Volume 11, Issue 30 July 30, 2019

CDC Science Clips: Volume 11, Issue 30, July 30, 2019

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

  1. Top Articles of the Week

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

    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions
      • Background Because family history is a known risk factor for heart disease, it is important to characterize its public health impact in terms of population prevalence of family history of heart disease, the burden of heart disease attributable to family history, and whether family history interacts with modifiable risk factors for heart disease. Methods and Results We used population data from NHANES (the National Health and Nutrition Examination Survey [2007-2014]) to measure the association of self-reported family history of premature heart disease ( FHPHD ) with cardiovascular disease (n=19 253) and to examine the association between cardiovascular health metrics and FHPHD (n=16 248). Using logistic regression and multivariable adjustment, family history odds ratios were 5.91 (95% CI , 3.34-10.44) for ages 20 to 39, 3.02 (95% CI, 2.41-3.79) for ages 40 to 59, and 1.87 (95% CI , 1.54-2.28) for age >/=60 for cardiovascular disease. The prevalence of cardiovascular disease for the population with a FHPHD (15.72%; 95% CI , 13.81-17.64) was more than double the prevalence of cardiovascular disease for those without a family history (6.25%; 95% CI , 5.82-6.69). Compared with participants with optimum cardiovascular health, the prevalence ratio for FHPHD was 1.98 (95% CI , 1.40-2.79) for those with inadequate cardiovascular health. Conclusions Millions of people who are at high risk of having cardiovascular disease could be identified using FHPHD . FHPHD can become an important component of public health campaigns that address modifiable risk factors that plan to reduce the overall risk of heart disease.

    • Communicable Diseases
      • Influenza-associated pneumonia hospitalizations in Uganda, 2013-2016external icon
        Emukule GO, Namagambo B, Owor N, Bakamutumaho B, Kayiwa JT, Namulondo J, Byaruhanga T, Tempia S, Chaves SS, Lutwama JJ.
        PLoS One. 2019 ;14(7):e0219012.
        BACKGROUND: Influenza is an important contributor to acute respiratory illness, including pneumonia, and results in substantial morbidity and mortality globally. Understanding the local burden of influenza-associated severe disease can inform decisions on allocation of resources toward influenza control programs. Currently, there is no national influenza vaccination program in Uganda. METHODS: In this study, we used data on pneumonia hospitalizations that were collected and reported through the Health Management Information System (HMIS) of the Ministry of Health, Uganda, and the laboratory-confirmed influenza positivity data from severe acute respiratory illness (SARI) surveillance in three districts (Wakiso, Mbarara, and Tororo) to estimate the age-specific incidence of influenza-associated pneumonia hospitalizations from January 2013 through December 2016. RESULTS: The overall estimated mean annual rate of pneumonia hospitalizations in the three districts was 371 (95% confidence interval [CI] 323-434) per 100,000 persons, and was highest among children aged <5 years (1,524 [95% CI 1,286-1,849]) compared to persons aged >/=5 years (123 [95% CI 105-144]) per 100,000 persons. The estimated mean annual rate of influenza-associated pneumonia hospitalization was 34 (95% CI 23-48) per 100,000 persons (116 [95% CI 78-165] and 16 [95% CI 6-28] per 100,000 persons among children aged <5 years and those >/=5 years, respectively). Among children aged <5 years, the rate of hospitalized influenza-associated pneumonia was highest among those who were <2 years old (178 [95% CI 109-265] per 100,000 persons). Over the period of analysis, the estimated mean annual number of hospitalized influenza-associated pneumonia cases in the three districts ranged between 672 and 1,436, of which over 70% represent children aged <5 years. CONCLUSIONS: The burden of influenza-associated pneumonia hospitalizations was substantial in Uganda, and was highest among young children aged <5 years. Influenza vaccination may be considered, especially for very young children.

      • HIV infection among women in the United States: 2000-2017external icon
        May S, Murray A, Sutton MY.
        AIDS Care. 2019 Jul 17:1-8.
        Although HIV diagnoses among women have declined in recent years in the United States (U.S.), women accounted for 19% of new HIV diagnoses in 2016. In addition, women comprise 24% of the 973,846 persons living with HIV infection in the U.S. However, HIV prevention interventions targeting women are limited. We performed a review on HIV infection in women to increase awareness, improve overall care, and inform intervention development. A systematic literature review was conducted using literature published in PubMed, PsychINFO (EBSCO), and Scopus from July 2000 and June 2017. We included studies that: (1) were conducted in the U.S., (2) enrolled at least 50 HIV-positive women, and (3) utilized a case-control, cohort, or surveillance study design. Of 7497 articles, 48 articles met inclusion criteria. HIV diagnoses among women declined 32% between 2001 and 2016. In 2016, 61% of diagnoses in women were among African American women, and 56% were in the South. Women reported barriers to HIV care largely due to psychosocial challenges and social/structural determinants of health (SDH) barriers. Though new diagnoses among women have declined, racial and regional disparities remain. HIV prevention and research efforts with women are vital to inform interventions and reduce disparities.

    • Maternal and Child Health
      • Children with Tourette Syndrome in the United States: Parent-reported diagnosis, co-occurring disorders, severity, and influence of activities on ticsexternal icon
        Wolicki SB, Bitsko RH, Danielson ML, Holbrook JR, Zablotsky B, Walkup JT, Woods DW, Mink JW.
        J Dev Behav Pediatr. 2019 Jul 10.
        OBJECTIVE: Describe the diagnostic process for Tourette syndrome (TS) based on parent report, as well as TS severity and associated impairment; the influence of common daily activities on tics; and the presence of co-occurring mental, behavioral, and developmental disorders among children in the United States. METHODS: Parent-report data from the 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome on 115 children ever diagnosed with TS were analyzed. Descriptive, unweighted analyses included frequencies and percentages, and means and standard deviations. Fisher’s exact test and t-tests were calculated to determine statistically significant differences. RESULTS: The mean age that tics were first noticed was 6.3 years, and, on average, TS was diagnosed at 7.7 years. The time from initially noticing tics to TS diagnosis averaged 1.7 years. The mean age when TS symptoms were most severe was 9.3 years. Tic severity was associated with impaired child functioning but not tic noticeability. Almost 70% of parents reported that fatigue and major transitions made their child’s tics worse. Children with ever-diagnosed TS had a mean of 3.2 ever-diagnosed co-occurring mental, behavioral, or developmental disorders; a quarter (26.9%) had 5 or more co-occurring disorders. DISCUSSION: In this sample of children with TS, the time to diagnosis averaged less than 2 years from when tics were initially noticed. More severe TS was associated with greater functional impairment, and co-occurring disorders were common among children with TS. This study provides insight into the current experiences of children with TS in the United States and their families.

    • Public Health Law
      • Public health surveillance: Electronic reporting as a point of referenceexternal icon
        Black J, Hulkower R, Suarez W, Patel S, Elliott B.
        J Law Med Ethics. 2019 Jun;47(2_suppl):19-22.
        Federal, state, and local laws shape the use of health information for public health purposes, such as the mandated collection of data through electronic disease reporting systems. Health professionals can leverage these data to better anticipate and plan for the needs of communities, which is seen in the use of electronic case reporting.

      • Healthy People: The role of law and policy in the nation’s public health agendaexternal icon
        McGowan AK, Kramer KT, Teitelbaum JB.
        J Law Med Ethics. 2019 Jun;47(2_suppl):63-67.
        Each decade since 1979, the Healthy People initiative establishes the national prevention agenda and provides the foundation for disease prevention and health promotion policies and programs. Law and policy have been included in Healthy People objectives from the start, but not integrated into the overall initiative as well as possible to potentially leverage change to meet Healthy People targets and goals. This article provides background on the Healthy People initiative and its use among various stakeholder groups, describes the work of a project aiming to better integrate law and policy into this initiative, and discusses the development of Healthy People 2030 – the next iteration of health goals for the nation. Lessons from the preliminary stages of developing Healthy People by the HHS Secretary’s Advisory Committee (Committee) on National Health Promotion and Disease Prevention Objectives for 2030 and a Federal Interagency Workgroup will be included. Efforts by the Committee focused on the role of law and policy as determinants of health and valuable resources around health equity are also shared. Finally, the article discusses ways that law and policy can potentially be tools to help meet Healthy People targets and to attain national health goals.

      • Emergency declarations for public health issues: Expanding our definition of emergencyexternal icon
        Sunshine G, Barrera N, Corcoran AJ, Penn M.
        J Law Med Ethics. 2019 Jun;47(2_suppl):95-99.
        Emergency declarations are a vital legal authority that can activate funds, personnel, and material and change the legal landscape to aid in the response to a public health threat. Traditionally, declarations have been used against immediate and unforeseen threats such as hurricanes, tornadoes, wildfires, and pandemic influenza. Recently, however, states have used emergency declarations to address public health issues that have existed in communities for months and years and have risk factors such as poverty and substance misuse. Leaders in these states have chosen to use emergency powers that are normally reserved for sudden catastrophes to address these enduring public health issues. This article will explore emergency declarations as a legal mechanism for response; describe recent declarations to address hepatitis A and the opioid overdose epidemic; and seek to answer the question of whether it is appropriate to use emergency powers to address public health issues that are not traditionally the basis for an emergency declaration.

    • Substance Use and Abuse
      • Heroin and healthcare: patient characteristics and healthcare prior to overdoseexternal icon
        Bohm MK, Bridwell L, Zibbell JE, Zhang K.
        Am J Manag Care. 2019 Jul;25(7):341-347.
        OBJECTIVES: To estimate heroin overdose trends among insured individuals and characterize patients and healthcare utilization preceding overdose to inform scale-up of effective prevention and treatment. STUDY DESIGN: Retrospective descriptive analysis. METHODS: We analyzed 2010 to 2014 IBM MarketScan Databases and calculated annual heroin overdose rates. For a subset of patients, we describe their comorbidities, where they accessed health services, and select prescription histories prior to their first heroin overdose. RESULTS: Heroin overdose rates were much lower, but increased faster, among the commercially insured compared with Medicaid enrollees from 2010 to 2014 (270.0% vs 94.3%). By 2012, rates among the commercially insured aged 15 to 24 years reached the overall rates in the Medicaid population. All patients had healthcare encounters in the 6 months prior to their first heroin overdose; two-thirds of commercially insured patients had outpatient visits, whereas two-thirds of Medicaid patients had emergency department visits. One month prior to overdose, 24.5% of Medicaid and 8.6% of commercially insured patients had opioid prescriptions. Fewer Medicaid patients had buprenorphine prescriptions (17.8% vs 27.3%) despite similar rates of known substance-related disorders. A higher proportion of Medicaid patients had non-substance-related comorbidities. CONCLUSIONS: Heroin overdose rates were persistently higher among the Medicaid population than the commercially insured, with the exception of those aged 15 to 24 years. Our findings on healthcare utilization, comorbidities, and where individuals access services could inform interventions at the point of care prior to a first heroin overdose. Outpatient settings are of particular importance for the growing cohort of young, commercially insured patients with opioid use disorders.

      • Standardization of state definitions for neonatal abstinence syndrome surveillance and the opioid crisisexternal icon
        Chiang KV, Okoroh EM, Kasehagen LJ, Garcia-Saavedra LF, Ko JY.
        Am J Public Health. 2019 Jul 18:e1-e5.
        Rates of neonatal abstinence syndrome (NAS) have increased fivefold in the past decade. To address this expanding and complex issue, state public health agencies have addressed the opioid crisis affecting newborns in diverse ways, leading to a variety of methods to quantify the burden of NAS. In an effort to understand this variability, we summarized clinical case and surveillance definitions used across jurisdictions in the United States. We confirmed that the rapid progression of the nation’s opioid crisis resulted in heterogeneous processes for identifying NAS. Current clinical case definitions use different combinations of clinician-observed signs of withdrawal and evidence of perinatal substance exposure. Similarly, there is discordance in diagnosis codes used in surveillance definitions. This variability makes it difficult to produce comparable estimates across jurisdictions, which are needed to effectively guide public health strategies and interventions. Although standardization is complicated, consistent NAS definitions would increase comparability of NAS estimates across the nation and would better guide prevention and treatment efforts for women and their infants. (Am J Public Health. Published online ahead of print July 18, 2019: e1-e5. doi:10.2105/AJPH.2019.305170).

    • Zoonotic and Vectorborne Diseases
      • Characterisation of infectious Ebola virus from the ongoing outbreak to guide response activities in the Democratic Republic of the Congo: a phylogenetic and in vitro analysisexternal icon
        McMullan LK, Flint M, Chakrabarti A, Guerrero L, Lo MK, Porter D, Nichol ST, Spiropoulou CF, Albarino C.
        Lancet Infect Dis. 2019 Jul 9.
        BACKGROUND: The ongoing Ebola virus outbreak in the Ituri and North Kivu Provinces of the Democratic Republic of the Congo, which began in July, 2018, is the second largest ever recorded. Despite civil unrest, outbreak control measures and the administration of experimental therapies and a vaccine have been initiated. The aim of this study was to test the efficacy of candidate therapies and diagnostic tests with the outbreak strain Ituri Ebola virus. Lacking a virus isolate from this outbreak, a recombinant Ituri Ebola virus was compared with a similarly engineered Makona virus from the 2013-16 outbreak. METHODS: Using Ebola virus sequences provided by organisations in DR Congo and a reverse genetics system, we generated an authentic Ebola virus from the ongoing outbreak in Ituri and North Kivu provinces. To relate this virus to other Ebola viruses in DR Congo, we did a phylogenetic analysis of representative complete Ebola virus genome sequences from previous outbreaks. We evaluated experimental therapies being tested in clinical trials in DR Congo, including remdesivir and ZMapp monoclonal antibodies, for their ability to inhibit the growth of infectious Ituri Ebola virus in cell culture. We also tested diagnostic assays for detection of the Ituri Ebola virus sequence. FINDINGS: The phylogenetic analysis of whole-genome sequences from each Ebola virus outbreak suggests there are at least two Ebola virus strains in DR Congo, which have independently crossed into the human population. The Ituri Ebola strain initially grew slower than the Makona strain, yet reached similar mean yields of 3 x 10(7) 50% tissue culture infectious dose by 72 h infection in Huh-7 cells. Ituri Ebola virus was similar to Makona in its susceptibility to inhibition by remdesivir and to neutralisation by monoclonal antibodies from ZMapp and other monoclonal antibodies. Remdesivir inhibited Ituri Ebola virus at a 50% effective concentration (EC50) of 12nM (with a selectivity index of 303) and Makona Ebola virus at 13nM (with a selectivity index of 279). The Zmapp monoclonal antibodies 2G4 and 4G7 neutralised Ituri Ebola virus with a mean EC50 of 0.24 mug/mL and 0.48 mug/mL, and Makona Ebola virus with a mean EC50 of 0.45 mug/mL and 0.2 mug/mL. The Xpert Ebola and US Centers for Disease Control and Prevention real-time RT-qPCR diagnostic assays detected Ituri and Makona Ebola virus sequences with similar sensitivities and efficiencies, despite primer site binding mismatches in the Ituri Ebola virus. INTERPRETATION: Our findings provide a rationale for the continued testing of investigational therapies, confirm the effectiveness of the diagnostic assays used in the region, and establish a paradigm for the use of reverse genetics to inform response activities in an outbreak. FUNDING: US Centers for Disease Control and Prevention.

