify the health care provider who will assume primary responsibility for her ongoing care in her primary medical home. Optimizing care and support for postpartum families will require policy changes. Changes in the scope of postpartum care should be facilitated by reimbursement policies that support postpartum care as an ongoing process, rather than an isolated visit. Obstetrician-gynecologists and other obstetric care providers should be in the forefront of policy efforts to enable all women to recover from birth and nurture their infants. This Committee Opinion has been revised to reinforce the importance of the “fourth trimester” and to propose a new paradigm for postpartum care.

      4. Pregnancy-Related Mortality in the United States, 2011-2013external icon
        Creanga AA, Syverson C, Seed K, Callaghan WM.
        Obstet Gynecol. 2017 Aug;130(2):366-373.
        OBJECTIVE: To update national population-level pregnancy-related mortality estimates and examine characteristics and causes of pregnancy-related deaths in the United States during 2011-2013. METHODS: We conducted an observational study using population-based data from the Pregnancy Mortality Surveillance System to calculate pregnancy-related mortality ratios by year, age group, and race-ethnicity groups. We explored 10 cause-of-death categories by pregnancy outcome during 2011-2013 and compared their distribution with those in our earlier reports since 1987. RESULTS: The 2011-2013 pregnancy-related mortality ratio was 17.0 deaths per 100,000 live births. Pregnancy-related mortality ratios increased with maternal age, and racial-ethnic disparities persisted with non-Hispanic black women having a 3.4 times higher mortality ratio than non-Hispanic white women. Among causes of pregnancy-related deaths, the following groups contributed more than 10%: cardiovascular conditions ranked first (15.5%) followed by other medical conditions often reflecting pre-existing illnesses (14.5%), infection (12.7%), hemorrhage (11.4%), and cardiomyopathy (11.0%). Relative to the most recent report of Pregnancy Mortality Surveillance System data for 2006-2010, the distribution of cause-of-death categories did not change considerably. However, compared with serial reports before 2006-2010, the contribution of hemorrhage, hypertensive disorders of pregnancy, and anesthesia complications declined, whereas that of cardiovascular and other medical conditions increased (population-level percentage comparison). CONCLUSION: The pregnancy-related mortality ratio and the distribution of the main causes of pregnancy-related mortality have been relatively stable in recent years.

      5. Reducing Disparities in Severe Maternal Morbidity and Mortalityexternal icon
        Howell EA.
        Clin Obstet Gynecol. 2018 Jun;61(2):387-399.
        Significant racial and ethnic disparities in maternal morbidity and mortality exist in the United States. Black women are 3 to 4 times more likely to die a pregnancy-related death as compared with white women. Growing research indicates that quality of health care, from preconception through postpartum care, may be a critical lever for improving outcomes for racial and ethnic minority women. This article reviews racial and ethnic disparities in severe maternal morbidities and mortality, underlying drivers of these disparities, and potential levers to reduce their occurrence.

      6. Reducing Maternal Mortality in the United Statesexternal icon
        Lu MC.
        Jama. 2018 Sep 25;320(12):1237-1238.

        [No abstract]

      7. Levels of maternal careexternal icon
        Menard MK, Kilpatrick S, Saade G, Hollier LM, Joseph GF, Barfield W, Callaghan W, Jennings J, Conry J.
        Am J Obstet Gynecol. 2015 Mar;212(3):259-71.
        In the 1970s, studies demonstrated that timely access to risk-appropriate neonatal and obstetric care could reduce perinatal mortality. Since the publication of the Toward Improving the Outcome of Pregnancy report, more than 3 decades ago, the conceptual framework of regionalization of care of the woman and the newborn has been gradually separated with recent focus almost entirely on the newborn. In this current document, maternal care refers to all aspects of antepartum, intrapartum, and postpartum care of the pregnant woman. The proposed classification system for levels of maternal care pertains to birth centers, basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). The goal of regionalized maternal care is for pregnant women at high risk to receive care in facilities that are prepared to provide the required level of specialized care, thereby reducing maternal morbidity and mortality in the United States.

      8. The maternal early warning criteria: a proposal from the national partnership for maternal safetyexternal icon
        Mhyre JM, D’Oria R, Hameed AB, Lappen JR, Holley SL, Hunter SK, Jones RL, King JC, D’Alton ME.
        Obstet Gynecol. 2014 Oct;124(4):782-6.
        Case reviews of maternal death have revealed a concerning pattern of delay in recognition of hemorrhage, hypertensive crisis, sepsis, venous thromboembolism, and heart failure. Early-warning systems have been proposed to facilitate timely recognition, diagnosis, and treatment for women developing critical illness. A multidisciplinary working group convened by the National Partnership for Maternal Safety used a consensus-based approach to define The Maternal Early Warning Criteria, a list of abnormal parameters that indicate the need for urgent bedside evaluation by a clinician with the capacity to escalate care as necessary in order to pursue diagnostic and therapeutic interventions. This commentary reviews the evidence supporting the use of early-warning systems and describes The Maternal Early Warning Criteria, along with considerations for local implementation.

      9. Approximately 700 women across the United States (U.S.) die each year as a result of pregnancy or pregnancy-related complications. Non-Hispanic black women experience maternal deaths at a rate three to four times that of non-Hispanic white women, a racial disparity that is mirrored across many maternal and infant outcomes. While surveillance using vital statistics can tell us about trends and disparities, state and local maternal mortality review committees (MMRC) are best positioned to comprehensively assess maternal deaths and identify opportunities for prevention. The Maternal Mortality Review Information Application (MMRIA) and its precursor, the Maternal Mortality Review Data System (MMRDS), assist MMRCs in abstracting relevant data from a diversity of sources, documenting committee decisions for each reviewed maternal death, and analyzing data for action. Using data from nine MMRCs (hereafter, the Nine Committees), this updated and expanded report includes – for the first time – recommendations for prevention, discussion of severe maternal morbidity review, and novel work on a MMRIA socio-spatial dashboard to incorporate health equity into MMRC discussions.

      10. Use of Maternal Early Warning Trigger tool reduces maternal morbidityexternal icon
        Shields LE, Wiesner S, Klein C, Pelletreau B, Hedriana HL.
        Am J Obstet Gynecol. 2016 Apr;214(4):527.e1-527.e6.
        BACKGROUND: Maternal mortality in the United States has increased unabated for the past 20 years. Maternal morbidity is also affecting an increasingly large number of women in the United States. A number of national and state organizations have recommend the use of maternal early warning tools as a method to combat this problem. There are limited data suggesting that the use of these types of clinical assessment tools can reduce maternal morbidity. OBJECTIVE: We sought to determine if maternal morbidity could be reduced with the implementation of a clinical pathway-specific Maternal Early Warning Trigger (MEWT) tool. STUDY DESIGN: The tool was developed internally and prospectively implemented as a pilot project in 6 of 29 hospitals within a large hospital system. The primary goal was early assessment and treatment of patients suspected of clinical deterioration. The tool addressed the 4 most common areas of maternal morbidity: sepsis, cardiopulmonary dysfunction, preeclampsia-hypertension, and hemorrhage. To be considered positive, triggers needed to be sustained for >20 minutes and were defined as severe (single abnormal value): maternal heart rate (HR) >130 beats/min (bpm), respiratory rate >30/min, mean arterial pressure <55 mm Hg, oxygen saturation <90%, or nurse concern; or nonsevere (required 2 abnormal values): temperature >38 or <36 degrees C, blood pressure >160/110 or <85/45 mm Hg, HR >110 or <50 bpm, respiratory rate >24 or <10/min, oxygen saturation <93%, fetal HR >160 bpm, altered mental status, or disproportionate pain. Within each group, recommended management or assessment was also provided. Outcome measures were Centers for Disease Control and Prevention (CDC)-defined severe maternal morbidity, composite maternal morbidity, and intensive care unit (ICU) admissions. Two time intervals were used to analyze the effect of the MEWT tool: a 24-month baseline control period and a 13-month MEWT study period. To determine that the findings noted were not simply changes that would have occurred without the utilization of the early warning tool, we also compared a control population from nonpilot sites during the same baseline and 13-month time periods. RESULTS: There were 36,832 deliveries at the pilot sites (24,221 pre- and 12,611 post-MEWT testing) and 146,359 at the nonpilot sites (95,718 pre- and 50,641 post-MEWT testing) during the 2 study time periods. Use of the MEWT tool resulted in significant reductions in CDC severe maternal morbidity (P < 0.01) and composite morbidity (P < 0.01). ICU admissions were unchanged. At nonpilot sites CDC severe maternal morbidity, composite morbidity, and ICU admissions were unchanged between baseline and the post-MEWT testing time period. CONCLUSION: The use of the MEWT tool in this study, designed to address 4 of the most common causes of maternal morbidity, as well as provide assessment and management recommendations, resulted in significant improvement in maternal morbidity. The variation in hospital delivery services at the pilot sites suggests that this maternal early warning tool would be suitable for use in the majority of maternity centers in the United States.

  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. Anemia affects a third of the world’s population and contributes to increased morbidity and mortality, decreased work productivity, and impaired neurological development. Understanding anemia’s varied and complex etiology is crucial for developing effective interventions that address the context-specific causes of anemia and for monitoring anemia control programs. We outline definitions and classifications of anemia, describe the biological mechanisms through which anemia develops, and review the variety of conditions that contribute to anemia development. We emphasize the risk factors most prevalent in low- and middle-income countries, including nutritional deficiencies, infection/inflammation, and genetic hemoglobin disorders. Recent work has furthered our understanding of anemia’s complex etiology, including the proportion of anemia caused by iron deficiency (ID) and the role of inflammation and infection. Accumulating evidence indicates that the proportion of anemia due to ID differs by population group, geographical setting, infectious disease burden, and the prevalence of other anemia causes. Further research is needed to explore the role of additional nutritional deficiencies, the contribution of infectious and chronic disease, as well as the importance of genetic hemoglobin disorders in certain populations.

      2. Anemia is an important public health problem that negatively affects health of individuals and economic potential of populations. An accurate case definition is critical for understanding burden and epidemiology of anemia, for planning public health interventions, and for clinical investigation and treatment of patients. The current threshold hemoglobin concentrations for diagnosis of anemia were proposed in 1968 and based on studies predominantly of Caucasian adult populations in Europe and North America. The World Health Organization is undertaking a project to review global guidelines for anemia. We describe the process of obtaining input from technical experts, researchers, blood bank experts, policy makers, and program implementers to identify key information or knowledge gaps for anemia diagnosis. From this scoping exercise, six priority areas were identified on diverse topics related to the use and interpretation of hemoglobin concentrations to diagnose anemia in individuals and populations. A call for authors was conducted to produce background, review, and research papers across priority topics. This paper summarizes the first technical meeting, which included commissioned papers as well as case studies, describes key data gaps identified, and describes the next steps in the guideline development process to assess available evidence and define knowledge gaps to improve anemia characterization.

      3. Cervical cancer death rates among U.S.- and foreign-born women: U.S., 2005-2014external icon
        Hallowell BD, Endeshaw M, McKenna MT, Senkomago V, Razzaghi H, Saraiya M.
        Am J Prev Med. 2019 Apr 12.
        INTRODUCTION: Historically, foreign-born women in the U.S. are less likely to be screened and are more likely to die from cervical cancer when compared with their U.S.-born counterparts. In order to inform prevention efforts and reduce this health disparity, mortality data were obtained from the National Center for Health Statistics to describe cervical cancer mortality among U.S.- and foreign-born women. METHODS: Annual population estimates were obtained from the U.S. Census Bureau’s American Community Survey from 2005 to 2014. From 2017 to 2018, age-adjusted mortality rates and rate ratios were calculated by nativity status, race/ethnicity, age, geographic region, and country of birth. RESULTS: From 2005 to 2014, a total of 5,924 deaths from cervical cancer were recorded among the foreign-born population, compared with 33,893 deaths among U.S.-born women. Overall, foreign-born women had a lower cervical cancer mortality rate when compared with the U.S.-born women (rate ratio=0.95, 95% CI=0.92, 0.97). However, older foreign-born women had significantly higher mortality rates compared with U.S.-born women: aged 65-79 years (rate ratio=1.15, 95% CI=1.09, 1.22) and >/=80 years (rate ratio=1.43, 95% CI=1.32, 1.55). Women born in Mexico had significantly elevated rates of cervical cancer mortality (rate ratio=1.35, 95% CI=1.27, 1.42) when compared with U.S.-born women. CONCLUSIONS: Efforts that work to increase cervical cancer screening access and guideline compliance might further reduce the cervical cancer deaths in the U.S., and the excess burden observed among older foreign-born women.

      4. Fertility-related experiences after breast cancer diagnosis in the Sister and Two Sister Studiesexternal icon
        Hawkins Bressler L, Mersereau JE, Anderson C, Rodriguez JL, Hodgson ME, Weinberg CR, Sandler DP, Nichols HB.
        Cancer. 2019 Apr 23.
        BACKGROUND: Commonly used chemotherapies can be toxic to the ovaries. To the authors’ knowledge, the majority of studies evaluating receipt of fertility counseling for women in their reproductive years have been performed in specific settings, thereby limiting generalizability. METHODS: A nationwide sample of US women diagnosed with breast cancer before age 45 years completed a survey assessing the prevalence of fertility counseling. Age-adjusted log-binomial regression was used to estimate prevalence ratios (PRs) and 95% CIs for fertility counseling. RESULTS: Among 432 survivors diagnosed between 2004 and 2011, 288 (67%) had not discussed the effects of treatment on fertility with a health care provider before or during treatment. Fertility discussion was associated with younger age (PR, 3.49 [95% CI, 2.66-4.58] for aged <35 years vs >/=40 years) and lower parity (PR, 1.81 [95% CI, 1.29-2.53] for parity 1 vs 2). Approximately 20% of respondents reported that they were interested in future fertility (87 of 432 respondents) at the time of their diagnosis, but not all of these individuals (66 of 87 respondents) received counseling regarding the impact of treatment on their fertility, and few (8 of 87 respondents) used fertility preservation strategies. Among 68 women with a fertility interest who provided reasons for not taking steps to preserve fertility, reasons cited included concern for an adverse impact on cancer treatment (56%), lack of knowledge (26%), decision to not have a child (24%), and cost (18%). CONCLUSIONS: Across multiple treatment settings, the majority of women of reproductive age who are diagnosed with breast cancer did not discuss fertility with a health care provider or use fertility preservation strategies. Discussing the potential impact of cancer treatment on future fertility is an important aspect of patient education.

