Volume 11, Issue 3, January 15, 2019

CDC Science Clips: Volume 11, Issue 3, January 15, 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
    • Chronic Diseases and Conditions – Cervical Cancer
      1. Screening for Cervical Cancer: US Preventive Services Task Force Recommendation Statementexternal icon
        Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW, Doubeni CA, Epling JW, Kemper AR, Kubik M, Landefeld CS, Mangione CM, Phipps MG, Silverstein M, Simon MA, Tseng CW, Wong JB.
        Jama. 2018 Aug 21;320(7):674-686.

        Importance: The number of deaths from cervical cancer in the United States has decreased substantially since the implementation of widespread cervical cancer screening and has declined from 2.8 to 2.3 deaths per 100000 women from 2000 to 2015. Objective: To update the US Preventive Services Task Force (USPSTF) 2012 recommendation on screening for cervical cancer. Evidence Review: The USPSTF reviewed the evidence on screening for cervical cancer, with a focus on clinical trials and cohort studies that evaluated screening with high-risk human papillomavirus (hrHPV) testing alone or hrHPV and cytology together (cotesting) compared with cervical cytology alone. The USPSTF also commissioned a decision analysis model to evaluate the age at which to begin and end screening, the optimal interval for screening, the effectiveness of different screening strategies, and related benefits and harms of different screening strategies. Findings: Screening with cervical cytology alone, primary hrHPV testing alone, or cotesting can detect high-grade precancerous cervical lesions and cervical cancer. Screening women aged 21 to 65 years substantially reduces cervical cancer incidence and mortality. The harms of screening for cervical cancer in women aged 30 to 65 years are moderate. The USPSTF concludes with high certainty that the benefits of screening every 3 years with cytology alone in women aged 21 to 29 years substantially outweigh the harms. The USPSTF concludes with high certainty that the benefits of screening every 3 years with cytology alone, every 5 years with hrHPV testing alone, or every 5 years with both tests (cotesting) in women aged 30 to 65 years outweigh the harms. Screening women older than 65 years who have had adequate prior screening and women younger than 21 years does not provide significant benefit. Screening women who have had a hysterectomy with removal of the cervix for indications other than a high-grade precancerous lesion or cervical cancer provides no benefit. The USPSTF concludes with moderate to high certainty that screening women older than 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer, screening women younger than 21 years, and screening women who have had a hysterectomy with removal of the cervix for indications other than a high-grade precancerous lesion or cervical cancer does not result in a positive net benefit. Conclusions and Recommendation: The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. (A recommendation) The USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with hrHPV testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting) in women aged 30 to 65 years. (A recommendation) The USPSTF recommends against screening for cervical cancer in women younger than 21 years. (D recommendation) The USPSTF recommends against screening for cervical cancer in women older than 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. (D recommendation) The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and do not have a history of a high-grade precancerous lesion or cervical cancer. (D recommendation).

      2. Trends in High-grade Cervical Lesions and Cervical Cancer Screening in Five States, 2008-2015external icon
        Gargano JW, Park IU, Griffin MR, Niccolai LM, Powell M, Bennett NM, Johnson Jones ML, Whitney E, Pemmaraju M, Brackney M, Abdullah N, Scahill M, Dahl RM, Cleveland AA, Unger ER, Markowitz LE.
        Clin Infect Dis. 2018 Aug 23.

        Background: We describe changes in rates of cervical intraepithelial neoplasia grades 2, 3 and adenocarcinoma in situ (CIN2+) during a period of human papillomavirus (HPV) vaccine uptake and changing cervical cancer screening recommendations. Methods: We conducted population-based laboratory surveillance for CIN2+ in catchment areas in five states, 2008-2015. Each site used local laboratory or administrative data to estimate the annual proportion of population receiving cervical cancer screening. We calculated population-based CIN2+ rates per 100,000 women by age group. We estimated incidence rate ratios (IRR) of CIN2+ for 2-year periods among all women and in the estimated screened population to evaluate changes over time. Results: A total of 16,572 CIN2+ cases were reported. Among women aged 18-20 and 21-24 years, CIN2+ rates declined in all sites, whereas in women aged 25-29, 30-34, and 35-39 years, trends in rates differed across sites. The percent of women screened annually declined in all sites and age groups. Compared to 2008-2009, rates among screened women were significantly lower for all three periods in women aged 18-20 years (2010-2011: IRR=0.82 (95% CI 0.67-0.99), 2012-2013: IRR=0.63 (0.47-0.85), 2014-2015: IRR=0.44 (0.28-0.68)) and lower for the latter two time periods in women aged 21-24 years (2012-2013: IRR=0.86 (0.79-0.94); 2014-2015: 0.61 (0.55-0.67)). Rates among screened women increased for age groups 25-29, 30-34, and 35-39. Conclusions: From 2008-2015, both CIN2+ rates and cervical cancer screening declined in women aged 18-24 years. The significant decreases in CIN2+ rates among screened women aged 18-24 years are consistent with population-level impact of HPV vaccination.

      3. Addressing the information gap: developing and implementing a cervical cancer prevention education campaign grounded in principles of community-based participatory actionexternal icon
        Moore-Monroy M, Wilkinson-Lee AM, Verdugo L, Lopez E, Paez L, Rodriguez D, Wilhelm M, Garcia F.
        Health Promot Pract. 2013 Mar;14(2):274-83.

        Despite significant advances in prevention, Mexican American women continue to experience disparities related to cervical cancer and access to current and relevant health information. To address this disparity a community-campus partnership initiated an outreach program to Latinas in Arizona as one part of an integrated approach. Promotoras (community health workers) provided the leadership in the development of a curriculum to (a) train promotoras on cervical cancer, (b) meet informational needs of community members, (c) address relevant social determinants of heath, and (d) promote access to health care. The purpose of this article is to describe the community-based participatory approach used in the development of the curriculum. Specifically, the article describes the leadership of promotoras, the curriculum development, and the use of continual feedback to inform the quality control. To address cervical cancer disparities for Mexican American women, the Pima County Cervical Cancer Prevention Partnership used principles of community-based participatory action.

      4. OBJECTIVE: Rural Hispanic and American Indian (AI) women are at risk of non-participation in cancer screening programs. The objective of this study was to compare breast and cervical cancer screening utilization among Hispanic and AI women that reside in rural areas of the Southwestern United States to their urban counterparts and to assess characteristics that influence cancer screening. METHODS: This study utilizes Behavioral Risk Factor Surveillance System (BRFSS) data from 2006 to 2008 for Arizona and New Mexico. The BRFSS is a federally funded telephone survey to collect data on risk factors contributing to the leading causes of death and chronic diseases. RESULTS: Rural Hispanic and AI populations reported some differences in screening rates compared with their urban counterparts. Among Hispanic women, 58 % of rural residents reported having had a mammogram within the past year, compared with 66 % of urban residents. Among AI women, 81 % of rural residents had ever had a mammogram, compared with 89 % of urban residents. Rural AI women were less likely to have ever had a mammogram (OR = 0.5; 95 % CI = 0.3-0.9) compared with urban AI women. Rural Hispanic women were less likely to have had a mammogram within 1 year (OR = 0.7; 95 % CI = 0.5-0.9) compared with urban Hispanic women. Results suggest that rural Hispanic women were less likely to have had a Pap smear within 3 years (OR = 0.7; 95 % CI = 0.4-1.3) compared with urban Hispanic women. CONCLUSION: Our results provide some evidence that Hispanic and AI women that reside in rural areas of the Southwestern United States have lower rates of breast and cervical cancer screening use compared with their urban counterparts. Special efforts are needed to identify ways to overcome barriers to breast and cervical cancer screening for rural Hispanic and AI women.

      5. BACKGROUND: Breast cancer is the most common neoplasm among Hispanic women. Cervical cancer has a higher incidence and mortality among Hispanic women compared with non-Hispanic White women. OBJECTIVE: To assess the effectiveness of a promotora-administered educational intervention to promote breast and cervical cancer screening among post-reproductive age, medically underserved Hispanic women residing along the U.S.-Mexico border. METHODS: Women age 50 or older were eligible to participate in this intervention study. A total of 381 subjects agreed to participate. Women were randomly assigned into one of two groups, educational intervention or usual care. The primary outcomes were self-reported mammogram and Pap smear screening. Logistic regression analysis was used to compute odds ratios for comparisons between intervention and control groups. RESULTS: Women in the intervention group were 2.0 times more likely to report having had a mammogram within the last year when compared with the usual care group (95% CI = 1.3-3.1). Likewise, women in the intervention group were 1.5 times more likely to report having a Pap smear within the last year when compared with the usual care group, although this was not statistically significant (95% CI = 0.9-2.6). In a secondary analysis, the intervention suggests a stronger effect on those that had not had a mammogram or Pap smear within the past year at baseline. CONCLUSIONS: A promotora-based educational intervention can be used to increase breast and cervical cancer screening utilization among Hispanic women.

