Volume 11, Issue 24 June 18, 2019

Public Health Grand Rounds

CDC Science Clips: Volume 11, Issue 24, June 18, 2019

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

  1. CDC Public Health Grand Rounds
    • Maternal, Infant and Early Childhood Nutrition
      1. Prevalence and characteristics associated with gestational weight gain adequacyexternal icon
        Deputy NP, Sharma AJ, Kim SY, Hinkle SN.
        Obstet Gynecol. 2015 Apr;125(4):773-81.
        OBJECTIVE: To estimate the prevalence of gestational weight gain adequacy according to the 2009 Institute of Medicine recommendations and examine demographic, behavioral, psychosocial, and medical characteristics associated with inadequate and excessive gain stratified by prepregnancy body mass index (BMI) category. METHODS: We used cross-sectional, population-based data on women delivering full-term (37 weeks of gestation or greater), singleton neonates in 28 states who participated in the 2010 or 2011 Pregnancy Risk Assessment Monitoring System. We estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for inadequate and excessive compared with adequate gain, stratified by prepregnancy BMI. RESULTS: Overall, 20.9%, 32.0%, and 47.2% of women gained inadequate, adequate, and excessive gestational weight, respectively. Prepregnancy BMI was strongly associated with weight gain outside recommendations. Compared with normal-weight women (prevalence 51.8%), underweight women (4.2%) had decreased odds of excessive gain (adjusted OR 0.50, CI 0.40-0.61), whereas overweight and obese class I, II, and III (23.6%, 11.7%, 5.4%, and 3.5%, respectively) women had increased odds of excessive gain (adjusted OR range 2.07, CI 1.63-2.62 to adjusted OR 2.99, CI 2.63-3.40). Underweight and obese class II and III women had increased odds of inadequate gain (adjusted OR 1.25, CI 1.01-1.55 to 1.86, CI 1.45-2.36). Most characteristics associated with weight gain adequacy were demographic such as racial or ethnic minority status and education and varied by prepregnancy BMI. Notably, one behavioral characteristic-smoking cessation-was associated with excessive gain among normal-weight and obese women. CONCLUSION: Most women gained weight outside recommendations. Understanding characteristics associated with inadequate or excessive weight gain may identify potentially at-risk women and inform much-needed interventions.

      2. Achieving Appropriate Gestational Weight Gain: The Role of Healthcare Provider Adviceexternal icon
        Deputy NP, Sharma AJ, Kim SY, Olson CK.
        J Womens Health (Larchmt). 2018 May;27(5):552-560.
        BACKGROUND: The Institute of Medicine (IOM) revised gestational weight gain recommendations in 2009. We examined associations between healthcare provider advice about gestational weight gain and inadequate or excessive weight gain, stratified by prepregnancy body mass index category. MATERIALS AND METHODS: We analyzed cross-sectional data from women delivering full-term (37-42 weeks of gestation), singleton infants from four states that participated in the 2010-2011 Pregnancy Risk Assessment Monitoring System (unweighted n = 7125). Women reported the weight gain range (start and end values) advised by their healthcare provider; advice was categorized as follows: starting below recommendations, starting and ending within recommendations (IOM consistent), ending above recommendations, not remembered, or not received. We examined associations between healthcare provider advice and inadequate or excessive, compared with appropriate, gestational weight gain using adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs). RESULTS: Overall, 26.3% of women reported receiving IOM-consistent healthcare provider advice; 26.0% received no advice. Compared with IOM-consistent advice, advice below recommendations was associated with higher likelihood of inadequate weight gain among underweight (aPR 2.22, CI 1.29-3.82) and normal weight women (aPR 1.57, CI 1.23-2.02); advice above recommendations was associated with higher likelihood of excessive weight gain among all but underweight women (aPR range 1.36, CI 1.08-1.72 to aPR 1.42, CI 1.19-1.71). Not remembering or not receiving advice was associated with both inadequate and excessive weight gain. CONCLUSIONS: Few women reported receiving IOM-consistent advice; not receiving IOM-consistent advice put women at-risk for weight gain outside recommendations. Strategies that raise awareness of IOM recommendations and address barriers to providing advice are needed.

      3. Randomized trial of peanut consumption in infants at risk for peanut allergyexternal icon
        Du Toit G, Roberts G, Sayre PH, Bahnson HT, Radulovic S, Santos AF, Brough HA, Phippard D, Basting M, Feeney M, Turcanu V, Sever ML, Gomez Lorenzo M, Plaut M, Lack G.
        N Engl J Med. 2015 Feb 26;372(9):803-13.
        BACKGROUND: The prevalence of peanut allergy among children in Western countries has doubled in the past 10 years, and peanut allergy is becoming apparent in Africa and Asia. We evaluated strategies of peanut consumption and avoidance to determine which strategy is most effective in preventing the development of peanut allergy in infants at high risk for the allergy. METHODS: We randomly assigned 640 infants with severe eczema, egg allergy, or both to consume or avoid peanuts until 60 months of age. Participants, who were at least 4 months but younger than 11 months of age at randomization, were assigned to separate study cohorts on the basis of preexisting sensitivity to peanut extract, which was determined with the use of a skin-prick test–one consisting of participants with no measurable wheal after testing and the other consisting of those with a wheal measuring 1 to 4 mm in diameter. The primary outcome, which was assessed independently in each cohort, was the proportion of participants with peanut allergy at 60 months of age. RESULTS: Among the 530 infants in the intention-to-treat population who initially had negative results on the skin-prick test, the prevalence of peanut allergy at 60 months of age was 13.7% in the avoidance group and 1.9% in the consumption group (P<0.001). Among the 98 participants in the intention-to-treat population who initially had positive test results, the prevalence of peanut allergy was 35.3% in the avoidance group and 10.6% in the consumption group (P=0.004). There was no significant between-group difference in the incidence of serious adverse events. Increases in levels of peanut-specific IgG4 antibody occurred predominantly in the consumption group; a greater percentage of participants in the avoidance group had elevated titers of peanut-specific IgE antibody. A larger wheal on the skin-prick test and a lower ratio of peanut-specific IgG4:IgE were associated with peanut allergy. CONCLUSIONS: The early introduction of peanuts significantly decreased the frequency of the development of peanut allergy among children at high risk for this allergy and modulated immune responses to peanuts. (Funded by the National Institute of Allergy and Infectious Diseases and others; number, NCT00329784.).

      4. This clinical report updates and replaces a 2008 clinical report from the American Academy of Pediatrics, which addressed the roles of maternal and early infant diet on the prevention of atopic disease, including atopic dermatitis, asthma, and food allergy. As with the previous report, the available data still limit the ability to draw firm conclusions about various aspects of atopy prevention through early dietary interventions. Current evidence does not support a role for maternal dietary restrictions during pregnancy or lactation. Although there is evidence that exclusive breastfeeding for 3 to 4 months decreases the incidence of eczema in the first 2 years of life, there are no short- or long-term advantages for exclusive breastfeeding beyond 3 to 4 months for prevention of atopic disease. The evidence now suggests that any duration of breastfeeding >/=3 to 4 months is protective against wheezing in the first 2 years of life, and some evidence suggests that longer duration of any breastfeeding protects against asthma even after 5 years of age. No conclusions can be made about the role of breastfeeding in either preventing or delaying the onset of specific food allergies. There is a lack of evidence that partially or extensively hydrolyzed formula prevents atopic disease. There is no evidence that delaying the introduction of allergenic foods, including peanuts, eggs, and fish, beyond 4 to 6 months prevents atopic disease. There is now evidence that early introduction of peanuts may prevent peanut allergy.

      5. Use of Iodine-Containing Dietary Supplements Remains Low among Women of Reproductive Age in the United States: NHANES 2011-2014external icon
        Gupta PM, Gahche JJ, Herrick KA, Ershow AG, Potischman N, Perrine CG.
        Nutrients. 2018 Mar 29;10(4).
        In the United States, the American Thyroid Association recommends that women take a dietary supplement containing 150 &micro;g of iodine 3 months prior to conception and while pregnant and lactating to support fetal growth and neurological development. We used data from the National Health and Nutrition Examination Survey 2011&ndash;2014 to describe the use of dietary supplements with and without iodine in the past 30 days among 2155 non-pregnant, non-lactating (NPNL) women; 122 pregnant women; and 61 lactating women. Among NPNL women, 45.3% (95% Confidence Interval [CI]: 42.0, 48.6) used any dietary supplement and 14.8% (95% CI: 12.7, 16.8) used a dietary supplement with iodine in the past 30 days. Non-Hispanic black and Hispanic women were less likely to use any dietary supplement as well as one with iodine, than non-Hispanic white or non-Hispanic Asian women (p < 0.05). Among pregnant women, 72.2% (95% CI: 65.8, 78.6) used any dietary supplement; however, only 17.8% (95% CI: 11.4, 24.3) used a dietary supplement with iodine. Among lactating women, 75.0% (95% CI: 63.0, 87.0) used a dietary supplement; however, only 19.0% (95% CI: 8.8, 29.2) used a dietary supplement with iodine. Among NPNL women using a supplement with iodine, median daily iodine intake was 75.0 &micro;g. Self-reported data suggests that the use of iodine containing dietary supplements among pregnant and lactating women remains low in contrast with current recommendations.

      6. Iron status of toddlers, nonpregnant females, and pregnant females in the United Statesexternal icon
        Gupta PM, Hamner HC, Suchdev PS, Flores-Ayala R, Mei Z.
        Am J Clin Nutr. 2017 Dec;106(Suppl 6):1640s-1646s.
        Background: Total-body iron stores (TBI), which are calculated from serum ferritin and soluble transferrin receptor concentrations, can be used to assess the iron status of populations in the United States.Objective: This analysis, developed to support workshop discussions, describes the distribution of TBI and the prevalence of iron deficiency (ID) and ID anemia (IDA) among toddlers, nonpregnant females, and pregnant females.Design: We analyzed data from NHANES; toddlers aged 12-23 mo (NHANES 2003-2010), nonpregnant females aged 15-49 y (NHANES 2007-2010), and pregnant females aged 12-49 y (NHANES 1999-2010). We used SAS survey procedures to plot distributions of TBI and produce prevalence estimates of ID and IDA for each target population. All analyses were weighted to account for the complex survey design.Results: According to these data, ID prevalences (+/- SEs) were 15.1% +/- 1.7%, 10.4% +/- 0.5%, and 16.3% +/- 1.3% in toddlers, nonpregnant females, and pregnant females, respectively. ID prevalence in pregnant females increased significantly with each trimester (5.3% +/- 1.5%, 12.7% +/- 2.3%, and 27.5% +/- 3.5% in the first, second, and third trimesters, respectively). Racial disparities in the prevalence of ID among both nonpregnant and pregnant females exist, with Mexican American and non-Hispanic black females at greater risk of ID than non-Hispanic white females. IDA prevalence was 5.0% +/- 0.4% and 2.6% +/- 0.7% in nonpregnant and pregnant females, respectively.Conclusions: Available nationally representative data suggest that ID and IDA remain a concern in the United States. Estimates of iron-replete status cannot be made at this time in the absence of established cutoffs for iron repletion based on TBI. The study was registered at as NCT03274726.

      7. Food Consumption Patterns among U.S. Children from Birth to 23 Months of Age, 2009-2014external icon
        Hamner HC, Perrine CG, Gupta PM, Herrick KA, Cogswell ME.
        Nutrients. 2017 Aug 26;9(9).
        Early dietary patterns can have long-term health consequences. This study describes food consumption patterns among US children </=23 months. We used one 24 h dietary recall from the National Health and Nutrition Examination Survey 2009-2014 to estimate the percentage of children </=23 months who consumed selected food/beverage categories on any given day by age and race/Hispanic origin. Among 0 to 5 month olds, 42.9% (95% Confidence Interval (CI): 37.0%, 49.1%) consumed breast milk, with non-Hispanic blacks less likely (21.2%, 95% CI: 13.2%, 32.2%) compared with non-Hispanic whites (49.0%, 95% CI: 39.0%, 59.1%) (p < 0.001). The percentage of children consuming vegetables was 57.4%, 48.2%, and 45.1% for ages 6 to 11, 12 to 18 and 19 to 23 months, respectively (p < 0.01 for trend). The percentage of children consuming sugar-sweetened beverages was 6.6%, 31.8% and 38.3% for ages 6 to 11, 12 to 18 and 19 to 23 months, respectively (p < 0.01 for trend). Among children aged >/=6 months, lower percentages of non-Hispanic black and Hispanic children consumed vegetables, and higher percentages consumed sugar-sweetened beverages and 100% juice compared with non-Hispanic white children, although differences were not always statistically significant. Compared with children in the second year of life, a higher percentage of children 6 to 11 months of age consumed vegetables and a lower percentage consumed 100% juice, sugar-sweetened beverages, snacks, or sweets; with differences by race/Hispanic origin. These data may be relevant to the upcoming 2020-2025 federal dietary guidelines.

      8. Effects of Delayed Cord Clamping on 4-Month Ferritin Levels, Brain Myelin Content, and Neurodevelopment: A Randomized Controlled Trialexternal icon
        Mercer JS, Erickson-Owens DA, Deoni SC, Dean DC, Collins J, Parker AB, Wang M, Joelson S, Mercer EN, Padbury JF.
        J Pediatr. 2018 Dec;203:266-272.e2.
        OBJECTIVE: To evaluate whether placental transfusion influences brain myelination at 4 months of age. STUDY DESIGN: A partially blinded, randomized controlled trial was conducted at a level III maternity hospital in the US. Seventy-three healthy term pregnant women and their singleton fetuses were randomized to either delayed umbilical cord clamping (DCC, >5 minutes) or immediate clamping (ICC, <20 seconds). At 4 months of age, blood was drawn for ferritin levels. Neurodevelopmental testing (Mullen Scales of Early Learning) was administered, and brain myelin content was measured with magnetic resonance imaging. Correlations between myelin content and ferritin levels and group-wise DCC vs ICC brain myelin content were completed. RESULTS: In the DCC and ICC groups, clamping time was 172 +/- 188 seconds vs 28 +/- 76 seconds (P < .002), respectively; the 48-hour hematocrit was 57.6% vs 53.1% (P < .01). At 4 months, infants with DCC had significantly greater ferritin levels (96.4 vs 65.3 ng/dL, P = .03). There was a positive relationship between ferritin and myelin content. Infants randomized to the DCC group had greater myelin content in the internal capsule and other early maturing brain regions associated with motor, visual, and sensory processing/function. No differences were seen between groups in the Mullen testing. CONCLUSION: At 4 months, infants born at term receiving DCC had greater ferritin levels and increased brain myelin in areas important for early life functional development. Endowment of iron-rich red blood cells obtained through DCC may offer a longitudinal advantage for early white matter development. TRIAL REGISTRATION: NCT01620008.

      9. Diet or exercise, or both, for preventing excessive weight gain in pregnancyexternal icon
        Muktabhant B, Lawrie TA, Lumbiganon P, Laopaiboon M.
        Cochrane Database Syst Rev. 2015 Jun 15(6):Cd007145.
        BACKGROUND: This is an update of a Cochrane review first published in 2012, Issue 4. Excessive weight gain during pregnancy is associated with poor maternal and neonatal outcomes including gestational diabetes, hypertension, caesarean section, macrosomia, and stillbirth. Diet or exercise interventions, or both, may reduce excessive gestational weight gain (GWG) and associated poor outcomes; however, evidence from the original review was inconclusive. OBJECTIVES: To evaluate the effectiveness of diet or exercise, or both, interventions for preventing excessive weight gain during pregnancy and associated pregnancy complications. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (5 November 2014), contacted investigators of the previously identified ongoing studies and scanned reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) of diet or exercise, or both, interventions for preventing excessive weight gain in pregnancy. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We organised RCTs according to the type of interventions and pooled data using the random-effects model in the Review Manager software. We also performed subgroup analyses according to the initial risk of adverse effects related to poor weight control. We performed sensitivity analysis to assess the robustness of the findings. MAIN RESULTS: We included 65 RCTs, out of which 49 RCTs involving 11,444 women contributed data to quantitative meta-analysis. Twenty studies were at moderate-to-high risk of bias. Study interventions involved mainly diet only, exercise only, and combined diet and exercise interventions, usually compared with standard care. Study methods varied widely; therefore, we estimated the average effect across studies and performed sensitivity analysis, where appropriate, by excluding outliers and studies at high risk of bias.Diet or exercise, or both, interventions reduced the risk of excessive GWG on average by 20% overall (average risk ratio (RR) 0.80, 95% confidence interval (CI) 0.73 to 0.87; participants = 7096; studies = 24; I(2) = 52%). This estimate was robust to sensitivity analysis, which reduced heterogeneity, therefore we graded this evidence as high-quality. Interventions involving low glycaemic load diets, supervised or unsupervised exercise only, or diet and exercise combined all led to similar reductions in the number of women gaining excessive weight in pregnancy.Women receiving diet or exercise, or both interventions were more likely to experience low GWG than those in control groups (average RR 1.14, 95% CI 1.02 to 1.27; participants = 4422; studies = 11; I(2) = 3%; moderate-quality evidence). We found no difference between intervention and control groups with regard to pre-eclampsia (RR 0.95, 95% CI 0.77 to 1.16; participants = 5330; studies = 15; I(2) = 0%; high-quality evidence); however, maternal hypertension (not a pre-specified outcome) was reduced in the intervention group compared with the control group overall (average RR 0.70, 95% CI 0.51 to 0.96; participants = 5162; studies = 11; I(2) = 43%; low-quality evidence).There was no clear difference between groups with regard to caesarean delivery overall (RR 0.95, 95% CI 0.88 to 1.03; participants = 7534; studies = 28; I(2) = 9%; high-quality evidence); although the effect estimate suggested a small difference (5%) in favour of the interventions. In addition, for combined diet and exercise counselling interventions there was a 13% (-1% to 25%) reduction in this outcome (borderline statistical significance).We found no difference between groups with regard to preterm birth overall (average RR 0.91, 95% CI 0.68 to 1.22; participants = 5923; studies = 16; I(2) = 16%; moderate-quality evidence); however limited evidence suggested that these effect estimates may differ according to the types of interventions, with a trend towards an increased risk for exercise-only interventions.We found no clear difference between intervention and control groups with regard to infant macrosomia (average RR 0.93, 95% CI 0.86 to 1.02; participants = 8598; studies = 27; I(2) = 0%; high-quality evidence), although the effect estimate suggested a small difference (7% reduction) in favour of the intervention group. The largest effect size occurred in the supervised exercise-only intervention group (RR 0.81, 95% CI 0.64 to 1.02; participants = 2445; studies = 7; I(2) = 0%), which approached statistical significance (P = 0.07). Furthermore, in subgroup analysis by risk, high-risk women (overweight or obese women, or women with or at risk of gestational diabetes) receiving combined diet and exercise counselling interventions experienced a 15% reduced risk of infant macrosomia (average RR 0.85, 95% CI 0.73 to 1.00; participants = 3252; studies = nine; I(2) = 0; P = 0.05; moderate-quality evidence)There were no differences in the risk of poor neonatal outcomes including shoulder dystocia, neonatal hypoglycaemia, hyperbilirubinaemia, or birth trauma (all moderate-quality evidence) between intervention and control groups; however, infants of high-risk women had a reduced risk of respiratory distress syndrome if their mothers were in the intervention group (RR 0.47, 95% CI 0.26 to 0.85; participants = 2256; studies = two; I(2) = 0%; moderate-quality evidence). AUTHORS’ CONCLUSIONS: High-quality evidence indicates that diet or exercise, or both, during pregnancy can reduce the risk of excessive GWG. Other benefits may include a lower risk of caesarean delivery, macrosomia, and neonatal respiratory morbidity, particularly for high-risk women receiving combined diet and exercise interventions. Maternal hypertension may also be reduced. Exercise appears to be an important part of controlling weight gain in pregnancy and more research is needed to establish safe guidelines. Most included studies were carried out in developed countries and it is not clear whether these results are widely applicable to lower income settings.