  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. Associations of perfluoroalkyl and polyfluoroalkyl substances with incident diabetes and microvascular diseaseexternal icon
        Cardenas A, Hivert MF, Gold DR, Hauser R, Kleinman KP, Lin PD, Fleisch AF, Calafat AM, Ye X, Webster TF, Horton ES, Oken E.
        Diabetes Care. 2019 Jul 11.
        OBJECTIVE: Perfluoroalkyl and polyfluoroalkyl substances (PFASs) are suspected endocrine disruptors widely detected across populations. We examine the extent to which PFASs are associated with diabetes incidence and microvascular disease. Secondarily, we tested whether a lifestyle intervention modifies associations and decreases concentrations. RESEARCH DESIGN AND METHODS: We analyzed data from a prospective cohort of 957 participants from the Diabetes Prevention Program (DPP) trial and Outcomes Study (DPPOS). At baseline, participants were randomized to an intensive lifestyle intervention of diet, physical activity, and behavior modification or a placebo medication. We quantified plasma concentrations of six PFASs at baseline and 2 years after randomization. Participants were monitored for approximately 15 years, repeatedly tested for diabetes, and evaluated for microvascular disease at the end of the follow-up. RESULTS: A doubling in baseline Sb-PFOA concentration was associated with a 14% increase in diabetes risk for the placebo (hazard ratio [HR] 1.14, 95% CI 1.04, 1.25) but not in the lifestyle intervention group (HR 1.01, 95% CI 0.92, 1.11, P interaction = 0.11). Mean change in plasma baseline branched perfluorooctanoic acid concentration was greater for the placebo (0.96 ng/mL; 95% CI 0.71, 1.22) compared with the lifestyle intervention group (0.31 ng/mL; 95% CI 0.14, 0.48) 2 years after randomization. Each doubling in N-ethyl-perfluorooctane sulfonamido acetic acid was associated with 17% greater odds of prevalent microvascular disease (OR 1.17, 95% CI 1.05, 1.31), and a similar association was observed for perfluorodimethylhexane sulfonic acid (OR 1.18, 95% CI 1.04, 1.35), regardless of treatment. CONCLUSIONS: Some plasma PFASs were associated with diabetes and microvascular disease. Our results suggest that exercise and diet may attenuate the diabetogenic association of PFASs.

      2. Geographic co-occurrence of mesothelioma and ovarian cancer incidenceexternal icon
        Henley SJ, Peipins LA, Rim SH, Larson TC, Miller JW.
        J Womens Health (Larchmt). 2019 Jul 16.
        Background: Asbestos is an established cause of several cancers, including mesothelioma and ovarian cancer. Incidence of mesothelioma, the sentinel asbestos-associated cancer, varies by state, likely reflecting different levels of asbestos exposure. We hypothesized that states with high mesothelioma incidence may also have high ovarian cancer incidence. Materials and Methods: Using data from the Centers for Disease Control and Prevention National Program for Cancer Registries and the National Cancer Institute Surveillance, Epidemiology, and End Results Program, we examined the geographic co-occurrence of mesothelioma and ovarian cancer incidence rates by U.S. state for 2003-2015. Results: By state, mesothelioma incidence ranged from 0.5 to 1.3 cases per 100,000 persons and ovarian cancer incidence ranged from 9 to 12 cases per 100,000 females. When states were grouped by quartile of mesothelioma incidence, the average ovarian cancer incidence rate was 10% higher in states with the highest mesothelioma incidence than in states with the lowest mesothelioma incidence. Ovarian cancer incidence tended to be higher in states with high mesothelioma incidence (Pearson correlation r = 0.54; p < 0.0001). Conclusions: Data from state cancer registries show ovarian cancer incidence was positively correlated with mesothelioma incidence, suggesting asbestos may be a common exposure. The potential for asbestos exposure has declined since the 1970s because fewer products contain asbestos; however, some products, materials, and buildings may still release asbestos and thousands of workers may be exposed. Ensuring that people are protected from exposure to asbestos in their workplaces, homes, schools, and communities may reduce the risk of several cancers.

      3. Correlates of colorectal cancer screening rates in primary care clinics serving low income, medically underserved populationsexternal icon
        Sharma KP, DeGroff A, Scott L, Shrestha S, Melillo S, Sabatino SA.
        Prev Med. 2019 Jul 15:105774.
        INTRODUCTION: Screening for colorectal cancer (CRC) is effective in reducing CRC burden. Primary care clinics have an important role in increasing screening. We investigated associations between clinic-level CRC screening rates of the clinics serving low income, medically underserved population, and clinic-level screening interventions, clinic characteristics and community contexts. METHODS: Using data (2015-16) from the Centers for Disease Control and Prevention’s (CDC) Colorectal Cancer Control Program, we linked clinic-level data with county-level contextual data from external sources. Analysis variables included clinic-level CRC screening rates, four different evidence-based interventions (EBIs) intended to increase screening, clinic characteristics, and clinic contexts. In the analysis (2018), we used weighted ordinary least square multiple regression analyses to associate EBIs and other covariates with clinic-level screening rates. RESULTS: Clinics (N=581) had an average screening rate of 36.3% (weighted. Client reminders had the highest association (5.6 percentage points) with screening rates followed by reducing structural barriers (4.9 percentage points), provider assessment and feedback (3.2 percentage points), and provider reminders (<1 percentage point). Increases in the number of EBIs was associated with steady increases in the screening rate (5.4 percentage points greater for one EBI). Screening rates were 16.4 percentage points higher in clinics with 4 EBIs vs. no EBI. Clinic characteristics, contexts (e.g. physician density), and context-EBI interactions were also associated with clinic screening rates. CONCLUSIONS: These results may help clinics, especially those serving low income, medically underserved populations, select individual or combinations of EBIs suitable to their contexts while considering costs.

      4. Socio-economic, demographic, and clinical correlates of poor glycaemic control within insulin regimens among children with Type 1 diabetes: the SEARCH for Diabetes in Youth Studyexternal icon
        Snyder LL, Stafford JM, Dabelea D, Divers J, Imperatore G, Law J, Lawrence JM, Pihoker C, Mayer-Davis EJ.
        Diabet Med. 2019 Aug;36(8):1028-1036.
        AIM: To examine the distribution and association of sociodemographic, adherence, and barriers-to-care factors in relation to glycaemic control within insulin regimens in US children with Type 1 diabetes in the SEARCH for Diabetes in Youth Study. METHODS: Self- or parent-reported data from 1095 children with Type 1 diabetes aged 10-17 years were collected on insulin regimen, sociodemographics, diabetes self-management, diabetes-related family conflict and barriers to care. Multivariable logistic regression analysis identified poor glycaemic control correlates within each insulin regimen. RESULTS: Participants included 694 children on insulin pump therapy, 188 receiving basal-bolus injections, and 213 on a mixed insulin regimen. Of these, 28.5%, 45.2% and 51.2%, respectively, had poor glycaemic control [HbA1c >/= 80 mmol/mol (9.5%)]. Family conflict between parent and child regarding diabetes management was the only factor significantly associated with poor glycaemic control in all insulin regimens (insulin pump, P</= 0.0001; basal-bolus injections, P=0.0002; mixed insulin regimen, P=0.0103). For children on insulin pump, poor control was significantly associated with non-white race (P=0.0008), living in multiple households (P=0.0331), having Medicaid insurance (P=0.0090), and decreased insulin adherence (P<0.0001). For children on a mixed insulin regimen, living in multiple households (P=0.0256) and not spending enough time with healthcare provider (P=0.0058) correlated with poor control. CONCLUSIONS: A high percentage of US children with Type 1 diabetes had poor glycaemic control, especially those not using an insulin pump. Early identification of children with risk factors associated with poor glycaemic control within insulin regimens and addressing diabetes-related family conflict may allow interventions to improve diabetes management.

    • Communicable Diseases
      1. Sexual risk behaviors and STDs among persons who inject drugs: A national studyexternal icon
        Brookmeyer KA, Haderxhanaj LT, Hogben M, Leichliter J.
        Prev Med. 2019 Jul 15:105779.
        Opioid use and the rising case reports of STDs represent co-occurring epidemics; research indicates that persons who inject drugs (PWID) may be at increased risk for acquiring STDs. We use the National Survey of Family Growth (NSFG, 2011-2015) to examine the prevalence of risky sexual behaviors and STD diagnoses among PWID. We describe demographic characteristics, sexual behaviors, and self-reported STD diagnoses of sexually active women and men, separately, by whether they had ever engaged in injection-related behaviors (age 15-44; N=9006 women, N=7210 men). Results indicate that in 2011-15, 1.4% of women and 2.6% of men reported ever engaging in injection-related behaviors. Examining the full logistic regression models indicate that for women, sex with a PWID in the past 12months (AOR=5.8, 95% CI: 2.9, 11.7), exchanging money/drugs for sex in the past 12months (AOR=3.6, 95% CI: 1.2, 10.9), chlamydia and/or gonorrhea diagnosis in the past 12months (AOR=2.6, 95% CI: 1.2, 5.3), ever having a syphilis diagnosis (AOR=8.5, 95% CI: 3.1, 23.4), and ever having a herpes diagnosis (AOR=3.3, 95% CI: 1.0, 10.3) were associated with increased odds of engaging in injection-related behaviors. For men, sex with a PWID in the past 12months (AOR=10.9, 95% CI: 4.3, 27.7), ever being diagnosed with syphilis (AOR=5.8, 95% CI: 1.8, 18.0), and ever being diagnosed with herpes (AOR=2.7, 95% CI: 1.0, 7.1) were significantly associated with increased odds of engaging in injection-related behaviors. Future research may examine critical intervention points, including co-occurring factors in both STD acquisition and injection drug use.

      2. Self-reported risky sexual practices among adolescents and young adults in Botswanaexternal icon
        Chakalisa U, Wirth K, Bennett K, Kadima E, Manyake K, Gaolathe T, Bachanas P, Marukutira T, Lebelonyane R, Dryden-Peterson S, Butler L, Mmalane M, Makhema J, Roland ME, Pretorius-Holme M, Essex M, Lockman S, Powis KM.
        South Afr J HIV Med. 2019 ;20(1):899.
        Background: Adolescents and young adults account for more than one-third of incident Human Immunodeficiency Virus (HIV) infections globally. Understanding sexual practices of this high-risk group is critical in designing HIV targeted prevention programming. Objectives: To describe self-reported risky sexual practices of adolescents and young adults aged 16-24 years from 30 Botswana communities. Methods: Cross-sectional, self-reported age at sexual debut; number of sexual partners; condom and alcohol use during sex; intergenerational sex; and transactional sex data were collected. Modified Poisson estimating equations were used to obtain univariate and multivariate-adjusted prevalence ratios (PR) and 95% confidence intervals (CI) comparing engagement in different sexual practices according to gender, accounting for the clustered design of the study. Results: Among the 3380 participants, 2311 reported being sexually active with more females reporting being sexually active compared to males (65% vs. 35%, respectively; p < 0.0001). In univariate analyses, female participants were more likely to report inconsistent condom use (PR 1.61; 95% CI 1.44-1.80), intergenerational sex (PR 9.00; 95% CI 5.84-13.88) and transactional sex (PR 3.46; 95% CI 2.07-5.77) than males, yet less likely to report engaging in sex before age 15 years (PR 0.59; 95% CI: 0.41-0.85), using alcohol around the time of intercourse (PR: 0.59; 95% CI 0.45-0.76) or having >/= two partners in the last 12 months (PR 0.65; 95% CI 0.57-0.74). Conclusions: Self-reported risky sexual practices of adolescents and young adults in Botswana differed significantly between males and females. Gender-specific risky sexual practices highlight the importance of developing tailored HIV prevention programming.

      3. Outcomes of immunocompromised adults hospitalized with laboratory-confirmed influenza in the United States, 2011-2015external icon
        Collins JP, Campbell AP, Openo K, Farley MM, Cummings CN, Hill M, Schaffner W, Lindegren ML, Thomas A, Billing L, Bennett N, Spina N, Bargsten M, Lynfield R, Eckel S, Ryan P, Yousey-Hindes K, Herlihy R, Kirley PD, Garg S, Anderson EJ.
        Clin Infect Dis. 2019 Jul 11.
        BACKGROUND: Hospitalized immunocompromised (IC) adults with influenza may have worse outcomes than hospitalized non-immunocompromised adults. METHODS: We identified adults (>/=18 years) hospitalized with laboratory-confirmed influenza during 2011-2015 seasons through CDC’s Influenza Hospitalization Surveillance Network. IC patients had >/=1: HIV/AIDS, cancer, stem cell or organ transplantation, non-steroid immunosuppressive therapy, immunoglobulin deficiency, asplenia, or other rare conditions. We compared demographic and clinical characteristics of IC and non-IC adults using descriptive statistics and used multivariable logistic regression and Cox proportional hazards models to control for confounding by patient demographic characteristics, pre-existing medical conditions, influenza vaccination, and other factors. RESULTS: Among 35,348 adults, 3633 (10%) were IC; cancer (44%), non-steroid immunosuppressive therapy (44%), and HIV (17%) were most common. IC patients were more likely than non-IC patients to have received influenza vaccination (53% vs. 46%; p<0.001), and ~85% of both groups received antivirals. In multivariable analysis, IC adults had higher mortality (adjusted odds ratio (aOR) [95% confidence interval (CI)]: 1.46 [1.20-1.76]). Intensive care was more likely among IC patients 65-79 years (aOR [95% CI]: 1.25 [1.06-1.48]) and >80 years (aOR [95% CI]: 1.35 [1.06-1.73]) compared with non-IC patients in those age groups. IC patients were hospitalized longer (adjusted hazard ratio of discharge [95% CI]: 0.86 [0.83-0.88]) and were more likely to require mechanical ventilation (aOR [95% CI] 1.19 [1.05-1.36]). CONCLUSIONS: Substantial morbidity and mortality occurred among IC adults hospitalized with influenza. Influenza vaccination and antiviral administration could be increased in both IC and non-IC adults.

      4. Changes in HIV preexposure prophylaxis awareness and use among men who have sex with men – 20 urban areas, 2014 and 2017external icon
        Finlayson T, Cha S, Xia M, Trujillo L, Denson D, Prejean J, Kanny D, Wejnert C.
        MMWR Morb Mortal Wkly Rep. 2019 Jul 12;68(27):597-603.
        In February 2019, the U.S. Department of Health and Human Services proposed a strategic initiative to end the human immunodeficiency (HIV) epidemic in the United States by reducing new HIV infections by 90% during 2020-2030* (1). Phase 1 of the Ending the HIV Epidemic initiative focuses on Washington, DC; San Juan, Puerto Rico; and 48 counties where the majority of new diagnoses of HIV infection in 2016 and 2017 were concentrated and on seven states with a disproportionate occurrence of HIV in rural areas relative to other states.(dagger) One of the four pillars in the initiative is protecting persons at risk for HIV infection using proven, comprehensive prevention approaches and treatments, such as HIV preexposure prophylaxis (PrEP), which is the use of antiretroviral medications that have proven effective at preventing infection among persons at risk for acquiring HIV. In 2014, CDC released clinical PrEP guidelines to health care providers (2) and intensified efforts to raise awareness and increase the use of PrEP among persons at risk for infection, including gay, bisexual, and other men who have sex with men (MSM), a group that accounted for an estimated 68% of new HIV infections in 2016 (3). Data from CDC’s National HIV Behavioral Surveillance (NHBS) were collected in 20 U.S. urban areas in 2014 and 2017, covering 26 of the geographic areas included in Phase I of the Ending the HIV Epidemic initiative, and were compared to assess changes in PrEP awareness and use among MSM. From 2014 to 2017, PrEP awareness increased by 50% overall, with >80% of MSM in 17 of the 20 urban areas reporting PrEP awareness in 2017. Among MSM with likely indications for PrEP (e.g., sexual risk behaviors or recent bacterial sexually transmitted infection [STI]), use of PrEP increased by approximately 500% from 6% to 35%, with significant increases observed in all urban areas and in almost all demographic subgroups. Despite this progress, PrEP use among MSM, especially among black and Hispanic MSM, remains low. Continued efforts to improve coverage are needed to reach the goal of 90% reduction in HIV incidence by 2030. In addition to developing new ways of connecting black and Hispanic MSM to health care providers through demonstration projects, CDC has developed resources and tools such as the Prescribe HIV Prevention program to enable health care providers to integrate PrEP into their clinical care.( section sign) By routinely testing their patients for HIV, assessing HIV-negative patients for risk behaviors, and prescribing PrEP as needed, health care providers can play a critical role in this effort.