      5. Health communications: provider assessment of asthma controlexternal icon
        Lewis LM, Johnson T, Lozier M, Zahran HS.
        J Asthma. 2019 Apr 22:1-6.
        OBJECTIVE: The patient-provider partnership is important for effective asthma care and improved asthma control. Our descriptive study describes demographic differences associated with patient-provider asthma communications using Healthy People 2020 indicators. METHODS: Using 2013 National Health Interview Survey (NHIS) data, we examined provider assessments of asthma control at last healthcare visit for children and adults with current asthma; assessments included questions on frequency of asthma symptoms, use of quick-relief inhalers, and limitation of daily activities due to asthma. We calculated weighted prevalence and prevalence ratios (PR) with 95% confidence intervals (CI). RESULTS: Overall, 3,684 (weighted prevalence = 7.3%; 95% confidence interval [CI] = 7.0-7.6) NHIS respondents reported current asthma. Among persons with current asthma, 58% reported a routine asthma care visit in the past year. Provider assessments of asthma symptoms, quick-relief inhaler use, and activity limitations were reported by 55.4%, 59.1% and 41.5% of respondents, respectively. Non-Hispanic blacks (PR = 1.11; 95% CI = 1.03-1.20), Puerto Ricans (PR = 1.23; 95% CI = 1.08-1.40), and Other-Hispanics (PR = 1.18; 95% CI = 1.05-1.32) were asked more often than non-Hispanic whites about >/=1 of the asthma control indicators. Providers more frequently assessed asthma symptoms (PR = 1.20; CI = 1.10-1.30), quick-relief inhaler use (PR = 1.10; CI = 1.02-1.19), and activity limitations (PR = 1.25; CI = 1.11-1.41) in children than adults. CONCLUSIONS: Healthcare providers often discuss asthma control indicators with patients. Children and some racial and ethnic minorities were more frequently assessed on key asthma control indicators compared to adults and non-Hispanic whites, respectively. These findings may reflect provider efforts to target asthma control communications to populations with higher risk of morbidity.

      6. A signature of circulating inflammatory proteins and development of end-stage renal disease in diabetesexternal icon
        Niewczas MA, Pavkov ME, Skupien J, Smiles A, Md Dom ZI, Wilson JM, Park J, Nair V, Schlafly A, Saulnier PJ, Satake E, Simeone CA, Shah H, Qiu C, Looker HC, Fiorina P, Ware CF, Sun JK, Doria A, Kretzler M, Susztak K, Duffin KL, Nelson RG, Krolewski AS.
        Nat Med. 2019 Apr 22.
        Chronic inflammation is postulated to be involved in the development of end-stage renal disease in diabetes, but which specific circulating inflammatory proteins contribute to this risk remain unknown. To study this, we examined 194 circulating inflammatory proteins in subjects from three independent cohorts with type 1 and type 2 diabetes. In each cohort, we identified an extremely robust kidney risk inflammatory signature (KRIS), consisting of 17 proteins enriched in tumor necrosis factor-receptor superfamily members, that was associated with a 10-year risk of end-stage renal disease. All these proteins had a systemic, non-kidney source. Our prospective study findings provide strong evidence that KRIS proteins contribute to the inflammatory process underlying end-stage renal disease development in both types of diabetes. These proteins point to new therapeutic targets and new prognostic tests to identify subjects at risk of end-stage renal disease, as well as biomarkers to measure responses to treatment of diabetic kidney disease.

      7. Psychological traits, heart rate variability, and risk of coronary heart disease in healthy aging women – The Women’s Health Initiativeexternal icon
        Salmoirago-Blotcher E, Hovey KM, Andrews CA, Allison M, Brunner RL, Denburg NL, Eaton C, Garcia L, Sealy-Jefferson SM, Zaslavsky O, Kang J, Lopez L, Post SG, Tindle H, Wassertheil-Smoller S.
        Psychosom Med. 2019 Apr;81(3):256-264.
        OBJECTIVE: Psychological traits such as optimism and hostility affect coronary heart disease (CHD) risk, but mechanisms for this association are unclear. We hypothesized that optimism and hostility may affect CHD risk via changes in heart rate variability (HRV). METHODS: We conducted a longitudinal analysis using data from the Women’s Health Initiative Myocardial Ischemia and Migraine Study. Participants underwent 24-hour ambulatory electrocardiogram monitoring 3 years after enrollment. Optimism (Life Orientation Test-Revised), cynical hostility (Cook-Medley), demographics, and coronary risk factors were assessed at baseline. HRV measures included standard deviation of average N-N intervals (SDNN); standard deviation of average N-N intervals for 5 minutes (SDANN); and average heart rate (HR). CHD was defined as the first occurrence of myocardial infarction, angina, coronary angioplasty, and bypass grafting. Linear and Cox regression models adjusted for CHD risk factors were used to examine, respectively, associations between optimism, hostility, and HRV and between HRV and CHD risk. RESULTS: Final analyses included 2655 women. Although optimism was not associated with HRV, hostility was inversely associated with HRV 3 years later (SDANN: adjusted beta = -0.54; 95% CI = -0.97 to -0.11; SDNN: -0.49; 95% CI = -0.93 to -0.05). HRV was inversely associated with CHD risk; for each 10-millisecond increase in SDNN or SDANN, there was a decrease in CHD risk of 9% (p = .023) and 12% (p = .006), respectively. CONCLUSIONS: HRV did not play a major role in explaining why more optimistic women seem to be somewhat protected from CHD risk. Although hostility was inversely associated with HRV, its role in explaining the association between hostility and CHD risk remains to be established.

      8. Occurrence of severe hypoglycaemic events among US youth and young adults with type 1 or type 2 diabetesexternal icon
        Saydah S, Imperatore G, Divers J, Bell R, Henkin L, Mayer-Davis E, Zhong VW, Dabelea D, Lawrence JM, Pihoker C.
        Endocrinol Diabetes Metab. 2019 Apr;2(2):e00057.
        Objective: Although severe hypoglycaemia (SH) can lead to adverse health outcomes, little is known about its occurrence and re-occurrence among youth with type 1 or type 2 diabetes. Methods: This study included 2740 participants aged <20 years at diabetes diagnosis and 5-14 years diabetes duration from the SEARCH for Diabetes in Youth Cohort Study. Participants reported SH events in the past 6 months. Differences in SH events by demographic and clinical factors were tested using logistic regression models. Results: Severe hypoglycaemia in the past 6 months was more common among youth with type 1 (7.0%, 168 of 2399) than with type 2 diabetes (2.6%, nine of 341) (P < 0.002). The median number of SH events per youth who had at least one SH event in the past 6 months was 1 for both type 1 type 2 diabetes. For youth with type 1 diabetes, those who reported SH events were older, were more likely to have obesity or to be physically active, and had lower HbA1c. After adjustments, one unit increase in HbA1c was associated with 16% lower likelihood (OR 0.84, 95% CI 0.75, 0.94) and being physically active was associated with an 87% higher likelihood (OR 1.87, 95% CI 1.23, 2.86) of reporting a SH event. There were too few SH events among youth with type 2 diabetes to analyse further. Conclusions: In youth with diabetes, SH was common even within a short 6-month window. Better understanding the causes of SH may help prevent them from occurring.

      9. Comparison of program resources required for colonoscopy and fecal screening: Findings from 5 years of the Colorectal Cancer Control Programexternal icon
        Subramanian S, Tangka FK, Hoover S, Cole-Beebe M, Joseph D, DeGroff A.
        Prev Chronic Dis. 2019 Apr 25;16:E50.
        INTRODUCTION: Colonoscopy and guaiac fecal occult blood tests and fecal immunochemical tests (FOBT/FIT) are the most common colorectal cancer screening methods in the United States. However, information is limited on the program resources required over time to use these tests. METHODS: We collected cost data from 29 Centers for Disease Control and Prevention Colorectal Cancer Control Program (CRCCP) grantees by using a standardized data collection instrument for 5 program years (2009-2014). We created a panel data set with 124 records and assessed differences by screening test used. RESULTS: Forty-four percent of all programs (N = 124) offered colonoscopy (55 of 124), 32% (39 of 124) offered FOBT/FIT, and 24% (30 of 124) offered both. Overall, total cost per person was higher in program year 1 ($3,962), the beginning of CRCCP than in subsequent program years ($1,714). The cost per person was $3,153 for programs using colonoscopy and $1,291 for those using FOBT/FIT with diagnostic colonoscopy. The average clinical cost per person was $1,369 for colonoscopy and $280 for FOBT/FIT during the program (these do not reflect cost of repeated FOBT/FIT screens). Programs serving a large number of people had lower per-person costs than those serving a small volume, probably because of fixed costs related to nonclinical expenses. CONCLUSION: Colorectal cancer screening programs incur costs in addition to the clinical cost of the screening procedures to support planning and management, contracting with providers, and tracking patients. Because programs can achieve potential economies of scale, partnerships among smaller programs for screening delivery could decrease overall costs.

      10. Which one? What kind? How many? Types, causes, and prevalence of disability among U.S. adultsexternal icon
        Theis KA, Steinweg A, Helmick CG, Courtney-Long E, Bolen JA, Lee R.
        Disabil Health J. 2019 Mar 28.
        BACKGROUND: Quantifying the number of people with and types of disabilities is helpful for medical, policy, and public health planning. OBJECTIVE/HYPOTHESIS: To update prior estimates on types, prevalence, and main causes of disability among U.S. adults using the Survey of Income and Program Participation (SIPP) data. METHODS: We used cross-sectional data from the SIPP 2008 Panel Wave 6 interviews collected May-August 2010. Analyses were restricted to non-institutionalized adults ages >/=18 years (n=66,410). Disability was ascertained via five non-mutually exclusive components: 1) specific activity difficulties, 2) selected impairments, 3) use of an assistive aid, 4) household work limitations, and 5) paid work limitations. Prioritized main cause of disability was established for the 95% of respondents with a disability type eligible for health condition questions. We generated weighted population estimates (number and percentage, with 95% confidence intervals (CIs)), accounting for the complex sample survey design. RESULTS: 50 million U.S. adults (21.8%) experienced a disability in 2010. Mobility-related activity limitations were the most prevalent disabilities across all five components. The most common main causes of disability were arthritis/rheumatism, 9.1 million (19.2%, 95% CI=18.4-20.0) and back or spine problems, 8.9 million (18.6%, 95% CI=17.9-19.3). CONCLUSIONS: A growing population with disabilities has the potential to put considerable and unsustainable demand on medical, public health, and senior service systems. Strengthening clinical community linkages and expanding the availability of existing evidence-based public health interventions to prevent, delay, and mitigate the effects of disability could improve health and outcomes for people with disabilities.

      11. The burden of cerebrovascular disease in the United Statesexternal icon
        Tong X, Yang Q, Ritchey MD, George MG, Jackson SL, Gillespie C, Merritt RK.
        Prev Chronic Dis. 2019 Apr 25;16:E52.
        INTRODUCTION: Little is known about trends in the overall combined burden of fatal and nonfatal cerebrovascular disease events in the United States. Our objective was to describe the combined burden by age, sex, and region from 2006 through 2014. METHODS: We used data on adults aged 35 and older from 2006 through 2014 Nationwide Emergency Department Sample, National Inpatient Sample of the Healthcare Cost and Utilization Project, and the National Vital Statistics System. We calculated age-standardized cerebrovascular disease event rates by using the 2010 US Census population. Trends in rates were assessed by calculating the relative percentage change (RPC) between 2006 and 2014, and by using Joinpoint to obtain P values for overall trends. RESULTS: The age-standardized rate increased significantly for total cerebrovascular disease events (primary plus comorbid events) from 1,050 per 100,000 in 2006 to 1,147 per 100,000 in 2014 (P < .05 for trend). Treat-and-release emergency department visits with comorbid cerebrovascular disease events increased significantly, from 114 per 100,000 in 2006 to 213 per 100,000 in 2014 (RPC of 87%, P < .05 for trend). Significant rate increases were identified among adults aged 35 to 64 with an RPC of 19% in primary cerebrovascular disease events, 48% in comorbid cerebrovascular disease events, and 36% in total events. CONCLUSION: Our findings have important implications for the increasing cerebrovascular disease burden among adults aged 35 to 64. Focused prevention strategies should be implemented, especially among young adults who may be unaware of existing modifiable risk factors.

    • Communicable Diseases
      1. BACKGROUND: Black men who have sex with men, who account for less than 1% of the U.S. population, account for approximately 25% of new HIV infections annually. Condomless anal sex contributes to HIV infection among black men who have sex with men. The capacity to recover quickly from difficulties (resilience) may be protective against condomless anal sex, but has been understudied among black men who have sex with men. Psychosocial factors related to resilience, i.e., condom use self-efficacy and internalized homophobia, may also affect condomless anal sex. We assessed the association between resilience, condom use self-efficacy, internalized homophobia and condomless anal sex among black men who have sex with men. METHODS: Data are from a 2010-2011 study examining condomless anal sex (past 60 days) among black men who have sex with men in New York City. Validated scales assessed resilience (theoretical range = 0-100), condom use self-efficacy (theoretical range = 27-135), and internalized homophobia (theoretical range = 9-36). We described continuous variables using median and interquartile range (IQR). Univariable and multivariable Poisson regression models assuming a robust variance estimator were used to compute unadjusted and adjusted prevalence ratios, respectively, and their corresponding 95% confidence intervals (CI). Adjusted prevalence ratios (aPR) examined the association of resilience, condom use self-efficacy, and internalized homophobia with condomless anal sex, while controlling for potential confounders (e.g., having >1 sex partner). RESULTS: The median resilience score within our sample (N = 228) was 75 (IQR = 66-83). Many black men who have sex with men reported condomless anal sex (55.7%) and >1 sex partner (58.8%). Decreased condomless anal sex was associated with increased levels of condom use self-efficacy (aPR: 0.94 per 10-point increase in condom use self-efficacy score; CI: 0.90-0.97; p-value: 0.001). Condomless anal sex was not associated with resilience or internalized homophobia. CONCLUSIONS: Within this sample of black men who have sex with men, condomless anal sex was prevalent. Greater resilience was not protective against condomless anal sex. Interventions that support condom use are warranted for black men who have sex with men.

      2. Evaluation and management of congenital Chagas disease in the United Statesexternal icon
        Edwards MS, Stimpert KK, Bialek SR, Montgomery SP.
        J Pediatric Infect Dis Soc. 2019 Apr 24.
        Chagas disease is underappreciated as a health concern in the United States. Approximately 40 000 women of childbearing age living in the United States have chronic Chagas disease. Most of them are unaware that they have an infection that is transmissible to their offspring. The estimated US maternal-to-infant transmission rate of Trypanosoma cruzi is 1% to 5%. Ten percent to 40% of neonates with congenital T cruzi infection have clinical signs consistent with a congenital infection but no findings are unique to Chagas disease. If left untreated, 20% to 40% of infants with Chagas disease will later develop potentially fatal cardiac manifestations. Molecular testing can confirm the diagnosis in neonates. Treatment is well tolerated in infancy and usually results in cure. Screening of at-risk women during pregnancy can identify maternal infection and allow early assessment and treatment for congenital T cruzi infection.

      3. In contrast to intervention studies that assess psychosocial factors only as mediators or moderators of HIV risk, the present study assessed the effects of an Mpowerment-based community-level intervention on psychosocial determinants (e.g., depressive symptoms, sexual stigma) of HIV risk behavior among young black MSM. Approximately 330 respondents were surveyed annually for 4 years in each of two sites. General linear models examined change across time between the intervention and comparison communities, and participation effects in the intervention site. Social diffusion (spreading information within networks) of safer sex messages (p < 0.01) and comfort with being gay (p < 0.05) increased with time in intervention versus control. Cross-sectionally, intervention participants responded more favorably (p < 0.05) on social diffusion and depressive symptoms, but less favorably (p < 0.01) on sex in difficult situations and attitudes toward condom use. Findings suggest a need to address broader health issues of MSM as well as sexual risk.