      10. Complementary feeding and micronutrient status: a systematic reviewexternal icon
        Obbagy JE, English LK, Psota TL, Wong YP, Butte NF, Dewey KG, Fox MK, Greer FR, Krebs NF, Scanlon KS, Stoody EE.
        Am J Clin Nutr. 2019 Mar 1;109(Supplement_7):852s-871s.
        BACKGROUND: Proper nutrition during early life is critical for growth and development. OBJECTIVES: The aim was to describe systematic reviews conducted by the Nutrition Evidence Systematic Review team for the USDA and the Department of Health and Human Services Pregnancy and Birth to 24 Months Project to answer the following: What is the relation between 1) timing of introduction of complementary foods and beverages (CFBs) or 2) types and/or amounts of CFBs consumed and micronutrient status (iron, zinc, vitamin D, vitamin B-12, folate, and fatty acid status)? METHODS: A literature search identified articles from developed countries published from January 1980 to July 2016 that met the inclusion criteria. Data were extracted and risk of bias assessed. Evidence was qualitatively synthesized to develop a conclusion statement, and the strength of the evidence was graded. RESULTS: Nine articles addressed the timing of CFB introduction and 31 addressed types or amounts or both of CFBs. Moderate evidence suggests that introducing CFBs at age 4 mo instead of 6 mo offers no advantages or disadvantages in iron status among healthy full-term infants. Evidence is insufficient on the timing of CFB introduction and other micronutrient status outcomes. Strong evidence suggests that CFBs containing iron (e.g., meat, fortified cereal) help maintain adequate iron status or prevent deficiency in the first year among infants at risk of insufficient iron stores or low intake. Benefits for infants with sufficient iron stores (e.g., infant formula consumers) are less clear. Moderate evidence suggests that CFBs containing zinc (e.g., meat, fortified cereal) support zinc status in the first year and CFB fatty acid composition influences fatty acid status. Evidence is insufficient with regard to types and amounts of CFBs and vitamin D, vitamin B-12, and folate status, or the relation between lower-iron-containing CFBs and micronutrient status. CONCLUSIONS: Several conclusions on CFBs and micronutrient status were drawn from these systematic reviews, but more research that addresses specific gaps and limitations is needed.

      11. Scaling up of breastfeeding promotion programs in low- and middle-income countries: the “breastfeeding gear” modelexternal icon
        Perez-Escamilla R, Curry L, Minhas D, Taylor L, Bradley E.
        Adv Nutr. 2012 Nov 1;3(6):790-800.
        Breastfeeding (BF) promotion is one of the most cost-effective interventions to advance mother-child health. Evidence-based frameworks and models to promote the effective scale up and sustainability of BF programs are still lacking. A systematic review of peer-reviewed and gray literature reports was conducted to identify key barriers and facilitators for scale up of BF programs in low- and middle-income countries. The review identified BF programs located in 28 countries in Africa, Latin America and the Caribbean, and Asia. Study designs included case studies, qualitative studies, and observational quantitative studies. Only 1 randomized, controlled trial was identified. A total of 22 enabling factors and 15 barriers were mapped into a scale-up framework termed “AIDED” that was used to build the parsimonious breastfeeding gear model (BFGM). Analogous to a well-oiled engine, the BFGM indicates the need for several key “gears” to be working in synchrony and coordination. Evidence-based advocacy is needed to generate the necessary political will to enact legislation and policies to protect, promote, and support BF at the hospital and community levels. This political-policy axis in turn drives the resources needed to support workforce development, program delivery, and promotion. Research and evaluation are needed to sustain the decentralized program coordination “gear” required for goal setting and system feedback. The BFGM helps explain the different levels of performance in national BF outcomes in Mexico and Brazil. Empirical research is recommended to further test the usefulness of the AIDED framework and BFGM for global scaling up of BF programs.

      12. Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic reviewexternal icon
        Perez-Escamilla R, Martinez JL, Segura-Perez S.
        Matern Child Nutr. 2016 Jul;12(3):402-17.
        The Baby-friendly Hospital Initiative (BFHI) is a key component of the World Health Organization/United Nations Children’s Fund Global Strategy for Infant and Young Child Feeding. The primary aim of this narrative systematic review was to examine the impact of BFHI implementation on breastfeeding and child health outcomes worldwide and in the United States. Experimental, quasi-experimental and observational studies were considered eligible for this review if they assessed breastfeeding outcomes and/or infant health outcomes for healthy, term infants born in a hospital or birthing center with full or partial implementation of BFHI steps. Of the 58 reports included in the systematic review, nine of them were published based on three randomized controlled trials, 19 followed quasi-experimental designs, 11 were prospective and 19 were cross-sectional or retrospective. Studies were conducted in 19 different countries located in South America, North America, Western Europe, Eastern Europe, South Asia, Eurasia and Sub-Saharan Africa. Adherence to the BFHI Ten Steps has a positive impact on short-term, medium-term and long-term breastfeeding (BF) outcomes. There is a dose-response relationship between the number of BFHI steps women are exposed to and the likelihood of improved BF outcomes (early BF initiation, exclusive breastfeeding (EBF) at hospital discharge, any BF and EBF duration). Community support (step 10) appears to be essential for sustaining breastfeeding impacts of BFHI in the longer term.

      13. Caregiver feeding practices and child weight outcomes: a systematic reviewexternal icon
        Spill MK, Callahan EH, Shapiro MJ, Spahn JM, Wong YP, Benjamin-Neelon SE, Birch L, Black MM, Cook JT, Faith MS, Mennella JA, Casavale KO.
        Am J Clin Nutr. 2019 Mar 1;109(Supplement_7):990s-1002s.
        BACKGROUND: As part of the USDA-Department of Health and Human Services Pregnancy and Birth to 24 Months Project, we conducted systematic reviews (SRs) on topics important for health and nutrition of young children. OBJECTIVES: The purpose of the present SR was to examine the relation between caregiver feeding practices in children from birth to 24 mo and child weight gain, size, and body composition. METHODS: A search of articles published from January 1980 to January 2017 in 4 databases identified 8739 references. Nutrition Evidence Systematic Review (NESR) analysts used the Nutrition Evidence Library Risk of Bias Assessment Tool to assess potential bias in the studies, and a Technical Expert Collaborative graded the body of evidence using the NESR grading rubric. RESULTS: Twenty-seven articles were included in this review (8 controlled trials, 19 longitudinal cohort studies). Moderate evidence from randomized controlled trials suggests that providing responsive feeding guidance to teach mothers to recognize and respond appropriately to children’s hunger and satiety cues can lead to “normal” weight gain and/or “normal” weight status in children aged </=2 y compared with children whose mothers did not receive responsive feeding guidance. Moderate evidence from longitudinal cohort studies indicates an association between maternal feeding practices and the child’s weight status and/or weight gain, but the direction of effect has not been adequately studied. Restrictive feeding practices are associated with increased weight gain and higher weight status, and pressuring feeding practices are associated with decreased weight gain and lower weight status. Evidence suggests that a mother’s feeding practices are related to concerns about her child’s body weight. CONCLUSIONS: This review highlights the importance of the interaction between caregivers and infants and toddlers related to child feeding practices on children’s weight outcomes. Research is needed on more diverse populations with consistent methodological app-roaches and objective measures.

      14. Repeated exposure to food and food acceptability in infants and toddlers: a systematic reviewexternal icon
        Spill MK, Johns K, Callahan EH, Shapiro MJ, Wong YP, Benjamin-Neelon SE, Birch L, Black MM, Cook JT, Faith MS, Mennella JA, Casavale KO.
        Am J Clin Nutr. 2019 Mar 1;109(Supplement_7):978s-989s.
        BACKGROUND: Repeated exposure has been found to be an effective strategy to increase acceptability of foods in older children and adults, but little is known about its effectiveness in the birth to 24-mo population. OBJECTIVES: This systematic review was conducted to examine the effects of repeated exposure to a single or multiple foods on acceptance of those or other foods among infants and toddlers. METHODS: A search was conducted for peer-reviewed articles related to food acceptability, flavor, taste, and infants and toddlers in 12 databases (e.g., PubMed, Embase, Cochrane, and CINAHL) with a date range of January 1980 to July 2017. The Nutrition Evidence Library (NEL) Bias Assessment Tool was used to assess potential bias in the included studies, and the NESR grading rubric was used to grade evidence supporting the conclusion statement. RESULTS: From the 10,844 references obtained, 21 studies (19 controlled trials and 2 longitudinal cohort studies) published from 1980 to 2015 were included in this review. Moderate evidence indicates that tasting a single vegetable or fruit or multiple vegetable(s) or fruit(s) 1 food per day for 8-10 or more days is likely to increase acceptability of an exposed food (indicated by an increase in intake or faster rate of feeding after comparison with before the exposure period) in infants and toddlers 4-24 mo old. The effect of repeated exposure on acceptability is likely to generalize to other foods within the same food category but not foods from a different food category. Findings are based on the effects of repeated exposure to mostly vegetables with some findings on repeated exposure to fruits. CONCLUSION: This review advances the understanding of early food experiences and the development of food acceptability. Additional research is needed using diverse foods and textures with a focus on the transition to table foods.

      15. An Online Calculator to Estimate the Impact of Changes in Breastfeeding Rates on Population Health and Costsexternal icon
        Stuebe AM, Jegier BJ, Schwarz EB, Green BD, Reinhold AG, Colaizy TT, Bogen DL, Schaefer AJ, Jegier JT, Green NS, Bartick MC.
        Breastfeed Med. 2017 Dec;12(10):645-658.
        OBJECTIVE: We sought to determine the impact of changes in breastfeeding rates on population health. MATERIALS AND METHODS: We used a Monte Carlo simulation model to estimate the population-level changes in disease burden associated with marginal changes in rates of any breastfeeding at each month from birth to 12 months of life, and in rates of exclusive breastfeeding from birth to 6 months of life. We used these marginal estimates to construct an interactive online calculator (available at ). The Institutional Review Board of the Cambridge Health Alliance exempted the study. RESULTS: Using our interactive online calculator, we found that a 5% point increase in breastfeeding rates was associated with statistically significant differences in child infectious morbidity for the U.S. population, including otitis media (101,952 cases, 95% confidence interval [CI] 77,929-131,894 cases) and gastrointestinal infection (236,073 cases, 95% CI 190,643-290,278 cases). Associated medical cost differences were $31,784,763 (95% CI $24,295,235-$41,119,548) for otitis media and $12,588,848 ($10,166,203-$15,479,352) for gastrointestinal infection. The state-level impact of attaining Healthy People 2020 goals varied by population size and current breastfeeding rates. CONCLUSION: Modest increases in breastfeeding rates substantially impact healthcare costs in the first year of life.

  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. OBJECTIVE: Research has not examined the use of health care by patients with myotonic muscular dystrophy (MMD), but it would provide insights into this population, which is prone to comorbidities and high service needs. This study is an analysis of this understudied subgroup, using a unique linked dataset to examine the characteristics and healthcare utilization patterns for people with MMD. METHODS: This analysis used 3 South Carolina datasets (2009-2014). The subjects included individuals with at least 1 encounter with an International Classification of Diseases, Ninth Revision, Clinical Modification code of 359.21. The variables included sex, race, visit type, payer, and diagnoses. The analyses examined characteristics and number of encounters. RESULTS: The subjects were predominately female, white, and 45 to 64 years old. A total of 44.6% of the study population had at least 1 inpatient visit, whereas 64.2% had at least 1 emergency department visit. A majority of the subjects had at least 1 office visit (55.0%), and most (85.3%) did not have a home health encounter. CONCLUSIONS: Investigation of the reasons for these inpatient and emergency department encounters may be helpful in identifying ways to deliver high-quality care.

      2. This study assesses the prevalence of falls, factors predicting future falls, and health impacts of falls and balance or walking problems for U.S. older adults. Data were participants >/=65years in the Medicare Health Outcomes Survey Cohort 15 (baseline survey in 2012; follow-up survey in 2014; n=164,597). We examined baseline factors predicting falls at follow-up and estimated the impact of falls and balance/walking problems on health-related quality of life (HRQOL), mortality, and quality-adjusted life years (QALYs). About 23% reported falls and 34% reported balance/walking problems in the past 12months. The strongest predictors of falls were previous falls [adjusted odds ratio (OR)=2.9] and balance/walking problems (OR=1.7). Many self-reported chronic conditions (e.g., depression, stroke, and diabetes), geriatric symptoms (e.g., urine leakage), and limitations of activities of daily living (e.g., transferring and walking) also predicted falls, but at a smaller magnitude (ORs=1.1-1.3). Having balance/walking problems was associated with a greater decrease in HRQOL scores (0.195 points) than falls (0.077 points), while falls were associated with a greater increase in mortality [adjusted hazard ratio (HR)=1.5] than balance/walking problems (HR=1.1). Falls were associated with a 4.6-year (48%) decrease in QALYs, while balance/walking problems was associated with a 7.3-year (62%) decrease in QALYs. Falls are a major problem for U.S. elderly and will continue to have an even greater impact as the population ages. The nearly 50% decrease in QALYs for falls and >60% decrease for balance or walking problems demonstrates the substantial burden associated with these problems among older Americans.

      3. Family history is a strong risk factor for many common chronic diseases and summarizes shared environmental and genetic risk, but how this increased risk is mediated is unknown. We developed a “Family History-Wide Association Study” (FamWAS) to systematically and comprehensively test Clinical and Environmental Quantitative Traits (CEQTs) for their association with family history of disease. We implemented our method on 457 CEQTs for association with family history of diabetes, asthma, and coronary heart disease (CHD) in 42,940 adults spanning 8 waves of the 1999-2014 National Health and Nutrition Examination Survey (NHANES). We conducted pooled analyses of the 8 survey waves and analyzed trait associations using survey-weighted logistic regression. We identified 172 (37.6% of total), 32 (7.0%), and 78 (17.1%) CEQTs associated with family history of diabetes, asthma, and CHD, respectively, in sub-cohorts of individuals without the respective disease. 20 associated CEQTs were shared across family history of diabetes, asthma, and CHD, far more than expected by chance. FamWAS can examine traits not previously studied in association with family history and uncover trait overlap, highlighting a putative shared mechanism by which family history influences disease risk.

      4. OBJECTIVE: In vitro and clinical studies suggest that urate may contribute to osteoarthritis (OA) risk. We tested the associations between hyperuricemia and knee OA, and examined the role of obesity, using a cross-sectional, nationally representative dataset. METHOD: NHANES III used a multistage, stratified probability cluster design to select U.S. civilians from 1988 to 1994. Using NHANES III we studied adults > 60 years, with or without hyperuricemia (serum urate > 6.8 mg/dL), excluding individuals with gout (i.e., limiting to asymptomatic hyperuricemia (AH)). Radiographic knee OA (RKOA) was defined as Kellgren-Lawrence grade >/= 2 in any knee, and symptomatic RKOA (sRKOA) was defined as RKOA plus knee pain (most days for 6 weeks) in the same knee. RESULTS: AH prevalence was 17.9% (confidence interval (CI) 15.3-20.5). RKOA prevalence was 37.7% overall (CI 35.0-40.3), and was 44.0% for AH vs 36.3% for normouricemic adults (p = 0.056). sRKOA was more prevalent in AH vs normouricemic adults (17.4% vs 10.9%, p=0.046). In multivariate models adjusting for obesity, model-based associations between AH and knee OA were attenuated (for RKOA, prevalence ratio (PR) = 1.14, 95% CI 0.95, 1.36; for sRKOA, PR = 1.40, 95% CI 0.98, 2.01). In stratified multivariate analyses, AH was associated with sRKOA in adults without obesity (PR= 1.66, 95% CI 1.02, 2.71) but not adults with obesity (PR = 1.21, 95% CI 0.66, 2.23). CONCLUSIONS: Among adults aged 60 or older, AH is associated with knee OA risk that is more apparent in adults without obesity.

    • Communicable Diseases
      1. Middle East respiratory syndrome coronavirus infection dynamics and antibody responses among clinically diverse patients, Saudi Arabiaexternal icon
        Al-Abdely HM, Midgley CM, Alkhamis AM, Abedi GR, Lu X, Binder AM, Alanazi KH, Tamin A, Banjar WM, Lester S, Abdalla O, Dahl RM, Mohammed M, Trivedi S, Algarni HS, Sakthivel SK, Algwizani A, Bafaqeeh F, Alzahrani A, Alsharef AA, Alhakeem RF, Jokhdar HA, Ghazal SS, Thornburg NJ, Erdman DD, Assiri AM, Watson JT, Gerber SI.
        Emerg Infect Dis. 2019 Apr;25(4):753-766.
        Middle East respiratory syndrome coronavirus (MERS-CoV) shedding and antibody responses are not fully understood, particularly in relation to underlying medical conditions, clinical manifestations, and mortality. We enrolled MERS-CoV-positive patients at a hospital in Saudi Arabia and periodically collected specimens from multiple sites for real-time reverse transcription PCR and serologic testing. We conducted interviews and chart abstractions to collect clinical, epidemiologic, and laboratory information. We found that diabetes mellitus among survivors was associated with prolonged MERS-CoV RNA detection in the respiratory tract. Among case-patients who died, development of robust neutralizing serum antibody responses during the second and third week of illness was not sufficient for patient recovery or virus clearance. Fever and cough among mildly ill patients typically aligned with RNA detection in the upper respiratory tract; RNA levels peaked during the first week of illness. These findings should be considered in the development of infection control policies, vaccines, and antibody therapeutics.

      2. Medical pluralism and rationalities for HIV care utilization among discordant couples in Siaya County, rural western Kenyaexternal icon
        Arego J, Ondenge K, Odero I, Awuonda E, Omoro T, Akelo V, Mudhune V, Gust DA.
        Int J STD AIDS. 2019 Jun 3:956462419843691.
        Understanding healthcare seeking and utilization of members of discordant couples can help in implementing effective HIV treatment, care, and support. We conducted a qualitative study comprised of in-depth interviews (n = 26) and ten focus group discussions (n = 73) with community members including opinion leaders, healthcare workers, and members of discordant couples. A portion of the latter group had been participants in the HIV Prevention Trials Network (HPTN) 052 study. Themes that emerged from the data were pragmatism and the realities of hospital care, quest for a cure through traditional medicine, and religious dogma. Medical pluralism is practiced by members of discordant couples seeking HIV care through intersections of hospital facility services and traditional and religious therapeutic options. It would be prudent for healthcare policy makers and conventional medical providers to recognize the importance of traditional medicine and religion in the lives of members of HIV discordant couples and make efforts to integrate the positive concepts of both into the couples’ overall health plan.