      6. OBJECTIVE: We estimated the prevalence of human papillomavirus (HPV) vaccination by ethnicity and race and compared vaccination use by known risk factors. MATERIALS AND METHODS: We applied a cross-sectional design using an anonymous, online survey distributed in 2011 to female undergraduates (n = 284) between the ages of 18 and 26 years. The study was approved by the University of Arizona Institutional Review Board. RESULTS: Overall, 55% of women reported receiving the HPV vaccine. Within racial and ethnic groups, HPV vaccination was highest among American Indian/Alaska Native women with 71%, followed by Hispanic women with 68%, black/African American women with 58%, white women with 51%, and Asian/Pacific Island women with 31%. Moreover, Hispanic women were twice as likely to be vaccinated compared with white women (OR = 2.08; 95% CI = 1.14-3.78). Among unvaccinated women, 55% had discussed HPV with a provider and 56% had reported no concerns about the vaccine and/or had high levels of HPV knowledge. CONCLUSIONS: Human papillomavirus vaccine is highly acceptable among college women, particularly among Hispanic women. Efforts to vaccinate should include time of college enrollment. Such efforts are critical for the large scale prevention of cervical cancer and its precursor lesions and ultimately for preventable cervical cancer mortality.

      7. Prevalence of human papillomavirus among females after vaccine introduction – National Health and Nutrition Examination Survey, United States, 2003-2014external icon
        Oliver SE, Unger ER, Lewis R, McDaniel D, Gargano JW, Steinau M, Markowitz LE.
        J Infect Dis. 2017 Sep 1;216(5):594-603.

        Background: Human papillomavirus (HPV) vaccine was recommended in 2006 for routine vaccination of US females aged 11-12 years. Most vaccine used through 2014 was quadrivalent vaccine (4vHPV), which prevents HPV-6, -11, -16, and -18 infection. To evaluate vaccine impact, we measured HPV prevalence in the National Health and Nutrition Examination Survey (NHANES). Methods: We analyzed HPV DNA types detected in self-collected cervicovaginal specimens and demographic, sexual behavior, and self-reported vaccination data from females 14-34 years old. We estimated HPV prevalence in the prevaccine (2003-2006) and vaccine eras (2007-2010 and 2011-2014). Results: Among 14- to 19-year-olds, 4vHPV-type prevalence decreased from 11.5% (95% confidence interval [CI], 9.1%-14.4%) in 2003-2006 to 3.3% (95% CI, 1.9%-5.8%) in 2011-2014, when >/=1-dose coverage was 55%. Among 20- to 24-year-olds, prevalence decreased from 18.5% (95% CI, 14.9%-22.8%) in 2003-2006 to 7.2% (95% CI, 4.7%-11.1%) in 2011-2014, when >/=1-dose coverage was 43%. Compared to 2003-2006, 4vHPV prevalence in sexually active 14- to 24-year-olds in 2011-2014 decreased 89% among those vaccinated and 34% among those unvaccinated. Vaccine effectiveness was 83%. Conclusions: Within 8 years of vaccine introduction, 4vHPV-type prevalence decreased 71% among 14- to 19-year-olds and 61% among 20- to 24-year-olds. Estimated vaccine effectiveness was high. The decrease in 4vHPV-type prevalence among unvaccinated females suggests herd protection.

      8. US assessment of HPV types in cancers: implications for current and 9-valent HPV vaccinesexternal icon
        Saraiya M, Unger ER, Thompson TD, Lynch CF, Hernandez BY, Lyu CW, Steinau M, Watson M, Wilkinson EJ, Hopenhayn C, Copeland G, Cozen W, Peters ES, Huang Y, Saber MS, Altekruse S, Goodman MT.
        J Natl Cancer Inst. 2015 Jun;107(6):djv086.

        BACKGROUND: This study sought to determine the prevaccine type-specific prevalence of human papillomavirus (HPV)-associated cancers in the United States to evaluate the potential impact of the HPV types in the current and newly approved 9-valent HPV vaccines. METHODS: The Centers for Disease Control and Prevention partnered with seven US population-based cancer registries to obtain archival tissue for cancers diagnosed from 1993 to 2005. HPV testing was performed on 2670 case patients that were fairly representative of all participating cancer registry cases by age and sex. Demographic and clinical data were evaluated by anatomic site and HPV status. Current US cancer registry data and the detection of HPV types were used to estimate the number of cancers potentially preventable through vaccination. RESULTS: HPV DNA was detected in 90.6% of cervical, 91.1% of anal, 75.0% of vaginal, 70.1% of oropharyngeal, 68.8% of vulvar, 63.3% of penile, 32.0% of oral cavity, and 20.9% of laryngeal cancers, as well as in 98.8% of cervical cancer in situ (CCIS). A vaccine targeting HPV 16/18 potentially prevents the majority of invasive cervical (66.2%), anal (79.4%), oropharyngeal (60.2%), and vaginal (55.1%) cancers, as well as many penile (47.9%), vulvar (48.6%) cancers: 24 858 cases annually. The 9-valent vaccine also targeting HPV 31/33/45/52/58 may prevent an additional 4.2% to 18.3% of cancers: 3944 cases annually. For most cancers, younger age at diagnosis was associated with higher HPV 16/18 prevalence. With the exception of oropharyngeal cancers and CCIS, HPV 16/18 prevalence was similar across racial/ethnic groups. CONCLUSIONS: In the United States, current vaccines will reduce most HPV-associated cancers; a smaller additional reduction would be contributed by the new 9-valent vaccine.

      9. A cohort study of cervical screening using partial HPV typing and cytology triageexternal icon
        Schiffman M, Hyun N, Raine-Bennett TR, Katki H, Fetterman B, Gage JC, Cheung LC, Befano B, Poitras N, Lorey T, Castle PE, Wentzensen N.
        Int J Cancer. 2016 Dec 1;139(11):2606-15.

        HPV testing is more sensitive than cytology for cervical screening. However, to incorporate HPV tests into screening, risk-stratification (“triage”) of HPV-positive women is needed to avoid excessive colposcopy and overtreatment. We prospectively evaluated combinations of partial HPV typing (Onclarity, BD) and cytology triage, and explored whether management could be simplified, based on grouping combinations yielding similar 3-year or 18-month CIN3+ risks. We typed approximately 9,000 archived specimens, taken at enrollment (2007-2011) into the NCI-Kaiser Permanente Northern California (KPNC) HPV Persistence and Progression (PaP) cohort. Stratified sampling, with reweighting in the statistical analysis, permitted risk estimation of HPV/cytology combinations for the 700,000+-woman KPNC screening population. Based on 3-year CIN3+ risks, Onclarity results could be combined into five groups (HPV16, else HPV18/45, else HPV31/33/58/52, else HPV51/35/39/68/56/66/68, else HPV negative); cytology results fell into three risk groups (“high-grade,” ASC-US/LSIL, NILM). For the resultant 15 HPV group-cytology combinations, 3-year CIN3+ risks ranged 1,000-fold from 60.6% to 0.06%. To guide management, we compared the risks to established “benchmark” risk/management thresholds in this same population (e.g., LSIL predicted 3-year CIN3+ risk of 5.8% in the screening population, providing the benchmark for colposcopic referral). By benchmarking to 3-year risk thresholds (supplemented by 18-month estimates), the widely varying risk strata could be condensed into four action bands (very high risk of CIN3+ mandating consideration of cone biopsy if colposcopy did not find precancer; moderate risk justifying colposcopy; low risk managed by intensified follow-up to permit HPV “clearance”; and very low risk permitting routine screening.) Overall, the results support primary HPV testing, with management of HPV-positive women using partial HPV typing and cytology.

      10. Accelerating cervical cancer control and preventionexternal icon
        Wentzensen N, Schiffman M.
        Lancet Public Health. 2018 Jan;3(1):e6-e7.

        [No abstract]

      11. Triage of HPV positive women in cervical cancer screeningexternal icon
        Wentzensen N, Schiffman M, Palmer T, Arbyn M.
        J Clin Virol. 2016 Mar;76 Suppl 1:S49-s55.