      5. Successive norovirus outbreaks at an event center – Nebraska, October-November, 2017external icon
        Free RJ, Buss BF, Koirala S, Ulses M, Carlson A, Loeck B, Safranek T.
        MMWR Morb Mortal Wkly Rep. 2019 Jul 19;68(28):627-630.
        In October 2017, the Nebraska Department of Health and Human Services (NDHHS) was notified by a local health department of a gastrointestinal illness outbreak among attendees of a wedding reception at facility A, an event center. Shortly thereafter, state and local public health officials began receiving reports of similar gastrointestinal illness among attendees of subsequent facility A events. An investigation was initiated to identify cases, establish the cause, assess possible transmission routes, and provide control recommendations. Overall, 159 cases consistent with norovirus infection (three confirmed and 156 probable) were identified among employees of facility A and attendees of nine facility A events during October 27-November 18, 2017. The investigation revealed a public vomiting episode at the facility on October 27 and at least one employee involved with preparing and serving food who returned to work <24 hours after symptom resolution, suggesting that a combination of contaminated environmental surfaces and infected food handlers likely sustained the outbreak. Recommendations regarding sanitation and excluding ill employees were communicated to facility A management. However, facility A performed minimal environmental cleaning and did not exclude ill employees. Consequently, transmission continued. To prevent persistent norovirus outbreaks in similar settings, public health officials should ensure that involved facilities implement a comprehensive prevention strategy as early as possible that includes extensive sanitation and strict exclusion of ill food handlers for at least 48 hours after symptom resolution (1).

      6. [No abstract]

      7. Meningeal and pulmonary tuberculosis on a commercial fishing vessel – Hawaii, 2017external icon
        Imada EK, Roberson EK, Goswami ND, Brostrom RJ, Moser K, Tardivel K.
        Morb Mortal Wkly Rep. 2019 ;68(24):554-555.

        [No abstract]

      8. Barriers and facilitators to linkage to care and ART initiation in the setting of high ART coverage in Botswanaexternal icon
        Kebaabetswe P, Manyake K, Kadima E, Auletta-Young C, Chakalisa U, Sekoto T, Dintwa OM, Mmalane M, Makhema J, Lebelonyane R, Bachanas P, Plank R, Gaolathe T, Lockman S, Holme MP.
        AIDS Care. 2019 Jul 12:1-7.
        We conducted a qualitative study using focus groups and in-depth interviews to explore barriers to and facilitators of linkage-to-care and antiretroviral treatment (ART) initiation in Botswana. Participants were selected from communities receiving interventions through the Ya Tsie Study. Fifteen healthcare providers and 49 HIV-positive individuals participated. HIV-positive participants identified barriers including stigma, discrimination and overcrowded clinics, and negative staff attitudes; personal factors, such as a lack of acceptance of one’s HIV status, non-disclosure, and gender differences; along with lack of social/family support, and certain religious beliefs. Healthcare providers cited delayed test results, poverty, and transport difficulties as additional barriers. Major facilitators were support from healthcare providers, including home visits, social support, and knowing the benefits of ART. Participants were highly supportive of universal ART as a personal health measure. Our results highlighted a persistent structural health facility barrier: HIV-positive patients expressed strong discontent with HIV care/treatment being delivered differently than routine healthcare, feeling inconvenienced and stigmatized by separately designated locations and days of service. This barrier was particularly problematic for highly mobile persons. Addressing this structural barrier, which persists even in the context of high ART uptake, could bring gains in willingness to initiate ART and improved adherence in Botswana and elsewhere.

      9. Brief report: Routine use of oral PrEP in a phase 2 rectal microbicide study of tenofovir reduced-glycerin 1% gel (MTN-017)external icon
        Liu AY, Norwood A, Gundacker H, Carballo-Dieguez A, Johnson S, Patterson K, Bekker LG, Chariyalertsak S, Chitwarakorn A, Gonzales P, Holtz TH, Mayer KH, Zorrilla C, Buchbinder S, Piper JM, Lama JR, Cranston RD.
        J Acquir Immune Defic Syndr. 2019 Aug 15;81(5):516-520.
        BACKGROUND: As daily oral preexposure prophylaxis (PrEP) becomes standard for HIV prevention, routine use of PrEP is likely to increase within clinical trials of novel preventive agents. We describe the prevalence and characteristics of participants reporting nonstudy oral PrEP use within Microbicide Trials Network-017 (MTN-017), a phase 2 trial of a rectal microbicide. SETTING AND METHODS: One hundred ninety-five HIV-uninfected men who have sex with men and transgender women were enrolled and followed in MTN-017 across 8 sites in the United States, Thailand, South Africa, and Peru from 2013 to 2015. Nonstudy oral PrEP use was recorded on case report forms and progress notes. Characteristics of PrEP users and non-PrEP users were compared using tests of statistical significance. RESULTS: Overall, 11% of participants reported nonstudy oral PrEP use, all from the San Francisco (SF) site, accounting for 58% (22/38) of participants enrolled in SF. There was a higher median number of sex partners reported in the past 8 weeks before enrollment among oral PrEP users vs. nonusers (7 vs. 2, P = 0.02). Most PrEP users (18/22, 82%) began PrEP treatment during screening/after enrollment, and most (19/22, 86%) decided to continue oral PrEP after study completion. CONCLUSION: Nonstudy oral PrEP use in the first phase 2 study of tenofovir reduced-glycerin 1% gel was high at a single site in SF where community PrEP availability and use was expanding. Investigators should consider the evolving context of nonstudy oral PrEP use across trial sites when designing and interpreting trials of novel biomedical prevention modalities.

      10. Universal testing, expanded treatment, and incidence of HIV infection in Botswanaexternal icon
        Makhema J, Wirth KE, Pretorius Holme M, Gaolathe T, Mmalane M, Kadima E, Chakalisa U, Bennett K, Leidner J, Manyake K, Mbikiwa AM, Simon SV, Letlhogile R, Mukokomani K, van Widenfelt E, Moyo S, Lebelonyane R, Alwano MG, Powis KM, Dryden-Peterson SL, Kgathi C, Novitsky V, Moore J, Bachanas P, Abrams W, Block L, El-Halabi S, Marukutira T, Mills LA, Sexton C, Raizes E, Gaseitsiwe S, Bussmann H, Okui L, John O, Shapiro RL, Pals S, Michael H, Roland M, DeGruttola V, Lei Q, Wang R, Tchetgen Tchetgen E, Essex M, Lockman S.
        N Engl J Med. 2019 Jul 18;381(3):230-242.
        BACKGROUND: The feasibility of reducing the population-level incidence of human immunodeficiency virus (HIV) infection by increasing community coverage of antiretroviral therapy (ART) and male circumcision is unknown. METHODS: We conducted a pair-matched, community-randomized trial in 30 rural or periurban communities in Botswana from 2013 to 2018. Participants in 15 villages in the intervention group received HIV testing and counseling, linkage to care, ART (started at a higher CD4 count than in standard care), and increased access to male circumcision services. The standard-care group also consisted of 15 villages. Universal ART became available in both groups in mid-2016. We enrolled a random sample of participants from approximately 20% of households in each community and measured the incidence of HIV infection through testing performed approximately once per year. The prespecified primary analysis was a permutation test of HIV incidence ratios. Pair-stratified Cox models were used to calculate 95% confidence intervals. RESULTS: Of 12,610 enrollees (81% of eligible household members), 29% were HIV-positive. Of the 8974 HIV-negative persons (4487 per group), 95% were retested for HIV infection over a median of 29 months. A total of 57 participants in the intervention group and 90 participants in the standard-care group acquired HIV infection (annualized HIV incidence, 0.59% and 0.92%, respectively). The unadjusted HIV incidence ratio in the intervention group as compared with the standard-care group was 0.69 (P = 0.09) by permutation test (95% confidence interval [CI], 0.46 to 0.90 by pair-stratified Cox model). An end-of-trial survey in six communities (three per group) showed a significantly greater increase in the percentage of HIV-positive participants with an HIV-1 RNA level of 400 copies per milliliter or less in the intervention group (18 percentage points, from 70% to 88%) than in the standard-care group (8 percentage points, from 75% to 83%) (relative risk, 1.12; 95% CI, 1.09 to 1.16). The percentage of men who underwent circumcision increased by 10 percentage points in the intervention group and 2 percentage points in the standard-care group (relative risk, 1.26; 95% CI, 1.17 to 1.35). CONCLUSIONS: Expanded HIV testing, linkage to care, and ART coverage were associated with increased population viral suppression. (Funded by the President’s Emergency Plan for AIDS Relief and others; Ya Tsie number, NCT01965470.).

      11. Optimizing responses to drug safety signals in pregnancy: the example of dolutegravir and neural tube defectsexternal icon
        Mofenson LM, Pozniak AL, Wambui J, Raizes E, Ciaranello A, Clayden P, Ehrenkranz P, Fakoya A, Hill A, Khoo S, Mahaka I, Modi S, Moore C, Phillips A, Siberry G, Sikwese K, Thorne C, Watts HD, Doherty M, Ford NP.
        J Int AIDS Soc. 2019 Jul;22(7):e25352.
        INTRODUCTION: The unexpected identification of a neural tube defect (NTD) safety signal with preconception dolutegravir (DTG) exposure in the Botswana Tsepamo birth outcomes study brought into sharp focus the need for reliable data on use of new antiretrovirals in pregnancy, improved pharmacovigilance systems to evaluate safety of new drugs being introduced into populations including women of reproductive potential, and balanced risk-benefit messaging when a safety signal is identified. DISCUSSION: The Tsepamo study NTD safety signal and accompanying regulatory responses led to uncertainty about the most appropriate approach to DTG use among women of reproductive potential, affecting global DTG roll-out plans, and limiting DTG use in adolescent girls and women. It also revealed a tension between a public health approach to antiretroviral treatment (ART) and individual choice, and highlighted difficulties interpreting and messaging an unexpected safety signal with uncertainty about risk. This difficulty was compounded by the lack of high-quality data on pregnancy outcomes from women receiving ART outside the Tsepamo surveillance sites and countries other than Botswana, resulting in a prolonged period of uncertainty while data on additional exposures are evaluated to refute or confirm the initial safety signal. We discuss principles for evaluating and introducing new drugs in the general population that would ensure collection of appropriate data to inform drug safety in adolescent girls and women of reproductive potential and minimize confusion about drug use in this population when a safety signal is identified. CONCLUSIONS: The response to a signal suggesting a possible safety risk for a drug used in pregnancy or among women who may become pregnant needs to be rapid and comprehensive. It requires the existence of appropriately designed surveillance systems with broad population coverage; data analyses that examine risk-benefit trade-offs in a variety of contexts; guidance to transform this risk-benefit balance into effective and agreed-upon policy; involvement of the affected community and other key stakeholders; and a communication plan for all levels of knowledge and complexity. Implementation of this proposed framework for responding to safety signals is needed to ensure that any drug used in pregnancy can be rapidly and appropriately evaluated should a serious safety alert arise.

      12. A pharmacokinetic and pharmacogenetic evaluation of contraceptive implants and antiretroviral therapy among women in Kenya and Ugandaexternal icon
        Patel RC, Stalter RM, Thomas KK, Tamraz B, Blue SW, Erikson DW, Kim CJ, Kelley EJ, Nanda K, Kourtis AP, Lingappa JR, Mugo N, Baeten JM, Scarsi KK.
        Aids. 2019 Jul 10.
        OBJECTIVES: To evaluate pharmacokinetics and pharmacogenetics of contraceptive implant progestin concentrations in HIV-positive women initiating efavirenz- or nevirapine-containing antiretroviral therapy (ART). DESIGN: We analyzed stored samples from women self-reporting implant use in the Partners PrEP Study. METHODS: Plasma samples collected every six months were analyzed for levonorgestrel and etonogestrel concentrations. Progestin concentrations from samples collected after ART initiation were compared to pre-ART concentrations for intraindividual comparisons. We used adjusted linear mixed models to compare hormone concentrations between individuals on efavirenz and nevirapine to a no ART group. We then evaluated whether possessing certain alleles with known or possible influences on efavirenz, nevirapine, or progestin metabolism were associated with changes in progestin concentrations or modified the association between ART use and progestin concentrations. RESULTS: Our analysis included 11 women who initiated efavirenz, 13 who initiated nevirapine, and 36 who remained ART-naive. In the efavirenz group, the adjusted geometric mean ratio (aGMR) of levonorgestrel was 0.39 (90% confidence intervals (0.31, 0.49); p < 0.001) and the etonogestrel aGMR was 0.51 (0.34, 0.76); p = 0.006) compared to the control group. No difference was observed in the nevirapine group compared to controls (levonorgestrel 0.93 (0.74, 1.18); p = 0.64; etonogestrel 1.07 (0.77, 1.50); p = 0.73). Possession of four allele variants were found to result in further reductions in progestin concentrations among those receiving efavirenz. CONCLUSIONS: Concomitant use of efavirenz significantly reduces levonorgestrel or etonogestrel concentrations by 61% and 49%, respectively, compared to no ART use. We also report allelic variants in hepatic enzymes that influenced the extent of the observed drug-interaction between progestins and efavirenz.

      13. Extensively drug-resistant tuberculosis ‘hotspots’ and sociodemographic associations in Durban, South Africaexternal icon
        Peterson ML, Gandhi NR, Clennon J, Nelson KN, Morris N, Ismail N, Allana S, Campbell A, Brust JC, Auld SC, Mathema B, Mlisana K, Moodley P, Shah NS.
        Int J Tuberc Lung Dis. 2019 Jun 1;23(6):720-727.
        BACKGROUND In KwaZulu-Natal, South Africa, the incidence of extensively drug-resistant tuberculosis (XDR-TB) is driven by the transmission of resistant strains. As data suggest that cases may be spatially clustered, we sought to identify ‘hotspots’ and describe these communities. METHODS We enrolled XDR-TB patients diagnosed from 2011 to 2014 in eThekwini. Global positioning system (GPS) coordinates for participant homes were collected and hotspots were identified based on population-adjusted XDR-TB incidence. The sociodemographic features of hotspots were characterised using census data. For a subset of participants, we mapped non-home XDR-TB congregate locations and compared these with results including only homes. RESULTS Among 132 participants, 75 (57%) were female and 87 (66%) lived in urban or suburban locations. Fifteen of 197 census tracts were identified as XDR-TB hotspots with >/=95% confidence. Four spatial mapping methods identified one large hotspot in northeastern eThekwini. Hotspot communities had higher proportions of low educational attainment (12% vs. 9%) and unemployment (29.3% vs. 20.4%), and lower proportion of homes with flush toilets (36.4% vs. 68.9%). The case density shifted towards downtown Durban when congregate locations (e.g., workplaces) for 43 (33%) participants were mapped. CONCLUSIONS In eThekwini, XDR-TB case homes were clustered into hotspots with more poverty indicators than non-hotspots. Prevention efforts targeting hotspot communities and congregate settings may be effective in reducing community transmission..