      3. Strengthening provider-initiated testing and counselling in Zimbabwe by deploying supplemental providers: a time series analysisexternal icon
        Bochner AF, Tippett Barr BA, Makunike B, Gonese G, Wazara B, Mashapa R, Meacham E, Nyika P, Ncube G, Balachandra S, Levine R, Petracca F, Apollo T, Downer A, Wiktor SZ.
        BMC Health Serv Res. 2019 Jun 3;19(1):351.
        BACKGROUND: Expansion of provider-initiated testing and counselling (PITC) is one strategy to increase accessibility of HIV testing services. Insufficient human resources was identified as a primary barrier to increasing PITC coverage in Zimbabwe. We evaluated if deployment of supplemental PITC providers at public facilities in Zimbabwe was associated with increased numbers of individuals tested and diagnosed with HIV. METHODS: From July 2016 to May 2017, International Training and Education Center for Health (I-TECH) deployed 138 PITC providers to supplement existing ministry healthcare workers offering PITC at 249 facilities. These supplemental providers were assigned to facilities on a weekly basis. Each week, I-TECH providers reported the number of HIV tests and positive diagnoses they performed. Using routine reporting systems, we obtained from each facility the number of clients tested and diagnosed with HIV per month. Including data both before and during the intervention period, and utilizing the weekly variability in placement locations of the supplemental PITC providers, we employed generalized estimating equations to assess if the placement of supplemental PITC providers at a facility was associated with a change in facility outputs. RESULTS: Supplemental PITC providers performed an average of 62 (SD = 52) HIV tests per week and diagnosed 4.4 (SD = 4.9) individuals with HIV per week. However, using facility reports from the same period, we found that each person-week of PITC provider deployment at a facility was associated with an additional 16.7 (95% CI, 12.2-21.1) individuals tested and an additional 0.9 (95% CI, 0.5-1.2) individuals diagnosed with HIV. We also found that staff placement at clinics was associated with a larger increase in HIV testing than staff placement at polyclinics or hospitals (24.0 vs. 9.8; p < 0.001). CONCLUSIONS: This program resulted in increased numbers of individuals tested and diagnosed with HIV. The discrepancy between the average weekly HIV tests conducted by supplemental PITC providers (62) and the increase in facility-level HIV tests associated with one week of PITC provider deployment (16.7) suggests that supplemental PITC providers displaced existing staff who may have been reassigned to fulfil other duties at the facility.

      4. Facilitators and barriers affecting PrEP adherence among Thai men who have sex with men (MSM) in the HPTN 067/ADAPT Studyexternal icon
        Chemnasiri T, Varangrat A, Amico KR, Chitwarakorn A, Dye BJ, Grant RM, Holtz TH.
        AIDS Care. 2019 Jun 3:1-6.
        The HPTN 067/ADAPT Study evaluated the feasibility, acceptability, patterns of adherence and coverage for three randomly assigned oral FTC/TDF pre-exposure prophylaxis (PrEP) dosing regimens to prevent HIV infection. Using qualitative methods, we explored facilitators and barriers among a subset of men who have sex with men (MSM) participants in Bangkok, Thailand. Between August 2013 and March 2014, 32 HPTN 067/ADAPT participants joined in 6 focus group discussions, and 6 attended key informant interviews. Facilitators of PrEP adherence included use of strategies to have PrEP available when needed, simplicity in regimen requirements with recognition that more complex regimens may take some time to master, ability to plan for sex, receipt of social and technology support, ability to use a PrEP regimen that best matches to one’s own patterns of sex, and experiences with PrEP as a part of health and well-being. Challenges to PrEP adherence included perceptions of no or low HIV risk, difficulties following regimens when intoxicated, concerns about side effects, experience of HIV stigma, and affordability of PrEP outside of study context influencing uptake and use in the community. Preferences for regimens varied, suggesting that multiple PrEP effective regimen options should be available to fit those with different needs.

      5. Cutaneous granulomatous disease with presence of rubella virus in lesionsexternal icon
        Dhossche J, Johnson L, White K, Funk T, Leitenberger S, Perelygina L, Krol A.
        JAMA Dermatol. 2019 Jun 5.

        [No abstract]

      6. Novel method for rapid detection of spatiotemporal HIV clusters potentially warranting interventionexternal icon
        Fitzmaurice AG, Linley L, Zhang C, Watson M, France AM, Oster AM.
        Emerg Infect Dis. 2019 May;25(5):988-991.
        Rapid detection of increases in HIV transmission enables targeted outbreak response efforts to reduce the number of new infections. We analyzed US HIV surveillance data and identified spatiotemporal clusters of diagnoses. This systematic method can help target timely investigations and preventive interventions for maximum public health benefit.

      7. Scaling-up hepatitis C prevention and treatment interventions for achieving elimination in the United States – a rural and urban comparisonexternal icon
        Fraser H, Vellozzi C, Hoerger TJ, Evans JL, Kral AH, Havens J, Young AM, Stone J, Handanagic S, Hariri S, Barbosa C, Hickman M, Leib A, Martin NK, Nerlander L, Raymond HF, Page K, Zibbell J, Ward JW, Vickerman P.
        Am J Epidemiol. 2019 May 31.
        In the U.S. Hepatitis C virus (HCV) transmission is increasing among people who inject drugs (PWID). Many regions have insufficient prevention intervention coverage. Using modelling, we investigate the impact of scaling-up prevention and treatment interventions on HCV transmission among PWID in Perry County, Kentucky (PC), and San Francisco, California (SF), where HCV sero-prevalence among PWID is >50%. A greater proportion of PWID access medication-assisted treatment (MAT) or syringe service programs (SSP) in urban SF (established community) than rural PC (young, expanding community). We model the proportion of HCV-infected PWID needing HCV-treatment annually to reduce HCV-incidence by 90% by 2030, with and without MAT scale-up (50% coverage, both settings) and SSP scale-up (PC only) from 2017. With current MAT&SSP coverage during 2017-2030, HCV-incidence will increase in PC (21.3 to 22.6 per 100 person-years (/100pyrs)) and decrease in SF (12.9 to 11.9/100pyrs). With concurrent MAT&SSP scale-up, 5%/year of HCV-infected PWID need HCV-treatment in PC to achieve incidence targets; 13%/year without MAT&SSP scale-up. In SF, a similar proportion need HCV-treatment (10%/year) irrespective of MAT scale-up. Reaching the same impact by 2025 requires increases in treatment rates of 45-82%. Achievable provision of HCV-treatment, alongside MAT&SSP scale-up (PC) and MAT scale-up (SF), could reduce HCV-incidence.

      8. Characteristics and care outcomes among persons living with perinatally acquired HIV infection in the United States, 2015external icon
        Gray KM, Banez Ocfemia MC, Wang X, Li J, Nesheim SR.
        J Acquir Immune Defic Syndr. 2019 Jun 4.
        BACKGROUND: Medical advancements have improved the survival of persons with perinatally acquired HIV infection (PHIV). We describe persons living with diagnosed PHIV and assess receipt of HIV care, retention in care, and viral suppression. METHODS: Data reported to the National HIV Surveillance System (NHSS) through December 2017 were used to characterize persons living with diagnosed PHIV by year-end 2015 in the United States and 6 dependent areas. NHSS data from 40 jurisdictions with complete laboratory reporting were used to assess receipt of HIV care (>/=1 CD4 or viral load during 2015), retention in HIV care (>/=2 CD4 or viral load tests >/=3 months apart during 2015) and viral suppression (<200 copies/mL during 2015) among persons with PHIV diagnosed by year-end 2014 and alive at year-end 2015. RESULTS: By year-end 2015, 11,747 persons were living with PHIV and half were aged 18-25 years. Of 9,562 persons with HIV diagnosed by year-end 2014 and living with PHIV at year-end 2015 in the 40 jurisdictions, 75.4% received any care, 61.1% were retained in care, and 49.0% achieved viral suppression. Persons </=17 years of age had a significantly higher prevalence of being retained in care (PR=1.2, 95%CI=1.2-1.3) and virally suppressed (PR=1.4, 95%CI=1.3-1.5) than persons aged 18-25 years. CONCLUSIONS: Efforts to improve care outcomes among persons with PHIV are needed. Enhanced collaboration between pediatric and adult medical providers may ensure continuity of care during the transition from adolescence to adulthood.

      9. The Southeast accounted for most HIV diagnoses (52%) in the United States in 2015. Primary care providers (PCPs) play a vital role in HIV prevention for at-risk persons and treatment of persons living with HIV. We studied HIV-related training, knowledge, and clinical practices among PCPs in the Southeast to address knowledge gaps to inform HIV prevention strategies. Between April and August 2017, we conducted an on-line survey of a representative sample of PCPs in six Southeast jurisdictions with high rates of HIV diagnoses (Atlanta; Baltimore; Baton Rouge; District of Columbia; Miami; New Orleans). We defined HIV-related training as self-reported completion of any certified HIV/STD course or continuing education in past 24 months (prior to survey completion). We assessed associations between training and HIV testing practices, familiarity with nonoccupational post-exposure prophylaxis (nPEP) and pre-exposure prophylaxis (PrEP), and ever prescribing nPEP or PrEP. There were 820 participants after fielding 4595 surveys (29.6% adjusted response rate). In weighted analyses, 36.3% reported HIV-related training. Using adjusted prevalence ratio (aPR) and confidence intervals (CI), we found that PCPs with HIV-related training (compared to those with no training) were more likely to be familiar with nPEP (aPR = 1.32, 95% CI 1.05, 1.67) and PrEP (aPR = 1.67, 95% CI 1.19, 2.38); and to have ever prescribed PrEP to patients (aPR = 1.75, 95% CI 1.10, 2.78). Increased HIV-related trainings among PCPs in high HIV prevalence Southeast jurisdictions may be warranted. Strengthening nPEP and PrEP familiarity among PCPs in Southeast may advance national HIV prevention goals.

      10. Creation of a national infection prevention and control programme in Sierra Leone, 2015external icon
        Kanu H, Wilson K, Sesay-Kamara N, Bennett S, Mehtar S, Storr J, Allegranzi B, Benya H, Park B, Kolwaite A.
        BMJ Global Health. 2019 ;4(3).
        Prior to the 2014-2016 Ebola epidemic, Sierra Leone’s Ministry of Health and Sanitation had no infection prevention and control programme. High rates of Ebola virus disease transmission in healthcare facilities underscored the need for infection prevention and control in the healthcare system. The Ministry of Health and Sanitation led an effort among international partners to rapidly stand up a national infection prevention and control programme to decrease Ebola transmission in healthcare facilities and strengthen healthcare safety and quality. Leadership and ownership by the Ministry of Health and Sanitation was the catalyst for development of the programme, including the presence of an infection prevention and control champion within the ministry. A national policy and guidelines were drafted and approved to outline organisation and standards for the programme. Infection prevention and control focal persons were identified and embedded at public hospitals to manage implementation. The Ministry of Health and Sanitation and international partners initiated training for new infection prevention and control focal persons and committees. Monitoring systems to track infection prevention and control implementation were also established. This is a novel example of rapid development of a national infection prevention and control programme under challenging conditions. The approach to rapidly develop a national infection prevention and control programme in Sierra Leone may provide useful lessons for other programmes in countries or contexts starting from a low baseline for infection prevention and control.

      11. OBJECTIVES: Adiponectin levels are inversely related to cardiovascular risk and are low in diabetics and obese persons. We examined the association between adiponectin concentration and HIV-associated lipodystrophy, which remains unclear. METHODS: The Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy (SUN) was a prospective cohort study of HIV-infected adults conducted in four US cities. Lean body and fat masses were assessed using dual-energy X-ray absorptiometry scans. Using baseline data from 2004 to 2006, we defined lipodystrophy using a sex-specific fat mass ratio and performed cross-sectional analyses of associated risks using multivariable logistic regression. RESULTS: Among 440 male participants (median age 42 years; 68% non-Hispanic white; 88% prescribed combination antiretroviral therapy; median CD4 lymphocyte count 468 cells/muL; 76% with viral load < 400 HIV-1 RNA copies/mL; 5% diabetic; median body mass index 25 kg/m(2) ), median concentrations of leptin and adiponectin were 3.04 ng/L [interquartile range (IQR) 1.77-5.43 ng/L] and 8005 mug/mL (IQR 4950-11 935 mug/mL), respectively. The prevalence of lipodystrophy was 14%. Lipodystrophy was significantly associated with increasing age [prevalence ratio (PR) 1.50; 95% confidence interval (CI) 1.10-2.06, per 10 years], adiponectin < 8005 mug/mL (PR 5.02; 95% CI 2.53-9.95), ever stavudine use (PR 2.26; 95% CI 1.36-3.75), CD4 cell count > 500 cells/muL (PR 2.59; 95% CI 1.46-4.61), viral load < 400 copies/mL (PR 3.98; 95% CI 1.25-12.6), highly sensitive C-reactive protein < 1.61 mg/L (PR 1.91; 95% CI 1.11-3.28) and smoking (PR 0.42; 95% CI 0.22-0.78). CONCLUSIONS: Among men in this HIV-infected cohort, the prevalence of lipodystrophy was similar to previous estimates for persons living with HIV, and was associated with lower adiponectin levels, potentially indicating increased cardiovascular disease risk.

      12. Neonatal conjunctivitis caused by Neisseria meningitidis US urethritis clade, New York, USA, August 2017external icon
        Kretz CB, Bergeron G, Aldrich M, Bloch D, Del Rosso PE, Halse TA, Ostrowsky B, Liu Q, Gonzalez E, Omoregie E, Chicaiza L, Zayas G, Tha B, Liang A, Wang JC, Levi M, Hughes S, Musser KA, Weiss D, Rakeman JL.
        Emerg Infect Dis. 2019 May;25(5):972-975.
        We characterized a case of neonatal conjunctivitis in New York, USA, caused by Neisseria meningitidis by using whole-genome sequencing. The case was a rare occurrence, and the isolate obtained belonged to an emerging clade (N. meningitidis US nongroupable urethritis) associated with an increase in cases of urethritis since 2015.

      13. Impact of choice of test for latent tuberculosis infection on treatment acceptance and completionexternal icon
        Lambert LA, Katz D, Feng PJ, Djojonegoro BM, Fair E, Jasuja S, Marantz S, Horsburgh CR, Ho C.
        Microbiol Insights. 2018 ;11:1178636118811311.
        Objective: The aim of this study is to assess whether choice of test for tuberculosis (TB) infection affects decisions to accept and complete treatment among contacts to TB cases. Methods: Retrospective study is conducted in which TB contacts, 15 years old during 2005 and 2009, were tested for infection with either a tuberculin skin test (TST) or an interferon-gamma release assay test, the QuantiFERON-TB Gold In-Tube (QFT-GIT). Results: Of 658 persons with valid test results, 185 (28%) had positive results, including 128 of 406 (32%) who had TST and 57 of 252 (23%) who received QFT-GIT. Treatment acceptance was 43 of 57 (75%) among QFT-GIT-positive and 97 of 128 (76%) among TST-positive persons (risk ratio [RR] = 1.0, 95% confidence interval [CI], 0.83-1.2). Treatment completion was 56% among QFT-GIT-positive (32 of 57) and 59% (75 of 128) among TST-positive persons (RR = 0.96, 95% CI, 0.73-1.26). Discussion: Our study showed no difference in proportions of TB contacts 15 years old with positive TST results who accepted or completed LTBI treatment compared with those with positive QFT-GIT results. Future studies should include high-risk persons with no known TB exposure, who constitute the main reservoir for TB cases in the United States.

      14. Scaling up testing for human immunodeficiency virus infection among contacts of index patients – 20 countries, 2016-2018external icon
        Lasry A, Medley A, Behel S, Mujawar MI, Cain M, Diekman ST, Rurangirwa J, Valverde E, Nelson R, Agolory S, Alebachew A, Auld AF, Balachandra S, Bunga S, Chidarikire T, Dao VQ, Dee J, Doumatey LE, Dzinotyiweyi E, Dziuban EJ, Ekra KA, Fuller WB, Herman-Roloff A, Honwana NB, Khanyile N, Kim EJ, Kitenge SF, Lacson RS, Loeto P, Malamba SS, Mbayiha AH, Mekonnen A, Meselu MG, Miller LA, Mogomotsi GP, Mugambi MK, Mulenga L, Mwangi JW, Mwangi J, Nicoue AA, Nyangulu MK, Pietersen IC, Ramphalla P, Temesgen C, Vergara AE, Wei S.
        MMWR Morb Mortal Wkly Rep. 2019 May 31;68(21):474-477.
        In 2017, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that worldwide, 36.9 million persons were living with human immunodeficiency virus (HIV) infection, the virus infection that causes acquired immunodeficiency syndrome (AIDS). Among persons with HIV infection, approximately 75% were aware of their HIV status, leaving 9.4 million persons with undiagnosed infection (1). Index testing, also known as partner notification or contact tracing, is an effective case-finding strategy that targets the exposed contacts of HIV-positive persons for HIV testing services. This report summarizes data from HIV tests using index testing in 20 countries supported by CDC through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) during October 1, 2016-March 31, 2018. During this 18-month period, 1,700,998 HIV tests with 99,201 (5.8%) positive results were reported using index testing. The positivity rate for index testing was 9.8% among persons aged >/=15 years and 1.5% among persons aged <15 years. During the reporting period, HIV positivity increased 64% among persons aged >/=15 years (from 7.6% to 12.5%) and 67% among persons aged <15 years (from 1.2% to 2.0%). Expanding index testing services could help increase the number of persons with HIV infection who know their status, are initiated onto antiretroviral treatment, and consequently reduce the number of persons who can transmit the virus.

      15. Underreporting of Hepatitis B and C virus infections – Pennsylvania, 2001-2015external icon
        Roberts H, Boktor SW, Waller K, Daar ZS, Boscarino JA, Dubin PH, Suryaprasad A, Moorman AC.
        PLoS One. 2019 ;14(6):e0217455.
        CONTEXT: In Pennsylvania, reporting of viral hepatitis B (HBV) and viral hepatitis C (HCV) infections to CDC has been mandated since 2002. Underreporting of HBV and HCV infections has long been identified as a problem. Few reports have described the accuracy of state surveillance case registries for recording clinically-confirmed cases of HBV and HCV infections, or the characteristics of populations associated with lower rates of reporting. OBJECTIVE: The primary objective of the current study is to estimate the proportion of HBV and HCV infections that went unreported to the Pennsylvania Department of Health (PDoH), among patients in the Geisinger Health System of Pennsylvania. As a secondary objective, we study the association between underreporting of HBV and HCV infections to PDoH, and the select patient characteristics of interest: sex, age group, race/ethnicity, rural status, and year of initial diagnosis. DESIGN: Per medical record review, the study population was limited to Geisinger Health System patients, residing in Pennsylvania, who were diagnosed with a chronic HBV and/or HCV infection, between 2001 and 2015. Geisinger Health System patient medical records were matched to surveillance records of confirmed cases reported to the Pennsylvania Department of Health (PDoH). To quantify the extent that underreporting occurred among the Geisinger Health System study participants, we calculated the proportion of study participants that were not reported to PDoH as confirmed cases of HBV or HCV infections. An analysis of adjusted prevalence ratio estimates was conducted to study the association between underreporting of HBV and HCV infections to PDoH, and the select patient characteristics of interest. RESULTS: Geisinger Health System patients living with HBV were reported to PDoH 88.4% (152 of 172) of the time; patients living with HCV were reported to PDoH 94.6% (2,257 of 2,386) of the time; and patients who were co-infected with both viruses were reported to PDoH 72.0% (18 of 25) of the time. Patients living with HCV had an increased likelihood of being reported if they were: less than or equal to age 30 vs ages 65+ {PR = 1.2, [95%CI, (1.1, 1.3)]}, and if they received their initial diagnosis of HCV during the 2010-2015 time period vs the 1990-1999 time period {PR = 1.08, [95%CI, (1.05, 1.12)]}. CONCLUSION: The findings in this study are promising, and suggests that PDoH has largely been successful with tracking and monitoring viral hepatitis B and C infections, among persons that were tested for HBV and/or HCV. Additional efforts should be placed on decreasing underreporting rates of HCV infections among seniors (ages 65 and over), and persons who are co-infected with HBV and HCV.