        Despite HPV vaccines, screening will remain central for decades to control cervical cancer. Recently, HPV testing alone or with cytology was introduced as an alternative to cytology screening. However, most HPV infections are harmless and additional tests are required to identify women with progressing infections or precancer. With three options for primary screening, and without clear strategies for triage of screen-positive women, there is great confusion about the best approach. Also, increasing HPV vaccination coverage will lead to lower disease prevalence, and force new screening approaches. Currently recommended triage strategies for primary HPV screening include HPV genotyping for HPV16 and HPV18 and cytology. Other alternatives that are currently evaluated include p16/Ki-67 dual stain cytology, host methylation, and viral methylation testing. Clinical management of women with cervical cancer screening results is moving to use risk thresholds rather than individual test results. Specific risk thresholds have been defined for return to primary screening, repeat testing, referral to colposcopy, and immediate treatment. Choice of test algorithms is based on comparison of absolute risk estimates from triage tests with established clinical thresholds. Importantly, triage tests need to be evaluated together with the primary screening test and the downstream clinical management. An optimal integrated screening and triage strategy should reassure the vast majority of women that they are at very low risk of cervical cancer, send the women at highest risk to colposcopy at the right time, when disease can be colposcopically detected, and minimize the intermediate risk group that requires continued surveillance.

  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. Recent studies of middle age and older adults with, or at risk for, arthritis demonstrate that engaging in physical activities like walking – even at levels below the current aerobic physical activity guideline of >/=150min of moderate-intensity activity – can protect against onset of functional limitations. Using a large nationally representative sample of US adults >/=18years with arthritis, we investigated whether, among those not meeting the aerobic activity guideline, walking >/=10min/week vs. <10min/week reduced the risk of six outcomes (fair/poor health and five physical limitations) over 2years. We conducted a prospective cohort study among adults with arthritis in the 2010 National Health Interview Survey who participated in the 2011-2012 Medical Expenditure Panel Survey (n=1426). Among adults not meeting the guideline, we examined the effect of walking on risk of developing each of six outcomes using hazard ratios (HRs) estimated from multivariable Cox regression models. Among adults with arthritis not meeting the guideline, compared to walking <10min/week, walking >/=10min/week was associated with a statistically significant decreased risk for all five limitations: walking three blocks (HR: 0.3 [95% CI=0.2-0.6]), climbing 10 stairs (HR: 0.5 [95% CI=0.3-0.8]), stooping/kneeling (HR: 0.4 [95% CI=0.2-0.8]), reaching overhead (HR: 0.5[95% CI=0.5-0.8]), and grasping (HR: 0.4 [95% CI=0.2-0.7]). The decrease in risk was not significant for fair/poor health. Even limited walking may prevent the onset of physical limitations among adults with arthritis of all ages not meeting the aerobic activity guideline.

    • Communicable Diseases
      1. [No abstract]

      2. Behavioral and clinical characteristics of American Indian/Alaska Native adults in HIV care – Medical Monitoring Project, United States, 2011-2015external icon
        Baugher AR, Beer L, Bradley HM, Evans ME, Luo Q, Shouse RL.
        MMWR Morb Mortal Wkly Rep. 2019 Jan 4;67(5152):1405-1409.

        The rate of diagnosis of human immunodeficiency virus (HIV) infection among American Indians and Alaska Natives (AI/ANs) in 2016 (10.2 per 100,000 population) was the fourth highest among seven racial/ethnic groups in the United States (1); the number of diagnoses of HIV infection among AI/AN persons increased by 70%, from 143 in 2011 to 243 in 2016 (1). However, little has been published about the sociodemographic, behavioral, and clinical characteristics of AI/AN patients with HIV infection in care because small sample sizes have led to infrequent analysis of AI/AN-specific estimates (2) and because of underestimation of AI/AN race/ethnicity in surveillance and other data sources (3). CDC analyzed data from the Medical Monitoring Project (MMP), a surveillance system that collects information about the experiences and needs of persons with diagnosed HIV infection, collected during 2011-2015 among AI/AN adults receiving HIV medical care. The results indicated that 64% of AI/AN patients with HIV infection in care achieved sustained viral suppression, and 76% achieved viral suppression at their most recent viral load test within the past 12 months, which is below the national HIV prevention goal of 80%, but comparable to or better than some other racial/ethnic groups (4). Based on self-report, 51% of AI/AN patients with HIV infection had incomes at or below the U.S. Department of Health and Human Services’ (HHS) annual poverty limit, 27% had symptoms of depression, 78% reported internalized HIV-related stigma, and 20% reported binge drinking in the past 30 days. To improve the health of AI/AN patients with HIV infection, it is important that health care providers, tribal organizations, and state and local health departments consider the sociodemographic and behavioral barriers to AI/AN patients with HIV infection achieving viral suppression and design care plans that seek to eliminate those barriers.

      3. Prescription of antibacterial drugs for HIV-exposed, uninfected infants, Malawi, 2004-2010external icon
        Ewing AC, Davis NL, Kayira D, Hosseinipour MC, van der Horst C, Jamieson DJ, Kourtis AP.
        Emerg Infect Dis. 2019 Jan;25(1).

        Antimicrobial drug resistance is a serious health hazard driven by overuse. Administration of antimicrobial drugs to HIV-exposed, uninfected infants, a population that is growing and at high risk for infection, is poorly studied. We therefore analyzed factors associated with antibacterial drug administration to HIV-exposed, uninfected infants during their first year of life. Our study population was 2,152 HIV-exposed, uninfected infants enrolled in the Breastfeeding, Antiretrovirals and Nutrition study in Lilongwe, Malawi, during 2004-2010. All infants were breastfed through 28 weeks of age. Antibacterial drugs were prescribed frequently (to 80% of infants), and most (67%) of the 5,329 prescriptions were for respiratory indications. Most commonly prescribed were penicillins (43%) and sulfonamides (23%). Factors associated with lower hazard for antibacterial drug prescription included receipt of cotrimoxazole preventive therapy, receipt of antiretroviral drugs, and increased age. Thus, cotrimoxazole preventive therapy may lead to fewer prescriptions for antibacterial drugs for these infants.

      4. Burdens of invasive methicillin-susceptible and methicillin-resistant Staphylococcus aureus disease, Minnesota, USAexternal icon
        Koeck M, Como-Sabetti K, Boxrud D, Dobbins G, Glennen A, Anacker M, Jawahir S, See I, Lynfield R.
        Emerg Infect Dis. 2019 Jan;25(1):171-174.

        During August 1, 2014-July 31, 2015, in 2 counties in Minnesota, USA, incidence of invasive methicillin-susceptible Staphylococcus aureus (MSSA) (27.1 cases/100,000 persons) was twice that of invasive methicillin-resistant S. aureus (13.1 cases/100,000 persons). MSSA isolates were more genetically diverse and susceptible to more antimicrobial drugs than methicillin-resistant S. aureus isolates.

      5. Meningococcal disease among college-aged young adults: 2014-2016external icon
        Mbaeyi SA, Joseph SJ, Blain A, Wang X, Hariri S, MacNeil JR.
        Pediatrics. 2019 Jan;143(1).

        : media-1vid110.1542/5839998266001PEDS-VA_2018-2130Video Abstract BACKGROUND: Freshman college students living in residence halls have previously been identified as being at an increased risk for meningococcal disease. In this evaluation, we assess the incidence and characteristics of meningococcal disease in college-aged young adults in the United States. METHODS: The incidence and relative risk (RR) of meningococcal disease among college students compared with noncollege students aged 18 to 24 years during 2014-2016 were calculated by using data from the National Notifiable Diseases Surveillance System and enhanced meningococcal disease surveillance. Differences in demographic characteristics and clinical features of meningococcal disease cases were assessed. Available meningococcal isolates were characterized by using slide agglutination, polymerase chain reaction, and whole genome sequencing. RESULTS: From 2014 to 2016, 166 cases of meningococcal disease occurred in persons aged 18 to 24 years, with an average annual incidence of 0.17 cases per 100 000 population. Six serogroup B outbreaks were identified on college campuses, accounting for 31.7% of serogroup B cases in college students during this period. The RR of serogroup B meningococcal (MenB) disease in college students versus noncollege students was 3.54 (95% confidence interval: 2.21-5.41), and the RR of serogroups C, W, and Y combined was 0.56 (95% confidence interval: 0.27-1.14). The most common serogroup B clonal complexes identified were CC32/ET-5 and CC41/44 lineage 3. CONCLUSIONS: Although the incidence is low, among 18- to 24-year-olds, college students are at an increased risk for sporadic and outbreak-associated MenB disease. Providers, college students, and parents should be aware of the availability of MenB vaccines.