      4. The characteristics of internet-based venue sex-seeking and mobility among money boys in Tianjin, Chinaexternal icon
        Guo C, Yu M, Deng X, Gong H, Li Y, Li C, Liu Y, Guo M, Gong X, Feng S, Xu J, Li Z, Gao Y, Yang J, Cui Z, Ma J.
        HIV Med. 2019 Apr 22.
        OBJECTIVES: Internet-based venue sex-seeking is prevalent among money boys (MBs), as is a high degree of mobility, which is crucial for HIV transmission in key populations with high risks of HIV infection. However, correlation studies in MBs are scarce because of the secretive nature of this hard-to-reach subpopulation. We conducted this project to explore the characteristics of MBs. METHODS: This survey was conducted from December 2014 to June 2015 in Tianjin; a total of 330 MBs were recruited by convenience sampling. Demographic and behavioural data were collected for analysis. RESULTS: Among the investigated MBs, 38 (11.52%) were HIV positive, 147 (44.55%) reported using internet-based venues to seek sexual partners and 257 (77.88%) had travelled to two or more destinations in the past 6 months. Compared with non-internet-based venue-using MBs, internet-based venue-using MBs were more likely to have part-time employment as MBs, to have a longer duration of working in the sex trade, to engage in finger intercourse and to present a history of substance abuse and sexually transmitted infections. However, internet-based venue-using MBs were less likely to exhibit consistent condom usage and undergo HIV testing. Origin of residence data showed that most MBs were from northern China, with Tianjin, Beijing and Shanghai as the main travel destinations. Mobile MBs were characterized as a group who were fully engaged in the sex trade and frequently took part in sexual activities but had a weak sense of self-protection. CONCLUSIONS: Internet-based venue sex-seeking and mobility are prevalent in MBs. Renewed efforts in internet-based health promotion and school-based primary health examination programmes may benefit more mobile and/or internet-based venue sex-seeking MBs.

      5. Sleep disturbances in HIV-infected patients associated with depression and high risk of obstructive sleep apneaexternal icon
        Gutierrez J, Tedaldi EM, Armon C, Patel V, Hart R, Buchacz K.
        SAGE Open Med. 2019 ;7:2050312119842268.
        Objective: To evaluate sleep disturbances in a diverse, contemporary HIV-positive patient cohort and to identify demographic, clinical, and immune correlates. Methods: A convenience sample of 176 patients from a racially and ethnically diverse HIV-positive patient cohort in an urban population. This was a cross-sectional, epidemiologic study. We surveyed participants using multiple standardized instruments to assess depression, sleep quality, and risk for sleep apnea. We analyzed demographic, behavioral, and clinical correlates. Results: A total of 56% of participants were female, 75% Black and 64% had heterosexual HIV risk. The median age was 49 years. Poor sleep quality (Pittsburgh Sleep Quality Index > 5) was reported by 73% of patients and 52% met insomnia diagnosis criteria. A single question about self-reported sleep problems predicted a Pittsburgh Sleep Quality Index > 5 with a sensitivity and specificity of 82% and 81%, respectively. Female sex was significantly associated with higher risk of poor sleep quality, depression, and insomnia, whereas higher risk of obstructive sleep apnea was significantly associated with older age, male sex, obesity (body mass index 30 kg/m(2)), and metabolic comorbidities. High risk for obstructive sleep apnea, high rate of depression, and poor sleep hygiene represent treatment targets for sleep problems in HIV patients. Conclusion: Sleep disturbances were common in this patient cohort, although largely undiagnosed and untreated. Sleep problems are linked to worse disease progression and increased cardiovascular mortality. Screening for sleep problems with a single question had high sensitivity and specificity. In those patients with self-reported sleep problems, screening for obstructive sleep apnea, depression, and sleep hygiene habits should be part of routine HIV care.

      6. Fecal colonization with multidrug-resistant E. coli among healthy infants in rural Bangladeshexternal icon
        Islam MA, Amin MB, Roy S, Asaduzzaman M, Islam MR, Navab-Daneshmand T, Mattioli MC, Kile ML, Levy K, Julian TR.
        Front Microbiol. 2019 ;10:640.
        Third generation cephalosporins (3GC) are one of the main choices for treatment of infections caused by multidrug-resistant (MDR) Gram-negative bacteria. Due to their overuse, an increasing trend of resistance to 3GC has been observed in developing countries. Here, we describe fecal colonization of 3GC-resistant (3GCr) Escherichia coli in healthy infants (1-12 months old) living in rural areas of Bangladesh. We found that stool samples of 82% of infants (n = 100) were positive for 3GCr E. coli with a mean +/- standard deviation of 6.21 +/- 1.32 log10 CFU/g wet weight of stool. 3GCr E. coli encompasses an average one third (33%) of the total E. coli of stool. Almost 77% (n = 63) of these 3GCr E. coli were MDR (or resistant to >/=3 classes of antibiotics). Around 90% (n = 74) of 3GCr E. coli were extended spectrum beta-lactamase (ESBL)-producing in which bla CTX-M-group-1 was the predominant (96%, n = 71) ESBL-gene followed by bla TEM (41%, n = 30) and bla OXA-1 (11%, n = 8). A significant proportion (26.5%, n = 22) of 3GCr E. coli was pathogenic, comprising two types, enteroaggregative (EAEC, n = 19) and enteropathogenic (EPEC, n = 3). Colonization of 3GCr E. coli in infant guts was not associated with demographic characteristics such as age, sex, mode of delivery, maternal and infant antibiotic use, disease morbidity, and feeding practices. The high rate of colonization of 3GCr E. coli in infants’ guts is a serious public health concern which needs immediate attention and warrants further studies to explore the cause.

      7. Barriers and facilitators to engaging African American men who have sex with men in the HIV Care Continuum: A theory-based qualitative studyexternal icon
        Jemmott JB, Zhang J, Croom M, Icard LD, Rutledge SE, O’Leary A.
        J Assoc Nurses AIDS Care. 2019 May-Jun;30(3):352-361.
        African American men who have sex with men (MSM) have high rates of HIV, but interventions are needed to address their low rates of engagement in the HIV care continuum. To identify modifiable factors potentially affecting such engagement, we conducted qualitative interviews guided by the Theory of Planned Behavior with 27 African American MSM who had participated in an HIV risk-reduction intervention trial. Qualitative analyses resulted in four overarching themes: stigma, concerns with health care providers (HCPs), social support, and logistical issues. Facilitators of care continuum engagement included reassurance about health, feeling and looking better, receiving treatment, avoiding infecting others, good relations with HCP, and social support. Barriers included HIV stigma, concerns about confidentiality, negative perceptions of HCP, convenience and availability of testing/treatment facilities, cost, and lack of social support. Efforts to improve African American MSM HIV care continuum engagement should focus on individual and health care system changes.

      8. [No abstract]

      9. Emerging and reemerging fungal infectionsexternal icon
        Lockhart SR, Guarner J.
        Semin Diagn Pathol. 2019 Apr 17.
        Fungal infections throughout the world appear to be increasing. This may in part be due to the increase in the population of patients that are susceptible to otherwise rare fungal infections resulting from the use of immune modulating procedures such as hematopoietic stem cell transplants and drugs like tissue necrosis factor antagonists. Histoplasma capsulatum, an endemic fungus throughout North and South America, is reemerging among HIV+ patients in Central and South America and among patients taking tissue necrosis factor antagonists and other biologics in North America. Fusarium species, a relatively rare fungal infection, is reemerging worldwide in the immunocompromised populations, especially those who are neutropenic like hematopoietic stem cell transplant recipients. A new yeast species is currently emerging worldwide: Candida auris, unknown just a decade ago. It is causing large healthcare-associated outbreaks on four continents and is spreading throughout the world through patient travel. In this review the epidemiology, pathology, detection and treatment of these three emerging and reemerging fungi will be discussed.

      10. Syphilis is (still) here: How must sexually transmitted disease public health programs adapt?external icon
        Philip SS, Bernstein KT.
        Sex Transm Dis. 2018 Sep;45(9S Suppl 1):S63-s64.

        [No abstract]

      11. Dust or disease? Perceptions of influenza in rural Southern Malawiexternal icon
        Phiri M, Gooding K, Peterson I, Mambule I, Nundwe S, McMorrow M, Desmond N.
        PLoS One. 2019 ;14(4):e0208155.
        Influenza virus infections cause between 291 243 and 645 832 deaths annually, with the highest burden in low-income settings. Research in high-income countries has examined public understanding of influenza, but there is little information on views and behaviours about influenza in low-income countries. We explored communities’ ideas about the severity, causes, prevention and treatment of influenza in Chikwawa district, Malawi. We conducted 64 in-depth interviews with parents of children aged <5 years, and 7 focus groups with community health workers, parents, and traditional healers. Data were analysed thematically and using a framework matrix to compare views between groups. Respondents held varied ideas about influenza, and many were uncertain about its causes and treatment. Some parents, traditional healers and health workers thought influenza was not severe because they felt it did not cause death or limit activities, but others disagreed. Many saw influenza as a symptom of other conditions, especially malaria and pneumonia, rather than as a disease of its own. Most mentioned dust as the main cause of influenza and believed influenza could be prevented by cleaning the home thoroughly. Treatment seeking for influenza followed different stages, usually starting with home remedies followed by purchasing drugs from groceries and then visiting a health centre. Seeking a clinician tended to be triggered by severe symptoms like high fever or difficulty breathing, and suspicions of malaria or pneumonia. Community health workers provide health education for communities, but some lacked understanding of influenza. Our findings suggest uncertainty about the causes and control of influenza among parents and varied levels of understanding among health providers. Strengthening the capacity of community health workers to provide relevant information about influenza prevention and treatment could address parents’ interest in further information and support informed health seeking and engagement with future influenza interventions.

      12. Understanding quality of care and satisfaction with sexual and reproductive healthcare among young menexternal icon
        Pilgrim NA, Jennings JM, Sanders R, Page KR, Loosier PS, Dittus PJ, Marcell AV.
        J Healthc Qual. 2018 Nov/Dec;40(6):354-366.
        OBJECTIVE: Sexual and reproductive healthcare (SRHC) guidelines recommend the delivery of quality preventive SRHC to males beginning in adolescence. A quality of care (QOC) framework was used to examine factors associated with young male’s perceptions of QOC and satisfaction with care, which can influence their engagement and use of SRHC. METHODS: Cross-sectional surveys were conducted from August 2014 to September 2016 with 385 male patients aged 15-24 years, recruited from primary care and sexually transmitted disease (STD) clinics. Surveys measured QOC received, satisfaction with care, and domains of a QOC framework. Poisson regression analyses examined associations between domains of quality and perceived QOC as well as satisfaction with care. RESULTS: Over half of males reported QOC as excellent (59%) and were very satisfied with the services (56.7%). Excellent QOC and high satisfaction with services was associated with timely care, higher Clinician-Client Centeredness, and being a bisexual male. Excellent QOC was also associated with greater comfort in the clinic, being tested for human immunodeficiency virus/STDs, attending primary care settings, and receipt of higher number of SRHC services. CONCLUSIONS: Using a QOC framework as part of providing SRHC to young males can be important in improving their perceptions of QOC and satisfaction with services.

      13. Evaluation of an emergency bulk chlorination project targeting drinking water vendors in cholera-affected wards of Dar es Salaam and Morogoro, Tanzaniaexternal icon
        Rajasingham A, Hardy C, Kamwaga S, Sebunya K, Massa K, Mulungu J, Martinsen A, Nyasani E, Hulland E, Russell S, Blanton C, Nygren B, Eidex R, Handzel T.
        Am J Trop Med Hyg. 2019 Apr 22.
        In August 2015, an outbreak of cholera was reported in Tanzania. In cholera-affected areas of urban Dar es Salaam and Morogoro, many households obtained drinking water from vendors, who sold water from tanks ranging in volume from 1,000 to 20,000 L. Water supplied by vendors was not adequately chlorinated. The Tanzanian Ministry of Health, Community Development, Gender, Elderly and Children and the U.N. Children’s Fund, Tanzania, collaborated to enroll and train vendors to treat their water with 8.68-g sodium dichloroisocyanurate tablets. The CDC provided monitoring and evaluation support. Vendors were provided a 3-month supply of chlorine tablets. A baseline assessment and routine monitoring were conducted by ward environmental health officers. Approximately 3 months after chlorine tablet distribution, an evaluation of the program was conducted. The evaluation included a full enumeration of all vendors, an in-depth survey with half of the vendors enumerated, and focus group discussions. In total, 797 (88.9%) vendors were included in the full enumeration and 392 in the in-depth survey. Free residual chlorine (FRC) was detected in 12.0% of tanks at baseline and 69.6% of tanks during the evaluation; however, only 17.4% of these tanks had FRC >/= 0.5 mg/L. The results suggest high acceptability and use of the chlorine tablets by water vendors. However, given variation in the water source used and longer storage times, dosing could be increased in future programming. Bulk chlorination using chlorine tablets offers an efficient community-level approach to treating water closer to the point of use.

      14. Serological markers for syphilis among persons presenting with syndromes associated with sexually transmitted infections results from the Zimbabwe STI Etiology Studyexternal icon
        Rietmeijer CA, Mungati M, Kilmarx PH, Tippett Barr B, Gonese E, Kularatne RS, Lewis DA, Klausner JD, Rodgers L, Handsfield HH.
        Sex Transm Dis. 2019 Apr 17.
        BACKGROUND: Syphilis prevalence in sub-Saharan Africa appears to be stable or declining but is still the highest globally. Ongoing sentinel surveillance in high-risk populations is necessary to inform management and detect changes in syphilis trends. We assessed serological syphilis markers among persons with sexually transmitted infections in Zimbabwe. METHODS: We studied a predominantly urban, regionally diverse group of women and men presenting with genital ulcer disease (GUD), women with vaginal discharge and men with urethral discharge at clinics in Zimbabwe. Syphilis tests included Rapid Plasma Reagin (RPR) and the Treponema pallidum Haemagglutination Assay (TPHA). RESULTS: Among 436 evaluable study participants, 36 (8.3%) tested positive for both RPR and TPHA: women with GUD: 19.2%, men with GUD: 12.6%, women with vaginal discharge: 5.7% and men with urethral discharge: 1.5% (p<0.0001). CONCLUSIONS: Syphilis rates in Zimbabwe are high in sentinel populations, especially men and women with GUD.

      15. Tuberculosis – United States, 2018external icon
        Talwar A, Tsang CA, Price SF, Pratt RH, Walker WL, Schmit KM, Langer AJ.
        Am J Transplant. 2019 May;19(5):1582-1588.