      16. Causal inference with multiple concurrent medications: A comparison of methods and an application in multidrug-resistant tuberculosisexternal icon
        Siddique AA, Schnitzer ME, Bahamyirou A, Wang G, Holtz TH, Migliori GB, Sotgiu G, Gandhi NR, Vargas MH, Menzies D, Benedetti A.
        Stat Methods Med Res. 2018 Oct 31:962280218808817.
        This paper investigates different approaches for causal estimation under multiple concurrent medications. Our parameter of interest is the marginal mean counterfactual outcome under different combinations of medications. We explore parametric and non-parametric methods to estimate the generalized propensity score. We then apply three causal estimation approaches (inverse probability of treatment weighting, propensity score adjustment, and targeted maximum likelihood estimation) to estimate the causal parameter of interest. Focusing on the estimation of the expected outcome under the most prevalent regimens, we compare the results obtained using these methods in a simulation study with four potentially concurrent medications. We perform a second simulation study in which some combinations of medications may occur rarely or not occur at all in the dataset. Finally, we apply the methods explored to contrast the probability of patient treatment success for the most prevalent regimens of antimicrobial agents for patients with multidrug-resistant pulmonary tuberculosis.

      17. Low Disclosure of PrEP nonadherence and HIV risk behaviors associated with poor HIV PrEP adherence in the HPTN 067/ADAPT Studyexternal icon
        Victoria DO, Rivet AK, James PH, Ethan W, Maoji L, Timothy HH, Anupong C, Robert MG, Bonnie D, Linda-Gail B, Sharon M, Mark M, Craig WH.
        J Acquir Immune Defic Syndr. 2019 May 21.
        OBJECTIVE: We evaluated the relationship between two types of social relationships (i.e., 1) external support for use of HIV pre-exposure prophylaxis [PrEP] and related study supplies 2) participants’ disclosure of PrEP use and condom use and HIV PrEP adherence among daily-dosing regimen participants in HPTN 067, an open-label trial of oral tenofovir (TFV) disoproxil fumarate (TDF) 300 mg/emtricitabine (FTC) 200 mg. METHODS: Using HPTN-067 survey data, we developed scales examining 1) Low Perceived External Support for PrEP: low perceived support by others for PrEP use or perceived negative reactions to the pill case (scoring ranges from 0 to 2) and 2) Participant-Staff Disclosure Challenges Scale which identifies challenges to sharing non-use of PrEP or condoms to study staff (scoring ranges from 0 to 4); these scales are the primary independent variables. Adherence, the dependent variable, was determined using log-transformed plasma TFV concentrations. GEE linear regression was used to assess the association between both scales and adherence. RESULTS: Participants (n=161) included HIV-uninfected women in South Africa, and men who have sex with men and transgender women, in Thailand and the U.S. In multivariable analyses, higher scores in the Participant-Staff Disclosure Challenges Scale were significantly associated with lower PrEP adherence (exp(beta) = 0.62, 95% CI (0.46- 0.84); p=0.002) as were increased days since the last PrEP dose (exp(beta) = 0.73, 95% CI (0.65- 0.83); p</=0.001). CONCLUSIONS: Given the association with adherence, study staff-participant interactions and participants’ disclosure of PrEP challenges may be worthwhile intervention targets for improving PrEP adherence in confirmatory studies.

      18. Using social media to increase HIV testing among men who have sex with men – Beijing, China, 2013-2017external icon
        Wang L, Podson D, Chen Z, Lu H, Wang V, Shepard C, Williams JK, Mi G.
        MMWR Morb Mortal Wkly Rep. 2019 May 31;68(21):478-482.
        The prevalence of human immunodeficiency virus (HIV) infection in China is low overall (0.06%) (1); however, it is substantially higher (8.0%) among men who have sex with men (MSM) (2), and the stigmatization of same-sex behaviors in China presents challenges for HIV prevention and treatment efforts. In 2015, Blued, a Beijing-based media company that operates an online dating application popular among Chinese MSM, launched an ongoing HIV testing campaign that combined its push-notification(dagger) platform and geolocation capabilities to encourage HIV testing among MSM in Beijing. To assess trends in use of HIV testing services, Blued and CDC’s China HIV program examined testing at six Blued-operated Beijing HIV testing centers from 2 years before the campaign launch in 2015 through December 31, 2017. A sharp increase in HIV testing followed the launch of Blued’s online campaign, indicating that leveraging social media platforms and their geolocation-based text messaging functionality might be useful in increasing HIV testing among MSM, particularly those aged </=35 years.

      19. The rate of reported gonorrhea among men who have sex with men (MSM) has been steadily increasing in recent years, but little is known about how much changing testing practices and incidence each contribute to this trend. We report that both factors are likely contributing to the observed rate increases.

      20. Evaluation of the influenza-like illness surveillance system in Tunisia, 2012-2015external icon
        Yazidi R, Aissi W, Bouguerra H, Nouira M, Kharroubi G, Maazaoui L, Zorraga M, Abdeddaiem N, Chlif S, El Moussi A, Ben Hadj Kacem MA, Snoussi MA, Ghawar W, Koubaa M, Polansky L, McCarron M, Boussarsar M, Menif K, Amine S, Ben Khelil J, Ben Jemaa M, Bettaieb J, Bouafif Ben Alaya N, Ben Salah A.
        BMC Public Health. 2019 Jun 6;19(1):694.
        BACKGROUND: This study was initiated to evaluate, for the first time, the performance and quality of the influenza-like illness (ILI) surveillance system in Tunisia. METHODS: The evaluation covered the period of 2012-2015 and used different data sources to measure indicators related to data quality and completeness, representativeness, timeliness, simplicity, acceptability, flexibility, stability and utility. RESULTS: During the evaluation period, 485.221 ILI cases were reported among 6.386.621 outpatients at 268 ILI sentinel sites. To conserve resources, cases were only enrolled and tested for influenza during times when the number of patients meeting the ILI case definition exceeded 7% (10% after 2014) of the total number of outpatients for the week. When this benchmark was met, five to 10 patients were enrolled and sampled by nasopharyngeal swabs the following week. In total, The National Influenza Center (NIC) received 2476 samples, of which 683 (27.6%) were positive for influenza. The greatest strength of the system was its representativeness and flexibility. The timeliness of the data and the acceptability of the surveillance system performed moderately well; however, the utility of the data and the stability and simplicity of the surveillance system need improvement. Overall, the performance of the Tunisian influenza surveillance system was evaluated as performing moderately well for situational awareness in the country and for collecting representative influenza virologic samples. CONCLUSIONS: The influenza surveillance system in Tunisia provided pertinent evidence for public health interventions related to influenza situational awareness. To better monitor influenza, we propose that ILI surveillance should be limited to sites that are currently performing well and the quality of data collected should be closely monitored and improved.

    • Disaster Control and Emergency Services
      1. Hurricane-associated mold exposures among patients at risk for invasive mold infections after Hurricane Harvey – Houston, Texas, 2017external icon
        Chow NA, Toda M, Pennington AF, Anassi E, Atmar RL, Cox-Ganser JM, Da Silva J, Garcia B, Kontoyiannis DP, Ostrosky-Zeichner L, Leining LM, McCarty J, Al Mohajer M, Murthy BP, Park JH, Schulte J, Shuford JA, Skrobarcek KA, Solomon S, Strysko J, Chiller TM, Jackson BR, Chew GL, Beer KD.
        MMWR Morb Mortal Wkly Rep. 2019 May 31;68(21):469-473.
        In August 2017, Hurricane Harvey caused unprecedented flooding and devastation to the Houston metropolitan area (1). Mold exposure was a serious concern because investigations after Hurricanes Katrina and Rita (2005) had documented extensive mold growth in flood-damaged homes (2,3). Because mold exposure can cause serious illnesses known as invasive mold infections (4,5), and immunosuppressed persons are at high risk for these infections (6,7), several federal agencies recommend that immunosuppressed persons avoid mold-contaminated sites (8,9). To assess the extent of exposure to mold and flood-damaged areas among persons at high risk for invasive mold infections after Hurricane Harvey, CDC and Texas health officials conducted a survey among 103 immunosuppressed residents in Houston. Approximately half of the participants (50) engaged in cleanup of mold and water-damaged areas; these activities included heavy cleanup (23), such as removing furniture or removing drywall, or light cleanup (27), such as wiping down walls or retrieving personal items. Among immunosuppressed persons who performed heavy cleanup, 43% reported wearing a respirator, as did 8% who performed light cleanup. One participant reported wearing all personal protective equipment (PPE) recommended for otherwise healthy persons (i.e., respirator, boots, goggles, and gloves). Immunosuppressed residents who are at high risk for invasive mold infections were exposed to mold and flood-damaged areas after Hurricane Harvey; recommendations from health care providers to avoid exposure to mold and flood-damaged areas could mitigate the risk to immunosuppressed persons.

      2. Addressing disease-related stigma during infectious disease outbreaksexternal icon
        Fischer LS, Mansergh G, Lynch J, Santibanez S.
        Disaster Med Public Health Prep. 2019 Jun 3:1-6.
        ABSTRACTOutbreaks of emerging infectious disease are a constant threat. In the last 10 years, there have been outbreaks of 2009 influenza A (H1N1), Ebola virus disease, and Zika virus. Stigma associated with infectious disease can be a barrier to adopting healthy behaviors, leading to more severe health problems, ongoing disease transmission, and difficulty controlling infectious disease outbreaks. Much has been learned about infectious disease and stigma in the context of nearly 4 decades of the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome pandemic. In this paper, we define stigma, discuss its relevance to infectious disease outbreaks, including how individuals and communities can be affected. Adapting lessons learned from the rich literature on HIV-related stigma, we propose a strategy for reducing stigma during infectious disease outbreaks such as Ebola virus disease and Zika virus. The implementation of brief, practical strategies such as the ones proposed here might help reduce stigma and facilitate more effective control of emerging infectious diseases.

    • Disease Reservoirs and Vectors
      1. A chromosome-scale assembly of the major African malaria vector Anopheles funestusexternal icon
        Ghurye J, Koren S, Small ST, Redmond S, Howell P, Phillippy AM, Besansky NJ.
        Gigascience. 2019 Jun 1;8(6).
        BACKGROUND: Anopheles funestus is one of the 3 most consequential and widespread vectors of human malaria in tropical Africa. However, the lack of a high-quality reference genome has hindered the association of phenotypic traits with their genetic basis in this important mosquito. FINDINGS: Here we present a new high-quality A. funestus reference genome (AfunF3) assembled using 240x coverage of long-read single-molecule sequencing for contigging, combined with 100x coverage of short-read Hi-C data for chromosome scaffolding. The assembled contigs total 446 Mbp of sequence and contain substantial duplication due to alternative alleles present in the sequenced pool of mosquitos from the FUMOZ colony. Using alignment and depth-of-coverage information, these contigs were deduplicated to a 211 Mbp primary assembly, which is closer to the expected haploid genome size of 250 Mbp. This primary assembly consists of 1,053 contigs organized into 3 chromosome-scale scaffolds with an N50 contig size of 632 kbp and an N50 scaffold size of 93.811 Mbp, representing a 100-fold improvement in continuity versus the current reference assembly, AfunF1. CONCLUSION: This highly contiguous and complete A. funestus reference genome assembly will serve as an improved basis for future studies of genomic variation and organization in this important disease vector.

      2. Enhanced vector surveillance to control arbovirus epidemics in Colombiaexternal icon
        Guagliardo SA, Ardila Roldan SC, Santacoloma L, Luna C, Cordovez Alvarez JM, Rojas Gacha JD, Mansur M, Levine RS, Lenhart A, Oviedo PF.
        Rev Panam Salud Publica. 2019 ;43:e50.
        In the wake of the Zika epidemic, there has been intensified interest in the surveillance and control of the arbovirus vectors Aedes aegypti and Aedes albopictus, yet many existing surveillance systems could benefit from improvements. Vector control programs are often directed by national governments, but are carried out at the local level, resulting in the discounting of spatial heterogeneities in ecology and epidemiology. Furthermore, entomological and epidemiological data are often collected by separate governmental entities, which can slow vector control responses to outbreaks. Colombia has adopted several approaches to address these issues. First, a web-based, georeferenced Aedes surveillance system called SIVIEN AEDES was developed to allow field entomologists to record vector abundance and insecticide resistance data. Second, autocidal gravid oviposition (AGO) traps are deployed as an alternative way to measure vector abundance. Third, data collected by SIVIEN AEDES are used to develop mathematical models predicting Ae. aegypti abundance down to a city block, thus allowing public health authorities to target interventions to specific neighborhoods within cities. Finally, insecticide resistance is monitored through bioassays and molecular testing in 15 high-priority cities, providing a comprehensive basis to inform decisions about insecticide use in different regions. The next step will be to synchronize SIVIEN AEDES data together with epidemiological and climatic data to improve the understanding of the drivers of local variations in arbovirus transmission dynamics. By integrating these surveillance data, health authorities will be better equipped to develop tailored and timely solutions to control and prevent Aedes-borne arbovirus outbreaks.

      3. Field identification key and guide for bats of the United States of Americaexternal icon
        Morgan CN, Ammerman LK, Demere KD, Doty JB, Nakazawa YJ, Mauldin MR.
        Occas Pap Tex Tech Univ Mus. 2019 ;360.
        Bats are the second most speciose lineage of mammals with more than 1,300 recognized species. Overall, bats are extremely ecologically and morphologically diverse, making them of interest to a wide variety of biologists. Bats are also known reservoirs for an assortment of zoonotic diseases, including rabies, for which they are commonly tested if identified as sick, behaving abnormally, or in instances where there has been a significant human exposure. In these cases, proper identification of bat species is important to public health experts as it will inform future testing procedures and management practices, as well as broaden our understanding of rabies virus bat variant distributions and disease ecology. Despite the multiple disciplines interested in bats, no key has been developed which includes all species found within the United States. For this reason, a dichotomous key and bat identification guide, designed to differentiate bats to species level, has been developed. This document can be used by people with a variety of backgrounds to morphologically identify bats quickly and accurately using only a scale, a ruler, and attention to detail.

      4. Community assessments for mosquito prevention and control experiences, attitudes, and practices – U.S. Virgin Islands, 2017 and 2018external icon
        Seger KR, Roth J, Schnall AH, Ellis BR, Ellis EM.
        MMWR Morb Mortal Wkly Rep. 2019 Jun 7;68(22):500-504.
        Aedes aegypti, the mosquito that carries dengue, chikungunya, and Zika viruses, is present throughout the U.S. Virgin Islands (USVI). To reduce mosquitoborne disease transmission, the USVI Department of Health (VIDOH) is responsible for integrated mosquito management. During January 2016-January 2018, USVI experienced its first Zika outbreak, with most cases reported during January-December 2016, as well as two Category 5 hurricanes (Irma on St. Thomas/St. John on September 6, 2017, and Maria on St. Croix on September 19, 2017). The hurricanes severely damaged mosquito protection-related building structures (e.g., screens, roofs) and infrastructure (e.g., electricity, air conditioning) and might have created an environment more conducive to mosquito breeding. VIDOH, with requested technical assistance from CDC, conducted three Community Assessments for Public Health Emergency Response (CASPERs) to provide rapid community information at the household level. The three CASPERs were conducted to inform 1) the Zika outbreak response, 2) the hurricane response, and 3) the hurricane recovery. The CASPERs assessed mosquito prevention and control-related experiences, attitudes, and practices; household and environmental conditions associated with mosquito breeding, prevention, and control; and other nonmosquito-related information to inform outbreak and disaster response planning. Approximately 40% of households were very concerned about contracting Zika virus during the Zika outbreak and hurricane responses. Environmental conditions were reported to become more favorable for mosquito breeding between the Zika outbreak and hurricane response. Between 75%-80% of the community supported mosquito-spraying in all assessments. VIDOH used these data to support real-time outbreak and hurricane response planning. Mosquito prevention and control community assessments can provide rapid, actionable information to advise both mosquito education and control and emergency response and recovery efforts. The CASPER design can be used by vector control programs to enhance routine and response operations.

    • Environmental Health
      1. State-level policies concerning private wells in the United Statesexternal icon
        Bowen K, Krishna T, Backer L, Hodgins K, Waller LA, Gribble MO.
        Water Policy. 2019 ;21(2):428-435.
        Currently, no federal policies exist in the United States regarding private wells; this authority is devolved to states. This study inventoried state-level policies governing private wells in the United States in order to identify the topics addressed by each state, division of responsibilities across state agencies, and geographic differences in policy comprehensiveness. From May to August 2018, two independent reviewers conducted an online search followed by directly contacting state agencies (98% response) to identify all state-level policies in the United States that directly reference private wells. The search, updated in April 2018, confirmed the existing water policy list and identified 23 additional policies. Policies were then coded according to nine not-mutually-exclusive classifications. The results indicate that all states had at least one policy addressing private well drilling or construction. Significant geographic differences exist in maintenance related policies. In conclusion, although drilling and construction safety are addressed by each state, some policy domains are addressed inconsistently across states, and other policy domains are absent in most states.

      2. Development of a WebGIS-based analysis tool for human health protection from the impacts of prescribed fire smoke in southeastern USAexternal icon
        Hu Y, Ai HH, Odman MT, Vaidyanathan A, Russell AG.
        Int J Environ Res Public Health. 2019 Jun 4;16(11).
        We have developed the Southern Integrated Prescribed Fire Information System (SIPFIS) to disseminate prescribed fire information, including daily forecasts of potential air quality impacts for southeastern USA. SIPFIS is a Web-based Geographic Information Systems (WebGIS) assisted online analysis tool that provides easy access to air quality and fire-related data products, and it facilitates visual analysis of exposure to smoke from prescribed fires. We have demonstrated that the information that SIPFIS provides can help users to accomplish several fire management activities, especially those related to assessing environmental and health impacts associated with prescribed burning. SIPFIS can easily and conveniently assist tasks such as checking residential community-level smoke exposures for personal use, pre-screening for fire-related exceptional events that could lead to air quality exceedances, supporting analysis for air quality forecasts, and the evaluation of prescribed burning operations, among others. The SIPFIS database is currently expanding to include social vulnerability and human health information, and this will evolve to bring more enhanced interactive functions in the future.

      3. Per- and polyfluoroalkyl substances and blood lipid levels in pre-diabetic adults-longitudinal analysis of the diabetes prevention program outcomes studyexternal icon
        Lin PD, Cardenas A, Hauser R, Gold DR, Kleinman KP, Hivert MF, Fleisch AF, Calafat AM, Webster TF, Horton ES, Oken E.
        Environ Int. 2019 May 28;129:343-353.
        Exposure to per- and polyfluoroalkyl substances (PFASs) may interfere with lipid regulation. However, most previous studies were cross-sectional with the risk of reverse causation, suggesting a need for long-term prospective studies. We examined the relationship of baseline plasma PFAS concentrations with repeated measures of blood lipids. We included 888 prediabetic adults from the Diabetes Prevention Program (DPP) and DPP Outcomes Study, who had measurements of 6 plasma PFAS concentrations at baseline (1996-1999) and repeated measures of blood lipids over 15years of follow-up, and were initially randomized to placebo or a lifestyle intervention. We used linear regression to examine cross-sectional associations of PFAS concentrations and lipid levels at baseline, and evaluated prospective risks of hypercholesterolemia and hypertriglyceridemia using Cox proportional hazard models, and tested for effect modification by study arm. Participants (65.9% female, 57.0% White, 65.9% aged 40-59years) had comparable PFAS concentrations [e.g., median (IQR) perfluorooctanoic acid (PFOA) 4.9ng/mL (3.2)] with the general U.S. population in 1999-2000. We observed higher total cholesterol at baseline per doubling of PFOA (beta: 6.1mg/dL, 95% CI: 3.1, 9.04), perfluorohexane sulfonic acid (PFHxS, beta: 2.2mg/dL, 95% CI: 0.2, 4.3), and perfluorononanoic acid (PFNA, beta: 2.9mg/dL, 95% CI: 0.7, 5.0). Prospectively, baseline concentrations of several PFASs, including PFOA, PFOS, PFHxS and PFNA, predicted higher risks of incident hypercholesterolemia and hypertriglyceridemia, but only in the placebo group and not the lifestyle intervention group. For example, participants in the placebo group with PFOA concentration>median (4.9ng/mL) were almost twice as likely (HR: 1.90, 95% CI: 1.25, 2.88) to develop hypertriglyceridemia compared to those </=median. Findings suggest adverse effects of some PFASs on lipid profiles in prediabetic adults. However, the detrimental effect was attenuated with a lifestyle intervention.