      6. Spectrum of changes seen with placental intravascular organismsexternal icon
        Schubert PT, Mason D, Martines R, Deleon-Carnes M, Zaki SR, Roberts DJ.
        Pediatr Dev Pathol. 2018 Oct 18:1093526618801616.

        Fetal bacterial infections are a common cause of fetal/neonatal morbidity and mortality. The pathologic correlates of congenital bacterial infection include acute chorioamnionitis, acute villitis, and acute intervillositis. The strength of the association of congenital bacterial infection differs among these pathologies. Acute chorioamnionitis results usually from an ascending infection, and damage to the fetus is thought to be cytokine driven rather than damage secondary to bacteremia. Acute villitis is strongly associated with fetal sepsis due to congenital infections. A much less common variant on acute villitis pattern has been described with additional presence of bacteria in the fetal capillaries of the chorionic villi. We describe the spectrum of bacteria that would induce this unique pattern. The histological archives were searched from 2 institutions for cases with intravascular bacteria present in the villous capillaries of the placenta. Thirteen cases were identified, of which 11 cases had acute chorioamnionitis and all cases showed an acute villitis. Eight cases had Escherichia coli identified and 3 cases had Group B Streptococcus. All cases were associated with fetal death. In 9 cases, the mother showed signs of a significant infection including 1 maternal death. We conclude that finding intravascular bacteria is a serious complication of congenital infection with serious fetal and maternal sequela.

    • Environmental Health
      1. OBJECTIVE: Dimethyl sulfide (DMS, CAS 75-18-3) is an industrial chemical. It is both an irritant and neurotoxicant that may be life-threatening because of accidental release. The effects of DMS on public health and associated public health response depend on the exposure concentration and duration. However, currently, public health advisory information exists for only a 1 h exposure duration, developed by the American Industrial Hygiene Association (AIHA). In the present work, the AIHA-reviewed data were computationally extrapolated to other common short-term durations. METHODS: The extrapolation was carried out using the toxic load equation, C(n) x t = TL, where C and t are exposure concentration and duration, TL is toxic load, and n is a chemical-specific toxic load exponent derived in the present work using probit meta-analysis. The developed threshold levels were vetted against the AIHA database of clinical and animal health effects induced by DMS. RESULTS: Tier-1 levels were derived based on human exposures that resulted in an easily detectable odor, because DMS is known to have a disagreeable odor that may cause nausea. Tier-2 levels were derived from the lower 95% confidence bounds on a benchmark concentration that caused 10% incidence (BMCL10) of coma in rats during a 15 min inhalation exposure to DMS. Tier-3 levels were based on a BMCL05 for mortality in rats. CONCLUSION: Emergency responders and health assessors may consider these computationally derived threshold levels as a supplement to traditional chemical risk assessment procedures in instances where AIHA developed public health advisory levels do not exist.

    • Food Safety
      1. Use of omics methods for the advancement of food quality and food safetyexternal icon
        Cook PW, Nightingale KK.
        Animal Frontiers. 2018 ;8(4):33-41.

        Advancing food quality and food safety is critical for improving global food security and public health metrics. Omics tools (i.e., genomics, transcriptomics, proteomics, and metabolomics) are robust tools to gain further insight into microbial communities along the food chain and their implications for human and animal health. Whole genome sequencing facilitates early detection of foodborne illness outbreaks, including smaller clusters of related illnesses spanning over longer time periods, and microbial source tracking. Omics approaches can provide insight into adaptation of microorganisms to specific niches along the food continuum and other strain-specific characteristics that affect human and animal health, including virulence genes and antimicrobial resistance.

      2. Notes from the field: Environmental investigation of a multistate salmonellosis outbreak linked to live backyard poultry from a mail-order hatchery – Michigan, 2018external icon
        Hardy MC, Robertson SA, Sidge J, Signs K, Stobierski MG, Jones K, Soehnlen M, Stefanovsky L, Hambley A, Brandenburg JM, Martin H, Lauer AC, Fields P, Koski L, Stevenson LM, Pabilonia KL, Nichols MC, Basler CA, Ribot EM, Hise KB.
        MMWR Morb Mortal Wkly Rep. 2019 Jan 4;67(5152):1430-1431.

        [No abstract]

    • Genetics and Genomics
      1. Enterotoxigenic Escherichia coli (ETEC) are an important cause of diarrhea globally, particularly among children under the age of five in developing countries. ETEC O6 is the most common ETEC serogroup, yet the genome wide population structure of isolates of this serogroup is yet to be determined. In this study, we have characterized 40 ETEC O6 isolates collected between 1975-2016 by whole genome sequencing (WGS) and by phenotypic antimicrobial susceptibility testing. To determine the relatedness of isolates, we evaluated two methods-whole genome high-quality single nucleotide polymorphism (whole genome-hqSNP) and core genome SNP analyses using Lyve-SET and Parsnp respectively. All isolates were tested for antimicrobial susceptibility using a panel of 14 antibiotics. ResFinder 2.1 and a custom quinolone resistance determinants workflow were used for resistance determinant detection. VirulenceFinder 1.5 was used for prediction of the virulence genes. Thirty-seven isolates clustered into three major clades (I, II, III) by whole genome-hqSNP and core genome SNP analyses, while three isolates included in the whole genome-hqSNP analysis only did not cluster with clades I-III by both analyses and formed a distantly related outgroup, designated clade IV. Median number of pairwise whole genome-hqSNPs in clonal ETEC O6 outbreaks ranged from 0 to 5. Of the 40 isolates tested for antimicrobial susceptibility, 18 isolates were pansusceptible. Twenty-two isolates were resistant to at least one antibiotic, nine of which were multidrug resistant. Phenotypic antimicrobial resistance (AR) correlated with AR determinants in 22 isolates. Thirty-two isolates harbored both enterotoxin virulence genes while the remaining 8 isolates had only one of the two virulence genes. In summary, whole genome-hqSNP and core genome SNP analyses from this study revealed similar evolutionary relationships and an overall diversity of ETEC O6 isolates independent of time of isolation. Less than 5 pairwise hqSNPs between ETEC O6 isolates is circumstantially indicative of an outbreak cluster. Findings from this study will be a basis for quicker outbreak detection and control by efficient subtyping by WGS.

      2. Zoonotic source attribution of Salmonella enterica serotype typhimurium using genomic surveillance data, United Statesexternal icon
        Zhang S, Li S, Gu W, den Bakker H, Boxrud D, Taylor A, Roe C, Driebe E, Engelthaler DM, Allard M, Brown E, McDermott P, Zhao S, Bruce BB, Trees E, Fields PI, Deng X.
        Emerg Infect Dis. 2019 Jan;25(1):82-91.

        Increasingly, routine surveillance and monitoring of foodborne pathogens using whole-genome sequencing is creating opportunities to study foodborne illness epidemiology beyond routine outbreak investigations and case-control studies. Using a global phylogeny of Salmonella enterica serotype Typhimurium, we found that major livestock sources of the pathogen in the United States can be predicted through whole-genome sequencing data. Relatively steady rates of sequence divergence in livestock lineages enabled the inference of their recent origins. Elevated accumulation of lineage-specific pseudogenes after divergence from generalist populations and possible metabolic acclimation in a representative swine isolate indicates possible emergence of host adaptation. We developed and retrospectively applied a machine learning Random Forest classifier for genomic source prediction of Salmonella Typhimurium that correctly attributed 7 of 8 major zoonotic outbreaks in the United States during 1998-2013. We further identified 50 key genetic features that were sufficient for robust livestock source prediction.

    • Healthcare Associated Infections
      1. Scope and extent of healthcare-associated Middle East respiratory syndrome coronavirus transmission during two contemporaneous outbreaks in Riyadh, Saudi Arabia, 2017external icon
        Alanazi KH, Killerby ME, Biggs HM, Abedi GR, Jokhdar H, Alsharef AA, Mohammed M, Abdalla O, Almari A, Bereagesh S, Tawfik S, Alresheedi H, Alhakeem RF, Hakawi A, Alfalah H, Amer H, Thornburg NJ, Tamin A, Trivedi S, Tong S, Lu X, Queen K, Li Y, Sakthivel SK, Tao Y, Zhang J, Paden CR, Al-Abdely HM, Assiri AM, Gerber SI, Watson JT.
        Infect Control Hosp Epidemiol. 2019 Jan;40(1):79-88.