      14. Epidemiological aspects of travel-related systemic endemic mycoses: a GeoSentinel analysis, 1997-2017external icon
        Salzer HJ, Stoney RJ, Angelo KM, Rolling T, Grobusch MP, Libman M, Lopez-Velez R, Duvignaud A, Asgeirsson H, Crespillo-Andujar C, Schwartz E, Gautret P, Bottieau E, Jordan S, Lange C, Hamer DH.
        J Travel Med. 2018 Aug 1;25(1).
        Background: International travel has increased in the past few decades, placing more travellers at risk of acquiring systemic endemic mycoses. There are limited published data on systemic endemic mycoses among international travellers. We report epidemiological characteristics of non-migrant, international travellers who acquired systemic endemic mycoses during travel. Methods: We analysed records of non-migrant international travellers with a confirmed diagnosis of histoplasmosis, coccidioidomycosis, paracoccidioidomycosis, blastomycosis or talaromycosis reported from 1997 through 2017 to GeoSentinel, a global surveillance network now consisting of 70 travel or tropical medicine centres in 31 countries. Results: Sixty-nine records met the inclusion criteria. Histoplasmosis was most frequently reported; the 51 travellers with histoplasmosis had the lowest median age (30 years; range: 8-85) and shortest median duration of travel (12 days; range: 5-154). Coccidioidomycosis was reported in 14 travellers; travellers with coccidioidomycosis were older (median 62 years; range: 22-78) and had the longest median number of days between return from travel and presentation to a GeoSentinel site (55 days; range: 17-273). Almost all travellers with coccidioidomycosis were exposed in the USA. Other systemic endemic mycoses were less frequently reported, including blastomycosis (three travellers) and talaromycosis (one traveller). Conclusions: Although relatively rare, systemic endemic mycoses should be considered as potential travel-related infections in non-migrant international travellers. Epidemiological exposures should be used to guide diagnostic evaluations and treatment.

      15. Syphilis diagnosis and treatment during antenatal care: the potential catalytic impact of the dual HIV and syphilis rapid diagnostic testexternal icon
        Storey A, Seghers F, Pyne-Mercier L, Peeling RW, Owiredu MN, Taylor MM.
        Lancet Glob Health. 2019 Aug;7(8):e1006-e1008.

        [No abstract]

      16. Delays in fast track ART initiation and reasons for not starting treatment among eligible children in Eastern Cape, South Africaexternal icon
        Teasdale CA, Yuengling KA, Mutiti A, Arpadi S, Nxele M, Pepeta L, Mogashoa M, Rivadeneira ED, Abrams EJ.
        Aids. 2019 Jul 10.
        We report data from an observational cohort of South African children living with HIV <12 years of age eligible for fast track ART (rapid) initiation. We found that less than half those eligible for rapid ART initiation based on immunologic and disease status started treatment within one week.

      17. Meeting report: 32nd International Conference on Antiviral Researchexternal icon
        Tramontano E, Tarbet B, Spengler JR, Seley-Radtke K, Meier C, Jordan R, Janeba Z, Gowen B, Gentry B, Este JA, Bray M, Andrei G, Schang LM.
        Antiviral Res. 2019 Jul 11:104550.
        The 32nd International Conference on Antiviral Research (ICAR), sponsored by the International Society for Antiviral Research (ISAR) was held in Baltimore, Maryland, USA, on May 12-15, 2019. This report gives an overview of the conference on behalf of the Society. It provides a general review of the meeting and awardees, summarizing the presentations, and their main conclusions from the perspective of researchers active in many different areas of antiviral research and development. As in past years, ICAR promoted and showcased the most recent progress in antiviral research, and continued to foster collaborations and interactions in drug discovery and development. The 33rd ICAR will be held in Seattle, Washington, USA, March 30th-April 3rd, 2020.

      18. Neuraminidase Inhibitors and Hospital Length of Stay: A Meta-analysis of Individual Participant Data to Determine Treatment Effectiveness Among Patients Hospitalized With Nonfatal 2009 Pandemic Influenza A(H1N1) Virus Infectionexternal icon
        Venkatesan S, Myles PR, Bolton KJ, Muthuri SG, Al Khuwaitir T, Anovadiya AP, Azziz-Baumgartner E, Bajjou T, Bassetti M, Beovic B, Bertisch B, Bonmarin I, Booy R, Borja-Aburto VH, Burgmann H, Cao B, Carratala J, Chinbayar T, Cilloniz C, Denholm JT, Dominguez SR, Duarte PA, Dubnov-Raz G, Fanella S, Gao Z, Gerardin P, Giannella M, Gubbels S, Herberg J, Higuera Iglesias AL, Hoeger PH, Hu XY, Islam QT, Jimenez MF, Keijzers G, Khalili H, Kusznierz G, Kuzman I, Langenegger E, Lankarani KB, Leo YS, Libster RP, Linko R, Madanat F, Maltezos E, Mamun A, Manabe T, Metan G, Mickiene A, Mikic D, Mohn KG, Oliva ME, Ozkan M, Parekh D, Paul M, Rath BA, Refaey S, Rodriguez AH, Sertogullarindan B, Skret-Magierlo J, Somer A, Talarek E, Tang JW, To K, Tran D, Uyeki TM, Vaudry W, Vidmar T, Zarogoulidis P, Nguyen-Van-Tam JS.
        J Infect Dis. 2019 Jul 17.
        BACKGROUND: The effect of neuraminidase inhibitor (NAI) treatment on length of stay (LoS) in patients hospitalized with influenza is unclear. METHODS: We conducted a one-stage individual participant data (IPD) meta-analysis exploring the association between NAI treatment and LoS in patients hospitalized with 2009 influenza A(H1N1) virus (A[H1N1]pdm09) infection. Using mixed-effects negative binomial regression and adjusting for the propensity to receive NAI, antibiotic, and corticosteroid treatment, we calculated incidence rate ratios (IRRs) and 95% confidence intervals (CIs). Patients with a LoS of <1 day and those who died while hospitalized were excluded. RESULTS: We analyzed data on 18 309 patients from 70 clinical centers. After adjustment, NAI treatment initiated at hospitalization was associated with a 19% reduction in the LoS among patients with clinically suspected or laboratory-confirmed influenza A(H1N1)pdm09 infection (IRR, 0.81; 95% CI, .78-.85), compared with later or no initiation of NAI treatment. Similar statistically significant associations were seen in all clinical subgroups. NAI treatment (at any time), compared with no NAI treatment, and NAI treatment initiated <2 days after symptom onset, compared with later or no initiation of NAI treatment, showed mixed patterns of association with the LoS. CONCLUSIONS: When patients hospitalized with influenza are treated with NAIs, treatment initiated on admission, regardless of time since symptom onset, is associated with a reduced LoS, compared with later or no initiation of treatment.

    • Disaster Control and Emergency Services
      1. Characterizing chemical terrorism incidents collected by the Global Terrorism Database, 1970-2015external icon
        Santos C, El Zahran T, Weiland J, Anwar M, Schier J.
        Prehosp Disaster Med. 2019 Jul 8:1-8.
        BACKGROUND: The Global Terrorism Database (GTD) is an open-source database on terrorist incidents around the world since 1970, and it is maintained by the National Consortium for the Study of Terrorism and Responses to Terrorism (START; College Park, Maryland USA), a US Department of Homeland Security Center of Excellence. The consortium reviews media reports to determine if an event meets eligibility to be categorized as a terrorism incident for entry into the database. OBJECTIVE: The objective of this study was to characterize chemical terrorism incidents reported to the GTD and understand more about the kinds of chemical agents used, the associated morbidity and mortality, the geography of incidents, and the intended targets. METHODS: Chemical terrorism incidents from 1970 through 2015 were analyzed by chemical agent category, injury and fatality, geographic region, and target. RESULTS: During the study period, 156,772 terrorism incidents were reported to the GTD, of which 292 (0.19%) met the inclusion criteria for analysis as a chemical terrorism incident. The reported chemical agent categories were: unknown chemical (30.5%); corrosives (23.3%); tear gas/mace (12.3%); unspecified gas (11.6%); cyanide (8.2%); pesticides (5.5%); metals (6.5%); and nerve gas (2.1%). On average, chemical terrorism incidents resulted in 51 injuries (mean range across agents: 2.5-1,622.0) and seven deaths (mean range across agents: 0.0-224.3) per incident. Nerve gas incidents (2.1%) had the highest mean number of injuries (n = 1,622) and fatalities (n = 224) per incident. The highest number of chemical terrorism incidents occurred in South Asia (29.5%), Western Europe (16.8%), and Middle East/North Africa (13.0%). The most common targets were private citizens (19.5%), of which groups of women (22.8%) were often the specific target. Incidents targeting educational institutions often specifically targeted female students or teachers (58.1%). CONCLUSIONS: Chemical terrorism incidents rarely occur; however, the use of certain chemical terrorism agents, for example nerve gas, can cause large mass-causality events that can kill or injure thousands with a single use. Certain regions of the world had higher frequency of chemical terrorism events overall, and also varied in their frequencies of the specific chemical terrorism agent used. Data suggest that morbidity and mortality vary by chemical category and by region. Results may be helpful in developing and optimizing regional chemical terrorism preparedness activities.

      2. Notes from the Field: Hurricane Florence-related emergency department visits – North Carolina, 2018external icon
        Tanz LJ, Hoffman MN, Dandeneau D, Faigen Z, Moore Z, Proescholdbell S, Kansagra SM.
        MMWR Morb Mortal Wkly Rep. 2019 Jul 19;68(28):631-632.

        [No abstract]

    • Disease Reservoirs and Vectors
      1. Characterizing the molecular and metabolic mechanisms of insecticide resistance in Anopheles gambiae in Faranah, Guineaexternal icon
        Stica C, Jeffries CL, Irish SR, Barry Y, Camara D, Yansane I, Kristan M, Walker T, Messenger LA.
        Malar J. 2019 Jul 17;18(1):244.
        BACKGROUND: In recent years, the scale-up of long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) has greatly reduced malaria transmission. However, malaria remains a global public health concern with the majority of the disease burden in sub-Saharan Africa. Insecticide resistance is a growing problem among Anopheles vector populations, with potential implications for the continued effectiveness of available control interventions. Improved understanding of current resistance levels and underlying mechanisms is essential to design appropriate management strategies and to mitigate future selection for resistance. METHODS: Anopheles gambiae sensu lato mosquitoes were collected from three villages in Faranah Prefecture, Guinea and their levels of susceptibility to seven insecticides were measured using CDC resistance intensity bioassays. Synergist assays with piperonyl butoxide (PBO) were also undertaken to assess the role of elevated mixed-function oxidases in resistance. Five hundred and sixty-three mosquitoes underwent molecular characterization of vector species, presence of target site mutations (L1014F kdr, N1575Y and G119S Ace-1), Plasmodium falciparum infection, and relative expression of three metabolic genes (CYP6M2, CYP6P3 and GSTD3). RESULTS: In Faranah, resistance to permethrin and deltamethrin was observed, as well as possible resistance to bendiocarb. All assayed vector populations were fully susceptible to alpha-cypermethrin, pirimiphos-methyl, clothianidin and chlorfenapyr. Plasmodium falciparum infection was detected in 7.3% (37/508) of mosquitoes tested. The L1014F kdr mutation was found in 100% of a sub-sample of 60 mosquitoes, supporting its fixation in the region. The N1575Y mutation was identified in 20% (113/561) of individuals, with ongoing selection evidenced by significant deviations from Hardy-Weinberg equilibrium. The G119S Ace-1 mutation was detected in 62.1% (18/29) of mosquitoes tested and was highly predictive of bendiocarb bioassay survival. The metabolic resistance genes, CYP6M2, CYP6P3 and GSTD3, were found to be overexpressed in wild resistant and susceptible An. gambiae sensu stricto populations, compared to a susceptible G3 colony. Furthermore, CYP6P3 was significantly overexpressed in bendiocarb survivors, implicating its potential role in carbamate resistance in Faranah. CONCLUSIONS: Identification of intense resistance to permethrin and deltamethrin in Faranah, is of concern, as the Guinea National Malaria Control Programme (NMCP) relies exclusively on the distribution of pyrethroid-treated LLINs for vector control. Study findings will be used to guide current and future control strategies in the region.

    • Environmental Health
      1. Perceptions of drinking water safety and their associations with plain water intake among US Hispanic adultsexternal icon
        Park S, Onufrak S, Patel A, Sharkey JR, Blanck HM.
        J Water Health. 2019 Aug;17(4):587-596.
        We described sociodemographic differences in perceptions of drinking water safety and examined associations between perceptions and plain water intake. We used the 2015 Estilos survey of 1,000 US Hispanic adults conducted in both Spanish and English. Outcome was water intake. Exposures were the level of agreement about water perceptions (My tap water is safe to drink; Community tap water is safe to drink; Bottled water is safer; I would buy less bottled water if my tap water was safe). Covariates were sociodemographics, region, Hispanic heritage, and acculturation. We used chi-square tests and multinomial logistic regression to examine associations of water perceptions and intake. Overall, 24% of Hispanic adults consumed water </=1 time/day. Although 34% disagreed their home tap water was safe to drink, and 41% disagreed their community tap water was safe to drink, 65% agreed bottled water is safer than tap water, and 69% agreed they would buy less bottled water if they knew their tap water was safe. Perceptions differed by some covariates but were not significantly associated with plain water intake. In conclusion, negative perceptions of tap water were common among US Hispanic adults, which can inform efforts to increase awareness about safe public water systems.

      2. Perfluorooctanoate and changes in anthropometric parameters with age in young girls in the Greater Cincinnati and San Francisco Bay Areaexternal icon
        Pinney SM, Windham GC, Xie C, Herrick RL, Calafat AM, McWhorter K, Fassler CS, Hiatt RA, Kushi LH, Biro FM.
        Int J Hyg Environ Health. 2019 Jul 9.
        METHODS: We conducted a study of per- and polyfluoroalkyl substance biomarkers, including PFOA, in girls from Greater Cincinnati (CIN, N=353) and the San Francisco Bay Area (SFBA, N=351). PFOA was measured in the baseline serum sample collected in 2004-2007 of 704 girls at age 6-8 years. Mixed effects models were used to derive the effect of PFOA on BMI, waist-to-height and waist-to-hip ratios over increasing age in this longitudinal cohort. RESULTS: Median PFOA serum concentrations were 7.3 (CIN) and 5.8 (SFBA) ng/mL, above the U.S. population median for children 12-19 years in 2005-2006 (3.8 ng/mL). Log-transformed serum PFOA had a strong inverse association with BMIz in the CIN girls (p = 0.0002) and the combined two-site data (p = 0.0008); the joint inverse effect of PFOA and Age*PFOA weakened at age at 10-11 years. However, in the SFBA group alone, the relationship was not significant (p = 0.1641) with no evidence of changing effect with age. The effect of PFOA on waist:height ratio was similar to BMIz at both sites, but we did not find a significant effect of PFOA on waist:hip ratio in either the CIN or SFBA girls. CONCLUSIONS: PFOA is associated with decreased BMI and waist:height ratio in young girls, but the strength of the relationship decreases with age. Site heterogeneity may be due to greater early life exposure in Cincinnati. DISCLAIMER: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Use of trade names is for identification only and does not imply endorsement by the CDC, the Public Health Service, or the US Department of Health and Human Services.