    • Food Safety
      1. A systematic approach to identify and characterize the effectiveness and safety of novel probiotic strains to control foodborne pathogensexternal icon
        Ayala DI, Cook PW, Franco JG, Bugarel M, Kottapalli KR, Loneragan GH, Brashears MM, Nightingale KK.
        Front Microbiol. 2019 ;10:1108.
        A total of 44 lactic acid bacteria (LAB) strains originally isolated from cattle feces and different food sources were screened for their potential probiotic features. The antimicrobial activity of all isolates was tested by well-diffusion assay and competitive exclusion on broth against Salmonella Montevideo, Escherichia coli O157:H7 and Listeria monocytogenes strain N1-002. Thirty-eight LAB strains showed antagonistic effect against at least one of the pathogens tested in this study. Improved inhibitory effect was observed against L. monocytogenes with zones of inhibition up to 24 mm when LAB overnight cultures were used, and up to 21 mm when cell-free filtrates were used. For E. coli O157:H7 and Salmonella maximum inhibitions of 12 and 11.5 mm were observed, respectively. On broth, 43 strains reduced L. monocytogenes up to 9.06 log10 CFU/ml, 41 reduced E. coli O157:H7 up to 0.84 log10 CFU/ml, and 32 reduced Salmonella up to 0.94 log10 CFU/ml 24 h after co-inoculation. Twenty-eight LAB isolates that exhibited the highest inhibitory effect among pathogens were further analyzed to determine their antimicrobial resistance profile, adhesion potential, and cytotoxicity to Caco-2 cells. All LAB strains tested were susceptible to ampicillin, linezolid, and penicillin. Twenty-six were able to adhere to Caco-2 cells, five were classified as highly adhesive with > 40 bacterial cells/Caco-2 cells. Low cytotoxicity percentages were observed for the candidate LAB strains with values ranging from -5 to 8%. Genotypic identification by whole genome sequencing confirmed all as members of the LAB group; Enterococcus was the genus most frequently isolated with 21 isolates, followed by Pediococcus with 4, and Lactobacillus with 3. In this study, a systematic approach was used for the improved identification of novel LAB strains able to exert antagonistic effect against important foodborne pathogens. Our findings suggest that the selected panel of LAB probiotic strains can be used as biocontrol cultures to inhibit and/or reduce the growth of L. monocytogenes, Salmonella, and E. coli O157:H7 in different matrices, and environments.

      2. Metagenomic approaches for public health surveillance of foodborne infections: Opportunities and challengesexternal icon
        Carleton HA, Besser J, Williams-Newkirk AJ, Huang A, Trees E, Gerner-Smidt P.
        Foodborne Pathog Dis. 2019 Jun 6.
        Foodborne disease surveillance in the United States is at a critical point. Clinical and diagnostic laboratories are using culture-independent diagnostic tests (CIDTs) to identify the pathogen causing foodborne illness from patient specimens. CIDTs are molecular tests that allow doctors to rapidly identify the bacteria causing illness within hours. CIDTs, unlike previous gold standard methods such as bacterial culture, do not produce an isolate that can be subtyped as part of the national molecular subtyping network for foodborne disease surveillance, PulseNet. Without subtype information, cases can no longer be linked using molecular data to identify potentially related cases that are part of an outbreak. In this review, we discuss the public health needs for a molecular subtyping approach directly from patient specimen and highlight different approaches, including amplicon and shotgun metagenomic sequencing.

      3. Notes from the Field: Acute Intoxications from Consumption of Amanita muscaria Mushrooms – Minnesota, 2018external icon
        Taylor J, Holzbauer S, Wanduragala D, Ivaskovic A, Spinosa R, Smith K, Corcoran J, Jensen A.
        MMWR Morb Mortal Wkly Rep. 2019 May 31;68(21):483-484.

        [No abstract]

    • Global Health
      1. BACKGROUND: Health care provider (HCP) performance in low- and middle-income countries (LMICs) is often inadequate. The Health Care Provider Performance Review (HCPPR) is a comprehensive systematic review of the effectiveness and cost of strategies to improve HCP performance in LMICs. We present the HCPPR’s methods, describe methodological and contextual attributes of included studies, and examine time trends of study attributes. METHODS: The HCPPR includes studies from LMICs that quantitatively evaluated any strategy to improve HCP performance for any health condition, with no language restrictions. Eligible study designs were controlled trials and interrupted time series. In 2006, we searched 15 databases for published studies; in 2008 and 2010, we completed searches of 30 document inventories for unpublished studies. Data from eligible reports were double-abstracted and entered into a database, which is publicly available. The primary outcome measure was the strategy’s effect size. We assessed time trends with logistic, Poisson, and negative binomial regression modeling. We were unable to register with PROSPERO (International Prospective Register of Systematic Reviews) because the protocol was developed prior to the PROSPERO launch. RESULTS: We screened 105,299 citations and included 824 reports from 499 studies of 161 intervention strategies. Most strategies had multiple components and were tested by only one study each. Studies were from 79 countries and had diverse methodologies, geographic settings, HCP types, work environments, and health conditions. Training, supervision, and patient and community supports were the most commonly evaluated strategy components. Only 33.6% of studies had a low or moderate risk of bias. From 1958-2003, the number of studies per year and study quality increased significantly over time, as did the proportion of studies from low-income countries. Only 36.3% of studies reported information on strategy cost or cost-effectiveness. CONCLUSIONS: Studies have reported on the efficacy of many strategies to improve HCP performance in LMICs. However, most studies have important methodological limitations. The HCPPR is a publicly accessible resource for decision-makers, researchers, and others interested in improving HCP performance.

    • Health Economics
      1. A review of the cost-effectiveness of adult influenza vaccination and other preventive servicesexternal icon
        Dabestani NM, Leidner AJ, Seiber EE, Kim H, Graitcer SB, Foppa IM, Bridges CB.
        Prev Med. 2019 May 29.
        The Centers for Disease Control and Prevention recommend annual influenza vaccination of persons >/=6months old. However, in 2016-17, only 43.3% of U.S. adults reported receiving an influenza vaccination. Limited awareness about the cost-effectiveness (CE) or the economic value of influenza vaccination may contribute to low vaccination coverage. In 2017, we conducted a literature review to survey estimates of the CE of influenza vaccination of adults compared to no vaccination. We also summarized CE estimates of other common preventive interventions that are recommended for adults by the U.S. Preventive Services Task Force. Results are presented as costs in US$2015 per quality-adjusted life-year (QALY) saved. Among adults aged 18-64, the CE of influenza vaccination ranged from $8000 to $39,000 per QALY. Assessments for adults aged >/=65 yielded lower CE ratios, ranging from being cost-saving to $15,300 per QALY. Influenza vaccination was cost-saving to $85,000 per QALY for pregnant women in moderate or severe influenza seasons and $260,000 per QALY in low-incidence seasons. For other preventive interventions, CE estimates ranged from cost-saving to $170,000 per QALY saved for breast cancer screening among women aged 50-74, from cost-saving to $16,000 per QALY for colorectal cancer screening, and from $27,000 to $600,000 per QALY for hypertension screening and treatment. Influenza vaccination in adults appears to have a similar CE profile as other commonly utilized preventive services for adults. Efforts to improve adult vaccination should be considered by adult-patient providers, healthcare systems and payers given the health and economic benefits of influenza vaccination.

      2. Annual out-of-pocket expenditures and financial hardship among cancer survivors aged 18-64 years – United States, 2011-2016external icon
        Ekwueme DU, Zhao J, Rim SH, de Moor JS, Zheng Z, Khushalani JS, Han X, Kent EE, Yabroff KR.
        MMWR Morb Mortal Wkly Rep. 2019 Jun 7;68(22):494-499.
        In the United States in 2019, an estimated 16.9 million persons are living after receiving a cancer diagnosis (1). These cancer survivors face many challenges, including functional limitations, serious psychological distress (2), and other lasting and late effects of cancer treatments. Because of the high cost of cancer therapy, many cancer survivors are more likely to face substantial out-of-pocket health care expenditures and financial hardship, compared with persons without a history of cancer (3,4). Out-of-pocket expenditures and financial hardship associated with cancer have been higher among survivors aged 18-64 years than they have been among older survivors (5). To estimate annual out-of-pocket expenditures and financial hardship among cancer survivors aged 18-64 years, compared with persons without a cancer history, CDC, the American Cancer Society, and the National Cancer Institute analyzed data from the 2011-2016 Medical Expenditure Panel Survey (MEPS).* The average annual out-of-pocket spending per person was significantly higher among cancer survivors ($1,000; 95% confidence interval [CI] = $886-$1,113) than among persons without a cancer history ($622; CI = $606-$639). Financial hardship was common; 25.3% of cancer survivors reported material hardship (e.g., problems paying medical bills), and 34.3% reported psychological hardship (e.g., worry about medical bills). These findings add to accumulating evidence documenting the financial difficulties of many cancer survivors. Mitigating the negative impact of cancer in the United States will require implementation of strategies aimed at alleviating the disproportionate financial hardship experienced by many survivors. These strategies include systematic screening for financial hardship at cancer diagnosis and throughout cancer care, integration of discussions about the potential for adverse financial consequences of treatments in shared treatment decision-making, and linkage of patients and survivors to available resources to ensure access to high-quality evidence-based care.

      3. Costs associated with acute respiratory illness and select virus infections in hospitalized children, El Salvador and Panama, 2012-2013external icon
        Jara JH, Azziz-Baumgartner E, De Leon T, Luciani K, Brizuela YS, Estripeaut D, Castillo JM, Barahona A, Corro M, Cazares R, Vergara O, Rauda R, Rodriguez R, Franco D, Widdowson MA, Clara W, Alvis-Estrada JP, Murray CT, Ortega-Sanchez IR, Dawood FS.
        J Infect. 2019 May 30.
        BACKGROUND AND OBJECTIVES: Although acute respiratory illness (ARI) is a leading cause of hospitalization among young children, few data are available about cost of hospitalization in middle-income countries. We estimated direct and indirect costs associated with severe ARI resulting in hospitalization among children aged <10 years in El Salvador and Panama through the societal perspective. METHODS: During 2012 and 2013, we surveyed caregivers of children hospitalized with ARI about their direct medical (i.e. outpatient consultation, medications, hospital fees), non-medical (transportation, childcare), and indirect costs (lost wages) at discharge and 7 days after discharge. We multiplied subsidized hospital bed cost derived from administrative data by hospitalization days to estimate provider costs. RESULTS: Overall, 638 children were enrolled with a median age of 12 months (IQR 6-23). Their median length of hospitalization was 4 days (IQR 3-6). In El Salvador, caregivers incurred a median of US$38 (IQR 22-72) in direct and indirect costs per illness episode, while the median government-paid hospitalization cost was US$118 (IQR 59-384) generating an overall societal cost of US$219 (IQR 101-416) per severe ARI episode. In Panama, caregivers incurred a median of US$75 (IQR 39-135) iin direct and indirect costs, and the health-care system paid US$280 (IQR 150-420) per hospitalization producing an overall societal cost of US$393 (IQR 258-552). CONCLUSIONS: The cost of severe ARI to caregivers and the health care system was substantive. Our estimates will inform models to estimate national costs of severe ARI and cost-benefit of prevention and treatment strategies.

      4. BACKGROUND: The staging method for activities of daily living (ADLs) limitations developed by Stineman and colleagues that classifies people into five stages can reflect severity of activity limitations. OBJECTIVE: To assess the impact of stages of limitations in ADLs on quality-adjusted life years (QALYs) and the relative severity of each ADL limitation for a large, nationally-representative sample of the U.S. community-dwelling older population. METHODS: Data were obtained from the Limited Dataset of the Medicare Health Outcomes Survey Cohort 15 (2012 baseline survey, 2014 follow-up survey). We included respondents aged >/=65 years (n=105,473). We estimated expected QALYs throughout the remaining lifetime of participants stratified by the ADL limitation status and stages of ADL limitations. RESULTS: Overall, the expected QALYs was 5.6 years. QALYs decreased with increasing stages of ADL limitations. The adjusted QALYs for Stage 0 (no limitation) participants were 6.8; for Stage I (mild) participants, 3.9; for Stage II (moderate) participants, 2.2; for Stage III (severe) participants, 1.8; and for Stage IV (complete limitations) participants, 1.5. Differences in QALYs occurred between individual ADL items within an ADL stage. In Stage I, for example, participants who reported only problems with getting in or out of chairs had 6.7 QALYs which was markedly higher than participants who reported only problems with walking (3.8 QALYs). CONCLUSIONS: Our findings provide additional evidence that Stineman’s ADL stages serve as valid estimates of the overall health of elderly Americans. Self-reported ADL status should be routinely collected as a patient-reported outcome in the elderly population.

    • Healthcare Associated Infections
      1. Candida auris is an emerging yeast species that was first described in 2009. This ascomycetous yeast is notable for resistance to azole antifungal agents, for environmental persistence, and for its ability to contaminate health care environments, resulting in patient colonization and nosocomial infections. OBJECTIVE: To review the state of current knowledge addressing challenges in the accurate identification of C auris in the diagnostic microbiology laboratory, including application of phenotypic, proteomic, and genomic methodologies; characteristics that may predispose the human host to acquiring C auris; transmission; clinical presentations; treatment modalities; environmental decontamination; and infection prevention in health care settings. DATA SOURCES: The PubMed search engine was used to access peer-reviewed literature published from 2009 to 2019. CONCLUSIONS: The rapid emergence of C auris has presented unique challenges for the areas of laboratory diagnostics and infection prevention and in options for antifungal treatment, which are limited. The current lack of established antifungal susceptibility test breakpoints complicates therapeutic decision making. Enhanced awareness of this pathogen is essential to monitor outbreaks and to reduce the risk of spread within health care environments.

      2. Implementation research for the prevention of antimicrobial resistance and healthcare-associated infections; 2017 Geneva infection prevention and control (IPC)-think tank (part 1)external icon
        Zingg W, Storr J, Park BJ, Ahmad R, Tarrant C, Castro-Sanchez E, Tomczyk S, Kilpatrick C, Allegranzi B, Cardo D, Pittet D.
        Antimicrob Resist Infect Control. 2019 ;8:87.
        Background: Around 5-15% of all hospital patients worldwide suffer from healthcare-associated infections (HAIs), and years of excessive antimicrobial use in human and animal medicine have created emerging antimicrobial resistance (AMR). A considerable amount of evidence-based measures have been published to address these challenges, but the largest challenge seems to be their implementation. Methods: In June 2017, a total of 42 experts convened at the Geneva IPC-Think Tank to discuss four domains in implementation science: 1) teaching implementation skills; 2) fostering implementation of IPC and antimicrobial stewardship (AMS) by policy making; 3) national/international actions to foster implementation skills; and 4) translational research bridging social sciences and clinical research in infection prevention and control (IPC) and AMR. Results: Although neglected in the past, implementation skills have become a priority in IPC and AMS. They should now be part of any curriculum in health care, and IPC career paths should be created. Guidelines and policies should be aligned with each other and evidence-based, each document providing a section on implementing elements of IPC and AMS in patient care. International organisations should be advocates for IPC and AMS, framing them as patient safety issues and emphasizing the importance of implementation skills. Healthcare authorities at the national level should adopt a similar approach and provide legal frameworks, guidelines, and resources to allow better implementation of patient safety measures in IPC and AMS. Rather than repeating effectiveness studies in every setting, we should invest in methods to improve the implementation of evidence-based measures in different healthcare contexts. For this, we need to encourage and financially support collaborations between social sciences and clinical IPC research. Conclusions: Experts of the 2017 Geneva Think Tank on IPC and AMS, CDC, and WHO agreed that sustained efforts on implementation of IPC and AMS strategies are required at international, country, and hospital management levels, to provide an adequate multimodal framework that addresses (not exclusively) leadership, resources, education and training for implementing IPC and AMS. Future strategies can build on this agreement to make strategies on IPC and AMS more effective.

    • Immunity and Immunization
      1. Heterologous prime-boost with A(H5N1) pandemic influenza vaccines induces broader cross-clade antibody responses than homologous prime-boostexternal icon
        Levine MZ, Holiday C, Jefferson S, Gross FL, Liu F, Li S, Friel D, Boutet P, Innis BL, Mallett CP, Tumpey TM, Stevens J, Katz JM.
        NPJ Vaccines. 2019 ;4:22.
        Highly pathogenic avian influenza (HPAI) A(H5Nx) viruses continue to pose a pandemic threat. US national vaccine stockpiles are a cornerstone of the influenza pandemic preparedness plans. However, continual genetic and antigenic divergence of A(H5Nx) viruses requires the development of effective vaccination strategies using stockpiled vaccines and adjuvants for pandemic preparedness. Human sera collected from healthy adults who received either homologous (2 doses of a AS03A-adjuvanted A/turkey/Turkey/1/2005, A/Turkey), or heterologous (primed with AS03A-adjuvanted A/Indonesia/5/2005, A/Indo, followed by A/Turkey boost) prime-boost vaccination regimens were analyzed by hemagglutination inhibition and microneutralization assays against 8 wild-type HPAI A(H5Nx) viruses from 6 genetic clades. Molecular, structural and antigenic features of the A(H5Nx) viruses that could influence the cross-clade antibody responses were also explored. Compared with homologous prime-boost vaccinations, priming with a clade antigen (A/Indo) followed by one booster dose of a clade 2.2.1 antigen (A/Turkey) administered 18 months apart did not compromise the antibody responses to the booster vaccine (A/Turkey), it also broadened the cross-clade antibody responses to several antigenically drifted variants from 6 heterologous clades, including an antigenically distant A(H5N8) virus (A/gyrfalcon/Washington/410886/2014, clade that caused recent outbreaks in US poultry. The magnitude and breadth of the cross-clade antibody responses against emerging HPAI A(H5Nx) viruses are associated with genetic, structural and antigenic differences from the vaccine viruses and enhanced by the inclusion of an adjuvant. Heterologous prime-boost vaccination with AS03A adjuvanted vaccine offers a vaccination strategy to use existing stockpiled vaccines for pandemic preparedness against new emerging HPAI A(H5Nx) viruses.