        OBJECTIVE: To investigate a Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak event involving multiple healthcare facilities in Riyadh, Saudi Arabia; to characterize transmission; and to explore infection control implications. DESIGN: Outbreak investigation. SETTING: Cases presented in 4 healthcare facilities in Riyadh, Saudi Arabia: a tertiary-care hospital, a specialty pulmonary hospital, an outpatient clinic, and an outpatient dialysis unit. METHODS: Contact tracing and testing were performed following reports of cases at 2 hospitals. Laboratory results were confirmed by real-time reverse transcription polymerase chain reaction (rRT-PCR) and/or genome sequencing. We assessed exposures and determined seropositivity among available healthcare personnel (HCP) cases and HCP contacts of cases. RESULTS: In total, 48 cases were identified, involving patients, HCP, and family members across 2 hospitals, an outpatient clinic, and a dialysis clinic. At each hospital, transmission was linked to a unique index case. Moreover, 4 cases were associated with superspreading events (any interaction where a case patient transmitted to >/=5 subsequent case patients). All 4 of these patients were severely ill, were initially not recognized as MERS-CoV cases, and subsequently died. Genomic sequences clustered separately, suggesting 2 distinct outbreaks. Overall, 4 (24%) of 17 HCP cases and 3 (3%) of 114 HCP contacts of cases were seropositive. CONCLUSIONS: We describe 2 distinct healthcare-associated outbreaks, each initiated by a unique index case and characterized by multiple superspreading events. Delays in recognition and in subsequent implementation of control measures contributed to secondary transmission. Prompt contact tracing, repeated testing, HCP furloughing, and implementation of recommended transmission-based precautions for suspected cases ultimately halted transmission.

      2. [No abstract]

      3. Hepatitis C virus (HCV) infection is more common among hemodialysis patients than the general population and transmission of HCV in dialysis clinics has been reported. In the context of the increased morbidity and mortality associated with HCV infection in the end stage renal disease population, it is important that dialysis clinics have processes in place for ensuring recommended infection control practices, including Standard Precautions, through regular audits and training of the staff. This review will summarize the epidemiology of HCV infection and risk factors for HCV transmission among hemodialysis patients. In addition, the proper protocols are required to investigate suspected cases of HCV transmission in dialysis facilities and recommendations for prevention of HCV transmission in will be reviewed.

    • Immunity and Immunization
      1. Primary care physicians’ perspectives on respiratory syncytial virus (RSV) disease in adults and a potential RSV vaccine for adultsexternal icon
        Hurley LP, Allison MA, Kim L, O’Leary ST, Crane LA, Brtnikova M, Beaty BL, Allen KE, Poser S, Lindley MC, Kempe A.
        Vaccine. 2018 Dec 28.

        BACKGROUND: Deaths attributable to respiratory syncytial virus (RSV) among adults are estimated to exceed 11,000 annually, and annual adult hospitalizations for influenza and RSV may be comparable. RSV vaccines for older adults are in development. We assessed the following among primary care physicians (PCPs) who treat adults: (1) perception of RSV disease burden; (2) current RSV testing practices; and (3) anticipated barriers to adoption of an RSV vaccine. METHODS: We administered an Internet and mail survey from February to March 2017 to national networks of 930 PCPs. RESULTS: The response rate was 67% (620/930). Forty-nine percent of respondents (n=303) were excluded from analysis as they reported never or rarely caring for an adult patient with possible RSV in the past year. Among respondents who reported taking care of RSV patients (n=317), 73% and 57% responded that in patients>/=50years, influenza is generally more severe than RSV and that they rarely consider RSV as a potential pathogen, respectively. Most (61%) agreed that they do not test for RSV because there is no treatment. The most commonly reported anticipated barriers to a RSV vaccine were potential out-of-pocket expenses for patients if the vaccine is not covered by insurance (93%) and lack of reimbursement for vaccination (74%). CONCLUSIONS: Physicians reported little experience with RSV disease in adults. They are generally not testing for it and the majority believe that influenza disease is more severe. Physicians will require more information about RSV disease burden in adults and the potential need for a vaccine in their adult patients.

      2. Increasing human papillomavirus vaccination at the recommended ageexternal icon
        Lin X, Shrader L, Rodgers L, Stokley S, Markowitz LE.
        Vaccine. 2018 Dec 24.

        In the United States, human papillomavirus (HPV) vaccine has been recommended for females since 2006 and for males since 2011. However, national HPV vaccination coverage among adolescents is lower than national targets, and many adolescents initiate HPV vaccination later than the recommended age. We analyzed records for >2 million persons born during 1996-2000 who initiated HPV vaccination at age 9 through 16years from six Immunization Information Systems Sentinel Sites, displayed the distribution of HPV vaccination initiation age, and calculated HPV vaccination coverage. More adolescents in recent cohorts initiated HPV vaccination at the recommended age of 11-12years, the majority of whom received another recommended vaccine on the same day. However, >40% of all vaccinated adolescents did not initiate the HPV vaccination until age 13years or later. Continued efforts are needed to increase HPV vaccination initiation at the recommended age.

    • Injury and Violence
      1. All things in moderation? Threshold effects in adolescent extracurricular participation intensity and behavioral problemsexternal icon
        Matjasko JL, Holland KM, Holt MK, Espelage DL, Koenig BW.
        J Sch Health. 2019 Feb;89(2):79-87.

        BACKGROUND: School-based extracurricular activity participation is one of the primary avenues for prosocial activity engagement during adolescence. In this study, we test the “overscheduling hypothesis” or whether the negative relationship between structured activity intensity (ie, hours) and adolescent bullying and fighting levels off or declines at moderate to high intensity (ie, threshold effects). METHODS: This study uses the Dane County Youth Survey (N = 14,124) to investigate the relationship between school-based extracurricular activity participation intensity and bullying perpetration and physical fighting and whether there are threshold effects of activity participation intensity. RESULTS: The results indicate that there is a negative relationship between extracurricular activity participation intensity and bullying perpetration and physical fighting and that there are threshold effects in these relationships at 3 to 4 hours per week. Results also suggest that low-income adolescents engage in more fighting than other youth and the negative relationship between activity participation intensity and physical fighting was mainly concentrated among low-income adolescents. CONCLUSIONS: School-based extracurricular activity participation-in moderation (ie, up to 3-4 hours per week)-may provide a positive, supportive context that could be a promising prevention strategy for bullying and fighting. Implications for future research on how school-based extracurricular activity participation intensity benefits adolescent functioning are discussed.

      2. Co-occurrence of chronic traumatic encephalopathy and prion diseaseexternal icon
        Nemani SK, Notari S, Cali I, Alvarez VE, Kofskey D, Cohen M, Stern RA, Appleby B, Abrams J, Schonberger L, McKee A, Gambetti P.
        Acta Neuropathol Commun. 2018 Dec 18;6(1):140.

        Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with repetitive traumatic brain injury (TBI). CTE is generally found in athletes participating in contact sports and military personnel exposed to explosive blasts but can also affect civilians. Clinically and pathologically, CTE overlaps with post-traumatic stress disorder (PTSD), a term mostly used in a clinical context. The histopathology of CTE is defined by the deposition of hyperphosphorylated tau protein in neurons and astrocytes preferentially with perivascular distribution and at the depths of the cortical sulci. In addition to hyperphosphorylated tau, other pathologic proteins are deposited in CTE, including amyloid beta (Abeta), transactive response (TAR) DNA-binding protein 43 kDa (TDP-43) and alpha-synuclein. However, the coexistence of prion disease in CTE has not been observed. We report three cases of histopathologically validated CTE with co-existing sporadic prion disease. Two were identified in a cohort of 55 pathologically verified cases of CTE submitted to the CTE Center of Boston University. One was identified among brain tissues submitted to the National Prion Disease Pathology Surveillance Center of Case Western Reserve University. The histopathological phenotype and properties of the abnormal, disease-related prion protein (PrP(D)) of the three CTE cases were examined using lesion profile, immunohistochemistry, electrophoresis and conformational tests. Subjects with sporadic Creutzfeldt-Jakob disease (sCJD) matched for age, PrP genotype and PrP(D) type were used as controls. The histopathology phenotype and PrP(D) properties of the three CTE subjects showed no significant differences from their respective sCJD controls suggesting that recurring neurotrauma or coexisting CTE pathology did not detectably impact the prion disease phenotype and PrP(D) conformational characteristics. Based on the reported incidence of sporadic prion disease, the detection of two cases with sCJD in the CTE Center series of 55 CTE cases by chance alone would be highly unlikely (p = 8.93*10(- 6)). Nevertheless, examination of a larger cohort of CTE is required to conclusively determine whether the risk of CJD is significantly increased in patients with CTE.