      3. Collaborative response to arsenic-contaminated soil in an Appalachian Kentucky neighborhoodexternal icon
        Yaffee AQ, Scott B, Kaelin C, Cambron J, Sanderson W, Christian WJ, Moran TP, Chamness J.
        J Toxicol Environ Health A. 2019 Jul 15:1-5.
        The aim of this study was to identify factors associated with an increased exposure to arsenic-contaminated soil in a Kentucky neighborhood as part of collaborative public health response. An exposure assessment survey was administered to residents and toenail clippings and soil samples analyzed for arsenic concentration. The associations between exposure variables and arsenic concentrations were evaluated using a multivariate-generalized estimating equation. An ecological assessment of cancer incidence in the community was also conducted using standardized incidence ratio maps. Median toenail arsenic was 0.48 micrograms/gram (microg/g), twice the expected regional level of 0.2 microg/g. Mean residence surface soil arsenic level was 64.8 ppm. An increase of 1 ppm of residence concentration was significantly associated with a 0.003 microg/g rise in toenail levels. Concentrations for respondents who engaged in digging were 0.68 microg/g significantly higher compared to individuals who did not. No significantly elevated rates of lung or bladder cancer were observed in the affected ZIP codes. Living in areas with high soil arsenic contamination might lead to (1) increased exposure; (2) elevated residence soil arsenic concentrations and (3) the action of digging in the soil was associated with elevated toenail arsenic levels. Based upon elevated soil levels identified, residents were recommended to move from the contaminated environment until remediation was complete. Additional recommendations included regular health-care follow-up.

      4. Compilation and spatio-temporal analysis of publicly available total solar and UV irradiance data in the contiguous United Statesexternal icon
        Zhou Y, Meng X, Belle JH, Zhang H, Kennedy C, Al-Hamdan MZ, Wang J, Liu Y.
        Environ Pollut. 2019 Jun 26;253:130-140.
        Skin cancer is the most common type of cancer in the United States, the majority of which is caused by overexposure to ultraviolet (UV) irradiance, which is one component of sunlight. National Environmental Public Health Tracking Program at CDC has collaborated with partners to develop and disseminate county-level daily UV irradiance (2005-2015) and total solar irradiance (1991-2012) data for the contiguous United States. UV irradiance dataset was derived from the Ozone Monitoring Instrument (OMI), and solar irradiance was extracted from National Solar Radiation Data Base (NSRDB) and SolarAnywhere data. Firstly, we produced daily population-weighted UV and solar irradiance datasets at the county level. Then the spatial distributions and long-term trends of UV irradiance, solar irradiance and the ratio of UV irradiance to solar irradiance were analyzed. The national average values across all years are 4300Wh/m(2), 2700J/m(2) and 130mW/m(2) for global horizontal irradiance (GHI), erythemally weighted daily dose of UV irradiance (EDD) and erythemally weighted UV irradiance at local solar noon time (EDR), respectively. Solar, UV irradiances and the ratio of UV to solar irradiance all increased toward the South and in some areas with high altitude, suggesting that using solar irradiance as indicator of UV irradiance in studies covering large geographic regions may bias the true pattern of UV exposure. National annual average daily solar and UV irradiances increased significantly over the years by about 0.3% and 0.5% per year, respectively. Both datasets are available to the public through CDC’s Tracking network. The UV irradiance dataset is currently the only publicly-available, spatially-resolved, and long-term UV irradiance dataset covering the contiguous United States. These datasets help us understand the spatial distributions and temporal trends of solar and UV irradiances, and allow for improved characterization of UV and sunlight exposure in future studies.

    • Epidemiology and Surveillance
      1. Using “outbreak science” to strengthen the use of models during epidemicsexternal icon
        Rivers C, Chretien JP, Riley S, Pavlin JA, Woodward A, Brett-Major D, Maljkovic Berry I, Morton L, Jarman RG, Biggerstaff M, Johansson MA, Reich NG, Meyer D, Snyder MR, Pollett S.
        Nat Commun. 2019 Jul 15;10(1):3102.

        [No abstract]

    • Food Safety
      1. Whole genome sequencing: Bridging one-health surveillance of foodborne diseasesexternal icon
        Gerner-Smidt P, Besser J, Concepcion-Acevedo J, Folster JP, Huffman J, Joseph LA, Kucerova Z, Nichols MC, Schwensohn CA, Tolar B.
        Front Public Health. 2019 ;7:172.
        Infections caused by pathogens commonly acquired from consumption of food are not always transmitted by that route. They may also be transmitted through contact to animals, other humans or the environment. Additionally, many outbreaks are associated with food contaminated from these non-food sources. For this reason, such presumed foodborne outbreaks are best investigated through a One Health approach working across human, animal and environmental sectors and disciplines. Outbreak strains or clones that have propagated and continue to evolve in non-human sources and environments often show more sequence variation than observed in typical monoclonal point-source outbreaks. This represents a challenge when using whole genome sequencing (WGS), the new gold standard for molecular surveillance of foodborne pathogens, for outbreak detection and investigation. In this review, using recent examples from outbreaks investigated in the United States (US) some aspects of One Health approaches that have been used successfully to solve such outbreaks are presented. These include using different combinations of flexible WGS based case definition, efficient epidemiological follow-up, traceback, surveillance, and testing of potential food and environmental sources and animal hosts.

    • Genetics and Genomics
      1. Beyond public health genomics: Can big data and predictive analytics deliver precision public health?external icon
        Khoury MJ, Engelgau M, Chambers DA, Mensah GA.
        Public Health Genomics. 2019 Jul 17:1-6.
        The field of public health genomics has matured in the past two decades and is beginning to deliver genomic-based interventions for health and health care. In the past few years, the terms precision medicine and precision public health have been used to include information from multiple fields measuring biomarkers as well as environmental and other variables to provide tailored interventions. In the context of public health, “precision” implies delivering the right intervention to the right population at the right time, with the goal of improving health for all. In addition to genomics, precision public health can be driven by “big data” as identified by volume, variety, and variability in biomedical, sociodemographic, environmental, geographic, and other information. Most current big data applications in health are in elucidating pathobiology and tailored drug discovery. We explore how big data and predictive analytics can contribute to precision public health by improving public health surveillance and assessment, and efforts to promote uptake of evidence-based interventions, by including more extensive information related to place, person, and time. We use selected examples drawn from child health, cardiovascular disease, and cancer to illustrate the promises of precision public health, as well as current methodologic and analytic challenges to big data to fulfill these promises.

    • Health Economics
      1. Cost-effectiveness of patient navigation for breast cancer screening in the National Breast and Cervical Cancer Early Detection Programexternal icon
        Allaire BT, Ekweme D, Hoerger TJ, DeGroff A, Rim SH, Subramanian S, Miller JW.
        Cancer Causes Control. 2019 Jul 11.
        OBJECTIVES: Patient navigation (PN) services have been shown to improve cancer screening in disparate populations. This study estimates the cost-effectiveness of implementing PN services within the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). METHODS: We adapted a breast cancer simulation model to estimate a population cohort of women aged 40-64 years from the NBCCEDP through their lifetime. We incorporated their screening frequency and screening and diagnostic costs. RESULTS: Within the NBCCEDP, Program with PN (vs. No PN) resulted in a greater number of mammograms per woman (4.23 vs. 4.14), lower lifetime mortality from breast cancer (3.53% vs. 3.61%), and fewer missed diagnostic resolution per woman (0.017 vs. 0.025). The estimated incremental cost-effectiveness ratios for a Program with PN was $32,531 per quality-adjusted life-years relative to Program with No PN. CONCLUSIONS: Incorporating PN services within the NBCCEDP may be a cost-effective way of improving adherence to screening and diagnostic resolution for women who have abnormal results from screening mammography. Our study highlights the value of supportive services such as PN in improving the quality of care offered within the NBCCEDP.

      2. Cost-effectiveness of scaling up HCV prevention and treatment in the United States for people who inject drugsexternal icon
        Barbosa C, Fraser H, Hoerger TJ, Leib A, Havens JR, Young A, Kral A, Page K, Evans J, Zibbell J, Hariri S, Vellozzi C, Nerlander L, Ward JW, Vickerman P.
        Addiction. 2019 Jul 15.
        AIMS: To examine the cost-effectiveness of hepatitis C (HCV) treatment of people who inject drugs (PWID), combined with medication-assisted treatment (MAT) and syringe-service programs (SSP), to tackle the increasing HCV epidemic in the United States. DESIGN: HCV-transmission and disease progression models with cost-effectiveness analysis using a health care perspective. SETTING: Rural Perry County, Kentucky (PC), and urban San Francisco, California (SF),USA. Compared with PC, SF has a greater proportion of PWID with access to MAT or SSP. HCV treatment of PWID is negligible in both settings. PARTICIPANTS: PWID, data collected between 1998 and 2015 from Social Networks Among Appalachian People, U Find Out, Urban Health Study, and National HIV Behavioral Surveillance System studies. INTERVENTIONS AND COMPARATOR: Three intervention scenarios modeled: baseline-existing SSP and MAT coverage with HCV screening and treatment with direct-acting antiviral for ex-injectors only as per standard of care; Intervention 1-scale-up of SSP and MAT without changes to treatment; and Intervention 2-scale-up as Intervention 1 combined with HCV screening and treatment for current PWID. MEASUREMENTS: Incremental cost-effectiveness ratios (ICERs) and uncertainty using cost-effectiveness acceptability curves. Benefits were measured in quality-adjusted life-years (QALYs). FINDINGS: For both settings, Intervention 2 is preferred to Intervention 1 and the appropriate comparator for Intervention 2 is the baseline scenario. Relative to baseline, for PC Intervention 2 averts 1,852 more HCV infections, increases QALYS by 3,095, costs $21.6 million more, and has an ICER of $6,975/QALY. For SF, Intervention 2 averts 36,473 more HCV infections, increases QALYs by 78,93, costs $ 872 million more, and has an ICER of $11,044/QALY. The cost-effectiveness of Intervention 2 was robust to several sensitivity analysis. CONCLUSIONS: Hepatitis C screening and treatment for people who inject drugs, combined with medication-assisted treatment and syringe-service programs, is a cost-effective strategy for reducing hepatitis C burden in the United States.

      3. Higher prevalence of health-risk factors among US adults with unmet health care needs due to cost, 2016external icon
        Xu F, Wheaton AG, Liu Y, Lu H, Greenlund KJ.
        J Public Health Manag Pract. 2019 Jul 11.
        CONTEXT: Adults with unmet health care needs (UHCN) due to cost have fewer opportunities to receive behavioral counseling in clinical settings, which may be associated with a higher likelihood of having health-risk behaviors. OBJECTIVE: This study assessed associations between UHCN and health-risk factors. DESIGN/SETTING: We used 2016 Behavioral Risk Factor Surveillance System data to calculate age-adjusted weighted prevalence of 5 health-risk factors by UHCN and insurance status and to assess the association of UHCN with these factors using multivariable logistic regression. PARTICIPANTS: US adults aged 18 to 64 years who participated in the survey (N = 301 035). MAIN OUTCOME MEASURES: Five health-risk factors: obesity, current cigarette smoking, excessive alcohol use, sleeping less than 7 hours per 24-hour period, and no leisure-time physical activity within the past month. RESULTS: In 2016, among adults aged 18 to 64 years, 11.2% of those with insurance and 40.1% of those without insurance (both age-adjusted) had UHCN. In both study populations, compared with adults with no UHCN, adults reporting UHCN were more likely to be a current cigarette smoker, report excessive alcohol use, and sleep less than 7 hours per 24-hour period. The prevalence of 3 or more health-risk factors was higher among adults with UHCN than among adults without UHCN (adults with insurance: adjusted prevalence ratio = 1.40; 95% confidence interval = 1.33-1.48; adults without insurance: adjusted prevalence ratio = 1.39; 95% confidence interval = 1.27-1.53). CONCLUSIONS: Unmet health care needs was associated with more health-risk factors regardless of insurance status. Addressing cost barriers to behavioral counseling may be one approach to consider when seeking to reduce health-risk behaviors among high-risk populations.

    • Healthcare Associated Infections
      1. A fatal case of disseminated microsporidiosis due to Anncaliia algerae in a renal and pancreas allograft recipientexternal icon
        Anderson NW, Muehlenbachs A, Arif S, Bruminhent J, Deziel PJ, Razonable RR, Wilhelm MP, Metcalfe MG, Qvarnstrom Y, Pritt BS.
        Open Forum Infect Dis. 2019 Jul;6(7):ofz285.
        Microsporidiosis is an emerging opportunistic infection in immunocompromised patients. We report a case of fatal disseminated Anncaliia algerae infection in a profoundly immunosuppressed pancreas and kidney transplant recipient.

      2. Unnecessary and inappropriate use of antibiotics in human healthcare is a major driver for the development and spread of antimicrobial resistance; many countries are implementing measures to limit the overuse and misuse of antibiotics e.g. through the establishment of antimicrobial use reduction targets. We performed a review of antimicrobial use reduction goals in human medicine in Transatlantic Taskforce on Antimicrobial Resistance partner countries. On 31 March 2017, the European Centre for Disease Prevention and Control sent a questionnaire to National Focal Points for Antimicrobial Consumption and the National Focal Points for Antimicrobial Resistance in 28 European Union countries, Iceland and Norway. The same questionnaire was sent to the TATFAR implementers in Canada and the United States. Thirty of 32 countries replied. Only nine countries indicated that they have established targets to reduce antimicrobial use in humans. Twenty-one countries replied that no target had been established. However, 17 of these 21 countries indicated that work to establish such targets is currently underway, often in the context of developing a national action plan against antimicrobial resistance. The reported targets varied greatly between countries and can be a useful resource for countries willing to engage in the reduction of antibiotic use in humans.

      3. Bacterial septic arthritis infections associated with intra-articular injection practices for osteoarthritis knee pain – New Jersey, 2017external icon
        Ross KM, Mehr JS, Carothers BL, Greeley RD, Benowitz I, Henry D, McHugh LA, DiFedele L, Adler E, Naqvi S, Taylor L, Lifshitz E, Tan C, Montana BE.
        Infect Control Hosp Epidemiol. 2019 Jul 17:1-6.
        BACKGROUND: In March 2017, the New Jersey Department of Health received reports of 3 patients who developed septic arthritis after receiving intra-articular injections for osteoarthritis knee pain at the same private outpatient facility in New Jersey. The risk of septic arthritis resulting from intra-articular injection is low. However, outbreaks of septic arthritis associated with unsafe injection practices in outpatient settings have been reported. METHODS: An infection prevention assessment of the implicated facility’s practices was conducted because of the ongoing risk to public health. The assessment included an environmental inspection of the facility, staff interviews, infection prevention practice observations, and a medical record and office document review. A call for cases was disseminated to healthcare providers in New Jersey to identify patients treated at the facility who developed septic arthritis after receiving intra-articular injections. RESULTS: We identified 41 patients with septic arthritis associated with intra-articular injections. Cultures of synovial fluid or tissue from 15 of these 41 case patients (37%) recovered bacteria consistent with oral flora. The infection prevention assessment of facility practices identified multiple breaches of recommended infection prevention practices, including inadequate hand hygiene, unsafe injection practices, and poor cleaning and disinfection practices. No additional cases were identified after infection prevention recommendations were implemented by the facility. DISCUSSION: Aseptic technique is imperative when handling, preparing, and administering injectable medications to prevent microbial contamination. CONCLUSIONS: This investigation highlights the importance of adhering to infection prevention recommendations. All healthcare personnel who prepare, handle, and administer injectable medications should be trained in infection prevention and safe injection practices.