      2. Declines in HPV vaccine type prevalence in women screened for cervical cancer in the United States: Evidence of direct and herd effects of vaccinationexternal icon
        Markowitz LE, Naleway AL, Lewis RM, Crane B, Querec TD, Weinmann S, Steinau M, Unger ER.
        Vaccine. 2019 May 31.
        BACKGROUND: Human papillomavirus (HPV) vaccine has been recommended in the United States since 2006 for routine vaccination of girls at age 11-12years and through age 26years for women not previously vaccinated. Changes in vaccine-type HPV (VT) prevalence can be used to evaluate vaccine impact, including herd effects. METHODS: We determined type-specific HPV in cytology specimens from women aged 20-29years screened for cervical cancer at Kaiser Permanente Northwest in 2007 and in two vaccine era periods: 2012-2013 and 2015-2016. Detection and typing used L1 consensus PCR with hybridization for 37 types, including quadrivalent vaccine types (HPV 6/11/16/18). RESULTS: Among 20-24year-olds in 2012-2013 and 2015-2016, 44% and 64% had a history of >/=1-dose vaccination. VT prevalence decreased from 13.1% in 2007 to 2.9% in 2015-2016 (prevalence ratio [PR]=0.22; 95% confidence interval [CI] 0.17-0.29). HPV 31 prevalence was also lower in the vaccine periods compared with 2007. VT prevalence in 2015-2016 among 20-24year-olds was lower in both vaccinated, 1.3% (PR=0.10; 95% CI 0.06-0.16), and unvaccinated women, 5.8% (PR=0.45; 95% CI 0.33-0.61). Among 25-29year-olds, 21% and 32% had a history of >/=1-dose vaccination. VT prevalence decreased from 8.1% in 2007 to 5.0% in 2015-2016 (PR=0.62; 95% CI 0.50-0.78). Non-VT high risk prevalence was higher in the vaccine periods compared with the pre-vaccine era in both age groups, however, not in 2015-2016 compared with 2012-2013. CONCLUSION: Within 9-10years of vaccine introduction, VT prevalence decreased 78% among 20-24year-olds and 38% in 25-29year-olds. There were declines in both vaccinated and unvaccinated women, showing evidence of direct and herd protection.

      3. Progress toward measles elimination – Pakistan, 2000-2018external icon
        Mere MO, Goodson JL, Chandio AK, Rana MS, Hasan Q, Teleb N, Alexander JP.
        MMWR Morb Mortal Wkly Rep. 2019 Jun 7;68(22):505-510.
        In 1997, the 21 countries in the World Health Organization (WHO) Eastern Mediterranean Region* (EMR) passed a resolution during the 41st session of the Regional Committee for the Eastern Mediterranean to eliminate measles(dagger) (1). In 2015, this goal was included as a priority in the Eastern Mediterranean Vaccine Action Plan 2016-2020 (2), approved at the 62nd session of the Regional Committee (3). To achieve measles elimination, the WHO Regional Office for the Eastern Mediterranean developed the following four-pronged strategy: 1) achieve >/=95% vaccination coverage with the first dose of measles-containing vaccine (MCV) among children in every district of each country through routine immunization services; 2) achieve >/=95% vaccination coverage with a second MCV dose in every district of each country either through implementation of a routine 2-dose vaccination schedule or through supplementary immunization activities (SIAs)( section sign); 3) conduct high-quality, case-based measles surveillance in all countries; and 4) provide optimal measles clinical case management, including dietary supplementation with vitamin A (4). Pakistan, an EMR country with a population of approximately 200 million, accounts for nearly one third of the overall EMR population. This report describes progress and challenges toward measles elimination in Pakistan during 2000-2018. During the study period, estimated coverage with the first MCV dose (MCV1) increased from 57% in 2000 to 76% in 2017. The second MCV dose (MCV2) was introduced nationwide in 2009, and MCV2 coverage increased from 30% in 2009 to 45% in 2017. During 2000-2018, approximately 232.5 million children received doses of MCV during SIAs. Reported confirmed measles incidence increased from an average of 24.6 per 1 million persons during 2000-2009 to an average of 80.4 during 2010-2018, with peaks in 2013 (230.3) and 2018 (153.6). In 2017 and 2018, the rates of suspected cases discarded as nonmeasles after investigation were 2.1 and 1.5 per 100,000 population, reflecting underreporting of cases. To achieve measles elimination, additional efforts are needed to increase MCV1 and MCV2 coverage, develop strategies to identify and reach communities not accessing immunization services, and increase sensitivity of case-based measles surveillance in all districts.

      4. BACKGROUND: The administration of an extra dose of a vaccine may occur due to a programmatic error (e.g., vaccination error) when there is need to provide one of the antigens of a combination vaccine not readily available as a single antigen, or when there is need to provide immunization in a person with uncertain vaccination histories (e.g., refugees). There is little data available on the safety of an extra dose of vaccine. OBJECTIVE: To assess for the presence of adverse events (AEs) most commonly reported following the administration of excess doses of vaccine in the Vaccine Adverse Event Reporting System (VAERS). METHODS: We searched VAERS for US reports where an excess dose of vaccine was administered to a person received from 1/1/2007 through 1/26/2018. We reviewed medical records for all serious reports and a random sample of non-serious reports. The most common AEs among reports of excess dose of vaccine administered were compared with the corresponding AEs for all vaccines reported to VAERS during the same period. RESULTS: Out of 366,815 total VAERS reports received, 5067 (1.4%) reported an excess dose of vaccine was administered; 3898 (76.9%) did not describe an adverse health event (AHE). The most common vaccines reported were trivalent inactivated influenza (15.4%), varicella (13.9%), hepatitis A (11.4%), and measles, mumps, rubella, varicella (11.1%). Among reports where only AHEs were reported, the most common were pyrexia (12.8%), injection site erythema (9.7%), injection site pain (8.9%), and headache (6.6%). The percentage of AHEs among these reports was comparable to all reports submitted to VAERS during the same study period. CONCLUSION: More than three-fourths of reports of an excess dose of vaccine did not describe an AHE. Among reports where an AHE event was reported, we did not observe any unexpected conditions or clustering of AEs.

      5. Evaluation of educational interventions to enhance adolescent specific vaccination coverageexternal icon
        Underwood NL, Gargano LM, Sales J, Vogt TM, Seib K, Hughes JM.
        J Sch Health. 2019 Jun 4.
        BACKGROUND: In this study, we assessed impact of two educational interventions designed to increase coverage of three vaccines recommended during adolescence among Georgia middle and high school students (tetanus diphtheria pertussis [Tdap], meningococcal [MenACWY], and human papillomavirus [HPV] vaccines). METHODS: We randomized 11 middle and high schools in one school district into one of three arms: (1) control; (2) educational intervention for parents only (P only); and (3) multicomponent educational intervention for parents and adolescents (P + A), which consisted of educational brochures for parents about vaccines recommended during adolescence and a vaccine-focused curriculum delivered to adolescents by science teachers. We obtained vaccination coverage data during intervention years from the state immunization registry. RESULTS: Odds of receiving at least one vaccine during the study were higher among adolescents in P + A arm compared to control (Odds Ratio [OR]: 1.4; 95% Confidence Interval [CI]: 1.1-2.0). Adolescents in P + A arm had greater odds of receiving at least one vaccine compared with those in P only arm (OR: 1.4; 95% CI: 1.1-1.7). CONCLUSIONS: A multicomponent educational intervention for adolescents and parents increased adolescent vaccination uptake. Results suggest similar interventions can increase awareness and demand for vaccines among parents and adolescents.

      6. Association between the timing of maternal vaccination and newborns’ anti-pertussis toxin antibody levelsexternal icon
        Vaz-de-Lima LR, Sato HK, Fernandes EG, Sato AP, Pawloski LC, Tondella ML, de Brito CA, Luna EJ, Carvalhanas T, de Castilho EA.
        Vaccine. 2019 May 29.
        BACKGROUND: Pertussis remains an important global public health concern, despite the presence of extensive immunization programs. Incidence and severity of pertussis are typically higher in neonates and young infants. As a strategy to protect these young infants, maternal vaccination with Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) has been recommended in Brazil. The objective of this study was to evaluate the effects of Tdap vaccination during pregnancy on the anti-pertussis toxin (PT) IgG response in mothers and their infants at birth. MATERIAL AND METHODS: Maternal and cord blood samples were collected from vaccinated (n=243) and unvaccinated (n=75) pregnant women, at the time of delivery, from July 2015 to August 2016 in Sao Paulo, Brazil. Anti-PT IgG antibodies were quantified by Enzyme-Linked Immunosorbent Assay (ELISA) and geometric mean concentrations (GMC) were calculated. Relationship between timing of vaccination and antibody concentrations were evaluated. RESULTS: Maternal and cord blood GMCs among the vaccinated group were 5.4 and 5.6 fold higher [66.5 International Units (IU)/mL and 89.8IU/mL] compared to the unvaccinated group (12.4IU/mL and 16.1IU/mL), respectively (p<0.001). Higher anti-PT IgG GMCs were observed when vaccination occurred >/=60days before delivery compared to <60days, suggesting that vaccination early in the third trimester may be more effective than later in pregnancy. CONCLUSION: Tdap maternal vaccination results in significantly higher anti-PT IgG in newborn infants and supports the current recommendation of the Brazilian Immunization Program.

      7. Human infections caused by avian influenza A(H7N9) viruses have raised concerns of a pandemic. The capability of the current stockpiled A(H7N9) vaccines to induce cross-protective, non-neutralizing functional antibodies against antigenically drifted A(H7N9) viruses has not been evaluated before. Here we show that vaccination with either MF59- or AS03-adjuvanted inactivated A(H7N9) vaccines elicited robust, cross-reactive ADCC-mediating and neuraminidase-inhibiting functional antibodies against the antigenically drifted A(H7N9) viruses that emerged recently during the 5th wave outbreak in China, including a highly pathogenic A(H7N9) human isolate. Such cross-reactive humoral immunity may provide vital first-line defense against fatal outcomes in case of a A(H7N9) pandemic.

    • Informatics
      1. Harnessing the power of collaboration and training within clinical data science to generate real-world evidence in the era of precision oncologyexternal icon
        Rivera DR, Lee JS, Hsu E, Khoury MJ, Meng F, Olivero O, Penberthy L, Tourassi GD.
        Clin Pharmacol Ther. 2019 Jun 5.
        The complexity of delivering oncology patient care is reflected in the intricate aggregation of real- world data (RWD), data collected from clinical practice settings outside of interventional studies (e.g., administrative claims, electronic health records, reports, imaging), utilized to generate real- world evidence (RWE). Embracing collaborative interdisciplinary teams and enhancing clinical data scientist training opportunities are ways to begin harnessing the volume, variety, veracity, and velocity of health data for evidence-based patient care.

    • Injury and Violence
      1. Teen dating violence perpetration: Protective factor trajectories from middle to high school among adolescentsexternal icon
        Espelage DL, Leemis RW, Niolon PH, Kearns M, Basile KC, Davis JP.
        J Res Adolesc. 2019 Jun 6.
        Protecting adolescents from the risk of teen dating violence (TDV) perpetration is critical to enhancing prevention efforts. This study examined longitudinal trajectories of four protective factors (i.e., empathy, social support, parental monitoring, and school belonging) across adolescence in relation to four TDV types (i.e., verbal, relational, physical, and sexual). Adolescents (n = 1,668) who reported being in a relationship or dating during high school completed self-report measures from middle through high school. Results indicated that all protective factors differentiated between TDV perpetrators and nonperpetrators, although these trajectories varied for boys and for girls and across the different types of TDV. Overall, youth who did not perpetrate TDV in high school generally displayed higher protective factors across the TDV perpetration types.

      2. Mortality from falls among US adults aged 75 years or older, 2000-2016external icon
        Hartholt KA, Lee R, Burns ER, van Beeck EF.
        Jama. 2019 Jun 4;321(21):2131-2133.

        [No abstract]

    • Laboratory Sciences
      1. Entropy of mitochondrial DNA circulating in blood is associated with hepatocellular carcinomaexternal icon
        Campo DS, Nayak V, Srinivasamoorthy G, Khudyakov Y.
        BMC Med Genomics. 2019 Jun 6;12(Suppl 4):74.
        BACKGROUND: Ultra-Deep Sequencing (UDS) enabled identification of specific changes in human genome occurring in malignant tumors, with current approaches calling for the detection of specific mutations associated with certain cancers. However, such associations are frequently idiosyncratic and cannot be generalized for diagnostics. Mitochondrial DNA (mtDNA) has been shown to be functionally associated with several cancer types. Here, we study the association of intra-host mtDNA diversity with Hepatocellular Carcinoma (HCC). RESULTS: UDS mtDNA exome data from blood of patients with HCC (n = 293) and non-cancer controls (NC, n = 391) were used to: (i) measure the genetic heterogeneity of nucleotide sites from the entire population of intra-host mtDNA variants rather than to detect specific mutations, and (ii) apply machine learning algorithms to develop a classifier for HCC detection. Average total entropy of HCC mtDNA is 1.24-times lower than of NC mtDNA (p = 2.84E-47). Among all polymorphic sites, 2.09% had a significantly different mean entropy between HCC and NC, with 0.32% of the HCC mtDNA sites having greater (p < 0.05) and 1.77% of the sites having lower mean entropy (p < 0.05) as compared to NC. The entropy profile of each sample was used to further explore the association between mtDNA heterogeneity and HCC by means of a Random Forest (RF) classifier The RF-classifier separated 232 HCC and 232 NC patients with accuracy of up to 99.78% and average accuracy of 92.23% in the 10-fold cross-validation. The classifier accurately separated 93.08% of HCC (n = 61) and NC (n = 159) patients in a validation dataset that was not used for the RF parameter optimization. CONCLUSIONS: Polymorphic sites contributing most to the mtDNA association with HCC are scattered along the mitochondrial genome, affecting all mitochondrial genes. The findings suggest that application of heterogeneity profiles of intra-host mtDNA variants from blood may help overcome barriers associated with the complex association of specific mutations with cancer, enabling the development of accurate, rapid, inexpensive and minimally invasive diagnostic detection of cancer.

      2. Pyrethroid exposure alters internal and cuticle surface bacterial communities in Anopheles albimanusexternal icon
        Dada N, Lol JC, Benedict AC, Lopez F, Sheth M, Dzuris N, Padilla N, Lenhart A.
        Isme j. 2019 Jun 6.
        A deeper understanding of the mechanisms underlying insecticide resistance is needed to mitigate its threat to malaria vector control. Following previously identified associations between mosquito microbiota and insecticide resistance, we demonstrate for the first time, the effects of pyrethroid exposure on the microbiota of F1 progeny of field-collected Anopheles albimanus. Larval and adult mosquitoes were exposed to the pyrethroids alphacypermethrin (only adults), permethrin, and deltamethrin. While there were no significant differences in bacterial composition between insecticide-resistant and insecticide-susceptible mosquitoes, bacterial composition between insecticide-exposed and non-exposed mosquitoes was significantly different for alphacypermethrin and permethrin exposure. Along with other bacterial taxa not identified to species, Pantoea agglomerans (a known insecticide-degrading bacterial species) and Pseudomonas fragi were more abundant in insecticide-exposed compared to non-exposed adults, demonstrating that insecticide exposure can alter mosquito bacterial communities. We also show for the first time that the cuticle surfaces of both larval and adult An. albimanus harbor more diverse bacterial communities than their internal microbial niches. Together, these findings demonstrate how insecticide pressure could be selecting for certain bacteria within mosquitoes, especially insecticide-metabolizing bacteria, thus potentially contributing to insecticide resistance.

      3. Lassa virus targeting of anterior uvea and endothelium of cornea and conjunctiva in eye of guinea pig modelexternal icon
        Gary JM, Welch SR, Ritter JM, Coleman-McCray J, Huynh T, Kainulainen MH, Bollweg BC, Parihar V, Nichol ST, Zaki SR, Spiropoulou CF, Spengler JR.
        Emerg Infect Dis. 2019 May;25(5):865-874.
        Lassa virus (LASV), a hemorrhagic fever virus endemic to West Africa, causes conjunctivitis in patients with acute disease. To examine ocular manifestations of LASV, we histologically examined eyes from infected guinea pigs. In fatal disease, LASV immunostaining was most prominent in the anterior uvea, especially in the filtration angle, ciliary body, and iris and in and around vessels in the bulbar conjunctiva and peripheral cornea, where it co-localized with an endothelial marker (platelet endothelial cell adhesion molecule). Antigen was primarily associated with infiltration of T-lymphocytes around vessels in the anterior uvea and with new vessel formation at the peripheral cornea. In animals that exhibited clinical signs but survived infection, eyes had little to no inflammation and no LASV immunostaining 6 weeks after infection. Overall, in this model, LASV antigen was restricted to the anterior uvea and was associated with mild chronic inflammation in animals with severe disease but was not detected in survivors.

      4. Hematology and clinical chemistry reference intervals for inbred strain 13/n guinea pigs (Cavia Porcellus )external icon
        Genzer SC, Huynh T, Coleman-Mccray JD, Harmon JR, Welch SR, Spengler JR.
        J Am Assoc Lab Anim Sci. 2019 May 1;58(3):293-303.
        Inbred Strain 13/N Guinea Pigs are Frequently Used As Animal Models in Studies of Emerging and High-pathogenicity Viruses. To Date, Clinical Reference Intervals Have Not Been Established for Hematology and Clinical Chemistry Parameters in This Strain. We Obtained Whole-blood Samples from the Cranial Vena Cava of Healthy Strain 13/N Colony Animals for Inhouse Cbc and Clinical Chemistry Analyses. Analyte Values Were Investigated to Determine Subpopulation Differences According to Age and Sex. Glucose, Albumin, Alp, Lymphocyte Percentage, Hgb, and Mchc Decreased with Age, Whereas Neutrophil and Monocyte Percentages, Bun, Creatinine, Calcium, and Amylase Increased with Age. Total Protein and Wbc Counts Increased Over the First 300 D of Life Before Stabilizing. Across All Age Categories, Female Guinea Pigs Consistently Had Lower Rbc, Hct, Hgb, Alt, Alp, and Amylase Levels and Higher Mcv Values Than Males. These Trends Were Strongest in Adults (age, 151 Through 900 D). Most Parameters Stabilized by 300 D; Previous Studies Used 60 D or 120 D As Adult Age and 90 to 120 D As Sexual Maturity. We Recommend Age Group Definitions of 0 Through 150 D for Juveniles, 151 Through 900 D for Adults, and Older Than 900 D for Geriatric Adult Strain 13/N Guinea Pigs.

      5. Protection from lethal Lassa disease can be achieved both before and after virus exposure by administration of single-cycle replicating Lassa virus replicon particlesexternal icon
        Kainulainen MH, Spengler JR, Welch SR, Coleman-McCray JD, Harmon JR, Scholte FE, Goldsmith CS, Nichol ST, Albarino CG, Spiropoulou CF.
        J Infect Dis. 2019 Jun 1.
        Lassa fever is a frequently severe human disease that is endemic to several countries in West Africa. To date, no licensed vaccines are available to prevent Lassa virus (LASV) infection, even though Lassa fever is thought to be an important disease contributing to mortality and both acute and chronic morbidity. We have previously described a vaccine candidate composed of single-cycle LASV replicon particles (VRPs) and a stable cell line for their production. Here, we refine the genetic composition of the VRPs and demonstrate the ability to reproducibly purify them with high yields. Studies in the guinea pig model confirm efficacy of the vaccine candidate, demonstrate that single-cycle replication is necessary for complete protection by the VRP vaccine, and show that post-exposure vaccination can confer protection from lethal outcome.

      6. Nanoparticle exposure driven circulating bioactive peptidome causes systemic inflammation and vascular dysfunctionexternal icon
        Mostovenko E, Young T, Muldoon PP, Bishop L, Canal CG, Vucetic A, Zeidler-Erdely P, Erdely A, Campen M, Ottens A.
        Part Fibre Toxicol. 2019 May 29;16(1):20.
        The mechanisms driving systemic effects consequent pulmonary nanoparticle exposure remain unclear. Recent work has established the existence of an indirect process by which factors released from the lung into the circulation promote systemic inflammation and cellular dysfunction, particularly on the vasculature. However, the composition of circulating contributing factors and how they are produced remains unknown. Evidence suggests matrix protease involvement; thus, here we used a well-characterized multi-walled carbon nanotube (MWCNT) oropharyngeal aspiration model with known vascular effects to assess the distinct contribution of nanoparticle-induced peptide fragments in driving systemic pathobiology.