    • Laboratory Sciences
      1. The molecular mechanism of induction of unfolded protein response by Chlamydiaexternal icon
        George Z, Omosun Y, Azenabor AA, Goldstein J, Partin J, Joseph K, Ellerson D, He Q, Eko F, McDonald MA, Reed M, Svoboda P, Stuchlik O, Pohl J, Lutter E, Bandea C, Black CM, Igietseme JU.
        Biochem Biophys Res Commun. 2019 Jan 8;508(2):421-429.

        The unfolded protein response (UPR) contributes to chlamydial pathogenesis, as a source of lipids and ATP during replication, and for establishing the initial anti-apoptotic state of host cell that ensures successful inclusion development. The molecular mechanism(s) of UPR induction by Chlamydia is unknown. Chlamydia use type III secretion system (T3SS) effector proteins (e.g, the Translocated Actin-Recruiting Phosphoprotein (Tarp) to stimulate host cell’s cytoskeletal reorganization that facilitates invasion and inclusion development. We investigated the hypothesis that T3SS effector-mediated assembly of myosin-II complex produces activated non-muscle myosin heavy chain II (NMMHC-II), which then binds the UPR master regulator (BiP) and/or transducers to induce UPR. Our results revealed the interaction of the chlamydial effector proteins (CT228 and Tarp) with components of the myosin II complex and UPR regulator and transducer during infection. These interactions caused the activation and binding of NMMHC-II to BiP and IRE1alpha leading to UPR induction. In addition, specific inhibitors of myosin light chain kinase, Tarp oligomerization and myosin ATPase significantly reduced UPR activation and Chlamydia replication. Thus, Chlamydia induce UPR through T3SS effector-mediated activation of NMMHC-II components of the myosin complex to facilitate infectivity. The finding provides greater insights into chlamydial pathogenesis with the potential to identify therapeutic targets and formulations.

      2. Human and animal studies have confirmed that inhalation of particles from ambient air or occupational settings not only causes pathophysiological changes in the respiratory system, but causes cardiovascular effects as well. At an equal mass lung burden, nanoparticles are more potent in causing systemic microvascular dysfunction than fine particles of similar composition. Thus, accumulated evidence from animal studies has led to heightened concerns about the potential short- and long-term deleterious effects of inhalation of engineered nanoparticles on the cardiovascular system. This review highlights the new observations from animal studies, which document the adverse effects of pulmonary exposure to engineered nanoparticles on the cardiovascular system and elucidate the potential mechanisms involved in regulation of cardiovascular function, in particular, how the neuronal system plays a role and reacts to pulmonary nanoparticle exposure based on both in vivo and in vitro studies. In addition, this review also discusses the possible influence of altered autonomic nervous activity on preexisting cardiovascular conditions. Whether engineered nanoparticle exposure serves as a risk factor in the development of cardiovascular diseases warrants further investigation.

      3. Performance evaluation of the Bio-Rad Geenius HIV 1/2 supplemental assayexternal icon
        Luo W, Sullivan V, Smith T, Peters PJ, Gay C, Westheimer E, Cohen SE, Owen SM, Masciotra S.
        J Clin Virol. 2018 Dec 19;111:24-28.

        BACKGROUND: In the US, the HIV diagnostic algorithm for laboratory settings recommends the use of an HIV-1/HIV-2 differentiation supplemental assay after an initial reactive antigen/antibody (Ag/Ab) assay result. Since the discontinuation of the Multispot HIV-1/HIV-2 Rapid Test (MS), the Geenius HIV-1/2 Supplemental assay (Geenius) is the only FDA-approved supplemental differentiation test. OBJECTIVE: We compared the performance of Geenius to MS and Western Blot (WB). STUDY DESIGN: The relative seroconversion plasma reactivity of Geenius and MS was assessed using a 50% cumulative frequency analysis from 17 HIV-1 seroconverters. In addition, previously characterized plasma specimens, 186 HIV-1 positive, 100 HIV-2 positive, and 93 Ag/Ab-positive/HIV-1 RNA-negative, were tested with Geenius v1.1 software. McNemar’s test was used for paired comparison analysis. A subset of 48 specimens were retested with the upgraded Geenius v1.3 software. RESULTS: In HIV-1 seroconverters, the relative seroconversion reactivity was 2.5 and 2 days before the first positive HIV-1 WB for Geenius and MS, respectively. In HIV-1 positive samples, Geenius performed similarly to HIV-1 WB (p=0.1687) and MS (p=0.8312). In HIV-2 positive samples, Geenius underperformed compared to HIV-2 WB (p=0.0005) and MS (p=0.0012). When using the upgraded software among the HIV-1 positive and Ag/Ab-reactive/HIV-1 RNA-negative samples, gp140 reactivity decreased without affecting characterization of HIV-2 samples. CONCLUSIONS: With HIV-1 samples, Geenius, WB and MS performance was similar as supplemental tests. The updated Geenius software reduced false gp140 reactivity, but had no impact on identifying true HIV-2 infections. Further evaluation will assess the impact of the Geenius software update on final diagnostic interpretations.

      4. Many epidemiological studies have associated bioaerosol exposures with a variety of adverse health effects; however, the role of bioaerosol components in the development and manifestation of hypersensitivity and non-infectious respiratory diseases remains unclear. Despite many studies which have examined allergic responses to bioaerosols, less is known about non-allergenic effects. In order to elucidate the mechanisms by which bioaerosols can exert non-atopic stresses on a cellular level, there is a need for improving existing in vitro approaches. In response, a cohort of toxicology assays were optimized to create a robust analytical suite for studying the effects that biogenic atmospheric pollutants generate on two model human lung cell lines (A549 epithelial line and GDM-1 immature macrophage line). To demonstrate the utility for studying the cellular responses to select bioaerosols, cells exposed to curdlan (a linear (1 -> 3)-beta-glucan) were examined in a composite cytometry platform. Results suggest that curdlan has the potential to elicit significant responses in A549 and GDM-1 in two or more toxicological modes associated with exposure to airborne particulate matter. As designed, this suite provided a more powerful tool for characterizing curdlan-induced toxicological potential than any individual assay. Responses to curdlan were distinctly modal and cell line dependent, suggesting that the use of a suite of toxicological assays, in a common platform on different cell lines, can help provide important insights into the formative toxigenic responses that primary bioaerosols can induce in respiratory cells.

    • Maternal and Child Health
      1. The majority of studies of temperament in children with autism spectrum disorder (ASD) use scales normed on typical populations. The present study examined a widely used measure of temperament, the Behavioral Style Questionnaire (McDevitt and Carey in Behavioral Styles Questionnaire, Behavioral-Developmental Initiatives Scottsdale, AZ, 1975) to determine whether it contains the temperament traits theorized by its creators. Neither confirmatory nor exploratory factor analysis, using a sample of children with ASD and a population comparison group, identified the theorized nine temperament factors; many items did not strongly load on any of the original factors. A 10 factor solution best described the ASD data and a 9 factor solution best described the typical group’s data. There were substantial similarities in the 9 factor solutions, but groups differed from one another enough to question construct similarity for several factors. These results highlight that more basic psychometric research is needed to better understand the BSQ in children with ASD.

      2. Introduction: We aimed to assess changes in care coordination and health insurance coverage among US children with muscular dystrophy. Methods: We used 2005-2006 and 2009-2010 data from the National Survey of Children with Special Health Care Needs. We examined the distribution of sociodemographic and health characteristics of children with muscular dystrophy by survey cycle. Multivariable regression was used to calculate odds of not receiving effective care coordination, not having adequate health insurance coverage, receiving no help coordinating care, and having problems obtaining referrals in each survey cycle. Results: In the 2005-2006 and 2009-2010 survey cycles, there were 135 and 117 children with muscular dystrophy (representing 34,672 and 31,169 US children with muscular dystrophy), respectively. The percentage of children with muscular dystrophy who did not receive effective care coordination changed from 59.2% (95% confidence interval (CI), 45.6%-72.7%) in 2005-2006 to 53.4% (95% CI, 38.3%-68.6%) in 2009-2010. The odds of not receiving effective care coordination (adjusted odds ratio (aOR) = 0.77; 95% CI, 0.32-1.89) or having problems obtaining referrals (aOR = 0.52; 95% CI, 0.17-1.59) did not change significantly between the two periods, whereas odds of having inadequate insurance coverage decreased significantly (aOR = 0.41, 95% CI, 0.18-0.93) and odds of not receiving help coordinating care increased significantly (aOR = 4.22, 95% CI, 1.24-14.29) between the two periods. Conclusion: Our results suggest key health care needs for many families with children with muscular dystrophy have remained unmet for a prolonged period. Although there were significant improvements in health insurance coverage, nearly one-third of children with muscular dystrophy still had inadequate health insurance coverage in 2009-2010; it is likely that this situation has not changed much since then.