        [No abstract]

      16. Nationwide estimates of viral load suppression and acquired HIV drug resistance in Cameroonexternal icon
        Tchouwa GF, Eymard-Duvernay S, Cournil A, Lamare N, Serrano L, Butel C, Bertagnolio S, Mpoudi-Ngole E, Raizes E, Aghokeng AF.
        EClinicalMedicine. 2018 ;1:21-27.
        Background: Population-based studies to estimate viral load (VL) suppression and rate of acquired HIV drug resistance (ADR) are essential in sub-Saharan Africa. We conducted the first nationally representative study estimating VL suppression and ADR in Cameroon. Methods: Eligible participants were patients on antiretroviral therapy (ART) for 12 to 24 months (ART 12-24) or 48 to 60 months (ART 48-60). ART 12-24 participants were recruited from 24 randomly selected clinics in both urban and rural regions. ART 48-60 participants were recruited from 7 urban clinics. Recruitment occurred from February to August 2015. Dried blood spots (DBSs) and plasma specimens were collected and tested for HIV-1 RNA level and presence of drug resistance mutations (DRM) when VL ? 1000 copies/ml. Results: Overall, 1064 ART 12-24 and 388 ART 48-60 participants were recruited. Viral suppression in the ART 12-24 group was 72.1% (95% CI: 66.3-77.2) overall, 75.0% (65.2-82.7) in urban sites, and 67.7% (58.3-75.8) in rural sites. In the ART 48-60 group, viral suppression was 67.7% (55.8-77.7). Overall, HIV drug resistance (HIVDR) was 17.7% (15.1-20.6) and 28.3% (17.4-42.5) in the ART 12-24 and ART 48-60 groups, respectively. However, among patients with VL ? 1000 copies/ml, HIVDR was identified in 63.3% (52.0-73.3) of ART 12-24 patients, and in 87.7% (67.4-96.1) of ART 48-60 patients. Conclusions: Results of this first nationwide study indicate alarming levels of virological failure and ADR in Cameroon. Better ART management is urgently needed and should focus on improving ART adherence, availability of VL monitoring, and more timely switches to second-line ART.

      17. Evaluation of facility and community-based active household tuberculosis contact investigation in Ethiopia: a cross-sectional studyexternal icon
        Tefera F, Barnabee G, Sharma A, Feleke B, Atnafu D, Haymanot N, O’Malley G, Feleke G.
        BMC Health Serv Res. 2019 Apr 22;19(1):234.
        BACKGROUND: No established strategy for household tuberculosis (TB) contact investigation (HTCI) exists in Ethiopia. We implemented integrated, active HTCI model into two hospitals and surrounding community health services to determine yield of active HTCI of all forms of TB and explore factors associated with active TB diagnosis in household contacts (HHCs). METHODS: Case managers obtained HHC information from index cases at TB/DOTS clinic and liaised with health extension workers (HEWs) who screened HHCs for TB at household and referred contacts under five and presumptive cases for diagnostic investigation. RESULTS: From 363 all forms TB index cases, 1509 (99%) HHCs were screened and 809 (54%) referred, yielding 19 (1.3%) all forms TB cases. HTCI of sputum smear-positive pulmonary TB (SS + PTB) index cases produced yield of 4.3%. HHCs with active TB were more likely to be malnourished (OR: 3.39, 95%CI: 1.19-9.64), live in households with SS + PTB index case (OR: 7.43, 95%CI: 1.64-33.73) or TB history (OR: 4.18, 95%CI: 1.51-11.55). CONCLUSION: Active HTCI of all forms of TB cases produced comparable or higher yield than reported elsewhere. HTCI contributes to improved and timely case detection of Tuberculosis among population who may not seek health care due to minimal symptoms or access issues. Active HTCI can successfully be implemented through integrated approach with existing community TB programs for better coordination and efficiency. Referral criteria should include factors significantly associated with active disease.

    • Disaster Control and Emergency Services
      1. Approach to prioritizing respiratory protection when demand exceeds supplies during an influenza pandemic: A call to actionexternal icon
        Patel A, Lee L, Pillai SK, Valderrama AL, Delaney LJ, Radonovich L.
        Health Secur. 2019 Mar/Apr;17(2):152-155.

        [No abstract]

      2. Quality assurance sampling plans in US stockpiles for personal protective equipmentexternal icon
        Yorio PL, Rottach DR, Dubaniewicz M.
        Health Secur. 2019 Mar/Apr;17(2):140-151.
        Personal protective equipment (PPE) stockpiles in the United States were established to facilitate rapid deployment of medical assets to sites affected by public health emergencies. Large quantities of PPE were introduced into US stockpiles because of the need to protect healthcare and other professionals during these events. Because most stockpiled PPE was acquired during, or immediately following, large-scale public health events, such as pandemic influenza planning (2005-20080), SARS (2003), H1N1 (2009-10), and Ebola (2014-15), aging PPE poses a significant problem. PPE such as N95 filtering face piece respirators were not designed to be stored for long periods, and much of the currently stored PPE has exceeded its manufacturer-assigned shelf life. Given the significant investment in the procurement and storage of PPE, along with projections of consumption during public health emergencies, discarding large quantities of potentially viable PPE is not an attractive option. Although shelf-life extension programs exist for other stockpiled medical assets, no such option is currently available for stockpiled PPE. This article posits stockpile quality assurance sampling plans as a mechanism through which shelf-life extension programs for stockpiled PPE may be achieved. We discuss some of the nuances that should be considered when developing a plan tailored to stockpiles and provide basic decision tools that may be used in the context of a quality assurance program tailored to stockpiled PPE. We also explore basic information by comparing and contrasting different sample size options.

    • Environmental Health
      1. Review of acellular assays of ambient particulate matter oxidative potential: Methods and relationships with composition, sources, and health effectsexternal icon
        Bates JT, Fang T, Verma V, Zeng L, Weber RJ, Tolbert PE, Abrams JY, Sarnat SE, Klein M, Mulholland JA, Russell AG.
        Environ Sci Technol. 2019 Apr 16;53(8):4003-4019.
        Oxidative stress is a potential mechanism of action for particulate matter (PM) toxicity and can occur when the body’s antioxidant capacity cannot counteract or detoxify harmful effects of reactive oxygen species (ROS) due to an excess presence of ROS. ROS are introduced to the body via inhalation of PM with these species present on and/or within the particles (particle-bound ROS) and/or through catalytic generation of ROS in vivo after inhaling redox-active PM species (oxidative potential, OP). The recent development of acellular OP measurement techniques has led to a surge in research across the globe. In this review, particle-bound ROS techniques are discussed briefly while OP measurements are the focus due to an increasing number of epidemiologic studies using OP measurements showing associations with adverse health effects in some studies. The most common OP measurement techniques, including the dithiothreitol assay, glutathione assay, and ascorbic acid assay, are discussed along with evidence for utility of OP measurements in epidemiologic studies and PM characteristics that drive different responses between assay types (such as species composition, emission source, and photochemistry). Overall, most OP assays respond to metals like copper than can be found in emission sources like vehicles. Some OP assays respond to organics, especially photochemically aged organics, from sources like biomass burning. Select OP measurements have significant associations with certain cardiorespiratory end points, such as asthma, congestive heart disease, and lung cancer. In fact, multiple studies have found that exposure to OP measured using the dithiothreitol and glutathione assays drives higher risk ratios for certain cardiorespiratory outcomes than PM mass, suggesting OP measurements may be integrating the health-relevant fraction of PM and will be useful tools for future health analyses. The compositional impacts, including species and emission sources, on OP could have serious implications for health-relevant PM exposure. Though more work is needed, OP assays show promise for health studies as they integrate the impacts of PM species and properties on catalytic redox reactions into one measurement, and current work highlights the importance of metals, organic carbon, vehicles, and biomass burning emissions to PM exposures that could impact health.

    • Food Safety
      1. Preliminary incidence and trends of infections with pathogens transmitted commonly through food – Foodborne Diseases Active Surveillance Network, 10 U.S. Sites, 2015-2018external icon
        Tack DM, Marder EP, Griffin PM, Cieslak PR, Dunn J, Hurd S, Scallan E, Lathrop S, Muse A, Ryan P, Smith K, Tobin-D’Angelo M, Vugia DJ, Holt KG, Wolpert BJ, Tauxe R, Geissler AL.
        MMWR Morb Mortal Wkly Rep. 2019 Apr 26;68(16):369-373.
        Foodborne diseases represent a major health problem in the United States. The Foodborne Diseases Active Surveillance Network (FoodNet) of CDC’s Emerging Infections Program monitors cases of laboratory-diagnosed infection caused by eight pathogens transmitted commonly through food in 10 U.S. sites.* This report summarizes preliminary 2018 data and changes since 2015. During 2018, FoodNet identified 25,606 infections, 5,893 hospitalizations, and 120 deaths. The incidence of most infections is increasing, including those caused by Campylobacter and Salmonella, which might be partially attributable to the increased use of culture-independent diagnostic tests (CIDTs). The incidence of Cyclospora infections increased markedly compared with 2015-2017, in part related to large outbreaks associated with produce (1). More targeted prevention measures are needed on produce farms, food animal farms, and in meat and poultry processing establishments to make food safer and decrease human illness.

    • Health Behavior and Risk
      1. BACKGROUND: HIV and other sexually transmissible infections (HIV/STIs) are significant contributors to adolescent girls’ morbidity in the US. Risks for HIV/STIs are increased among adolescent girls involved in the juvenile justice system, and African American adolescent girls comprise nearly 50% of adolescent girls in detention centres. Although HIV prevention programs focus on HIV/STI knowledge, increased knowledge may not be sufficient to reduce sexual risk. The present study examined the interactive effects of HIV/STI knowledge and the importance of being in a relationship (a relationship imperative) on sexual risk behaviours in a sample of detained African American adolescent girls. METHODS: In all, 188 African American adolescent girls, 13-17 years of age, were recruited from a short-term detention facility in Atlanta, Georgia, and completed assessments on sexual risk behaviours, relationship characteristics, HIV/STI knowledge and several psychosocial risk factors. RESULTS: When girls endorsed a relationship imperative, higher HIV/STI knowledge was associated with low partner communication self-efficacy, inconsistent condom use and unprotected sex, when controlling for demographics and self-esteem. CONCLUSIONS: Young girls with high HIV/STI knowledge may have placed themselves at risk for HIV/STIs given the importance and value they place on being in a relationship. Contextual factors should be considered when developing interventions.

    • Health Economics
      1. Estimating the costs and income of providing vaccination to adults and childrenexternal icon
        Yarnoff B, Kim D, Zhou F, Leidner AJ, Khavjou O, Bates L, Bridges CB.
        Med Care. 2019 Apr 23.
        INTRODUCTION: Vaccinations are recommended to prevent serious morbidity and mortality. However, providers’ concerns regarding costs and payments for providing vaccination services are commonly reported barriers to adult vaccination. Information on the costs of providing vaccination is limited, especially for adults. METHODS: We recruited 4 internal medicine, 4 family medicine, 2 pediatric, 2 obstetrics and gynecology (OBGYN) practices, and 2 community health clinics in North Carolina to participate in a study to assess the economic costs and benefits of providing vaccination services for adults and children. We conducted a time-motion assessment of vaccination-related activities in the provider office and a survey to providers on vaccine management costs. We estimated mean cost per vaccination, minimum and maximum payments received, and income. RESULTS: Across all provider settings, mean cost per vaccine administration was $14 with substantial variation by practice setting (pediatric: $10; community health clinics: $15; family medicine: $17; OBGYN: $23; internal medicine: $23). When receiving the maximum payment, all provider settings had positive income for vaccination services. When receiving the minimum reported payments for vaccination services, pediatric and family medicine practices had positive income, internal medicine, and OBGYN practices had approximately equal costs and payments, and community health clinics had losses or negative income. CONCLUSIONS: Overall, vaccination service providers appeared to have small positive income from vaccination services. In some cases, providers experienced negative income, which underscores the need for providers and policymakers to design interventions and system improvements to make vaccination services financially sustainable for all provider types.

    • Healthcare Associated Infections
      1. Heartland virus infection in a heart transplant recipient from the Heartlandexternal icon
        Hevey MA, O’Halloran JA, Jagger BW, Staples JE, Lambert AJ, Panella AJ, Kosoy OI, Turabelidze G, Raymer DS, Ewald GA, Kwon JH.
        Transpl Infect Dis. 2019 Apr 22:e13098.
        Tick-borne infections represent a significant health risk each year in the United States. Immunocompromised patients are typically at risk of more severe disease manifestations than their immunocompetent counterparts. Here we report a case of a newly emerging phlebovirus, Heartland virus, in a heart transplant recipient. This article is protected by copyright. All rights reserved.

      2. Potential utility of pharmacy data to measure antibiotic use in nursing homesexternal icon
        Kabbani S, Palms DL, Bartoces M, Marek J, Stone ND, Hicks LA, Jump RL.
        Infect Control Hosp Epidemiol. 2019 Apr 24:1-2.

        [No abstract]

      3. Hepatitis C virus potentially transmitted by opioid drug diversion from a nurse – Washington, August 2017-March 2018external icon
        Njuguna HN, Stinson D, Montgomery P, Turner N, D’Angeli M, Carr J, Podczervinski S, Wasserman C, Ramachandran S, Lucas T, Bixler D, Perkins K, Benowitz I, Moorman A.
        MMWR Morb Mortal Wkly Rep. 2019 Apr 26;68(16):374-376.
        During January 22-March 23, 2018, a local health department in Washington was notified of two patients who received a diagnosis of acute hepatitis C virus (HCV) infection. Neither patient had behavioral risk factors associated with HCV acquisition; however, both had received injectable narcotic (opioid) drugs from the same nurse during separate visits to an emergency department (ED) at a local hospital on December 6 and December 16, 2017. Investigation revealed that the nurse had accessed the automated drug dispensing system at a higher frequency than had other staff members, admitted diverting* patients’ injectable narcotic and antihistamine drugs for personal use, and tested positive for HCV antibodies (anti-HCV) on March 19, 2018, but did not have quantifiable HCV RNA. Specimens from both patients were sent to CDC for genetic testing, and HCV viral variants analysis found a significant level of genetically similar HCV variants in both patients, indicating a common source of infection. Further investigation was conducted to confirm the infection source, identify other potentially exposed patients, and treat any new patients who received an HCV diagnosis. Monitoring frequency of access to drug dispensing systems can help identify staff members with abnormal dispensing patterns, including diversion activities (1). U.S. health care facilities are required to prevent, identify, and report any loss, diversion, or theft of controlled substances (2).

    • Immunity and Immunization
      1. Long intervals between two doses of HPV vaccines and magnitude of the immune response: A post-hoc analysis of two clinical trialsexternal icon
        Gilca V, Sauvageau C, Panicker G, De Serres G, Schiller J, Ouakki M, Unger ER.
        Hum Vaccin Immunother. 2019 Apr 24.
        The objective of this analysis was to compare the anti-HPV GMTs and their distribution after a 6- month or a 3-8 year interval between two HPV vaccine doses. The results from two clinical trials, conducted by the same team in the same region, with serological assays performed at the same laboratory using the same ELISA methodology were compared. In the first study, 173 9-10 year-old girls and boys received two doses of 9vHPV vaccine at a 6-month interval; in the second study, 31 girls vaccinated with one dose of 4vHPV at the age of 9-14 years received a dose of 9vHPV 3-8 years later (mean 5.4 years). In both studies blood samples were collected before and 1 month post-second dose. Despite large differences in the time since the first dose, all subjects (100%) were seropositive to the common 4 HPV types (6, 11, 16 and 18) to both vaccines, with comparable GMTs and titer distributions before the second dose. One-month post-second dose, the GMTs increased 40- to 91-fold for those with a 6-month interval between doses and 60- to 82-fold for those with a 3-8 year interval. Titer distributions after the booster dose were comparable in the two studies. These results indicate that 2-dose HPV vaccination schedules with an interval of several years could be used for pre-adolescents. Intervals longer than 6 months may facilitate logistics for immunization programs and could be useful during periods of vaccine shortage or as a transition while the effectiveness of a one-dose schedule is being evaluated. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or of the Quebec Public Health Institute.