      7. Clostridium botulinum produces botulinum neurotoxins (BoNTs) that are one of the most poisonous substances. In order to respond to public health emergencies, there is a need to develop sensitive and specific methods for detecting botulinum toxin in various clinical matrices. Our laboratory has developed a mass spectrometry-based Endopep-MS assay that is able to rapidly detect and differentiate BoNT serotypes A-G by immunoaffinity capture of toxins and detection of unique cleavage products of peptide substrates. To improve the sensitivity of the Endopep-MS assay for the detection of BoNT serotype G, we report here the optimization of synthetic peptide substrates through systematic substitution, deletion, and incorporation of unnatural amino acids. Our data show that the resulting optimized peptides produced a significant improvement (two orders of magnitude) in assay sensitivity and allowed the detection of 0.01 mouseLD50 toxin present in buffer solution.

      8. Methods and analyzers for hemoglobin measurement in clinical laboratories and field settingsexternal icon
        Whitehead RD, Mei Z, Mapango C, Jefferds ME.
        Ann N Y Acad Sci. 2019 Jun 4.
        This paper describes and compares methods and analyzers used to measure hemoglobin (Hb) in clinical laboratories and field settings. We conducted a literature review for methods used to measure Hb in clinical laboratories and field settings. We described methods to measure Hb and factors influencing results. Automated hematology analyzer (AHA) was reference for all Hb comparisons using evaluation criteria of +/-7% set by College of American Pathologists (CAP) and Clinical Laboratory Improvement Amendments (CLIA). Capillary fingerprick blood usually produces higher Hb concentrations compared with venous blood. Individual drops produced lower concentrations than pooled capillary blood. Compared with the AHA: (1) overall cyanmethemoglobin (1.0-8.0 g/L), WHO Colour Scale (0.5-10.0 g/L), paper-based devices (5.0-7.0 g/L), HemoCue(R) Hb-201 (1.0-16.0 g/L) and Hb-301 (0.5-6.0 g/L), and Masimo Pronto(R) (0.3-14.0 g/L) overestimated concentrations; (2) Masimo Radical(R)-7 both under- and overestimated concentrations (0.3-104.0 g/L); and (3) other methods underestimated concentrations (2.0-16.0 g/L). Most mean concentration comparisons varied less than +/-7% of the reference. Hb measurements are influenced by several analytical factors. With few exceptions, mean concentration bias was within +/-7%, suggesting acceptable performance. Appropriate, high-quality methods in all settings are necessary to ensure the accuracy of Hb measurements.This paper describes and compares methods and analyzers used to measure hemoglobin (Hb) in clinical laboratories and field settings. With few exceptions, mean concentration bias was within +/-7%, suggesting acceptable performance. Appropriate, high-quality methods in all settings are necessary to ensure the accuracy of Hb measurements.

    • Maternal and Child Health
      1. Potential risk factors for Ebstein anomaly, National Birth Defects Prevention Study, 1997-2011external icon
        Downing KF, Riehle-Colarusso T, Gilboa SM, Lin AE, Oster ME, Tinker SC, Farr SL.
        Cardiol Young. 2019 Jun 4:1-9.
        BACKGROUND: Ebstein anomaly is a rare congenital heart defect (CHD) that, when severe, requires corrective surgery or other catheter-based intervention in the first year of life. Due to its rarity, risk factors for Ebstein anomaly remain largely unknown. Using national data, we examined 18 potential risk factors for Ebstein anomaly. METHODS: Using 1997-2011 data from the National Birth Defects Prevention Study, a population-based case-control study, we calculated crude and adjusted odds ratios and 95% confidence intervals for paternal age, maternal socio-demographics, reproductive history, and modifiable risk factors, and infant characteristics reported by mothers of 135 Ebstein anomaly cases and 11,829 controls. RESULTS: Mothers of Ebstein anomaly cases had 4.1 (95% confidence interval: 1.8, 9.5) times the odds of reporting a family history of CHD compared with mothers of controls. Ebstein anomaly was associated with maternal second-hand cigarette smoke exposure at home (odds ratio = 2.2 [95% confidence interval: 1.1, 4.4]), but not maternal cigarette smoking (odds ratio = 1.3 [95% confidence interval: 0.8, 2.1]). Odds were elevated, but the 95% confidence interval included 1.0, for maternal marijuana use (odds ratio = 1.8 [95% confidence interval: 0.9, 3.8]) and paternal age >/=40 years at delivery (odds ratio = 1.9 [95% confidence interval: 1.0, 3.5]). CONCLUSIONS: Maternal exposure to second-hand cigarette smoke at home and a family history of CHD were associated with elevated odds of Ebstein anomaly. Genetic analyses could clarify the potential heritability of Ebstein anomaly.

    • Mining
      1. An underground limestone mine in eastern Ohio was experiencing significant floor heave and roof falls, attributed to high horizontal stresses. Areas of the mine showing floor heave were monitored with roof-to-floor extensometers and photogrammetry surveys to determine the rate and magnitude of heave. Extensometer data were recorded hourly at four locations across adjacent entries while photogrammetry surveys of the floor were performed at the same locations every two to five weeks. A final survey was performed using an I-Site 8200 laser scanner. Following instrumentation, floor heave up to 10.1 cm (4 in.) was measured by the extensometers, photogrammetric reconstructions and laser scanner over a six-month period. The extensometers were biased by the location where they were placed, failing to consistently capture the location and extent of floor heave and cracking. The photogrammetry surveys were not precise enough to capture small magnitude movements. Mining in the area was halted and within several months the floor movement and incidence of roof falls were significantly lessened.

    • Nutritional Sciences
      1. Receipt of breast milk by gestational age – United States, 2017external icon
        Chiang KV, Sharma AJ, Nelson JM, Olson CK, Perrine CG.
        MMWR Morb Mortal Wkly Rep. 2019 Jun 7;68(22):489-493.
        Breast milk is the optimal source of infant nutrition. For the nearly one in 10 infants born prematurely in the United States annually (1), breast milk is especially beneficial, helping prevent sepsis and necrotizing enterocolitis and promoting neurologic development (2). National estimates of newborn feeding practices by gestational age have not been available previously. CDC analyzed 2017 birth certificate data from 48 states and the District of Columbia (3,194,873; 82.7% of all births) to describe receipt of breast milk among extremely preterm (20-27 weeks), early preterm (28-33 weeks), late preterm (34-36 weeks), and term (>/=37 weeks) infants with further stratification by maternal and infant characteristics. The prevalence of infants receiving any breast milk was 83.9% overall and varied by gestational age, with 71.3% of extremely preterm infants, 76.0% of early preterm infants, 77.3% of late preterm infants, and 84.6% of term infants receiving any breast milk. Disparities in receipt of breast milk by several sociodemographic factors, including maternal race/ethnicity, were noted across gestational age groups. These estimates suggest that many infants, particularly infants at high risk for medical complications, might not be receiving breast milk. Efforts are needed to increase the implementation of existing evidence-based policies and practices that support breast milk feeding, particularly for medically fragile infants (2,3).

      2. Support for breastfeeding physiciansexternal icon
        Nelson JM, Onyema-Melton N, Hanley LE, Meek JY, Wood JK.
        J Pediatr. 2019 May 31.

        [No abstract]

      3. Nutritional profile of Syrian refugee children before resettlementexternal icon
        Pernitez-Agan S, Wickramage K, Yen C, Dawson-Hahn E, Mitchell T, Zenner D.
        Confl Health. 2019 ;13:22.
        Background: The year 2015 marked the highest number of refugees globally and included record numbers of Syrians moving to neighboring countries. Half of the Syrians were children aged </=18 years. Our study sought to examine undernutrition and overnutrition among a group of Syrian refugee children who underwent medical screening by IOM for resettlement. Methods: This is a retrospective review of Syrian refugee children aged 6 to 59 months from January 1, 2015 to December 31, 2016. The World Health Organization (WHO) Stata package computed Z-scores based on available weight and height data. Prevalence estimates of undernutrition (wasting and stunting) and overnutrition (overweight and obesity) were made using WHO standards. Multivariate analysis was used to determine the factors associated with wasting, stunting, and overnutrition, adjusting for age, sex, family size, and country of health assessment. Results: A total of 14,552 Syrian refugee children aged 6 to 59 months underwent health assessments in Jordan (43.1%), Lebanon (38.8%), Turkey (7.0%), Greece (6.7%), Egypt (2.4%), and Iraq (2.1%). Overall, this group of Syrian refugee children had a low prevalence of wasting (< 5%) and stunting (< 10%), and high prevalence of overweight or obese (10.6%). Differences were observed in the prevalence of wasting by country of health assessment. In the multiple regression analysis, the prevalence of stunting and overnutrition decreased with increasing age, and being male was associated with overnutrition but not wasting and stunting. Conclusions: Findings revealed an overall low prevalence of undernutrition among this group of Syrian children assessed, although prevalence varied by age group. This low prevalence may reflect the effectiveness, as well as expose possible gaps, of refugee nutrition programs or interventions in countries of asylum. Further studies are recommended to evaluate other possible contributors to malnutrition in this refugee group.

      4. [No abstract]

    • Occupational Safety and Health
      1. The occupational burden of nonmalignant respiratory diseases. An Official American Thoracic Society and European Respiratory Society Statementexternal icon
        Blanc PD, Annesi-Maesano I, Balmes JR, Cummings KJ, Fishwick D, Miedinger D, Murgia N, Naidoo RN, Reynolds CJ, Sigsgaard T, Toren K, Vinnikov D, Redlich CA.
        Am J Respir Crit Care Med. 2019 Jun 1;199(11):1312-1334.
        Rationale: Workplace inhalational hazards remain common worldwide, even though they are ameliorable. Previous American Thoracic Society documents have assessed the contribution of workplace exposures to asthma and chronic obstructive pulmonary disease on a population level, but not to other chronic respiratory diseases. The goal of this document is to report an in-depth literature review and data synthesis of the occupational contribution to the burden of the major nonmalignant respiratory diseases, including airway diseases; interstitial fibrosis; hypersensitivity pneumonitis; other noninfectious granulomatous lung diseases, including sarcoidosis; and selected respiratory infections. Methods: Relevant literature was identified for each respiratory condition. The occupational population attributable fraction (PAF) was estimated for those conditions for which there were sufficient population-based studies to allow pooled estimates. For the other conditions, the occupational burden of disease was estimated on the basis of attribution in case series, incidence rate ratios, or attributable fraction within an exposed group. Results: Workplace exposures contribute substantially to the burden of multiple chronic respiratory diseases, including asthma (PAF, 16%); chronic obstructive pulmonary disease (PAF, 14%); chronic bronchitis (PAF, 13%); idiopathic pulmonary fibrosis (PAF, 26%); hypersensitivity pneumonitis (occupational burden, 19%); other granulomatous diseases, including sarcoidosis (occupational burden, 30%); pulmonary alveolar proteinosis (occupational burden, 29%); tuberculosis (occupational burden, 2.3% in silica-exposed workers and 1% in healthcare workers); and community-acquired pneumonia in working-age adults (PAF, 10%). Conclusions: Workplace exposures contribute to the burden of disease across a range of nonmalignant lung conditions in adults (in addition to the 100% burden for the classic occupational pneumoconioses). This burden has important clinical, research, and policy implications. There is a pressing need to improve clinical recognition and public health awareness of the contribution of occupational factors across a range of nonmalignant respiratory diseases.

      2. Understanding airborne contaminants produced by different fuel packages during training firesexternal icon
        Fent KW, Mayer A, Bertke S, Kerber S, Smith D, Horn GP.
        J Occup Environ Hyg. 2019 Jun 6:1-12.
        Fire training may expose firefighters and instructors to hazardous airborne chemicals that vary by the training fuel. We conducted area and personal air sampling during three instructional scenarios per day involving the burning of two types (designated as alpha and bravo) of oriented strand board (OSB), pallet and straw, or the use of simulated smoke, over a period of 5 days. Twenty-four firefighters and ten instructors participated. Firefighters participated in each scenario once (separated by about 48 hr) and instructors supervised three training exercise per scenarios (completed in 1 day). Personal air samples were analyzed for polycyclic aromatic hydrocarbons (PAHs), volatile organic compounds (VOCs), and hydrogen cyanide during live-fire scenarios (excluding simulated smoke). Area air samples were analyzed for acid gases, aldehydes, isocyanates, and VOCs for all scenarios. For the live-fire scenarios, median personal air concentrations of benzene and PAHs exceeded applicable short-term exposure limits and were higher among firefighters than instructors. When comparing results by type of fuel, personal air concentrations of benzene and PAHs were higher for bravo OSB compared to other fuels. Median area air concentrations of aldehydes and isocyanates were also highest during the bravo OSB scenario, while pallet and straw produced the highest median concentrations of certain VOCs and acid gases. These results suggest usage of self-contained breathing apparatus (SCBA) by both instructors and firefighters is essential during training fires to reduce potential inhalation exposure. Efforts should be taken to clean skin and clothing as soon as possible after live-fire training to limit dermal absorption as well.

      3. Jet fuel exposure and auditory outcomes in Australian air force personnelexternal icon
        Fuente A, Hickson L, Morata TC, Williams W, Khan A, Fuentes-Lopez E.
        BMC Public Health. 2019 May 31;19(1):675.
        BACKGROUND: Animal data suggest that jet fuels such as JP-8 are associated with hearing deficits when combined with noise and that the effect is more pronounced than with noise exposure alone. Some studies suggest peripheral dysfunction while others suggest central auditory dysfunction. Human data are limited in this regard. The aim of this study was to investigate the possible chronic adverse effects of JP-8 combined with noise exposure on the peripheral and central auditory systems in humans. METHODS: Fifty-seven participants who were current personnel from the Royal Australian Air Force were selected. Based on their levels of exposure to jet fuels, participants were divided into three exposure groups (low, moderate, high). Groups were also categorised based on their noise exposure levels (low, moderate, high). All participants were evaluated by tympanometry, pure-tone audiometry (1-12 kHz), distortion product otoacoustic emissions (DPOAEs), auditory brainstem response (ABR), words-in-noise, compressed speech, dichotic digit test, pitch pattern sequence test, duration pattern sequence test and adaptive test of temporal resolution. All auditory tests were carried out after the participants were away from the Air Force base for a minimum of two weeks, thus two weeks without jet fuel and noise exposure. RESULTS: Jet fuel exposure was significantly associated with hearing thresholds at 4 and 8 kHz; average hearing thresholds across frequencies in the better ear; DPOAEs at 2.8, 4 and 6 kHz; ABR wave V latency in the right ear; compressed speech and words-in-noise. Further analyses revealed that participants with low exposure level to jet fuels showed significantly better results for the aforementioned procedures than participants with moderate and high exposure levels. All results were controlled for the covariates of age and noise exposure levels. CONCLUSIONS: The results suggest that jet fuel exposure, when combined with noise exposure, has an adverse effect on audibility in humans. Taking all the test results into consideration, jet fuel exposure combined with noise exposure specifically seems to affect the peripheral hearing system in humans.

      4. Motor vehicle crashes (MVCs) are a significant cause of lost-workday injuries, and consistently the leading cause of work-related fatalities in the United States for all industries combined. Prevention research has focused mainly on collisions fatal to the drivers of large trucks. This analytical observational study addresses gaps in the literature by: conducting a descriptive analysis of motor vehicle claim events involving light-vehicle drivers in a large health care industry fleet; identifying risk factors for work-related MVCs and injuries based on vehicle miles traveled; and providing details on circumstances of these events. The study examined 8068 motor vehicle events resulting in vehicle damage, property damage, or injury reported by 6680 U.S.-based drivers in a light-vehicle sales and service fleet operated by a health care company over a 4 (1/2)-year period (January 2010 through June 2014). Thirty-three percent (n = 2660) of the events were collisions. Collisions were segmented as recoverable or non-recoverable according to whether the company could recover costs from another party, and mileage-based collision and injury rates were calculated by gender, age, tenure, and vehicle type. Differences in collision and injury rates between groups of interest (for example, tenure and age categories) were assessed with Poisson regression techniques adjusted using generalized estimating equations (GEE) for repeated observations on the same employee over time. Age, gender, and job tenure were significant collision risk factors, and risk patterns for recoverable and non-recoverable collisions were similar to those for total collisions. Collisions per million miles (CPMM) were significantly higher for drivers 21-24.9 years of age compared to drivers age 25-54.9 years (9.58 CPMM vs 4.96 CPMM, p = .025), drivers employed for less than 2 years compared to those employed 2 or more years (6.22 CPMM vs 4.82 CPMM, p < .001), for female drivers compared to male drivers (6.37 CPMM vs 4.16 CPMM, p < .001), and for drivers of passenger cars compared to all other vehicles (5.27 CPMM vs 4.48 CPMM, p < .001). Among collisions between the employee’s vehicle and another vehicle in transport, those where the front of one vehicle hit another vehicle at an angle were the most likely to result in injury to the employee driver or another party (26%), followed by rear-end collisions (25%). Special attention should be given to preventing collisions among newly-hired employees, and to preventing angle and rear-end collisions, which were the most common types of collisions and also were most likely to result in injury than all other collisions combined.

      5. Peaks, means, and determinants of real-time TVOC exposures associated with cleaning and disinfecting tasks in healthcare settingsexternal icon
        Virji MA, Liang X, Su FC, LeBouf RF, Stefaniak AB, Stanton ML, Henneberger PK, Houseman EA.
        Ann Work Expo Health. 2019 Jun 4.
        Cleaning and disinfecting tasks and product use are associated with elevated prevalence of asthma and respiratory symptoms among healthcare workers; however, the levels of exposure that pose a health risk remain unclear. The objective of this study was to estimate the peak, average, and determinants of real-time total volatile organic compound (TVOC) exposure associated with cleaning tasks and product-use. TVOC exposures were measured using monitors equipped with a photoionization detector (PID). A simple correction factor was applied to the real-time measurements, calculated as a ratio of the full-shift average TVOC concentrations from a time-integrated canister and the PID sample, for each sample pair. During sampling, auxiliary information, e.g. tasks, products used, engineering controls, was recorded on standardized data collection forms at 5-min intervals. Five-minute averaged air measurements (n = 10 276) from 129 time-series comprising 92 workers and four hospitals were used to model the determinants of exposures. The statistical model simultaneously accounted for censored data and non-stationary autocorrelation and was fit using Markov-Chain Monte Carlo within a Bayesian context. Log-transformed corrected concentrations (cTVOC) were modeled, with the fixed-effects of tasks and covariates, that were systematically gathered during sampling, and random effect of person-day. The model-predicted geometric mean (GM) cTVOC concentrations ranged from 387 parts per billion (ppb) for the task of using a product containing formaldehyde in laboratories to 2091 ppb for the task of using skin wipes containing quaternary ammonium compounds, with a GM of 925 ppb when no products were used. Peak exposures quantified as the 95th percentile of 15-min averages for these tasks ranged from 3172 to 17 360 ppb. Peak and GM task exposures varied by occupation and hospital unit. In the multiple regression model, use of sprays was associated with increasing exposures, while presence of local exhaust ventilation, large room volume, and automatic sterilizer use were associated with decreasing exposures. A detailed understanding of factors affecting TVOC exposure can inform targeted interventions to reduce exposures and can be used in epidemiologic studies as metrics of short-duration peak exposures.