    • Immunity and Immunization
      1. Challenges with hepatitis B vaccination of high risk adults – A pilot programexternal icon
        Bridges CB, Watson TL, Nelson NP, Chavez-Torres M, Fineis P, Ntiri-Reid B, Wake E, Leahy JM, Kurian AK, Hall MA, Kennedy ED.
        Vaccine. 2019 Jul 11.
        BACKGROUND: Acute hepatitis B virus (HBV) infections in the United States occur predominantly among persons aged 30-59years. The Centers for Disease Control and Prevention (CDC) recommends vaccination of adults at increased risk for HBV infection. Completing the hepatitis B (HepB) vaccine dose-series is critical for optimal immune response. OBJECTIVES: CDC funded 14 health departments (awardees) from 2012 to 2015 to implement a pilot HepB vaccination program for high-risk adults. We evaluated the pilot program to assess vaccine utilization; vaccine dose-series completion, including by vaccination location type; and implementation challenges. METHODS: Awardees collaborated with sites providing health care to persons at increased risk for HBV infection. Awardees collected information on doses administered, vaccine dose-series completion, and challenges completing and tracking vaccinations, including use of immunization information systems (IIS). Data were reported by each awardee in aggregate to CDC. RESULTS: Six of 14 awardees administered 47,911 doses and were able to report patient-level dose-series completion. Among persons who received dose 1, 40.4% received dose 2, and 22.3% received dose 3. Local health department clinics had the highest 3-dose-series completion, 60.6% (531/876), followed by federally qualified health centers at 38.0% (923/2432). While sexually transmitted diseases (STD) clinics administered the most doses in total (17,173 [35.8% of 47,911 doses]), 3-dose-series completion was low (17.1%). The 14 awardees reported challenges regarding completing and tracking dose-series, including reaching high-risk adults for follow-up and inconsistencies in use of IIS or other tracking systems across sites. CONCLUSIONS: Dose-series completion was low in all settings, but lowest where patients may be less likely to return for follow-up (e.g., STD clinics). Routinely assessing HepB vaccination needs of high-risk adults, including through use of IIS where available, may facilitate HepB vaccine dose-series completion.

      2. Rotavirus vaccination coverage during a rotavirus outbreak resulting in a fatality at a subacute care facilityexternal icon
        Burke RM, Tate JE, Han GS, Quenelle R, Gautam R, Wadford DA, Bowen MD, Parashar UD.
        J Pediatric Infect Dis Soc. 2019 Jul 18.
        BACKGROUND: The introduction of rotavirus vaccine in the United States has reduced rotavirus disease burden, but outbreaks still occur. Complete-series rotavirus vaccination coverage is <75% in the United States, and it might be lower among vulnerable populations. We describe here the clinical characteristics and vaccination status of children during a rotavirus outbreak in a pediatric subacute care facility in 2017. METHODS: Clinical history, signs and symptoms, and vaccination history were abstracted for the 26 patients residing in the facility during the time of the outbreak. A case-patient was defined as one who experienced 3 or more loose stools in a period of 24 hours with onset between April 17 and May 17, 2017. Stool samples from 14 resident patients were tested for rotavirus with reverse-transcription polymerase chain reaction. RESULTS: The median patient age at the facility was 2.9 years. Of the 26 resident patients, 22 (85%) met the case definition. One child died. Stool samples from 11 case-patients were positive according to reverse-transcription polymerase chain reaction for rotavirus. Fifteen case-patients were unvaccinated against rotavirus; 3 were partially vaccinated, and 2 were fully vaccinated. Vaccination status could not be completely determined in 2 cases. CONCLUSIONS: An outbreak of rotavirus affected nearly all resident patients of a subacute care facility and caused 1 death. Because of recommendations against giving rotavirus vaccine in an intensive care setting, infants who require a prolonged intensive care stay might age out of rotavirus vaccine eligibility (the first dose must be given before 15 weeks of age according to Advisory Committee on Immunization Practices recommendations). The result is a vulnerable population of unvaccinated infants who might later congregate in another care setting.

      3. Current and new rotavirus vaccinesexternal icon
        Burke RM, Tate JE, Kirkwood CD, Steele AD, Parashar UD.
        Curr Opin Infect Dis. 2019 Jul 9.
        PURPOSE OF REVIEW: As of 2019, four rotavirus vaccines have been prequalified by the WHO for use worldwide. This review highlights current knowledge regarding rotavirus vaccines available, and provides a brief summary of the rotavirus vaccine pipeline. RECENT FINDINGS: Data generated from use of currently available products supports their effectiveness and impact in diverse settings. Rotavirus vaccines have a favorable risk-benefit profile, but previous associations of rotavirus vaccination with intussusception necessitate continued monitoring for this rare but serious adverse event. Implementation of rotavirus vaccines was jeopardized in late 2018 and 2019 by a shortage of vaccine supply. Fortunately, with the prequalification of two additional vaccines in 2018, countries have increased choice in products with different characteristics, pricing, and implementation strategies. Other vaccines currently in development may open up further immunization strategies, such as neonatal vaccination schedules or parenteral administration. SUMMARY: Rotavirus vaccines have demonstrated impact in reducing diarrheal morbidity and mortality worldwide. As countries begin to introduce the newly prequalified vaccines, additional data will become available on the safety and effectiveness of those products. Products in the pipeline have distinct profiles and could be an essential part of the expansion of rotavirus vaccine use worldwide.

      4. Does structurally-mature dengue virion matter in vaccine preparation in post-Dengvaxia era?external icon
        Galula JU, Salem GM, Chang GJ, Chao DY.
        Hum Vaccin Immunother. 2019 Jul 17.
        The unexpectedly low vaccine efficacy of Dengvaxia(R), developed by Sanofi Pasteur, and a higher risk of severe diseases after vaccination among dengue naive children or children younger than 6 years old, have cast skepticism about the safety of dengue vaccination resulting in the suspension of school-based immunization programs in the Philippines. The absence of immune correlates of protection from dengue virus (DENV) infection hampers the development of other potential DENV vaccines. While tetravalent live-attenuated tetravalent vaccines (LATVs), which mimic natural infection by inducing both cellular and humoral immune responses, are still currently favored, developing a vaccine that provides a balanced immunity to all four DENV serotypes remains a challenge. With the recently advanced understanding of virion structure and B cell immune responses from naturally infected DENV patients, two points of view in developing a next-generation dengue vaccine emerged: one is to induce potent, type-specific neutralizing antibodies (NtAbs) recognizing quaternary structure-dependent epitopes by having four components of vaccine strains replicate equivalently; the other is to induce protective and broadly NtAbs against the four serotypes of DENV with a universal vaccine. This article reviews the studies related to these issues and the current knowledge gap that needs to be filled in.

      5. Introduction: Policy-makers in many countries have been wary of introducing varicella vaccination programs because of concerns that reduced exposures to varicella zoster virus could increase incidence herpes zoster (HZ) incidence. The U.S. introduced varicella vaccination in 1996 and has empiric evidence regarding this concern. Areas covered: This comprehensive review provides background emphasizing the epidemiology of varicella and of HZ in the U.S. before and after introduction of their respective vaccines. The epidemiology is complex, and interpretation is complicated by methodologic challenges, by unexplained increases in age-specific HZ incidence that preceded varicella vaccination, and by introduction of vaccines for prevention of HZ. Nonetheless, observations from studies using different platforms and designs have yielded consistent findings, suggesting they are robust. Expert opinion: There has been no evidence that the U.S. varicella vaccination program increased HZ incidence in the general adult population over baseline trends. Furthermore, HZ incidence in children is declining. The U.S. experience can inform development of new generations of models to predict HZ trends. More importantly, it provides reassurance for countries considering varicella vaccination that an effective program can reduce varicella morbidity and mortality while reducing the likelihood of HZ among children, and potentially, over time, across the entire population.

      6. In response to global interest in the development of a universal influenza vaccine, the Bill & Melinda Gates Foundation, PATH, and the Global Funders Consortium for Universal Influenza Vaccine Development convened a meeting of experts (London, UK, May 2018) to assess the role of a standardized controlled human influenza virus infection model (CHIVIM) towards the development of novel influenza vaccine candidates. This report (in two parts) summarizes those discussions and offers consensus recommendations. This article (Part 1) covers challenge virus selection, regulatory and ethical considerations, and issues concerning standardization, access, and capacity. Part 2 covers specific methodologic considerations. Current methods for influenza vaccine development and licensure require large costly field trials. The CHIVIM requires fewer subjects and the controlled setting allows for better understanding of influenza transmission and host immunogenicity. The CHIVIM can be used to identify immune predictors of disease for at-risk populations and to measure efficacy of potential vaccines for further development. Limitations to the CHIVIM include lack of standardization, limited access to challenge viruses and assays, lack of consensus regarding role of the CHIVIM in vaccine development pathway, and concerns regarding risk to study participants and community. To address these issues, the panel of experts recommended that WHO and other key stakeholders provide guidance on standardization, challenge virus selection, and risk management. A common repository of well-characterized challenge viruses, harmonized protocols, and standardized assays should be made available to researchers. A network of research institutions performing CHIVIM trials should be created, and more study sites are needed to increase capacity. Experts agreed that a research network of institutions working with a standardized CHIVIM could contribute important data to support more rapid development and licensure of novel vaccines capable of providing long-lasting protection against seasonal and pandemic influenza strains.

      7. Convening on the influenza human viral challenge model for universal influenza vaccines, Part 2: Methodologic considerationsexternal icon
        Innis BL, Scorza FB, Blum JS, Jain VK, Aguilar AO, Post DJ, Roberts PC, Wairagkar N, White J, Bresee J.
        Vaccine. 2019 .
        In response to global interest in the development of a universal influenza vaccine, the Bill & Melinda Gates Foundation, PATH, and the Global Funders Consortium for Universal Influenza Vaccine Development convened a meeting of experts (London, UK, May 2018) to assess the role of a standardized controlled human influenza virus infection model (CHIVIM) towards the development of novel influenza vaccine candidates. This report (in two parts) summarizes those discussions and offers consensus recommendations. Part 1 covers challenge virus selection, regulatory and ethical considerations, and issues concerning standardization, access, and capacity. This article (Part 2) summarizes the discussion and recommendations concerning CHIVIM methods. The panelists identified an overall need for increased standardization of CHIVIM trials, in order to produce comparable results that can support universal vaccine licensure. Areas of discussion included study participant selection and screening, route of exposure and dose, devices for administering challenge, rescue therapy, protection of participants and institutions, clinical outcome measures, and other considerations. The panelists agreed upon specific recommendations to improve the standardization and usefulness of the model for vaccine development. Experts agreed that a research network of institutions working with a standardized CHIVIM could contribute important data to support more rapid development and licensure of novel vaccines capable of providing long-lasting protection against seasonal and pandemic influenza strains.

      8. Vaccines for maternal immunization against Group B Streptococcus disease: WHO perspectives on case ascertainment and case definitionsexternal icon
        Seale AC, Baker CJ, Berkley JA, Madhi SA, Ordi J, Saha SK, Schrag SJ, Sobanjo-Ter Meulen A, Vekemans J.
        Vaccine. 2019 Jul 11.
        Group B Streptococcus (GBS) is an important cause of disease in young infants, stillbirths, pregnant and post-partum women. GBS vaccines for maternal immunization are in development aiming to reduce this burden. Standardisation of case definitions and ascertainment methodologies for GBS disease is needed to support future trials of maternal GBS vaccines. Considerations presented here may also serve to promote consistency in observational studies and surveillance, to better establish disease burden. The World Health Organization convened a working group to provide consensus guidance for case ascertainment and case definitions of GBS disease in stillbirths, infants, pregnant and post-partum women, with feedback sought from external stakeholders. In intervention studies, case capture and case ascertainment for GBS disease should be based on antenatal recruitment of women, with active follow-up, systematic clinical assessment, standardised sampling strategies and optimised laboratory methods. Confirmed cases of invasive GBS disease in stillbirths or infants should be included in a primary composite endpoint for vaccine efficacy studies, with GBS cultured from a usually sterile body site (may be post-mortem). For additional endpoints, or observational studies, confirmed cases of GBS sepsis in pregnant and post-partum women should be assessed. Culture independent diagnostic tests (CIDTs) may detect additional presumed cases, however, the use of these diagnostics needs further evaluation. Efficacy of vaccination against maternal and neonatal GBS colonisation, and maternal GBS urinary tract infection could be included as additional, separate, endpoints and/or in observational studies. Whilst the focus here is on specific GBS disease outcomes, intervention studies also present an opportunity to establish the contribution of GBS across adverse perinatal outcomes, including all-cause stillbirth, preterm birth and neonatal encephalopathy.

    • Injury and Violence
      1. The association between exposure to violent pornography and teen dating violence in grade 10 high school studentsexternal icon
        Rostad WL, Gittins-Stone D, Huntington C, Rizzo CJ, Pearlman D, Orchowski L.
        Arch Sex Behav. 2019 Jul 15.
        Exposure to pornography in general has been linked with adolescent dating violence and sexual aggression, but less is known about exposure to violent pornography specifically. The current study examined the association of violent pornography exposure with different forms of teen dating violence (TDV) using baseline survey data from a sample of Grade 10 high school students who reported being in a dating relationship in the past year (n = 1694). Gender-stratified logistic regression models generated odds ratios adjusted for demographics, substance use, history of suspension/expulsion, gender equitable attitudes, and tolerance of rape myths to identify significant associations between violent pornography exposure and self-reported physical, sexual, and threatening TDV perpetration and victimization. Violent pornography exposure was associated with all types of TDV, though patterns differed by gender. Boys exposed to violent pornography were 2-3 times more likely to report sexual TDV perpetration and victimization and physical TDV victimization, while girls exposed to violent pornography were over 1.5 times more likely to be perpetrate threatening TDV compared to their non-exposed counterparts. Comprehensive prevention strategies for TDV may consider the potential risks associated with exposure to violent pornography, particularly for boys, and provide an alternative source of education about healthy sexual behavior and relationships.

    • Laboratory Sciences
      1. Identification of a carbapenemase-producing hypervirulent Klebsiella pneumoniae isolate in the United Statesexternal icon
        Karlsson M, Stanton RA, Ansari U, McAllister G, Chan MY, Sula E, Grass JE, Duffy N, Anacker ML, Witwer ML, Rasheed JK, Elkins CA, Halpin AL.
        Antimicrob Agents Chemother. 2019 Jul;63(7).
        We report on a carbapenemase-producing hypervirulent Klebsiella pneumoniae (CP-hvKP) isolate collected from a U.S. patient at an outpatient clinic. The isolate was identified as K. pneumoniae serotype K1 sequence type 23 and included both a hypervirulence (with rmpA, rmpA2 iroBCDN, peg-344, and iucABCD-iutA genes) and a carbapenemase-encoding (bla KPC-2) plasmid. The emergence of CP-hvKP underscores the importance of clinical awareness of this pathotype and the need for continued monitoring of CP-hvKP in the United States.