      2. International genomic definition of pneumococcal lineages, to contextualise disease, antibiotic resistance and vaccine impactexternal icon
        Gladstone RA, Lo SW, Lees JA, Croucher NJ, van Tonder AJ, Corander J, Page AJ, Marttinen P, Bentley LJ, Ochoa TJ, Ho PL, du Plessis M, Cornick JE, Kwambana-Adams B, Benisty R, Nzenze SA, Madhi SA, Hawkins PA, Everett DB, Antonio M, Dagan R, Klugman KP, von Gottberg A, McGee L, Breiman RF, Bentley SD.
        EBioMedicine. 2019 Apr 16.
        BACKGROUND: Pneumococcal conjugate vaccines have reduced the incidence of invasive pneumococcal disease, caused by vaccine serotypes, but non-vaccine-serotypes remain a concern. We used whole genome sequencing to study pneumococcal serotype, antibiotic resistance and invasiveness, in the context of genetic background. METHODS: Our dataset of 13,454 genomes, combined with four published genomic datasets, represented Africa (40%), Asia (25%), Europe (19%), North America (12%), and South America (5%). These 20,027 pneumococcal genomes were clustered into lineages using PopPUNK, and named Global Pneumococcal Sequence Clusters (GPSCs). From our dataset, we additionally derived serotype and sequence type, and predicted antibiotic sensitivity. We then measured invasiveness using odds ratios that relating prevalence in invasive pneumococcal disease to carriage. FINDINGS: The combined collections (n=20,027) were clustered into 621 GPSCs. Thirty-five GPSCs observed in our dataset were represented by >100 isolates, and subsequently classed as dominant-GPSCs. In 22/35 (63%) of dominant-GPSCs both non-vaccine serotypes and vaccine serotypes were observed in the years up until, and including, the first year of pneumococcal conjugate vaccine introduction. Penicillin and multidrug resistance were higher (p<.05) in a subset dominant-GPSCs (14/35, 9/35 respectively), and resistance to an increasing number of antibiotic classes was associated with increased recombination (R(2)=0.27 p<.0001). In 28/35 dominant-GPSCs, the country of isolation was a significant predictor (p<.05) of its antibiogram (mean misclassification error 0.28, SD+/-0.13). We detected increased invasiveness of six genetic backgrounds, when compared to other genetic backgrounds expressing the same serotype. Up to 1.6-fold changes in invasiveness odds ratio were observed. INTERPRETATION: We define GPSCs that can be assigned to any pneumococcal genomic dataset, to aid international comparisons. Existing non-vaccine-serotypes in most GPSCs preclude the removal of these lineages by pneumococcal conjugate vaccines; leaving potential for serotype replacement. A subset of GPSCs have increased resistance, and/or serotype-independent invasiveness.

      3. Safety profile of the RTS,S/AS01 malaria vaccine in infants and children: additional data from a phase III randomized controlled trial in sub-Saharan Africaexternal icon
        Guerra Mendoza Y, Garric E, Leach A, Lievens M, Ofori-Anyinam O, Pircon JY, Stegmann JU, Vandoolaeghe P, Otieno L, Otieno W, Owusu-Agyei S, Sacarlal J, Masoud NS, Sorgho H, Tanner M, Tinto H, Valea I, Mtoro AT, Njuguna P, Oneko M, Otieno GA, Otieno K, Gesase S, Hamel MJ, Hoffman I, Kaali S, Kamthunzi P, Kremsner P, Lanaspa M, Lell B, Lusingu J, Malabeja A, Aide P, Akoo P, Ansong D, Asante KP, Berkley JA, Adjei S, Agbenyega T, Agnandji ST, Schuerman L.
        Hum Vaccin Immunother. 2019 Apr 23:1-13.
        A phase III, double-blind, randomized, controlled trial (NCT00866619) in sub-Saharan Africa showed RTS,S/AS01 vaccine efficacy against malaria. We now present in-depth safety results from this study. 8922 children (enrolled at 5-17 months) and 6537 infants (enrolled at 6-12 weeks) were 1:1:1-randomized to receive 4 doses of RTS,S/AS01 (R3R) or non-malaria control vaccine (C3C), or 3 RTS,S/AS01 doses plus control (R3C). Aggregate safety data were reviewed by a multi-functional team. Severe malaria with Blantyre Coma Score </=2 (cerebral malaria [CM]) and gender-specific mortality were assessed post-hoc. Serious adverse event (SAE) and fatal SAE incidences throughout the study were 24.2%-28.4% and 1.5%-2.5%, respectively across groups; 0.0%-0.3% of participants reported vaccination-related SAEs. The incidence of febrile convulsions in children was higher during the first 2-3 days post-vaccination with RTS,S/AS01 than with control vaccine, consistent with the time window of post-vaccination febrile reactions in this study (mostly the day after vaccination). A statistically significant numerical imbalance was observed for meningitis cases in children (R3R: 11, R3C: 10, C3C: 1) but not in infants. CM cases were more frequent in RTS,S/AS01-vaccinated children (R3R: 19, R3C: 24, C3C: 10) but not in infants. All-cause mortality was higher in RTS,S/AS01-vaccinated versus control girls (2.4% vs 1.3%, all ages) in our setting with low overall mortality. The observed meningitis and CM signals are considered likely chance findings, that – given their severity – warrant further evaluation in phase IV studies and WHO-led pilot implementation programs to establish the RTS,S/AS01 benefit-risk profile in real-life settings.

      4. Association of state laws with influenza vaccination of hospital personnelexternal icon
        Lindley MC, Mu Y, Hoss A, Pepin D, Kalayil EJ, van Santen KL, Edwards JR, Pollock DA.
        Am J Prev Med. 2019 Apr 16.
        INTRODUCTION: Healthcare personnel influenza vaccination can reduce influenza illness and patient mortality. State laws are one tool promoting healthcare personnel influenza vaccination. METHODS: A 2016 legal assessment in 50 states and Washington DC identified (1) assessment laws: mandating hospitals assess healthcare personnel influenza vaccination status; (2) offer laws: mandating hospitals offer influenza vaccination to healthcare personnel; (3) ensure laws: mandating hospitals require healthcare personnel to demonstrate proof of influenza vaccination; and (4) surgical masking laws: mandating unvaccinated healthcare personnel to wear surgical masks during influenza season. Influenza vaccination was calculated using data reported in 2016 by short-stay acute care hospitals (n=4,370) to the National Healthcare Safety Network. Hierarchical linear modeling in 2018 examined associations between reported vaccination and assessment, offer, or ensure laws at the level of facilities nested within states, among employee and non-employee healthcare personnel and among employees only. RESULTS: Eighteen states had one or more healthcare personnel influenza vaccination-related laws. In the absence of any state laws, facility vaccination mandates were associated with an 11-12 percentage point increase in mean vaccination coverage (p<0.0001). Facility-level mandates were estimated to increase mean influenza vaccination coverage among all healthcare personnel by 4.2 percentage points in states with assessment laws, 6.6 percentage points in states with offer laws, and 3.1 percentage points in states with ensure laws. Results were similar in analyses restricted only to employees although percentage point increases were slightly larger. CONCLUSIONS: State laws moderate the effect of facility-level vaccination mandates and may help increase healthcare personnel influenza vaccination coverage in facilities with or without vaccination requirements.

      5. Building health workforce capacity for planning and monitoring through the Strengthening Technical Assistance for routine immunization training (START) approach in Ugandaexternal icon
        Ward K, Stewart S, Wardle M, Sodha SV, Tanifum P, Ayebazibwe N, Mayanja R, Luzze H, Ehlman DC, Conklin L, Abbruzzese M, Sandhu HS.
        Vaccine. 2019 Apr 15.
        INTRODUCTION: The Global Vaccine Action Plan identifies workforce capacity building as a key strategy to achieve strong immunization programs. The Strengthening Technical Assistance for Routine Immunization Training (START) approach aimed to utilize practical training methods to build capacity of district and health center staff to implement routine immunization (RI) planning and monitoring activities, as well as build supportive supervision skills of district staff. METHODS: First implemented in Uganda, the START approach was executed by trained external consultants who used existing tools, resources, and experiences to mentor district-level counterparts and, with them, conducted on-the-job training and mentorship of health center staff over several site visits. Implementation was routinely monitored using daily activity reports, pre and post surveys of resources and systems at districts and health centers and interviews with START consultants. RESULTS: From July 2013 through December 2014 three START teams of four consultants per team, worked 6months each across 50 districts in Uganda including the five divisions of Kampala district (45% of all districts). They conducted on-the-job training in 444 selected under-performing health centers, with a median of two visits to each (range 1-7, IQR: 1-3). More than half of these visits were conducted in collaboration with the district immunization officer, providing the opportunity for mentorship of district immunization officers. Changes in staff motivation and awareness of challenges; availability and completion of RI planning and monitoring tools and systems were observed. However, the START consultants felt that potential durability of these changes may be limited by contextual factors, including external accountability, availability of resources, and individual staff attitude. CONCLUSIONS: Mentoring and on-the-job training offer promising alternatives to traditional classroom training and audit-focused supervision for building health workforce capacity. Further evidence regarding comparative effectiveness of these strategies and durability of observed positive change is needed.

      6. The use of natural language processing to identify Tdap-related local reactions at five health care systems in the Vaccine Safety Datalinkexternal icon
        Zheng C, Yu W, Xie F, Chen W, Mercado C, Sy LS, Qian L, Glenn S, Lee G, Tseng HF, Duffy J, Jackson LA, Daley MF, Crane B, McLean HQ, Jacobsen SJ.
        Int J Med Inform. 2019 ;127:27-34.
        Objective: Local reactions are the most common vaccine-related adverse event. There is no specific diagnosis code for local reaction due to vaccination. Previous vaccine safety studies used non-specific diagnosis codes to identify potential local reaction cases and confirmed the cases through manual chart review. In this study, a natural language processing (NLP) algorithm was developed to identify local reaction associated with tetanus-diphtheria-acellular pertussis (Tdap) vaccine in the Vaccine Safety Datalink. Methods: Presumptive cases of local reactions were identified among members ? 11 years of age using ICD-9-CM codes in all care settings in the 1-6 days following a Tdap vaccination between 2012 and 2014. The clinical notes were searched for signs and symptoms consistent with local reaction. Information on the timing and the location of a sign or symptom was also extracted to help determine whether or not the sign or symptom was vaccine related. Reactions triggered by causes other than Tdap vaccination were excluded. The NLP algorithm was developed at the lead study site and validated on a stratified random sample of 500 patients from five institutions. Results: The NLP algorithm achieved an overall weighted sensitivity of 87.9%, specificity of 92.8%, positive predictive value of 82.7%, and negative predictive value of 95.1%. In addition, using data at one site, the NLP algorithm identified 3326 potential Tdap-related local reactions that were not identified through diagnosis codes. Conclusion: The NLP algorithm achieved high accuracy, and demonstrated the potential of NLP to reduce the efforts of manual chart review in vaccine safety studies.

    • Injury and Violence
      1. Children’s exposure to poly-victimization, which is the experience of multiple types of victimization, has been found to be associated with negative health outcomes and risk behaviors. We examined the collective effects of childhood sexual, physical, and emotional violence on selected self-reported health outcomes among young Kenyan females and males using the Violence Against Children Survey (VACS). Overall, 76.2% of females and 79.8% of males were victims of sexual, physical, or emotional violence prior to age 18, and one-third (32.9% and 34.5%, respectively) experienced two or more types of violence. Poly-victimization was significantly associated with current feelings of anxiety, depression, and suicidal thoughts in females and males, as well as self-reported fair or poor health in males (p < .05) as compared to those who experienced no violence. The study data demonstrate an urgent need to reduce all types of violence against children, as well develop appropriate strategies for its prevention.

    • Laboratory Sciences
      1. During the aging process, skeletal muscle performance and physiology undergoes alterations leading to decrements in functional capacity, health-span, and independence. Background: The utility and implementation of age-specific exercise is a paramount research agenda focusing on ameliorating the loss of both skeletal muscle performance and physiology; yet, to date, no consensus exists as to the most appropriate mechanical loading protocol design or overall exercise prescription that best meets this need. Thus, the purpose of this review is to highlight the most optimal type of exercise presently available and provide the most current, evidence-based findings for its efficacy. The hypothesis that high-intensity, stretch-shortening contractions (SSCs)-a form of “resistance-type exercise” training-present as the preferred exercise mode for serving as an intervention-based modality to attenuate dynapenia, sarcopenia, and decreased muscle quality with aging, even restoring the overall youthful phenotype, will be demonstrated. Conclusions: Appreciating the fundamental evidence supporting the use of high-intensity SSCs in positively impacting aging skeletal muscle’s responsivity and their use as a specific and sensitive countermeasure is crucial. Moreover, from an applied perspective, SSCs may improve skeletal muscle quality and rejuvenate health-span and, ultimately, lead to augmented functional capacity, independence, and quality of life concomitant with decreased morbidity.

      2. Assessment of eight nucleic acid amplification technologies for potential use to detect infectious agents in low-resource settingsexternal icon
        Cantera JL, White H, Diaz MH, Beall SG, Winchell JM, Lillis L, Kalnoky M, Gallarda J, Boyle DS.
        PLoS One. 2019 ;14(4):e0215756.
        Nucleic acid amplification technologies (NAATs) are high-performance tools for rapidly and accurately detecting infectious agents. They are widely used in high-income countries to diagnose disease and improve patient care. The complexities associated with test methods, reagents, equipment, quality control and assurance require dedicated laboratories with trained staff, which can exclude their use in low-resource and decentralized healthcare settings. For certain diseases, fully integrated NAAT devices and assays are available for use in environmentally-controlled clinics or emergency rooms where relatively untrained staff can perform testing. However, decentralized settings in many low- and middle-income countries with large burdens of infectious disease are challenged by extreme environments, poor infrastructure, few trained staff and limited financial resources. Therefore, there is an urgent need for low-cost, integrated NAAT tools specifically designed for use in low-resource settings (LRS). Two essential components of integrated NAAT tools are: 1) efficient nucleic acid extraction technologies for diverse and complex sample types; and 2) robust and sensitive nucleic acid amplification and detection technologies. In prior work we reported the performance and workflow capacity for the nucleic acid extraction component. In the current study we evaluated performance of eight novel nucleic acid amplification and detection technologies from seven developers using blinded panels of RNA and/or DNA from three pathogens to assess both diagnostic accuracy and suitability as an essential component for low-cost NAAT in LRS. In this exercise, we noted significant differences in performance among these technologies and identified those most promising for potential further development.