    • Occupational Safety and Health – Mining
      1. Intelligent monitoring system for improved worker safety during plant operation and maintenancepdf icon
        Parks D, McNinch M, Jacksha R, Nickerson H, Miller A.
        Min Eng. 2019 Mar;71(3):34-38.

        [No abstract]

      2. Towards a field-portable real-time organic and elemental carbon monitorexternal icon
        Parks D, Raj K, Berry C, Weakley A, Griffiths P, Miller A.
        Min Metall Explor. 2019 Apr.
        Diesel particulate matter (DPM) has been classified as a carcinogen to humans by the International Agency for Research on Cancer. As a result of its potential carcinogenic nature, DPM exposure is regulated by the Mine Safety and Health Administration. Currently, diesel emissions in the workplace are monitored by collecting the aerosol onto filters, which are then sent to a laboratory for thermal-optical analysis using the NIOSH method 5040. This process can take days or even weeks, and workers can potentially be exposed to excessive levels of DPM before the problem is identified. Moreover, the delay involved in getting the loaded filter to the lab inevitably means the loss of some of the more volatile organic carbon. To remedy this delay, researchers from the National Institute for Occupational Safety and Health are seeking to develop a field-portable, real-time method for measuring elemental and organic carbons in DPM aerosols. In the current study, the use of mid-infrared spectrometry was investigated. It is believed that mid-infrared spectroscopy is more suitable for use in a real-time field-portable device than thermo-optical analysis methods. This article presents a method for measuring organic carbon (OC) and elemental carbon (EC) in DPM for a broad range of OC/EC ratios. The method has been successfully applied to laboratory-generated and mine samples.

      3. Factors affecting the performance of trickle dusters for preventing explosive dust accumulations in return airwaysexternal icon
        Sapko M, Harris ML, Perera IE, Zlochower IA, Weiss ES.
        J Loss Prev Process Ind. 2019 Sep 1;61:1-7.
        Correctly applied rock dust can dilute, inert, and mitigate the explosive potential of float coal dust. Trickle dusters are one element of a comprehensive system to help prevent coal dust explosions in underground coal mines. Trickle dusters supply rock dust to inert fine float coal dust in areas where it is commonly deposited, such as the longwall tailgate returns, return airways, pillaring areas, and downwind of belt transfers. Dust deposition studies show that the effectiveness of trickle dusters depends on several key factors. Using multiple orifices, rock dust should be released near the mine roof in the direction of the airflow in order to spread the cloud cross the entry. The rock duster should have a mechanism to break up rock dust agglomerates as they leave the rock duster. The particle size distribution of the limestone rock dust and its airborne concentration should be proportional to the airborne size distribution and concentration of coal dust passing by the trickle duster. Specifically, rock dusts having a greater proportion of <74?microm material are more effective at minimizing downwind zones of explosible mixtures than mostly larger particles. In our testing, rock dusts having more than 95% of <74?microm sized particles were adequately dispersed by trickle dusters. Based on our results, the mass rate of rock dust discharge from the trickle duster should exceed the rate of float coal production by at least a factor of four in order to minimize accumulations of explosible dusts.

    • Parasitic Diseases
      1. Genotyping genetically heterogeneous Cyclospora cayetanensis infections to complement epidemiological case linkageexternal icon
        Barratt JL, Park S, Nascimento FS, Hofstetter J, Plucinski M, Casillas S, Bradbury RS, Arrowood MJ, Qvarnstrom Y, Talundzic E.
        Parasitology. 2019 May 31:1-33.

        [No abstract]

      2. Distinct amino acid and lipid perturbations characterize acute versus chronic malariaexternal icon
        Cordy RJ, Patrapuvich R, Lili LN, Cabrera-Mora M, Chien JT, Tharp GK, Khadka M, Meyer EV, Lapp SA, Joyner CJ, Garcia A, Banton S, Tran V, Luvira V, Rungin S, Saeseu T, Rachaphaew N, Pakala SB, DeBarry JD, Kissinger JC, Ortlund EA, Bosinger SE, Barnwell JW, Jones DP, Uppal K, Li S, Sattabongkot J, Moreno A, Galinski MR.
        JCI Insight. 2019 May 2;4(9).
        Chronic malaria is a major public health problem and significant challenge for disease eradication efforts. Despite its importance, the biological factors underpinning chronic malaria are not fully understood. Recent studies have shown that host metabolic state can influence malaria pathogenesis and transmission, but its role in chronicity is not known. Here, with the goal of identifying distinct modifications in the metabolite profiles of acute versus chronic malaria, metabolomics was performed on plasma from Plasmodium-infected humans and nonhuman primates with a range of parasitemias and clinical signs. In rhesus macaques infected with Plasmodium coatneyi, significant alterations in amines, carnitines, and lipids were detected during a high parasitemic acute phase and many of these reverted to baseline levels once a low parasitemic chronic phase was established. Plasmodium gene expression, studied in parallel in the macaques, revealed transcriptional changes in amine, fatty acid, lipid and energy metabolism genes, as well as variant antigen genes. Furthermore, a common set of amines, carnitines, and lipids distinguished acute from chronic malaria in plasma from human Plasmodium falciparum cases. In summary, distinct host-parasite metabolic environments have been uncovered that characterize acute versus chronic malaria, providing insights into the underlying host-parasite biology of malaria disease progression.

      3. Babesiosis surveillance – United States, 2011-2015external icon
        Gray EB, Herwaldt BL.
        MMWR Surveill Summ. 2019 May 31;68(6):1-11.
        PROBLEM/CONDITION: Babesiosis is caused by parasites of the genus Babesia, which are transmitted in nature by the bite of an infected tick. Babesiosis can be life threatening, particularly for persons who are asplenic, immunocompromised, or elderly. PERIOD COVERED: 2011-2015. DESCRIPTION OF SYSTEM: CDC has conducted surveillance for babesiosis in the United States since January 2011, when babesiosis became a nationally notifiable condition. Health departments in states in which babesiosis is reportable voluntarily notify CDC of cases through the National Notifiable Diseases Surveillance System (NNDSS) and submit supplemental case information by using a babesiosis-specific case report form (CRF). As of 2015, babesiosis was a reportable condition in 33 states compared with 22 states in 2011. RESULTS: For the 2011-2015 surveillance period, CDC was notified of 7,612 cases of babesiosis (6,277 confirmed [82.5%] and 1,335 probable [17.5%]). Case counts varied from year to year (1,126 cases for 2011, 909 for 2012, 1,761 for 2013, 1,742 for 2014, and 2,074 for 2015). Cases were reported among residents of 27 states. However, 7,194 cases (94.5%) occurred among residents of seven states with well-documented foci of tickborne transmission (i.e., Connecticut, Massachusetts, Minnesota, New Jersey, New York, Rhode Island, and Wisconsin). Maine (152 cases) and New Hampshire (149 cases) were the only other states that reported >100 cases for the 5-year period, and both states also reported increasing numbers of cases over time. The median age of the 7,173 patients with available information was 63 years (range: <1-99 years; interquartile range: 51-73 years); 4,156 (57.9%) were aged >/=60 years, and 15 (<1%) were aged <1 year. The proportion of patients with symptom onset during June-August was >70% for each of the 5 surveillance years. Approximately half (3,004 of 6,404 [46.9%]) of the patients with available data were hospitalized at least overnight. Hospitalization rates ranged from 16.0% among patients aged 10-19 years (16 of 100) to 72.6% among those aged >/=80 years (552 of 760). Hospitalizations were reported significantly more often among patients who were asplenic than among patients who were not (106 of 126 [84.1%] versus 643 of 1,396 [46.1%]). Fifty-one cases of babesiosis among recipients of blood transfusions were classified by the reporting health department as transfusion associated. The median intervals from the earliest date associated with each case of babesiosis to the initial report via NNDSS and submission of supplemental CRF data to CDC were approximately 3 months and 1 year, respectively. INTERPRETATION: For the first 5 years of babesiosis surveillance, the reported cases occurred most frequently during June-August in the Northeast and upper Midwest. Maine and New Hampshire reported increasing numbers of cases over time, which suggests that foci of transmission might be expanding. Hospitalizations were common, particularly among patients who were asplenic or elderly. PUBLIC HEALTH ACTION: Persons who live in or travel to regions where babesiosis is endemic should avoid tick-infested areas, apply repellent to skin and clothing, conduct full-body inspections for ticks after being outdoors, and remove attached ticks with fine-tipped tweezers as soon as possible. Prevention measures are especially important for persons at risk for severe babesiosis. Increases in the number and geographic range of reported cases warrant investigation to identify contributory factors (e.g., changes in tick density or in testing or surveillance methods). Complete and timely submission of risk factor data could facilitate assessments of the geographic ranges and transmission routes of Babesia parasites. Efforts to allow for electronic submission of CRF data are under way at CDC; electronic submission is expected to improve the timeliness, uniformity, and completeness of the data.

    • Reproductive Health
      1. Postorgasmic illness syndrome (POIS) is a rare condition that affects men and about which little is known. According to Waldinger and colleagues, men with POIS fulfill three or more of five preliminary diagnostic criteria regarding symptoms, time to onset, setting, duration, and spontaneous disappearance. We conducted a self-report study to assess, for the first time, the validity of these criteria. One hundred and twenty-seven men with self-reported POIS have completed the survey, making this the largest study of such men to date. Almost all respondents fulfill a majority of the criteria for POIS; a large minority fulfills all five criteria. Almost all respondents always experience symptoms after ejaculating in at least one ejaculatory setting (sex, masturbation, or nocturnal emission), though only a small majority fulfill the criterion that symptoms occur after all ejaculations because a large minority always experience symptoms in one setting but not always in another. The most common symptom cluster from the criteria, involving fatigue, irritation, and concentration difficulties, is always experienced by 80% of respondents. Median symptom severity is 8 on a 0-10 scale. While almost all men with POIS fulfill a majority of the preliminary diagnostic criteria, there is room for refining some of the criteria.

    • Zoonotic and Vectorborne Diseases
      1. Evaluating the risk of tick-borne relapsing fever among occupational cavers – Austin, TX, 2017external icon
        Campbell SB, Klioueva A, Taylor J, Nelson C, Tomasi S, Replogle A, Kwit N, Sexton C, Schwartz A, Hinckley A.
        Zoonoses Public Health. 2019 May 31.
        Tick-borne relapsing fever (TBRF) is a potentially serious spirochetal infection caused by certain species of Borrelia and acquired through the bite of Ornithodoros ticks. In 2017, Austin Public Health, Austin, TX, identified five cases of febrile illness among employees who worked in caves. A cross-sectional serosurvey and interview were conducted for 44 employees at eight organizations that conduct cave-related work. Antibodies against TBRF-causing Borrelia were detected in the serum of five participants, four of whom reported recent illness. Seropositive employees entered significantly more caves (Median 25 [SD: 15] versus Median 4 [SD: 16], p = 0.04) than seronegative employees. Six caves were entered more frequently by seropositive employees posing a potentially high risk. Several of these caves were in public use areas and were opened for tours. Education of area healthcare providers about TBRF and prevention recommendations for cavers and the public are advised.

      2. Anthrax epizootic in wildlife, Bwabwata National Park, Namibia, 2017external icon
        Cossaboom CM, Khaiseb S, Haufiku B, Katjiuanjo P, Kannyinga A, Mbai K, Shuro T, Hausiku J, Likando A, Shikesho R, Nyarko K, Miller LA, Agolory S, Vieira AR, Salzer JS, Bower WA, Campbell L, Kolton CB, Marston C, Gary J, Bollweg BC, Zaki SR, Hoffmaster A, Walke H.
        Emerg Infect Dis. 2019 May;25(5):947-950.
        In late September 2017, Bwabwata National Park in Namibia experienced a sudden die-off of hippopotamuses and Cape buffalo. A multiorganizational response was initiated, involving several ministries within Namibia and the US Centers for Disease Control and Prevention. Rapid interventions resulted in zero human or livestock cases associated with this epizootic.

      3. Evaluating the public health response to a mass bat exposure – Wyoming, 2017external icon
        Cote A, Wallace RM, Jackson DA, Said MA, Musgrave K, Tran CH, Van Houten C, Harrist A, Buttke D, Busacker A, Pickens V, Guagliardo SA.
        Zoonoses Public Health. 2019 May 31.
        Mass bat exposures (MBEs) occur when multiple people are exposed to a bat or a bat colony, often over an extended period. In August 2017, a public health investigation was started in response to an MBE that occurred during May-August 2017 at a national park research station in Wyoming. We identified 176 people who had slept primarily in two lodges (Lodges A and B) at the research station, and successfully contacted 165 (93.8%) of these individuals. Risk assessments (RAs) were administered to all 165 individuals to determine degree and type of exposures to bats (e.g., biting or scratching). Exposure status for research station guests was classified as “non-exposed,” “low risk” or “high risk,” and counselling was provided to guide post-exposure prophylaxis (PEP) recommendations. Prior to public health notification and intervention, 19 persons made the decision to pursue PEP. The healthcare-seeking behaviours of this group were taken to represent outcomes in the absence of public health intervention. (These persons received a RA, and their risk classification was retrospectively assigned.) Approximately 1-2 weeks after conducting the RAs, we conducted a follow-up survey to determine whether recommendations regarding PEP were ultimately followed. The proportion of individuals that unnecessarily pursued PEP was higher among the 19 individuals that sought health care prior to receiving the RA (p < 0.00001). Among those receiving the RA first, all persons classified as high risk followed public health guidance to seek PEP treatment. Despite this, upon re-interview, only 21/79 (26.6%) of guests could accurately recall their risk classification, with most people (55.7%) overestimating their risk. Study findings demonstrate that early public health interventions such as RAs can reduce unnecessary use of PEP and that messaging used during rabies counselling should be clear.

      4. Risk factors for MERS-CoV seropositivity among animal market and slaughterhouse workers, Abu Dhabi, United Arab Emirates, 2014-2017external icon
        Khudhair A, Killerby ME, Al Mulla M, Abou Elkheir K, Ternanni W, Bandar Z, Weber S, Khoury M, Donnelly G, Al Muhairi S, Khalafalla AI, Trivedi S, Tamin A, Thornburg NJ, Watson JT, Gerber SI, Al Hosani F, Hall AJ.
        Emerg Infect Dis. 2019 May;25(5):927-935.
        Camel contact is a recognized risk factor for Middle East respiratory syndrome coronavirus (MERS-CoV) infection. Because specific camel exposures associated with MERS-CoV seropositivity are not fully understood, we investigated worker-camel interactions and MERS-CoV seroprevalence. We assessed worker seroprevalence in 2 slaughterhouses and 1 live-animal market in Abu Dhabi, United Arab Emirates, during 2014-2017 and administered an epidemiologic survey in 2016 and 2017. Across 3 sampling rounds during 2014-2017, we sampled 100-235 workers, and 6%-19% were seropositive for MERS-CoV at each sampling round. One (1.4%) of 70 seronegative workers tested at multiple rounds seroconverted. On multivariable analyses, working as a camel salesman, handling live camels or their waste, and having diabetes were associated with seropositivity among all workers, whereas handling live camels and either administering medications or cleaning equipment was associated with seropositivity among market workers. Characterization of high-risk exposures is critical for implementation of preventive measures.

      5. Tick-borne relapsing fever in the White Mountains, Arizona, USA, 2013-2018external icon
        Mafi N, Yaglom HD, Levy C, Taylor A, O’Grady C, Venkat H, Komatsu KK, Roller B, Seville MT, Kusne S, Po JL, Thorn S, Ampel NM.
        Emerg Infect Dis. 2019 Apr;25(4):649-653.
        Tick-borne relapsing fever (TBRF) is a bacterial infection transmitted by tick bites that occurs in several different parts of the world, including the western United States. We describe 6 cases of TBRF acquired in the White Mountains of Arizona, USA, and diagnosed during 2013-2018. All but 1 case-patient had recurrent fever, and some had marked laboratory abnormalities, including leukopenia, thrombocytopenia, hyperbilirubinemia, and elevated aminotransaminases. One patient had uveitis. Diagnosis was delayed in 5 of the cases; all case-patients responded to therapy with doxycycline. Two patients had Jarisch-Herxheimer reactions. The White Mountains of Arizona have not been previously considered a region of high incidence for TBRF. These 6 cases likely represent a larger number of cases that might have been undiagnosed. Clinicians should be aware of TBRF in patients who reside, recreate, or travel to this area and especially for those who sleep overnight in cabins there.

      6. Estimating Risk to Responders Exposed to Avian Influenza A H5 and H7 Viruses in Poultry, United States, 2014-2017external icon
        Olsen SJ, Rooney JA, Blanton L, Rolfes MA, Nelson DI, Gomez TM, Karli SA, Trock SC, Fry AM.
        Emerg Infect Dis. 2019 May;25(5):1011-1014.
        In the United States, outbreaks of avian influenza H5 and H7 virus infections in poultry have raised concern about the risk for infections in humans. We reviewed the data collected during 2014-2017 and found no human infections among 4,555 exposed responders who were wearing protection.

      7. Nationally-representative serostudy of dengue in Bangladesh allows generalizable disease burden estimatesexternal icon
        Salje H, Paul KK, Paul R, Rodriguez-Barraquer I, Rahman Z, Alam MS, Rahman M, Al-Amin HM, Heffelfinger J, Gurley E.
        Elife. 2019 Apr 8;8.
        Serostudies are needed to answer generalizable questions on disease risk. However, recruitment is usually biased by age or location. We present a nationally-representative study for dengue from 70 communities in Bangladesh. We collected data on risk factors, trapped mosquitoes and tested serum for IgG. Out of 5866 individuals, 24% had evidence of historic infection, ranging from 3% in the north to >80% in Dhaka. Being male (aOR:1.8, [95%CI:1.5-2.0]) and recent travel (aOR:1.3, [1.1-1.8]) were linked to seropositivity. We estimate that 40 million [34.3-47.2] people have been infected nationally, with 2.4 million ([1.3-4.5]) annual infections. Had we visited only 20 communities, seropositivity estimates would have ranged from 13% to 37%, highlighting the lack of representativeness generated by small numbers of communities. Our findings have implications for both the design of serosurveys and tackling dengue in Bangladesh.

      8. Serologic Prevalence of Ebola Virus in Equatorial Africaexternal icon
        Steffen I, Lu K, Yamamoto LK, Hoff NA, Mulembakani P, Wemakoy EO, Muyembe-Tamfum JJ, Ndembi N, Brennan CA, Hackett J, Stramer SL, Switzer WM, Saragosti S, Mbensa GO, Laperche S, Rimoin AW, Simmons G.
        Emerg Infect Dis. 2019 May;25(5):911-918.
        We conducted a serologic survey of 2,430 serum samples collected during 1997-2012 for various studies to determine the prevalence of the hemorrhagic fever virus Ebola virus (EBOV) in equatorial Africa. We screened serum samples for neutralizing antibodies by using a pseudotype microneutralization assay and a newly developed luciferase immunoprecipitation system assay. Specimens seroreactive for EBOV were confirmed by using an ELISA. Our results suggest a serologic prevalence of 2%-3.5% in the Republic of the Congo and the Democratic Republic of the Congo, which have reported outbreaks of infection with EBOV. In addition we detected a seroprevalence of 1.3% in southern Cameroon, which indicated a low risk for exposure in this region.

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CDC Science Clips Production Staff

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  • William (Bill) Thomas, MLIS, Librarian
  • Jarvis Sims, MIT, MLIS, Librarian


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

Page last reviewed: June 13, 2019, 12:00 AM