      2. N-linked glycosylation of the West Nile virus envelope protein is not a requisite for avian virulence or vector competenceexternal icon
        Maharaj PD, Langevin SA, Bolling BG, Andrade CC, Engle XA, Ramey WN, Bosco-Lauth A, Bowen RA, Sanders TA, Huang CY, Reisen WK, Brault AC.
        PLoS Negl Trop Dis. 2019 Jul 15;13(7):e0007473.
        The N-linked glycosylation motif at amino acid position 154-156 of the envelope (E) protein of West Nile virus (WNV) is linked to enhanced murine neuroinvasiveness, avian pathogenicity and vector competence. Naturally occurring isolates with altered E protein glycosylation patterns have been observed in WNV isolates; however, the specific effects of these polymorphisms on avian host pathogenesis and vector competence have not been investigated before. In the present study, amino acid polymorphisms, NYT, NYP, NYF, SYP, SYS, KYS and deletion (A’DEL), were reverse engineered into a parental WNV (NYS) cDNA infectious clone to generate WNV glycosylation mutant viruses. These WNV glycosylation mutant viruses were characterized for in vitro growth, pH-sensitivity, temperature-sensitivity and host competence in American crows (AMCR), house sparrows (HOSP) and Culex quinquefasciatus. The NYS and NYT glycosylated viruses showed higher viral replication, pH and temperature sensitivity than NYP, NYF, SYP, SYS, KYS and A’DEL viruses in vitro. Interestingly, in vivo results demonstrated asymmetric effects in avian and mosquito competence that were independent of the E-protein glycosylation status. In AMCRs and HOSPs, all viruses showed comparable viremias with the exception of NYP and KYS viruses that showed attenuated phenotypes. Only NYP showed reduced vector competence in both Cx. quinquefasciatus and Cx. tarsalis. Glycosylated NYT exhibited similar avian virulence properties as NYS, but resulted in higher mosquito oral infectivity than glycosylated NYS and nonglycosylated, NYP, NYF, SYP and KYS mutants. These data demonstrated that amino acid polymorphisms at E154/156 dictate differential avian host and vector competence phenotypes independent of E-protein glycosylation status.

      3. Repeated vaccination against matched H3N2 influenza virus gives less protection than single vaccination in ferretsexternal icon
        Music N, Tzeng WP, Liaini Gross F, Levine MZ, Xu X, Shieh WJ, Tumpey TM, Katz JM, York IA.
        NPJ Vaccines. 2019 ;4:28.
        Epidemiological studies suggest that humans who receive repeated annual immunization with influenza vaccine are less well protected against influenza than those who receive vaccine in the current season only. To better understand potential mechanisms underlying these observations, we vaccinated influenza-naive ferrets either twice, 10 months apart (repeated vaccination group; RV), or once (current season only group; CS), using a prime-boost regimen, and then challenged the ferrets with A/Hong Kong/4801/2014(H3N2). Ferrets that received either vaccine regimen were protected against influenza disease and infection relative to naive unvaccinated ferrets, but the RV group shed more virus, especially at the peak of virus shedding 2 days post infection (p < 0.001) and regained weight more slowly (p < 0.05) than those in the CS group. Qualitative, rather than quantitative, differences in the antibody response may affect protection after repeated influenza vaccination.

      4. We identified a strain of betacoronavirus BtKY72/Rhinolophus sp./Kenya/2007 (here BtKY72) from rectal swab samples in Kenyan bats. This paper reports the complete genomic sequence of BtKY72, which is closely related to BtCoV/BM48-31/Bulgaria/2008, a severe acute respiratory syndrome (SARS)-related virus from Rhinolophus bats in Europe.

    • Maternal and Child Health
      1. Infection and fever in pregnancy and autism spectrum disorders: Findings from the Study to Explore Early Developmentexternal icon
        Croen LA, Qian Y, Ashwood P, Zerbo O, Schendel D, Pinto-Martin J, Daniele Fallin M, Levy S, Schieve LA, Yeargin-Allsopp M, Sabourin KR, Ames JL.
        Autism Res. 2019 Jul 17.
        Maternal infection and fever during pregnancy have been implicated in the etiology of autism spectrum disorder (ASD); however, studies have not been able to separate the effects of fever itself from the impact of a specific infectious organism on the developing brain. We utilized data from the Study to Explore Early Development (SEED), a case-control study among 2- to 5-year-old children born between 2003 and 2006 in the United States, to explore a possible association between maternal infection and fever during pregnancy and risk of ASD and other developmental disorders (DDs). Three groups of children were included: children with ASD (N = 606) and children with DDs (N = 856), ascertained from clinical and educational sources, and children from the general population (N = 796), randomly sampled from state birth records. Information about infection and fever during pregnancy was obtained from a telephone interview with the mother shortly after study enrollment and maternal prenatal and labor/delivery medical records. ASD and DD status was determined by an in-person standardized developmental assessment of the child at 3-5 years of age. After adjustment for covariates, maternal infection anytime during pregnancy was not associated with ASD or DDs. However, second trimester infection accompanied by fever elevated risk for ASD approximately twofold (aOR = 2.19, 95% confidence interval 1.14-4.23). These findings of an association between maternal infection with fever in the second trimester and increased risk of ASD in the offspring suggest that the inflammatory response to the infectious agent may be etiologically relevant. Autism Res2019. (c) 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Using data from a large multisite study in the United States-the Study to Explore Early Development-we found that women who had an infection during the second trimester of pregnancy accompanied by a fever are more likely to have children with ASD. These findings suggest the possibility that only more severe infections accompanied by a robust inflammatory response increase the risk of ASD.

      2. Injury-related treatments and outcomes in preschool children with autism spectrum disorder: Study to Explore Early Development (SEED)external icon
        DiGuiseppi C, Sabourin KR, Levy SE, Soke GN, Lee LC, Wiggins L, Schieve LA.
        Res Autism Spectr Disord. 2019 October;66.
        Background: Evidence about injury management and outcomes in children with autism spectrum disorder (ASD) is limited. Method(s): Cross-sectional analyses included children aged 30-68 months with at least one medically attended injury. Standardized diagnostic instruments determined ASD cases. Parent-reported injury treatments and outcomes were examined in ASD cases (n = 224) versus developmental delays/disorders (DD) (n = 188) and population (POP) (n = 267) controls, adjusting for child and family characteristics using logistic regression. Result(s): Injury characteristics were similar between groups. Most children (82.5%) had emergency care (EC) or hospitalization after injury. Nearly half (46.4%) ever received a medication or injection, mostly analgesics (53.4%) and local anesthetics (23.8%), while 9.4% ever received surgery, most often for open wound (47.0%) or fracture (16.7%). ASD group children were less likely than DD group children to receive medication/injection (41.1% vs. 53.2%, adjusted odds ratio [aOR] = 0.60 [0.40, 0.90]); receipt of EC/hospitalization and surgery were comparable. Children with ASD more often had surgery than POP children (14.3% vs. 4.9%, aOR = 2.62 [1.31, 5.25]); receipt of EC/hospitalization and medication/injection were similar. Loss of consciousness was uncommon (ASD = 6.3%, DD = 5.3%, POP = 3.4%), as was long-term or significant behavior change (ASD = 5.4%, DD = 3.2%, POP = 3.2%); differences were not significant. Conclusion(s): Injured children with ASD received fewer medications/injections than children with non-ASD developmental delays/disorders and more surgical treatments than general population children. Injury management was otherwise similar between groups. Understanding whether these results reflect child or injury characteristics or provider perceptions about behaviors and pain thresholds of children with ASD, and how these may influence care, requires further study.

      3. Hypospadias prevalence and trends in international birth defect surveillance systems, 1980-2010external icon
        Yu X, Nassar N, Mastroiacovo P, Canfield M, Groisman B, Bermejo-Sanchez E, Ritvanen A, Kiuru-Kuhlefelt S, Benavides A, Sipek A, Pierini A, Bianchi F, Kallen K, Gatt M, Morgan M, Tucker D, Canessa MA, Gajardo R, Mutchinick OM, Szabova E, Csaky-Szunyogh M, Tagliabue G, Cragan JD, Nembhard WN, Rissmann A, Goetz D, Bower C, Baynam G, Lowry RB, Leon JA, Luo W, Rouleau J, Zarante I, Fernandez N, Amar E, Dastgiri S, Contiero P, Martinez-de-Villarreal LE, Borman B, Bergman JE, de Walle HE, Hobbs CA, Nance AE, Agopian AJ.
        Eur Urol. 2019 Jul 9.
        BACKGROUND: Hypospadias is a common male birth defect that has shown widespread variation in reported prevalence estimates. Many countries have reported increasing trends over recent decades. OBJECTIVE: To analyze the prevalence and trends of hypospadias for 27 international programs over a 31-yr period. DESIGN, SETTING, AND PARTICIPANTS: The study population included live births, stillbirths, and elective terminations of pregnancy diagnosed with hypospadias during 1980-2010 from 27 surveillance programs around the world. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We used joinpoint regression to analyze changes over time in international total prevalence of hypospadias across programs, prevalence for each specific program, and prevalence across different degrees of severity of hypospadias. RESULTS AND LIMITATIONS: The international total prevalence of hypospadias for all years was 20.9 (95% confidence interval: 19.2-22.6) per 10000 births. The prevalence for each program ranged from 2.1 to 39.1 per 10000 births. The international total prevalence increased 1.6 times during the study period, by 0.25 cases per 10000 births per year (p<0.05). When analyzed separately, there were increasing trends for first-, second-, and third-degree hypospadias during the early 1990s to mid-2000s. The majority of programs (61.9%) had a significantly increasing trend during many of the years evaluated. Limitations include known differences in data collection methods across programs. CONCLUSIONS: Although there have been changes in clinical practice and registry ascertainment over time in some countries, the consistency in the observed increasing trends across many programs and by degrees of severity suggests that the total prevalence of hypospadias may be increasing in many countries. This observation is contrary to some previous reports that suggested that the total prevalence of hypospadias was no longer increasing in recent decades. PATIENT SUMMARY: We report on the prevalence and trends of hypospadias among 27 birth defect surveillance systems, which indicate that the prevalence of hypospadias continues to increase internationally.

    • Occupational Safety and Health
      1. Suicide and drug-related mortality following occupational injuryexternal icon
        Applebaum KM, Asfaw A, O’Leary PK, Busey A, Tripodis Y, Boden LI.
        Am J Ind Med. 2019 Jul 12.
        BACKGROUND: Drug overdoses and suicides have been rising since 2000 and are major contributors to a 3-year decline in US life expectancy. Studies suggest that injured workers have elevated rates of depression and opioid use, but no studies have measured excess mortality related to these risks. MATERIALS AND METHODS: We linked New Mexico workers’ compensation data for 100 806 workers injured in 1994 through 2000 with Social Security Administration earnings and mortality data through 2013 and National Death Index cause of death data. We then estimated the association between receiving lost-time workers’ compensation benefits and mortality hazard ratios (HRs) and 95% confidence intervals (CIs) based on Fine and Gray cause-specific subdistribution hazards for common causes of death and for drug-related, suicide, and alcohol-related mortality. RESULTS: There was almost a 3-fold increase in combined drug-related and suicide mortality hazard among women (HR = 2.63, 95% CI = 1.91-3.64) and a substantial increase among men (HR = 1.42, 95% CI = 1.13-1.79). Circulatory disease mortality hazard was elevated for men (HR = 1.25, 95% CI = 1.05-1.50). CONCLUSION: Workplace injuries severe enough to require more than a week off work may impair workers’ long-term health and well-being. Drug-related deaths and suicides may be important contributors to the long-term excess mortality of injured workers. Improved workplace conditions, improved pain treatment, better treatment of substance use disorders, and treatment of postinjury depression may substantially reduce mortality consequent to workplace injuries.

      2. Evaluation of a 25-mm disposable sampler relative to the inhalable aerosol conventionexternal icon
        Borsh FB, Sleeth DK, Handy RG, Pahler LF, Andrews R, Ashley K.
        J Occup Environ Hyg. 2019 Jul 12:1-9.
        An ideal inhalable aerosol sampler for occupational exposure monitoring would have a sampling efficiency that perfectly matches the inhalable particulate matter (IPM) criterion. Two common aerosol samplers in use worldwide are the closed-face cassette (CFC) and the Institute of Occupational Medicine (IOM) sampler. However, the CFC is known to under-sample, with near zero sampling efficiency for particles >30 microm, whereas the IOM, considered by many to be the “gold standard” in inhalable samplers, has been shown to over-sample particles >60 microm. A new sampler in development incorporates characteristics of both the CFC and the IOM. Like the CFC, it would be disposable, have a simple design, and is intended to be oriented at a 45 degrees downward angle. Like the IOM, the new sampler has a 15-mm inlet diameter and incorporates a 25-mm filter cassette with a protruding lip. The IOM is oriented at 0 degrees to the horizontal, so it is hypothesized that orienting the new sampler at approximately 45 degrees downward angle will reduce oversampling of larger particles. In comparison, the CFC’s inlet diameter is 4 mm; increasing the size of the inlet should allow the new sampler to have an increased efficiency relative to the CFC for all particles. A unique characteristic of the new sampler is the incorporation of a one-piece capsule-style filter that mimics the IOM’s cassette but is made of disposable material. Seven different sizes of alumina particles (mean aerodynamic diameters from 4.9-62.4 microm) were tested (total = 124 samples collected). For each test, six samplers were placed on a manikin located inside a wind tunnel operated at 0.2 m/sec. Results indicated that the new sampler improved on the CFC for smaller particles, providing a larger range for which it matches the IPM criterion, up to 44.3 microm. However, the efficiency was significantly lower in comparison to the IPM criterion for particle sizes above 60 microm. Overall, the new sampler showed promise, but additional modifications may help improve sampling efficiency for larger particles.

      3. Prevalence of COPD among workers with work-related asthmaexternal icon
        Dodd KE, Mazurek JM.
        J Asthma. 2019 Jul 15:1-9.
        Objective: Concurrent asthma and chronic obstructive pulmonary disease (COPD) diagnoses occur in 15%-20% of patients, and have been associated with worse health outcomes than asthma or COPD alone. Work-related asthma (WRA), asthma that is caused or made worse by exposures in the workplace, is characterized by poorly controlled asthma. The objective of this study was to assess the proportion of ever-employed adults (>/=18 years) with current asthma who have been diagnosed with COPD, by WRA status. Methods: Data from 23 137 respondents to the 2012-2014 Behavioral Risk Factor Surveillance System Asthma Call-back Survey from 31 states and the District of Columbia were examined. Logistic regression was used to calculate adjusted prevalence ratios (PRs), examining six disjoint categories of WRA-COPD overlap with non-WRA/no COPD as the referent category. Results: An estimated 51.9% of adults with WRA and 25.6% of adults with non-WRA had ever been diagnosed with COPD. Adults with WRA/COPD were more likely than those with non-WRA/no COPD to have an asthma attack (PR = 1.77), urgent treatment for worsening asthma (PR = 2.85), an asthma-related emergency room visit (PR = 4.21), overnight stay in a hospital because of asthma (PR = 6.57), an activity limitation on 1-13 days (PR = 2.01) or >/=14 days (PR = 5.02), and very poorly controlled asthma (PR = 3.22). Conclusions: COPD was more frequently diagnosed among adults with WRA than those with non-WRA, and adults diagnosed with both WRA and COPD appear to have more severe adverse asthma outcomes than those with non-WRA and no COPD.

      4. Prevalence of workplace discrimination and mistreatment in a national sample of older U.S. workers: The REGARDS cohort studyexternal icon
        Fekedulegn D, Alterman T, Charles LE, Kershaw KN, Safford MM, Howard VJ, MacDonald LA.
        SSM – Population Health. 2019 August;8.
        Although workplace discrimination and mistreatment (WDM) has recently drawn widespread media attention, our understanding of the prevalence of these phenomena remains limited. In the current study, we generated national prevalence estimates of WDM from a community-based cohort of employed black and white men and women aged >=48 years. Measures of WDM in the current job were obtained by computer-assisted telephone interview (2011-2013) involving dichotomous responses (yes or no) to five questions and deriving a composite measure of discrimination (yes to at least one). Prevalence estimates and age- and region-adjusted prevalence ratios were derived with use of SUDAAN software to account for the complex sample design. Analyses were stratified by race and sex subgroups. This sample represents over 40 million U.S. workers aged >=48 years. The prevalence of workplace discrimination ranged from a high of 25% for black women to a low of 11% for white men. Blacks reported a 60% higher rate of discrimination compared to whites; women reported a 53% higher prevalence of discrimination, compared with men. The prevalence of workplace mistreatment ranged from 13% for black women to 8% for white men. Women reported a 52% higher prevalence of mistreatment compared to men, while differences by race were not significant. Mistreatment was 4-8 times more prevalent among those reporting discrimination than among those reporting none. Subgroup differences in mistreatment were confined to the wage-employed. Findings suggest that middle age and older wage-employed blacks and women experience the highest prevalence of WDM; moreover, discrimination is strongly associated with mistreatment. This study contributes to our understanding of at-risk segments of the U.S. labor market and the need for targeted interventions to reduce WDM.