      3. Comparison of nucleic acid extraction methods for next-generation sequencing of avian influenza A virus from ferret respiratory samplesexternal icon
        Di H, Thor S, Trujillo AA, Stark T, Marinova-Petkova A, Jones J, Wentworth DE, Barnes J, Davis CT.
        J Virol Methods. 2019 Apr 17.
        Influenza A virus is a negative-sense RNA virus with a segmented genome consisting of eight RNA segments. Avian influenza A virus (AIV) primarily infects avian hosts and sporadically infects mammals, which can lead to adaptation to new species. Next-generation sequencing (NGS) of emerging AIV genomes extracted from respiratory samples collected on sequential days from animal models and clinical patients enables analysis of the emergence of evolutionary variants within the virus population over time. However, obtaining codon complete AIV genome at a sufficient coverage depth for nucleotide variant calling remains a challenge, especially from post-inoculation respiratory samples collected at late time points that have low viral titers. In this study, nasal wash samples from ferrets inoculated with different subtypes of AIV were collected on various days post-inoculation. Each nasal wash sample was aliquoted and extracted using five commercially available nucleic acid extraction methods. Extracted influenza virus RNA was amplified and NGS conducted using Illumina Mi-Seq. For each nasal wash sample, completeness of AIV genome segments and coverage depth were compared among five extraction methods. Nucleic acids extracted by MagNA pure compact RNA isolation consistently yielded codon complete sequences for all eight genome segments at the required coverage depth at each time point sampled. The study revealed that DNase treatment was critical to the amplification of influenza genome segments and the downstream success of codon complete NGS from nasal wash samples. The findings from this study can be applied to improve NGS of influenza and other RNA viruses that infect the respiratory tract and are collected from respiratory samples.

      4. A real-time multiplex PCR assay for detection of Elizabethkingia species and differentiation between Elizabethkingia anophelis and E. meningosepticaexternal icon
        Kelly AJ, Karpathy SE, Gulvik CA, Ivey ML, Whitney AM, Bell ME, Nicholson AC, Humrighouse BW, McQuiston JR.
        J Clin Microbiol. 2019 Apr;57(4).
        Nosocomial infections of Elizabethkingia species can have fatal outcomes if not identified and treated properly. The current diagnostic tools available require culture and isolation, which can extend the reporting time and delay treatment. Using comparative genomics, we developed an efficient multiplex real-time PCR for the simultaneous detection of all known species of Elizabethkingia, as well as differentiating the two most commonly reported species, Elizabethkingia anophelis and Elizabethkingia meningoseptica.

      5. Multiple ion transition summation of isotopologues for improved mass spectrometric detection of N-Acetyl-S-(1,2-dichlorovinyl)-L-cysteineexternal icon
        Movassaghi CS, McCarthy DP, Bhandari D, Blount BC, De Jesus VR.
        J Am Soc Mass Spectrom. 2019 Apr 22.
        Multiple ion transition summation of isotopologues (MITSI) is an adaptable and easy-to-implement methodology for improving analytical sensitivity, especially for halogenated compounds and otherwise abundant isotopologues. This novel application of signal summing was applied to measure and quantitate the two most abundant ion transitions of two isotopologues of N-acetyl-S-(1,2-dichlorovinyl)-L-cysteine (1DCV), a urinary metabolite of trichloroethylene (TCE). Because 1DCV is dichlorinated, only approximately half of the total potential signal is quantifiable when the monoisotopic ion transition (i.e., 256 –> 127 for (35)Cl2) is monitored. By summing the intensity of a separate and high-abundance 1DCV isotopologue ion transition (i.e., 258 –> 129 to include (35)Cl and (37)Cl), overall signal intensity increased by over 70%. This summation technique improved the analytical sensitivity and limit of detection (LOD) by factors of 2.3 and 2.9, respectively, compared to monitoring the two transitions separately, without summation. Separation and detection were performed using liquid chromatography-tandem mass spectrometry (LC-MS/MS) in negative-ion mode with scheduled selected reaction monitoring. This approach was verified for accuracy and precision using two quality control materials. In addition, we derived a modified signal summation equation to calculate predicted signal enhancements specific to the MITSI approach. Graphical Abstract .

      6. The taxonomic position of strain 15-057A(T), an acidophilic actinobacterium isolated from the bronchial lavage of an 80-year-old male, was determined using a polyphasic approach incorporating morphological, phenotypic, chemotaxonomic and genomic analyses. Pairwise 16S rRNA gene sequence similarities calculated using the GGDC web server between strain 15-057A(T) and its closest phylogenetic neighbours, Streptomyces griseoplanus NBRC 12779(T) and Streptacidiphilus oryzae TH49(T), were 99.7 and 97.6 %, respectively. The G+C content of isolate 15-057A(T) was determined to be 72.6 mol%. DNA-DNA relatedness and average nucleotide identity between isolate 15-057A(T) and Streptomyces griseoplanus DSM 40009(T) were 29.2+/-2.5 % and 85.97 %, respectively. Chemotaxonomic features of isolate 15-057A(T) were consistent with its assignment within the genus Streptacidiphilus: the whole-cell hydrolysate contained ll-diaminopimelic acid as the diagnostic diamino acid and glucose, mannose and ribose as cell-wall sugars; the major menaquinone was MK9(H8); the polar lipid profile consisted of diphosphatidylglycerol, phosphatidylethanolamine, phosphatidylinositol, glycophospholipid, aminoglycophospholipid and an unknown lipid; the major fatty acids were anteiso-C15 : 0 and iso-C16 : 0. Phenotypic and morphological traits distinguished isolate 15-057A(T) from its closest phylogenetic neighbours. The results of our taxonomic analyses showed that strain 15-057A(T) represents a novel species within the evolutionary radiation of the genus Streptacidiphilus, for which the name Streptacidiphilus bronchialis sp. nov. is proposed. The type strain is 15-057A(T) (=DSM 106435(T)=ATCC BAA-2934(T)).

      7. Comparison of minimally invasive tissue sampling with conventional autopsy to detect pulmonary pathology among respiratory deaths in a resource-limited settingexternal icon
        Roberts DJ, Njuguna HN, Fields B, Fligner CL, Zaki SR, Keating MK, Rogena E, Walong E, Gachii AK, Maleche-Obimbo E, Irimu G, Mathaiya J, Orata N, Lopokoiyit R, Michuki J, Emukule GO, Onyango CO, Gikunju S, Owuor C, Muturi PK, Bunei M, Widdowson MA, Mott JA, Chaves SS.
        Am J Clin Pathol. 2019 Apr 22.
        OBJECTIVES: We compared minimally invasive tissue sampling (MITS) with conventional autopsy (CA) in detection of respiratory pathology/pathogens among Kenyan children younger than 5 years who were hospitalized with respiratory disease and died during hospitalization. METHODS: Pulmonary MITS guided by anatomic landmarks was followed by CA. Lung tissues were triaged for histology and molecular testing using TaqMan Array Cards (TACs). MITS and CA results were compared for adequacy and concordance. RESULTS: Adequate pulmonary tissue was obtained by MITS from 54 (84%) of 64 respiratory deaths. Comparing MITS to CA, full histologic diagnostic concordance was present in 23 (36%) cases and partial concordance in 19 (30%), an overall 66% concordance rate. Pathogen detection using TACs had full concordance in 27 (42%) and partial concordance in 24 (38%) cases investigated, an overall 80% concordance rate. CONCLUSIONS: MITS is a viable alternative to CA in respiratory deaths in resource-limited settings, especially if combined with ancillary tests to optimize diagnostic accuracy.

    • Maternal and Child Health
      1. BACKGROUND: For women of reproductive age, a population-level red blood cell (RBC) folate concentration below the threshold 906 nmol/L or 400 ng/mL indicates folate insufficiency and suboptimal neural tube defect (NTD) prevention. A corresponding population plasma/serum folate concentration threshold for optimal NTD prevention has not been established. OBJECTIVE: The aim of this study was to examine the association between plasma and RBC folate concentrations and estimated a population plasma folate insufficiency threshold (pf-IT) corresponding to the RBC folate insufficiency threshold (RBCf-IT) of 906 nmol/L. METHODS: We analyzed data on women of reproductive age (n = 1673) who participated in a population-based, randomized folic acid supplementation trial in northern China. Of these women, 565 women with anemia and/or vitamin B-12 deficiency were ineligible for folic acid intervention (nonintervention group); the other 1108 received folic acid supplementation for 6 mo (intervention group). We developed a Bayesian linear model to estimate the pf-IT corresponding to RBCf-IT by time from supplementation initiation, folic acid dosage, methyltetrahydrofolate reductase (MTHFR) genotype, body mass index (BMI), vitamin B-12 status, or anemia status. RESULTS: Using plasma and RBC folate concentrations of the intervention group, the estimated median pf-IT was 25.5 nmol/L (95% credible interval: 24.6, 26.4). The median pf-ITs were similar between the baseline and postsupplementation samples (25.7 compared with 25.2 nmol/L) but differed moderately (+/-3-4 nmol/L) by MTHFR genotype and BMI. Using the full population-based baseline sample (intervention and nonintervention), the median pf-IT was higher for women with vitamin B-12 deficiency (34.6 nmol/L) and marginal deficiency (29.8 nmol/L) compared with the sufficient group (25.6 nmol/L). CONCLUSIONS: The relation between RBC and plasma folate concentrations was modified by BMI and genotype and substantially by low plasma vitamin B-12. This suggests that the threshold of 25.5 nmol/L for optimal NTD prevention may be appropriate in populations with similar characteristics, but it should not be used in vitamin B-12 insufficient populations. This trial was registered at as NCT00207558.

      2. Putting the “M” back in maternal-fetal medicine: A 5-year report card on a collaborative effort to address maternal morbidity and mortality in the United Statesexternal icon
        D’Alton ME, Friedman AM, Bernstein PS, Brown HL, Callaghan WM, Clark SL, Grobman WA, Kilpatrick SJ, O’Keeffe DF, Montgomery DM, Srinivas SK, Wendel GD, Wenstrom KD, Foley MR.
        Am J Obstet Gynecol. 2019 Mar 5.
        The Centers for Disease Control and Prevention have demonstrated continuous increased risk for maternal mortality and severe morbidity with racial disparities among non-Hispanic black women an important contributing factor. More than 50,000 women experienced severe maternal morbidity in 2014, with a mortality rate of 18.0 per 100,000, higher than in many other developed countries. In 2012, the first “Putting the ‘M’ back in Maternal-Fetal Medicine” session was held at the Society for Maternal-Fetal Medicine’s (SMFM) Annual Meeting. With the realization that rising risk for severe maternal morbidity and mortality required action, the “M in MFM” meeting identified the following urgent needs: (i) to enhance education and training in maternal care for maternal-fetal medicine (MFM) fellows; (ii) to improve the medical care and management of pregnant women across the country; and (iii) to address critical research gaps in maternal medicine. Since that first meeting, a broad collaborative effort has made a number of major steps forward, including the proliferation of maternal mortality review committees, advances in research, increasing educational focus on maternal critical care, and development of comprehensive clinical strategies to reduce maternal risk. Five years later, the 2017 M in MFM meeting served as a “report card” looking back at progress made but also looking forward to what needs to be done over the next 5 years, given that too many mothers still experience preventable harm and adverse outcomes.

      3. Sleep-related infant suffocation deaths attributable to soft bedding, overlay, and wedgingexternal icon
        Erck Lambert AB, Parks SE, Cottengim C, Faulkner M, Hauck FR, Shapiro-Mendoza CK.
        Pediatrics. 2019 Apr 22.
        BACKGROUND: Unintentional suffocation is the leading cause of injury death among infants <1 year old in the United States, with 82% being attributable to accidental suffocation and strangulation in bed. Understanding the circumstances surrounding these deaths may inform prevention strategies. METHODS: We analyzed data from the population-based Sudden Unexpected Infant Death Case Registry from 2011 to 2014. Cases categorized as explained suffocation with unsafe sleep factors (suffocation), per the Centers for Disease Control and Prevention’s Sudden Unexpected Infant Death Case Registry classification system, were included and assigned a mechanism of obstruction, including soft bedding, overlay, or wedging. We calculated frequencies and percentages of suffocation deaths by mechanism and selected demographic and sleep-environment characteristics. RESULTS: Fourteen percent of sudden unexpected infant death cases were classified as suffocation; these cases were most frequently attributed to soft bedding (69%), followed by overlay (19%) and wedging (12%). Median age at death in months varied by mechanism: 3 for soft bedding, 2 for overlay, and 6 for wedging. Soft-bedding deaths occurred most often in an adult bed (49%), in a prone position (82%), and with a blanket (or blankets) obstructing the airway (34%). Overlay deaths occurred most often in an adult bed (71%), and infants were overlaid by the mother (47%). Wedging deaths occurred most often when the infant became entrapped between a mattress and a wall (48%). CONCLUSIONS: Safe sleep environments can reduce infant suffocation deaths. Increased knowledge about the characteristics of suffocation deaths can help inform prevention strategies by targeting highest-risk groups.

    • Nutritional Sciences
      1. An understanding of the source of children’s foods and drinks is needed to identify the best intervention points for programs and policies aimed at improving children’s diets. The mean number and type of eating occasions and the relative proportions of foods and drinks consumed from different sources were calculated among children aged 1-4 years (n = 2640) using data from the 2009-2014 National Health and Nutrition Examination Surveys. Children consumed 2.9 meals and 2.4 snacks each day. Among children who received anything from childcare, childcare provided 36.2% of their foods and drinks. The majority of foods and drinks came from stores for all children (53.2% among those receiving anything from childcare and 84.9% among those not). Among children receiving food from childcare, childcare is an important source of foods and drinks. Because most foods and drinks consumed by children come from stores, parents and caregivers may benefit from nutrition education to promote healthful choices when buying foods.

    • Occupational Safety and Health
      1. Health effects from unintentional occupational exposure to opioids among law enforcement officers: Two case investigationsexternal icon
        Chiu SK, Hornsby-Myers JL, de Perio MA, Snawder JE, Wiegand DM, Trout D, Howard J.
        Am J Ind Med. 2019 Apr 23.
        Recent increases in the rate of drug overdose-related deaths, the emergence of potent opioids such as carfentanil, and media reports of incidents have raised concerns about the potential for work-related exposure to a variety of illicit drugs among law enforcement officers (LEOs), other emergency responders, and other workers in the United States. To characterize the risk associated with unintentional occupational exposure to drugs, we retrospectively investigated two incidents that occurred in 2017 and 2018 where LEOs were exposed to opioid and stimulant drugs and experienced health effects. We interviewed five affected LEOs and others. We reviewed records, including emergency department documentation, incident reports, forensic laboratory results, and when available, body camera footage. Multiple drug types, including opioids and nonopioids, were present at each incident. Potential routes of exposure varied among LEOs and were difficult to characterize with certainty. Health effects were not consistent with severe, life-threatening opioid toxicity, but temporarily precluded affected LEOs from performing their essential job duties. While health risks from occupational exposure to drugs during law enforcement activities cannot currently be fully characterized with certainty, steps to prevent such exposures should be implemented now. The creation and implementation of appropriate controls plus education and training are both important to protecting first responders from these hazardous agents. To more fully characterize potential exposures, timely prospective toxicological evaluation of affected responders is recommended.