    • Mining
      1. A method for estimating the low frequency coupling characteristics of a ferrite-cored rod antenna to a long conductorexternal icon
        Li J, Carr JL, Zhou CJ, Reyes MA, Noll JD.
        Prog Electromagn Res M Pier M. 2018 ;75:193-203.

        Magnetic proximity detection systems (PDSs) used in underground mines occasionally generate false alarms when the miner-wearable component (MWC) is close to nearby conductors such as power cables. This is because the signals from the generators (antennas) of the PDS wirelessly couple to nearby cables, travel along these cables, and then couple back from the cable to a distant MWC to cause a false alarm. In order to manage such a false alarm, it is necessary to understand the basic near-field coupling characteristics from a generator to a long wire. Researchers from the National Institute for Occupational Safety and Health (NIOSH) have developed a method to measure such coupling characteristics for a ferrite-cored antenna to a straight wire. The method is introduced in this paper along with the test results.

    • Nutritional Sciences
      1. Foods consumed by US adults from cafeterias and vending machines: NHANES 2005 to 2014external icon
        Onufrak SJ, Zaganjor H, Moore LV, Hamner HC, Kimmons JE, Maynard LM, Harris D.
        Am J Health Promot. 2019 Jan 2:890117118821846.

        PURPOSE:: As part of wellness efforts, employers may seek to improve the nutritional quality of foods offered and consumed in cafeterias and vending machines. However, little is known about who consumes food from these venues and the types and dietary quality of the foods consumed. DESIGN:: Cross-sectional. SETTING:: Nonschool cafeterias and vending machines. PARTICIPANTS:: US adults >/=20 years old. MEASURES:: Prevalence of consuming foods, most common foods eaten, leading calorie sources, 2010 Healthy Eating Index. ANALYSIS:: Using 24-hour dietary recall data from NHANES 2005-2014 (N = 25,549 adults), we estimated the prevalence of consuming foods, assessed the most commonly consumed foods, and calculated dietary quality of foods. RESULTS:: On a given day, 3.1% of adults consumed foods from cafeterias and 3.9% from vending machines. Consumers averaged 692 kcal from cafeterias and 264 kcal from vending machines. Cafeteria consumers had higher income and education, while vending consumers were more likely to be male and younger adults. Common cafeteria foods included vegetables and fruits, but cafeteria foods were generally high in sodium and low in whole grains. Sugar-sweetened beverages and candies accounted for approximately half of all vending calories. CONCLUSION:: Foods chosen from cafeterias and vending machines do not align well with the Dietary Guidelines for Americans. Improving the dietary quality of foods consumed from these venues could impact millions of adults.

    • Occupational Safety and Health
      1. Use of population data for assessing trends in work-related asthma mortalityexternal icon
        Mazurek JM, Henneberger PK.
        Curr Opin Allergy Clin Immunol. 2018 Dec 27.

        PURPOSE OF REVIEW: Work-related asthma has been associated with poorer asthma control and frequent unscheduled healthcare visits, and can be fatal. Case reports of work-related asthma deaths are rare, but can initiate efforts to prevent additional cases. We reviewed relevant literature and data sources to evaluate whether analyzing mortality data at the population level can help identify potential sources of exposures that contribute to work-related asthma. RECENT FINDINGS: A limited number of population-based studies have addressed work-related asthma mortality. Data on asthma mortality are derived from death certificates using the International Classification of Diseases (ICD) as a standard for coding cause. However, no discrete code for work-related asthma is available. Analysis of asthma mortality relative to industries and occupations appears to identify high-risk jobs that were not identified by analyzing asthma morbidity data. SUMMARY: Beyond recognized work-related asthma deaths, it is possible that occupational exposures have contributed to other asthma deaths that have gone unnoticed and could potentially be identified by the analysis of mortality data at the population level. Such analyses in the United States appear to assist in recognizing high-risk occupations and industries. Additional analyses would be possible if a work-related asthma ICD code were available.

      2. Suicide among veterinarians in the United States from 1979 through 2015external icon
        Tomasi SE, Fechter-Leggett ED, Edwards NT, Reddish AD, Crosby AE, Nett RJ.
        J Am Vet Med Assoc. 2019 ;254(1):104-112.

        OBJECTIVE To assess proportionate mortality ratios (PMRs) for suicide among male and female US veterinarians from 1979 through 2015. DESIGN PMR study. SAMPLE Death records for 11,620 veterinarians. PROCEDURES Information for veterinarians who died during 1979 through 2015 was obtained from AVMA obituary and life insurance databases and submitted to a centralized database of US death records to obtain underlying causes of death. Decedent data that met records-matching criteria were imported into a software program for calculation of PMRs for suicide stratified by sex and indirectly standardized for age, race, and 5-year calendar period with 95% confidence intervals. RESULTS 398 deaths resulted from suicide; 326 (82%) decedents were male, 72 (18%) were female, and most (298 [75%]) were </= 65 years of age. The PMRs for suicide for all veterinarian decedents (2.1 and 3.5 for males and females, respectively), those in clinical positions (2.2 and 3.4 for males and females, respectively), and those in nonclinical positions (1.8 and 5.0 for males and females, respectively) were significantly higher than for the general US population. Among female veterinarians, the percentage of deaths by suicide was stable from 2000 until the end of the study, but the number of such deaths subjectively increased with each 5-year period. CONCLUSIONS AND CLINICAL RELEVANCE Results of the study indicated that PMRs for suicide of female as well as male veterinarians were higher than for the general population. These data may help to inform stakeholders in the creation and implementation of suicide prevention strategies designed for veterinarians.

    • Parasitic Diseases
      1. Barriers to malaria prevention in US-based travelers visiting friends and relatives abroad: A qualitative study of West African immigrant travelersexternal icon
        Walz EJ, Volkman HR, Adedimeji AA, Abella J, Scott LA, Angelo KM, Gaines J, Coyle CM, Dunlop SJ, Wilson D, Biah AP, Wanduragala D, Stauffer WM.
        J Travel Med. 2019 Jan 2.

        BACKGROUND: Over half of malaria cases reported in the United States occur among people traveling to visit friends and relatives (VFRs), predominantly to West Africa. Few studies have queried VFR travelers directly on barriers to seeking pre-travel care. We aim to describe the knowledge, attitudes, and practices of VFRs traveling to malaria-endemic countries from the United States. With these findings, we aim to design interventions to encourage preventive behaviors before and during travel. METHODS: Sixteen focus groups were held in two US metropolitan areas with West African immigrant populations: Minneapolis-St. Paul, MN, and New York City, NY. A total of 172 people from 13 African countries participated. Focus group discussions were audio-recorded and transcribed, and modified grounded theory analysis was performed. Participants reviewed themes to verify intent of statements. RESULTS: Participants described the high cost of provider visits and chemoprophylaxis, challenges in advocating for themselves in healthcare settings, and concerns about offending or inconveniencing hosts as barriers to malaria prevention. Cultural barriers to accessing pre-travel care included competing priorities when trip planning, such as purchasing gifts for family, travel logistics, and safety concerns. When participants sought pre-travel care, most consulted their primary care provider. Participants expressed low confidence in US providers’ knowledge and training about malaria and other tropical diseases. CONCLUSION: Barriers to pre-travel care for VFR travelers are multifaceted and extend beyond their perception of disease risk. Only some barriers previously reported in anecdotal and qualitative literature were supported in our findings. Future interventions should be aimed at barriers identified by individual communities and involve primary and travel specialist healthcare providers. Additional work is needed to address systems-level barriers to accessing care and establishing community-based programs to support West African VFR traveler health.

    • Physical Activity
      1. Sampling methodology and reliability of a representative walkability auditpdf iconexternal icon
        Ussery EN, Omura JD, Paul P, Orr J, Spoon C, Geremia C, Carlson SA.
        J Transp Health. 2019 ;12:75-85.

        Background: Physical inactivity is a public health concern in the US Virgin Islands (USVI). A contributing factor may be a lack of pedestrian infrastructure and other environmental supports for walking. In this manuscript, we describe the methods used to conduct a walkability audit of environmental features related to physical activity in the USVI. Methods: In 2016, volunteer auditors conducted the audit using a modified version of the Microscale Audit of Pedestrian Streetscapes tool. A two-stage sampling method was developed using publicly available census data to select a sample of estates (n=46) and street segments (n=1550; 99.2 km) across the USVI. A subset of segments was audited by two independent auditors, and inter-rater reliability was assessed using Cohen’s kappa and percent agreement. Results: Audits were completed on 1114 segments (94.6 km), and estimates were weighted to represent accessible public street length in the study area (1155.9 km). Most items on the audit tool (62.7%) demonstrated good to excellent reliability. We found that it was feasible to conduct a reliable audit of environmental features related to physical activity across a large sample of streets in the USVI. Conclusions: These methods can be replicated in other settings to collect comprehensive data that can be used to guide strategies to improve the walkability of communities.