      2. OBJECTIVE: According to the National Asthma Education and Prevention Program (NAEPP), self-management education is an integral component of effective asthma care and should be offered to every patient with asthma. To estimate the proportion of persons with work-related asthma (WRA) who received asthma self-management education. METHODS: A cross-sectional analysis of 2012-2014 Behavioral Risk Factor Surveillance System Asthma Call-back Survey data was conducted among ever-employed adults (>/=18 years) with current asthma from 31 states and the District of Columbia. RESULTS: Adults with WRA were significantly more likely than those with non-WRA to have ever taken a course to manage their asthma (15.7% versus 6.5%; PR = 2.1), been given an asthma action plan (43.5% versus 26.1%; PR = 1.7), shown how to use an inhaler (97.2% versus 95.8%; PR = 1.0), taught how to recognize early symptoms of an asthma episode (79.4% versus 64.1%; PR = 1.2), taught what to do during an asthma episode (86.4% versus 76.3%; PR = 1.1), taught how to use a peak flow meter to adjust daily medications (57.9% versus 41.7%; PR = 1.3), and advised to change things in home, school, or work (56.9% versus 30.4%; PR = 2.0). Moreover, targets for corresponding Healthy People 2020 respiratory disease objectives were met only among adults with WRA. CONCLUSIONS: Although adults with WRA were more likely to have received asthma self-management education, results suggest missed opportunities to provide asthma self-management education. Every healthcare visit should be used as an opportunity to discuss asthma self-management.

      3. Depressive symptoms among police officers: Associations with personality and psychosocial factorsexternal icon
        Jenkins EN, Allison P, Innes K, Violanti JM, Andrew ME.
        J Police Crim Psychol. 2019 ;34(1):67-77.
        Protective psychosocial factors may reduce the risk of stress-related illnesses in policing. We assessed the association between protective factors and depressive symptoms among 242 police officers. Participants were from the Buffalo Cardio-Metabolic Occupational Police Stress (BCOPS) Study (2004-2014). Coping, hardiness, personality traits, and social support were assessed at baseline. Depressive symptoms were measured at baseline and follow-up using the Center for Epidemiologic Studies-Depression (CES-D) scale. The relationship between protective factors and the rate of change in depressive symptoms was assessed using linear regression. Logistic regression evaluated associations between protective factors and new-onset depression. Of participants free of depression at baseline, 23 (10.7%) developed probable depression during the follow-up. Odds of new-onset depression increased with increasing neuroticism (adjusted odds ratio [OR ADJ ] = 1.22, 95% confidence interval [CI], 1.11-1.35) and passive coping (OR ADJ = 2.07, 95% CI, 1.06-4.03). Increasing agreeableness (OR ADJ = 0.87, 95% CI, 0.78-0.96) and conscientiousness (OR ADJ = 0.90, 95% CI, 0.84-0.98) were associated with decreased odds of new-onset depression. New-onset depression was not significantly associated with other coping subscales, hardiness, or social support. There were no significant associations between protective factors and change in depressive symptom scores. This study suggests certain personality characteristics and passive coping may be associated with increased odds of new-onset depression in police officers.

      4. Critical investigation of glove-gown interface barrier performance in simulated surgical settingsexternal icon
        Kahveci Z, Selcen Kilinc-Balci F, Yorio PL.
        J Occup Environ Hyg. 2019 Apr 25:1-9.
        The barrier properties of personal protective equipment are vital to healthcare personnel to protect themselves from possible infectious body fluids. Intraoperative exposure of healthcare personnel to body fluids can be substantial in both inpatient and outpatient settings. The glove-gown interface is known as one of the weakest points of the whole personal protective equipment system. However, there is a lack of scientific research designed to investigate the problem. This paper reports the results of experiments using a new testing methodology developed to quantify fluid leakage through the glove-gown interface while simulating surgical settings in terms of operating room personnel activities, exposure types, exposure durations, and physical stresses applied on the interface. This study represents one of the first efforts investigating the amount of fluid leakage through the glove-gown interface for a number of surgical gown and glove models while considering glove material differences and single vs. double gloving. The test results showed that there is a significant difference in fluid leakage amounts between three gown models and four glove models studied. The results also demonstrated that double gloving significantly reduced the fluid leakage compared to single glove use. The mean fluid leakage was lower in the double synthetic glove configurations (M = 2.76g) compared with all other configurations (3GLV, M = 8.3g; 4GLV, M = 9.49g; 5GLV, M = 3.08g; 6GLV, M = 20.03g; double latex, M = 5.22g). Findings highlighted a significant interaction between glove and gown designs, which suggests that gown and gloves should be designed together as a system to minimize or eliminate the fluid leakage.

      5. Results of the Workplace Health in America Surveyexternal icon
        Linnan LA, Cluff L, Lang JE, Penne M, Leff MS.
        Am J Health Promot. 2019 Apr 22:890117119842047.
        PURPOSE: To provide a nationally representative snapshot of workplace health promotion (WHP) and protection practices among United States worksites. DESIGN: Cross-sectional, self-report Workplace Health in America (WHA) Survey between November 2016 and September 2017. SETTING: National. PARTICIPANTS: Random sample of US worksites with >/=10 employees, stratified by region, size, and North American Industrial Classification System sector. MEASURES: Workplace health promotion programs, program administration, evidence-based strategies, health screenings, disease management, incentives, work-life policies, implementation barriers, and occupational safety and health (OSH). ANALYSIS: Descriptive statistics, t tests, and logistic regression. RESULTS: Among eligible worksites, 10.1% (n = 3109) responded, 2843 retained in final sample, and 46.1% offered some type of WHP program. The proportion of comparable worksites with comprehensive programs (as defined in Healthy People 2010) rose from 6.9% in 2004 to 17.1% in 2017 ( P < .001). Occupational safety and health programs were more prevalent than WHP programs, and 83.5% of all worksites had an individual responsible for employee safety, while only 72.2% of those with a WHP program had an individual responsible for it. Smaller worksites were less likely than larger to offer most programs. CONCLUSION: The prevalence of WHP programs has increased but remains low across most health programs; few worksites have comprehensive programs. Smaller worksites have persistent deficits and require targeted approaches; integrated OSH and WHP efforts may help. Ongoing monitoring using the WHA Survey benchmarks OSH and WHP in US worksites, updates estimates from previous surveys, and identifies gaps in research and practice.

      6. Tuberculosis among healthcare personnel, United States, 2010-2016external icon
        Mongkolrattanothai T, Lambert LA, Winston CA.
        Infect Control Hosp Epidemiol. 2019 Apr 23:1-4.
        We describe characteristics of US healthcare personnel (HCP) diagnosed with tuberculosis (TB). Among 64,770 adults with TB during 2010-2016, 2,460 (4%) were HCP. HCP with TB were more likely to be born outside of the United States, and less likely to have TB attributed to recent transmission, than non-HCP.

      7. Clustering asthma symptoms and cleaning and disinfecting activities and evaluating their associations among healthcare workersexternal icon
        Su FC, Friesen MC, Humann M, Stefaniak AB, Stanton ML, Liang X, LeBouf RF, Henneberger PK, Virji MA.
        Int J Hyg Environ Health. 2019 Apr 19.
        Asthma is a heterogeneous disease with varying severity and subtypes. Recent reviews of epidemiologic studies have identified cleaning and disinfecting activities (CDAs) as important risk factors for asthma-related outcomes among healthcare workers. However, the complexity of CDAs in healthcare settings has rarely been examined. This study utilized a complex survey dataset and data reduction approaches to identify and group healthcare workers with similar patterns of asthma symptoms, and then explored their associations with groups of participants with similar patterns of CDAs. Self-reported information on asthma symptoms/care, CDAs, demographics, smoking status, allergic status, and other characteristics were collected from 2030 healthcare workers within nine selected occupations in New York City. Hierarchical clustering was conducted to systematically group participants based on similarity of patterns of the 27 asthma symptom/care variables, and 14 product applications during CDAs, separately. Word clouds were used to visualize the complex information on the resulting clusters. The associations of asthma health clusters (HCs) with exposure clusters (ECs) were evaluated using multinomial logistic regression. Five HCs were identified (HC-1 to HC-5), labelled based on predominant features as: “no symptoms”, “winter cough/phlegm”, “mild asthma symptoms”, “undiagnosed/untreated asthma”, and “asthma attacks/exacerbations”. For CDAs, five ECs were identified (EC-1 to EC-5), labelled as: “no products”, “housekeeping/chlorine”, “patient care”, “general cleaning/laboratory”, and “disinfection products”. Using HC-1 and EC-1 as the reference groups, EC-2 was associated with HC-4 (odds ratio (OR)=3.11, 95% confidence interval (95% CI)=1.46-6.63) and HC-5 (OR=2.71, 95% CI=1.25-5.86). EC-3 was associated with HC-5 (OR=2.34, 95% CI=1.16-4.72). EC-4 was associated with HC-5 (OR=2.35, 95% CI=1.07-5.13). EC-5 was associated with HC-3 (OR=1.81, 95% CI=1.09-2.99) and HC-4 (OR=3.42, 95% CI=1.24-9.39). Various combinations of product applications like using alcohols, bleach, high-level disinfectants, and enzymes to disinfect instruments and clean surfaces captured by the ECs were identified as risk factors for the different asthma symptoms clusters, indicating that prevention efforts may require targeting multiple products. The associations of HCs with EC can be used to better inform prevention strategies and treatment options to avoid disease progression. This study demonstrated hierarchical clustering and word clouds were useful techniques for analyzing and visualizing a complex dataset with a large number of potentially correlated variables to generate practical information that can inform prevention activities.

      8. PURPOSE: To examine how the availability of and participation in workplace health promotion programs (WHPPs) vary as a function of sociodemographic, occupation, and work organization characteristics. DESIGN: Cross-sectional study. SETTING: 2015 National Health Interview Survey and Occupational Health Supplement. PARTICIPANTS: The study sample included 17 469 employed adults who completed the WHPP questions. MEASURES: The 2 dependent outcome measures were availability of WHPPs and participation in these programs when available. Independent variables included occupation and 8 work organization and employment characteristics: company size, hours worked, supervisory responsibility, hourly pay, paid sick leave, health insurance offered by employer, work schedule, and work arrangement. ANALYSIS: Poisson regression analyses were conducted with SUDAAN 11.0.1. RESULTS: Overall, 57.8% of 46.6% employees who have WHPPs available reported participating in these programs. This study found that adults who worked </=20 h/wk, worked regular night shifts, were paid by the hour, or worked for temporary agencies were less likely to participate in WHPPs. Workers who supervised others were 13% more likely to participate than nonsupervisors. Borderline associations were seen for having access to employer-sponsored health insurance and working at a site with <10 employees. CONCLUSION: Despite the potential for improving physical and mental health, only 58% of US workers participated in WHPPs. Since barriers to WHPP participation (eg, time constraints, lack of awareness, and no perceived need) may vary across occupations and work organization characteristics, employers should tailor WHPPs based on their specific work organization characteristics to maximize participation.

    • Parasitic Diseases
      1. Cyclosporiasis surveillance – United States, 2011-2015external icon
        Casillas SM, Hall RL, Herwaldt BL.
        MMWR Surveill Summ. 2019 Apr 19;68(3):1-16.
        PROBLEM/CONDITION: Cyclosporiasis is an intestinal illness caused by the parasite Cyclospora cayetanensis, which is transmissible by ingestion of fecally contaminated food or water. Cyclosporiasis is most common in tropical and subtropical regions of the world. In the United States, foodborne outbreaks of cyclosporiasis have been linked to various types of imported fresh produce (e.g., basil, raspberries, and snow peas). Validated molecular typing tools, which could facilitate detection and investigation of outbreaks, are not yet available for C. cayetanensis. PERIOD COVERED: 2011-2015. DESCRIPTION OF SYSTEM: CDC has been conducting national surveillance for cyclosporiasis since it became a nationally notifiable disease in January 1999. As of 2015, cyclosporiasis was a reportable condition in 42 states, the District of Columbia, and New York City (NYC). Health departments voluntarily notify CDC of cases of cyclosporiasis through the National Notifiable Diseases Surveillance System and submit additional case information using the CDC cyclosporiasis case report form or the Cyclosporiasis National Hypothesis Generating Questionnaire (CNHGQ). RESULTS: For the 2011-2015 surveillance period, CDC was notified by 37 states and NYC of 2,207 cases of cyclosporiasis, including 1,988 confirmed cases (90.1%) and 219 probable cases (9.9%). The annual number of reported cases ranged from 130 in 2012 to 798 in 2013; the annual population-adjusted incidence rate ranged from 0.05 cases per 100,000 persons in 2012 to 0.29 in 2013. A total of 415 patients (18.8%) had a documented history of international travel during the 14 days before illness onset, 1,384 (62.7%) did not have a history of international travel, and 408 (18.5%) had an unknown travel history. Among the 1,359 domestically acquired cases with available information about illness onset, 1,263 (92.9%) occurred among persons who became ill during May-August. During 2011-2015, a total of 10 outbreaks of cyclosporiasis associated with 438 reported cases were investigated; a median of 21 cases were reported per outbreak (range: eight to 162). A food vehicle of infection (i.e., a food item or ingredient thereof) was identified (or suspected) for at least five of the 10 outbreaks; the food vehicles included a berry salad (one outbreak), cilantro imported from Mexico (at least three outbreaks), and a prepackaged salad mix from Mexico (one outbreak). INTERPRETATION: Cyclosporiasis continues to be a U.S. public health concern, with seasonal increases in reported cases during spring and summer months. The majority of cases reported for this 5-year surveillance period occurred among persons without a history of international travel who became ill during May-August. Many of the seemingly sporadic domestically acquired cases might have been associated with identified or unidentified outbreaks; however, those potential associations were not detected using the available epidemiologic information. Prevention of cases and outbreaks of cyclosporiasis in the United States depends on outbreak detection and investigation, including identification of food vehicles of infection and their sources, which could be facilitated by the availability of validated molecular typing tools. PUBLIC HEALTH ACTION: Surveillance for cases of cyclosporiasis and efforts to develop and validate molecular typing tools should remain U.S. public health priorities. During periods and seasons when increased numbers of domestically acquired cases are reported, the CNHGQ should be used to facilitate outbreak detection and hypothesis generation. Travelers to areas of known endemicity (e.g., in the tropics and subtropics) should follow food and water precautions similar to those for other enteric pathogens but should be advised that use of routine chemical disinfection or sanitizing methods is unlikely to kill C. cayetanensis. Health care providers should consider the possibility of Cyclospora infection in persons with persistent or remitting-relapsing diarrheal illness, especially for persons with a history of travel to areas of known endemicity or with symptom onset during spring or summer. If indicated, laboratory testing for Cyclospora should be explicitly requested because such testing is not typically part of routine examinations for ova and parasites and is not included in all gastrointestinal polymerase chain reaction panels. Newly identified cases of cyclosporiasis should be promptly reported to state or local public health authorities, who are encouraged to notify CDC of the cases.

      2. Barriers to malaria prevention in US-based travellers visiting friends and relatives abroad: a qualitative study of West African immigrant travellersexternal icon
        Walz EJ, Volkman HR, Adedimeji AA, Abella J, Scott LA, Angelo KM, Gaines J, Coyle CM, Dunlop SJ, Wilson D, Biah AP, Wanduragala D, Stauffer WM.
        J Travel Med. 2019 Feb 1;26(2).
        BACKGROUND: Over half of malaria cases reported in the USA occur among people travelling to visit friends and relatives (VFRs), predominantly to West Africa. Few studies have queried VFR travellers directly on barriers to seeking pre-travel care. We aim to describe the knowledge, attitudes and practices of VFRs travelling to malaria-endemic countries from the USA. With these findings, we aim to design interventions to encourage preventive behaviours before and during travel. METHODS: Sixteen focus groups were held in two US metropolitan areas with West African immigrant populations: Minneapolis-St. Paul, MN, and New York City, NY. A total of 172 people from 13 African countries participated. Focus group discussions were audio-recorded and transcribed, and modified grounded theory analysis was performed. Participants reviewed themes to verify intent of statements. RESULTS: Participants described the high cost of provider visits and chemoprophylaxis, challenges in advocating for themselves in healthcare settings and concerns about offending or inconveniencing hosts as barriers to malaria prevention. Cultural barriers to accessing pre-travel care included competing priorities when trip planning, such as purchasing gifts for family, travel logistics and safety concerns. When participants sought pre-travel care, most consulted their primary care provider. Participants expressed low confidence in US providers’ knowledge and training about malaria and other tropical diseases. CONCLUSION: Barriers to pre-travel care for VFR travellers are multifaceted and extend beyond their perception of disease risk. Only some barriers previously reported in anecdotal and qualitative literature were supported in our findings. Future interventions should be aimed at barriers identified by individual communities and involve primary and travel specialist healthcare providers. Additional work is needed to address systems-level barriers to accessing care and establishing community-based programs to support West African VFR traveller health.

    • Physical Activity
      1. INTRODUCTION: National objectives recommend healthcare professionals provide physical activity advice. This study examined health and demographic characteristics associated with receipt of medical advice to increase physical activity among U.S. health care-utilizing adults and differences in associations by age group. METHODS: Analyses included 8,410 health care-utilizing adults aged >/=20 years from the 2013-2016 National Health and Nutrition Examination Surveys (analyzed in 2018). Logistic regression was used to examine associations between receipt of medical advice to increase physical activity in the past year and measured health conditions, reported health behaviors, and demographic characteristics. Models were stratified by age group (20-39, 40-59, and >/=60 years). RESULTS: Physical activity medical advice was received by 42.9% (95% CI=40.8, 44.9) of adults overall. By age group, 32.7% of younger adults, 46.7% of middle-aged adults, and 48.9% of older adults received advice. Among all adults and across all age groups, receipt of advice was higher among adults with chronic health conditions: obesity (63.0%, 95% CI=60.3, 65.7), hypertension (56.5%, 95%=CI 53.8, 59.2), diabetes (69.8%, 95% CI=66.5, 72.8), hypercholesterolemia (55.6%, 95% CI=52.3, 59.0), and low high-density lipoprotein cholesterol (53.8%, 95% CI=50.1, 57.4). Among all adults, those with obesity, hypertension, and diabetes had significantly greater odds of receipt of advice after adjustment. Stronger associations between diabetes and hypercholesterolemia and receiving physical activity advice were observed among younger adults. CONCLUSIONS: Receipt of physical activity medical advice was highest among adults with specific chronic health conditions, and this pattern was stronger among younger adults with diabetes and hypercholesterolemia. However, most health care-utilizing adults did not receive physical activity medical advice.

    • Reproductive Health
      1. Assisted reproductive technology surveillance – United States, 2016external icon
        Sunderam S, Kissin DM, Zhang Y, Folger SG, Boulet SL, Warner L, Callaghan WM, Barfield WD.
        MMWR Surveill Summ. 2019 Apr 26;68(4):1-23.
        PROBLEM/CONDITION: Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to deliver multiple-birth infants. Multiple births pose substantial risks for both mothers and infants, including obstetric complications, preterm delivery (<37 weeks), and low birthweight (<2,500 g). This report provides state-specific information for the United States (including the District of Columbia and Puerto Rico) on ART procedures performed in 2016 and compares birth outcomes that occurred in 2016 (resulting from ART procedures performed in 2015 and 2016) with outcomes for all infants born in the United States in 2016. PERIOD COVERED: 2016. DESCRIPTION OF SYSTEM: In 1995, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493 [October 24, 1992]). Data are collected through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. This report includes data from 52 reporting areas (the 50 states, the District of Columbia, and Puerto Rico). RESULTS: In 2016, a total of 197,706 ART procedures (range: 162 in Wyoming to 24,030 in California) with the intent to transfer at least one embryo were performed in 463 U.S. fertility clinics and reported to CDC. These procedures resulted in 65,964 live-birth deliveries (range: 57 in Puerto Rico to 8,638 in California) and 76,892 infants born (range: 74 in Alaska to 9,885 in California). Nationally, the number of ART procedures performed per 1 million women of reproductive age (15-44 years), a proxy measure of the ART use rate, was 3,075. ART use rates exceeded the national rate in 14 reporting areas (Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Utah, and Virginia). ART use exceeded 1.5 times the national rate in nine states, including three (Illinois, Massachusetts, and New Jersey) that also had comprehensive mandated health insurance coverage for ART procedures (i.e., coverage for at least four oocyte retrievals). Nationally, among ART transfer procedures for patients using fresh embryos from their own eggs, the average number of embryos transferred increased with increasing age (1.5 among women aged <35 years, 1.7 among women aged 35-37 years, and 2.2 among women aged >37 years). Among women aged <35 years, the national elective single-embryo transfer (eSET) rate was 42.7% (range: 8.3% in North Dakota to 83.9% in Delaware). In 2016, ART contributed to 1.8% of all infants born in the United States (range: 0.3% in Puerto Rico to 4.7% in Massachusetts). ART also contributed to 16.4% of all multiple-birth infants, including 16.2% of all twin infants and 19.4% of all triplets and higher-order infants. ART-conceived twins accounted for approximately 96.5% (21,455 of 22,233) of all ART-conceived infants born in multiple deliveries. The percentage of multiple-birth infants was higher among infants conceived with ART (31.5%) than among all infants born in the total birth population (3.4%). Approximately 30.4% of ART-conceived infants were twins and 1.1% were triplets and higher-order infants. Nationally, infants conceived with ART contributed to 5.0% of all low birthweight (<2,500 g) infants. Among ART-conceived infants, 23.6% had low birthweight compared with 8.2% among all infants. ART-conceived infants contributed to 5.3% of all preterm (gestational age <37 weeks) infants. The percentage of preterm births was higher among infants conceived with ART (29.9%) than among all infants born in the total birth population (9.9%). The percentage of ART-conceived infants who had low birthweight was 8.7% among singletons, 54.9% among twins, and 94.9% among triplets and higher-order multiples; the corresponding percentages among all infants born were 6.2% among singletons, 55.4% among twins, and 94.6% among triplets and higher-order multiples. The percentage of ART-conceived infants who were born preterm was 13.7% among singletons, 64.2% among twins, and 97.0% among triplets and higher-order infants; the corresponding percentages among all infants were 7.8% for singletons, 59.9% for twins, and 97.7% for triplets and higher-order infants. INTERPRETATION: Multiple births from ART contributed to a substantial proportion of all twins, triplets, and higher-order infants born in the United States. For women aged <35 years, who typically are considered good candidates for eSET, on average, 1.5 embryos were transferred per ART procedure, resulting in higher multiple birth rates than could be achieved with single-embryo transfers. Of the four states (Illinois, Massachusetts, New Jersey, and Rhode Island) with comprehensive mandated health insurance coverage, three (Illinois, Massachusetts, and New Jersey) had rates of ART use >1.5 times the national average. Although other factors might influence ART use, insurance coverage for infertility treatments accounts for some of the difference in per capita ART use observed among states because most states do not mandate any coverage for ART treatment. PUBLIC HEALTH ACTION: Twins account for almost all of ART-conceived multiple births born in multiple deliveries. Reducing the number of embryos transferred and increasing use of eSET, when clinically appropriate, could help reduce multiple births and related adverse health consequences for both mothers and infants. Because multiple-birth infants are at increased risk for numerous adverse sequelae that cannot be ascertained from the data collected through NASS alone, long-term follow-up of ART infants through integration of existing maternal and infant health surveillance systems and registries with data available from NASS might be useful for monitoring adverse outcomes.

    • Substance Use and Abuse
      1. Rural-urban trends in opioid overdose discharges in Missouri emergency departments, 2012-2016external icon
        Coffey W, Hunter A, Mobley E, Vivolo-Kantor A.
        J Rural Health. 2019 Apr 25.
        PURPOSE: Opioid overdose death rates rose 36% from 2015 to 2016 in Missouri, indicating a worsening of the opioid overdose epidemic. To better understand urban and rural differences in nonfatal opioid overdoses treated in Missouri emergency departments, this paper analyzed hospital billing data from emergency departments due to opioid overdose from 2012 to 2016. METHODS: Emergency department records meeting the opioid overdose case definition were aggregated into 6 progressively rural groups using the National Center for Health Statistics (NCHS) urban-rural county classification from 2013. These data were analyzed to determine significant trends amongst and between the geographic groups. FINDINGS: Generally, the magnitude of opioid overdose morbidity decreased as levels of rurality increased, using annual percentage change as the metric of change. Over the study period, Missouri’s most urban counties had significantly higher rates of opioid overdose and saw larger percentage increases in rates compared to more rural areas. Statewide, all rural-urban classifications experienced increases in heroin overdose morbidity; however, there was extreme variation in the trajectory of those increases. Heroin overdose rates were much higher in urban areas than rural areas. Conversely, rural and urban areas saw relatively similar patterns for non-heroin opioid overdoses, though overall magnitude of these increases was more modest across all geographic groups. CONCLUSIONS: The results from this analysis can help inform prioritization of strategies and resources to implement activities addressing the opioid overdose epidemic. Using a rich hospital discharge database could allow for further analysis of subpopulations to enhance personalization and customization of care.

      2. Consumption of alcohol beverages and binge drinking among pregnant women aged 18-44 years – United States, 2015-2017external icon
        Denny CH, Acero CS, Naimi TS, Kim SY.
        MMWR Morb Mortal Wkly Rep. 2019 Apr 26;68(16):365-368.
        Drinking alcohol during pregnancy can cause fetal alcohol spectrum disorders (FASDs), including birth defects that involve central nervous system impairment, behavioral disorders, and impaired intellectual development, which can lead to difficulties with school and employment. A recent study in four U.S. communities found a 1.1%-5.0% prevalence of FASDs among first-grade students (1). Drinking during pregnancy might also be a risk factor for other adverse pregnancy and birth outcomes, including miscarriage and stillbirth (2). CDC estimated the prevalence of self-reported current drinking (at least one alcohol drink in the past 30 days) and binge drinking (consuming four or more drinks on at least one occasion in the past 30 days) among pregnant women aged 18-44 years, using 2015-2017 data from the Behavioral Risk Factor Surveillance System (BRFSS). Current drinking and binge drinking in the past 30 days were reported by 11.5% and 3.9% of pregnant women, respectively. Among pregnant women who binge drink, the average frequency of binge drinking in the past 30 days was 4.5 episodes, and the average intensity of binge drinking (the average largest number of drinks reported consumed on any occasion among binge drinkers) was 6.0 drinks. Increased implementation of evidence-based community-level and clinic-level interventions, such as universal alcohol screening and brief counseling in primary and prenatal care, could decrease the prevalence of drinking during pregnancy, which might ultimately reduce the prevalence of FASDs and other adverse pregnancy and birth outcomes.

      3. No shortcuts to safer opioid prescribingexternal icon
        Dowell D, Haegerich T, Chou R.
        N Engl J Med. 2019 Apr 24.

        [No abstract]

      4. U.S. national 90-day readmissions after opioid overdose dischargeexternal icon
        Peterson C, Liu Y, Xu L, Nataraj N, Zhang K, Mikosz CA.
        Am J Prev Med. 2019 Apr 16.
        INTRODUCTION: U.S. hospital discharges for opioid overdose increased substantially during the past two decades. This brief report describes 90-day readmissions among patients discharged from inpatient stays for opioid overdose. METHODS: In 2018, survey-weighted analysis of hospital stays in the 2016 Healthcare Cost and Utilization Project National Readmissions Database yielded the national estimated proportion of patients with opioid overdose stays that had all-cause readmissions within </=90 days. A multivariable logistic regression model assessed index stay factors associated with readmission by type (opioid overdose or not). Number of readmissions per patient was assessed. RESULTS: More than 24% (n=14,351/58,850) of patients with non-fatal index stays for opioid overdose had at least one all-cause readmission </=90 days of index stay discharge and 3% (n=1,658/58,850) of patients had at least one opioid overdose readmission. Less than 0.2% (n=104/58,850) of patients had more than one readmission for opioid overdose. Patient demographic characteristics (e.g., male, older age), comorbidities diagnosed during the index stay (e.g., drug use disorder, chronic pulmonary disease, psychoses), and other index stay factors (Medicare or Medicaid primary payer, discharge against medical advice) were significantly associated with both opioid overdose and non-opioid overdose readmissions. Nearly 30% of index stays for opioid overdose included heroin, which was significantly associated with opioid overdose readmissions. CONCLUSIONS: A quarter of opioid overdose patients have </=90 days all-cause readmissions, although opioid overdose readmission is uncommon. Effective strategies to reduce readmissions will address substance use disorder as well as comorbid physical and mental health conditions.

    • Zoonotic and Vectorborne Diseases
      1. ICTV virus taxonomy profile: Filoviridaeexternal icon
        Kuhn JH, Amarasinghe GK, Basler CF, Bavari S, Bukreyev A, Chandran K, Crozier I, Dolnik O, Dye JM, Formenty PB, Griffiths A, Hewson R, Kobinger GP, Leroy EM, Muhlberger E, Netesov SV, Palacios G, Palyi B, Paweska JT, Smither SJ, Takada A, Towner JS, Wahl V.
        J Gen Virol. 2019 Apr 25.
        Members of the family Filoviridae produce variously shaped, often filamentous, enveloped virions containing linear non-segmented, negative-sense RNA genomes of 15-19 kb. Several filoviruses (e.g., Ebola virus) are pathogenic for humans and are highly virulent. Several filoviruses infect bats (e.g., Marburg virus), whereas the hosts of most other filoviruses are unknown. This is a summary of the International Committee on Taxonomy of Viruses (ICTV) Report on Filoviridae, which is available at

      2. Development of a standardized Sanger-based method for partial sequencing and genotyping of dengue virusesexternal icon
        Santiago GA, Gonzalez GL, Cruz-Lopez F, Munoz-Jordan JL.
        J Clin Microbiol. 2019 Apr;57(4).
        The global expansion of dengue viruses (DENV-1 to DENV-4) has contributed to the divergence, transmission, and establishment of genetic lineages of epidemiological concern; however, tracking the phylogenetic relationships of these virus is not always possible due to the inability of standardized sequencing procedures in resource-limited public health laboratories. Consequently, public genomic data banks contain inadequate representation of geographical regions and historical periods. In order to improve detection of the DENV-1 to DENV-4 lineages, we report the development of a serotype-specific Sanger-based method standardized to sequence DENV-1 to DENV-4 directly from clinical samples using universal primers that detect most DENV genotypes. The resulting envelope protein coding sequences are analyzed for genotyping with phylogenetic methods. We evaluated the performance of this method by detecting, amplifying, and sequencing 54 contemporary DENV isolates, including 29 clinical samples, representing a variety of genotypes of epidemiological importance and global presence. All specimens were sequenced successfully and phylogenetic reconstructions resulted in the expected genotype classification. To further improve genomic surveillance in regions where dengue is endemic, this method was transferred to 16 public health laboratories in 13 Latin American countries, to date. Our objective is to provide an accessible method that facilitates the integration of genomics with dengue surveillance.

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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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