    • Reproductive Health
      1. US state-level infertility insurance mandates and health plan expenditures on infertility treatmentsexternal icon
        Boulet SL, Kawwass J, Session D, Jamieson DJ, Kissin DM, Grosse SD.
        Matern Child Health J. 2019 Jan 2.

        Objectives We aimed to examine the extent to which health plan expenditures for infertility services differed by whether women resided in states with mandates requiring coverage of such services and by whether coverage was provided through a self-insured plan subject to state mandates versus fully-insured health plans subject only to federal regulation. Methods This retrospective cohort study used individual-level, de-identified health insurance claims data. We included women 19-45 years of age who were continuously enrolled during 2011 and classified them into three mutually exclusive groups based on highest treatment intensity: in vitro fertilization (IVF), intrauterine insemination (IUI), or ovulation-inducing (OI) medications. Using generalized linear models, we estimated adjusted annual mean, aggregate, and per member per month (PMPM) expenditures among women in states with an infertility insurance mandate and those in states without a mandate, stratified by enrollment in a fully-insured or self-insured health plan. Results Of the 6,006,017 women continuously enrolled during 2011, 9199 (0.15%) had claims for IVF, 10,112 (0.17%) had claims for IUI, and 23,739 (0.40%) had claims for OI medications. Among women enrolled in fully insured plans, PMPM expenditures for infertility treatment were 3.1 times higher for those living in states with a mandate compared with states without a mandate. Among women enrolled in self-insured plans, PMPM infertility treatment expenditures were 1.2 times higher for mandate versus non-mandate states. Conclusions for Practice Recorded infertility treatment expenditures were higher in states with insurance reimbursement mandates versus those without mandates, with most of the difference in expenditures incurred by fully-insured plans.

    • Social and Behavioral Sciences
      1. This study used self-administered survey data from seven high schools in Florida with a majority Black and/or Hispanic sample to examine transgender students’ perceptions and experiences related to school climate in comparison to cisgender students. Using propensity score matching, a matched analytic sample was created of transgender and cisgender students (n = 542, including 186 transgender youth). Adjusted weighted logistic regression models indicated that transgender students were significantly more likely to report ever being bullied at school, being bullied in the past 3 months, and not going to school >/=3 days during the past 30 days. Transgender students were significantly less likely to report feeling safe at school and having positive perceptions of all five school connectedness items compared to cisgender students. Recent bullying experiences moderated the association between transgender status and past month absences. Findings can inform potential roles for school nurses in improving school climate for transgender youth.

      2. Policies have potential to help families obtain behavioral healthcare for their children, but little is known about evidence for specific policy approaches. We reviewed evaluations of select policy levers to promote accessibility, affordability, acceptability, availability, or utilization of children’s mental and behavioral health services. Twenty articles met inclusion criteria. Location-based policy levers (school-based services and integrated care models) were associated with higher utilization and acceptability, with mixed evidence on accessibility. Studies of insurance-based levers (mental health parity and public insurance) provided some evidence for affordability outcomes. We found no eligible studies of workforce development or telehealth policy levers, or of availability outcomes.

    • Substance Use and Abuse
      1. Wound botulism outbreak among persons who use black tar heroin – San Diego County, California, 2017-2018external icon
        Peak CM, Rosen H, Kamali A, Poe A, Shahkarami M, Kimura AC, Jain S, McDonald E.
        MMWR Morb Mortal Wkly Rep. 2019 Jan 4;67(5152):1415-1418.

        During September 29-October 6, 2017, the County of San Diego Public Health Services (COSD) was notified of two patients with suspected wound botulism and a history of using black tar heroin. On October 9, COSD, which had reported an average of one wound botulism case per year during 2001-2016, sent a health alert through the California Health Alert Network, notifying Southern California providers of these two patients, including their signs and symptoms and black tar heroin exposure. In collaboration with the California Department of Public Health, COSD conducted an investigation to identify additional cases, determine risk factors for illness, estimate cost of medical care, and develop recommendations to prevent further illness. By April 18, 2018, nine (eight confirmed and one probable) patients with wound botulism were identified, all of whom were hospitalized; one of the nine died. All nine were persons who inject drugs; seven specifically reported using black tar heroin and six practiced subcutaneous injection known as skin popping. Clinically compatible signs and symptoms included muscle weakness, difficulty swallowing, blurred vision, drooping eyelids, slurred speech, difficulty breathing, loss of facial expression, or descending paralysis. All patients were treated with heptavalent botulism antitoxin (BAT). Wound botulism is likely underrecognized because of its rarity and the overlapping signs and symptoms with opioid intoxication, overdose, and other neurologic syndromes including Guillain-Barre syndrome, the Miller Fisher variant of Guillain-Barre syndrome, and myasthenia gravis. Prompt diagnosis, administration of BAT, and provision of supportive care can help stop the progression of paralysis and be lifesaving.

      2. Drug and opioid-involved overdose deaths – United States, 2013-2017external icon
        Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G.
        MMWR Morb Mortal Wkly Rep. 2018 Jan 4;67(5152):1419-1427.

        The 63,632 drug overdose deaths in the United States in 2016 represented a 21.4% increase from 2015; two thirds of these deaths involved an opioid (1). From 2015 to 2016, drug overdose deaths increased in all drug categories examined; the largest increase occurred among deaths involving synthetic opioids other than methadone (synthetic opioids), which includes illicitly manufactured fentanyl (IMF) (1). Since 2013, driven largely by IMF, including fentanyl analogs (2-4), the current wave of the opioid overdose epidemic has been marked by increases in deaths involving synthetic opioids. IMF has contributed to increases in overdose deaths, with geographic differences reported (1). CDC examined state-level changes in death rates involving all drug overdoses in 50 states and the District of Columbia (DC) and those involving synthetic opioids in 20 states, during 2013-2017. In addition, changes in death rates from 2016 to 2017 involving all opioids and opioid subcategories,* were examined by demographics, county urbanization levels, and by 34 states and DC. Among 70,237 drug overdose deaths in 2017, 47,600 (67.8%) involved an opioid.(dagger) From 2013 to 2017, drug overdose death rates increased in 35 of 50 states and DC, and significant increases in death rates involving synthetic opioids occurred in 15 of 20 states, likely driven by IMF (2,3). From 2016 to 2017, overdose deaths involving all opioids and synthetic opioids increased, but deaths involving prescription opioids and heroin remained stable. The opioid overdose epidemic continues to worsen and evolve because of the continuing increase in deaths involving synthetic opioids. Provisional data from 2018 indicate potential improvements in some drug overdose indicators;( section sign) however, analysis of final data from 2018 is necessary for confirmation. More timely and comprehensive surveillance data are essential to inform efforts to prevent and respond to opioid overdoses; intensified prevention and response measures are urgently needed to curb deaths involving prescription and illicit opioids, specifically IMF.

    • Zoonotic and Vectorborne Diseases
      1. Human rabies – Virginia, 2017external icon
        Murphy J, Sifri CD, Pruitt R, Hornberger M, Bonds D, Blanton J, Ellison J, Cagnina RE, Enfield KB, Shiferaw M, Gigante C, Condori E, Gruszynski K, Wallace RM.
        MMWR Morb Mortal Wkly Rep. 2019 Jan 4;67(5152):1410-1414.

        On May 9, 2017, the Virginia Department of Health was notified regarding a patient with suspected rabies. The patient had sustained a dog bite 6 weeks before symptom onset while traveling in India. On May 11, CDC confirmed that the patient was infected with a rabies virus that circulates in dogs in India. Despite aggressive treatment, the patient died, becoming the ninth person exposed to rabies abroad who has died from rabies in the United States since 2008. A total of 250 health care workers were assessed for exposure to the patient, 72 (29%) of whom were advised to initiate postexposure prophylaxis (PEP). The total pharmaceutical cost for PEP (rabies immunoglobulin and rabies vaccine) was approximately $235,000. International travelers should consider a pretravel consultation with travel health specialists; rabies preexposure prophylaxis is warranted for travelers who will be in rabies endemic countries for long durations, in remote areas, or who plan activities that might put them at risk for a rabies exposures.

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CDC Science Clips Production Staff

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

Page last reviewed: January 31, 2019