      5. Background: Liquid chromatography-tandem mass spectrometry (LC-MSMS) for simultaneous analysis of multiple microbial secondary metabolites (MSMs) is potentially subject to interference by matrix components. Methods: We examined potential matrix effects (MEs) in analyses of 31 MSMs using ultraperformance LC-MSMS. Twenty-one dust aliquots from three buildings (seven aliquots/building) were spiked with seven concentrations of each of the MSMs (6.2 pg/mul-900 pg/mul) and then extracted. Another set of 21 aliquots were first extracted and then, the extract was spiked with the same concentrations. We added deepoxy-deoxynivalenol (DOM) to all aliquots as a universal internal standard. Ten microliters of the extract was injected into the ultraperformance LC-MSMS. ME was calculated by subtracting the percentage of the response of analyte in spiked extract to that in neat standard from 100. Spiked extract results were used to create a matrix-matched calibration (MMC) curve for estimating MSM concentration in dust spiked before extraction. Results: Analysis of variance was used to examine effects of compound (MSM), building and concentration on response. MEs (range: 63.4%-99.97%) significantly differed by MSM (p < 0.01) and building (p < 0.05). Mean percent recoveries adjusted with DOM and the MMC method were 246.3% (SD = 226.0) and 86.3% (SD = 70.7), respectively. Conclusion: We found that dust MEs resulted in substantial underestimation in quantifying MSMs and that DOM was not an optimal universal internal standard for the adjustment but that the MMC method resulted in more accurate and precise recovery compared with DOM. More research on adjustment methods for dust MEs in the simultaneous analyses of multiple MSMs using LC-MSMS is warranted.

      6. Intersegmental differences in facial warmth sensitivity during rest, passive heat and exerciseexternal icon
        Kim JH, Seo Y, Quinn T, Yorio P, Roberge R.
        Int J Hyperthermia. 2019 ;36(1):654-659.
        Background: Increased facial warmth sensations could lead to thermal discomfort, and different facial regions may demonstrate concurrent temperature differences. The study aim was examining facial warmth sensitivity differences by facial region under differing environmental conditions. Methods: Twelve men had heat flux measurements of six facial regions during 30 min each of rest in thermoneutral conditions (25 degrees C, 30% relative humidity (RH)), rest in warm conditions (40 degrees C, 30% RH), and cycling at 400 W of metabolic heat production (40 degrees C, 30% RH). Results: The forehead demonstrated highest temperatures at termination of all study conditions; lowest temperatures were noted for the nose under thermoneutral conditions and chin during warmth and exercise conditions. Five of six facial regions demonstrated significant differences in warmth sensitivity, decreasing to two of six regions during warm conditions and one of six regions during exercise, with the upper lip most sensitive in all conditions. Body thermal comfort (TC) perceptions, regressed individually on mean facial temperature (Tface) vs. core temperature (Tco), indicated that Tface was significantly more related than Tco to perceived TC (p = .001). Perceived TC, regressed individually on perceived overall body thermal sensation (TS) vs. facial TS, demonstrated that Tface was significantly more related to perceived TC (p = .004). Conclusion: There were regional differences in facial warmth sensitivity together with different facial temperatures moving toward equilibration when the body is subjected to heat-producing activities. Perceptions of TC were more strongly related to Tface than to Tco or overall body TS.

      7. Validity and reliability of the updated CDC Worksite Health ScoreCardexternal icon
        Roemer EC, Kent KB, Mummert A, McCleary K, Palmer JB, Lang JE, Matson-Koffman D, Goetzel RZ.
        J Occup Environ Med. 2019 Jul 12.
        OBJECTIVE: To evaluate the reliability and validity of the updated 2019 CDC Worksite Health ScoreCard (CDC ScoreCard), which includes four new modules. METHODS: We pilot tested the updated instrument at 93 worksites, examining question response concurrence between two representatives from each worksite. We conducted cognitive interviews and site visits to evaluate face validity, and refined the instrument for public distribution. RESULTS: The mean question concurrence rate was 73.4%. Respondents reported the tool to be useful for assessing current workplace programs and planning future initiatives. On average, 43% of possible interventions included in the CDC ScoreCard were in place at the pilot sites. CONCLUSIONS: The updated CDC ScoreCard is a valid and reliable tool for assessing worksite health promotion policies, educational and lifestyle counseling programs, environmental supports, and health benefits.

    • Occupational Safety and Health – Mining
      1. Investigating possible infectious causes of chronic kidney disease of unknown etiology in a Nicaraguan mining communityexternal icon
        Yih WK, Kulldorff M, Friedman DJ, Leibler JH, Amador JJ, Lopez-Pilarte D, Galloway RL, Ramirez-Rubio O, Riefkohl A, Brooks DR.
        Am J Trop Med Hyg. 2019 Jul 15.
        A chronic kidney disease of unknown etiology (CKDu) has been killing workers in Central America. Occupational heat stress is thought to play an important role. Leptospirosis and hantavirus have been suggested as additional possible risk factors. In a case-control study in a Nicaraguan mining community, a structured survey was administered to adults, and biological measurements and specimens were taken. Serum was analyzed for antibodies to Leptospira and hantavirus. Before statistical analysis, a board-certified nephrologist determined final case and control status based on serum creatinine and other laboratory values. Multivariable analysis was by logistic regression. In sensitivity analyses, cases were restricted to those diagnosed with CKDu in the previous 3 years. Of 320 eligible participants, 112 were classified as presumptive cases, 176 as controls and 32 as indeterminant. The risk of CKDu in those ever having worked in mining or construction was 4.4 times higher than in other participants (odds ratio = 4.44, 95% CI: 1.96-10.0, P = 0.0003). Eighty-three (26%) of the 320 participants were seropositive for at least one tested strain of Leptospira. No evidence of a causal link between leptospirosis or hantavirus and CKDu was found. The sensitivity analyses provide some evidence against the hypotheses that leptospirosis or hantavirus leads to CKDu within a few years. A major limitation was the impossibility of determining the absolute or relative timing of infection and CKDu onset. A prospective cohort design, with repeated collection of specimens over several years, could yield clearer answers about infections as potential etiologic agents in CKDu.

    • Parasitic Diseases
      1. Diagnostic dose determination and efficacy of chlorfenapyr and clothianidin insecticides against Anopheles malaria vector populations of western Kenyaexternal icon
        Agumba S, Gimnig JE, Ogonda L, Ombok M, Kosgei J, Munga S, Guyah B, Omondi S, Ochomo E.
        Malar J. 2019 Jul 17;18(1):243.
        BACKGROUND: Malaria vector control is dependent on chemical insecticides applied to walls by indoor residual spraying or on long-lasting insecticidal nets. The emergence and spread of insecticide resistance in major malaria vectors may compromise malaria control and elimination efforts. The aim of this study was to estimate a diagnostic dose for chlorfenapyr (class: pyrrole) and clothianidin (class: neonicotinoid) and assess the baseline susceptibility of three major Anopheles malaria vectors of western Kenya to these two insecticides. METHODS: The Centers for Disease Control and Prevention (CDC) bottle assay was used to determine the diagnostic doses of chlorfenapyr and clothianidin insecticides against the susceptible Kisumu strain of Anopheles gambiae. Probit analysis was used to determine the lethal doses at which 50% (LD50) and 99% (LD99) of the susceptible mosquitoes would be killed 24, 48 and 72 h following exposure for 1 h. Insecticidal efficacy of chlorfenapyr, clothianidin and the pyrethroid deltamethrin was then evaluated against field collected female Anopheles mosquitoes sampled from Nyando, Bumula and Ndhiwa sub-Counties in western Kenya. Members of Anopheles funestus and An. gambiae complexes were identified using polymerase chain reaction (PCR). RESULTS: The determined diagnostic doses of chlorfenapyr and clothianidin insecticides were 50 microg/bottle and 150 microg/bottle, respectively, for An. gambiae, Kisumu strain. When exposed to the diagnostic dose of each insecticide, Anopheles malaria vector populations in western Kenya were susceptible to both insecticides with 100% mortality observed after 72 h. Mortality of mosquitoes exposed to deltamethrin increased over time but did not reach 100%. Mortality of Anopheles arabiensis from Nyando exposed to deltamethrin was 83% at 24 h, 88% at 48 h and 94.5% at 72 h while An. funestus from Ndhiwa was 89% at 24 h, 91.5% at 48 h and 94.5% at 72 h. CONCLUSION: Mosquitoes of western Kenya, despite being resistant to pyrethroids, are susceptible to chlorfenapyr and clothianidin. Field evaluations of the formulated product are needed.

      2. Elimination of onchocerciasis in Africa by 2025: the need for a broad perspectiveexternal icon
        Cupp E, Sauerbrey M, Cama V, Eberhard M, Lammie PJ, Unnasch TR.
        Infect Dis Poverty. 2019 Jul 15;8(1):50.
        BACKGROUND: In response to the recent publication “Is onchocerciasis elimination in Africa feasible by 2025: a perspective based on lessons learnt from the African control programmes” by Dadzie et al., it is important to clarify and highlight the positive and unequivocal research and operational contributions from the American experience towards the worldwide elimination of human onchocerciasis (river blindness). MAIN TEXT: The strategies of twice or more rounds of mass drug administration (MDA) of ivermectin per year, as well as the use of OV-16 serology have allowed four American countries to be verified by World Health Organization to have eliminated transmission of Onchocerca volvulus, the etiological agent. These advances were also implemented in Sudan and Uganda; currently, both are the only African countries where ivermectin MDA was safely stopped in several transmission zones. CONCLUSIONS: Programmatic treatment and evaluation approaches, pioneered in the Americas, are the most efficient among the existing tools for elimination, and their broader use could catalyze the successful elimination of this disease in Africa.

      3. Ocular trematodiasis caused by the avian eye fluke philophthalmus in southern Texasexternal icon
        Sapp SG, Alhabshan RN, Bishop HS, Fox M, Ndubuisi M, Snider CE, Bradbury RS.
        Open Forum Infect Dis. 2019 Jul;6(7):ofz265.
        A trematode identified as a Philophthalmus sp was extracted from the bulbar conjunctiva of a patient in southern Texas with short-distance travel to Mexico. This parasite is very rarely reported from humans, and species identification is challenging. Aspects of diagnosis, zoonotic transmission, and unresolved questions about Philophthalmus spp are discussed.

      4. [No abstract]

    • Public Health Law
      1. Broadband internet access is a super-determinant of health that plays an important role in healthcare and public health outcomes. Laws and policies shape implementation and use of broadband for healthcare and public health. Connecting broadband and telehealth laws with their health impacts, through legal epidemiological research, enables states to make evidence-based decisions to improve health outcomes for underserved populations.

      2. Healthy spaces: Legal tools, innovations, and partnershipsexternal icon
        Brady RA, Stettner JL, York L.
        J Law Med Ethics. 2019 Jun;47(2_suppl):27-30.
        This article explores innovative legal tools in built environment settings. Using tangible examples, the discussion will leverage the authors’ expertise in the law, public health, and architecture to explore strategies in domestic and international settings to explain how healthy spaces make a direct public health impact on people’s lives.

      3. One fundamental barrier to eliminating health disparities, particularly with regard to the determinants of health, is the persistence of discrimination. Civil rights law is the primary legal mechanism used to address discrimination. Federal civil rights laws have been the subject of wider analyses as a determinant of health as well as a tool to address health disparities. The research on state civil rights laws, while more limited, is growing. This article will highlight a few examples of how some states are using civil rights laws to combat discrimination, particularly in more expansive ways and in the interest of new populations, presenting tools that can target determinants and address the goal of reducing health disparities.

      4. Building the legal capacity of the public health workforce: Introducing the Public Health Law Academyexternal icon
        Ransom MM, Johnson R, Ashe M, Penn M, Ferrell FA, Baffour K.
        J Law Med Ethics. 2019 Jun;47(2_suppl):80-82.
        Knowledge of the law and its impact on health outcomes is increasingly important in public health practice. The CDC’s Public Health Law Academy helps satisfy this need by providing online trainings, facilitator toolkits, and legal epidemiology tools to aid practitioners in learning about the law’s role in promoting public health.

    • Public Health Leadership and Management
      1. Tracking public health workforce retention: Observations from CDC’s Public Health Associate Programexternal icon
        Wigington CJ, Colman LT, Sobelson RK, Young AC.
        Am J Public Health. 2019 Jul 18:e1-e3.
        Objectives. To describe the career trajectories of 1 cohort of US Public Health Associate Program (PHAP) alumni over 3 years since completing PHAP. Methods. We distributed a Web-based survey at 3 time points between 2014 and 2017 (response rate = 76%). We calculated descriptive statistics in SPSS. Results. At all time points, most alumni were employed. Of those, the percentage employed in public health was 100% at program completion, 86% at year 1, and 68% at year 3. Conclusions. Most alumni were employed in public health jobs at each time point. At the 3-year mark, approximately a third of the alumni had left public health employment, which is in line with documented rates of turnover within the broader public health workforce. Public Health Implications. Service learning programs like PHAP are effective at recruiting early career professionals into public health. The extent to which PHAP is effective at retaining workers in public health after the program appears most promising immediately following the program or in the short term after the program concludes. The extent to which workers are retained in the longer term requires further study. (Am J Public Health. Published online ahead of print July 18, 2019: e1-e3. doi:10.2105/AJPH.2019.305156).

    • Reproductive Health
      1. Healthcare provider knowledge regarding oral contraception effectiveness for women with a history of bariatric malabsorptive proceduresexternal icon
        Shah JP, Jatlaoui TC, Zapata LB, Curtis KM, Pagano HP, Whiteman MK.
        Surg Obes Relat Dis. 2019 Jun 17.
        BACKGROUND: Clinical practice guidelines that recommend women avoid pregnancy immediately after bariatric surgery, highlighting the need for effective contraception. However, women with a history of malabsorptive bariatric procedures should generally not use oral contraceptives, as these procedures may decrease oral contraceptive effectiveness. OBJECTIVES: To identify provider characteristics associated with knowledge of combined oral contraceptive (COC) effectiveness. SETTING: United States. METHODS: We analyzed weighted survey data collected from national samples of public-sector health centers and office-based physicians who regularly provide family planning services (N = 2060). We asked providers about the effectiveness of COCs for women with a history of malabsorptive procedures compared with healthy women, giving them the response options of more/equally effective, less effective, and do not know. We used multinomial logistic regression to calculate adjusted odds ratios and 95% confidence intervals to identify characteristics associated with knowledge of COC effectiveness. RESULTS: Approximately 55% of providers correctly answered that COCs are less effective for women with malabsorptive procedures; 25% considered COCs more/equally effective, and 20% were uncertain. Among public-sector providers, the adjusted odds of uncertainty were significantly higher for those whose clinical focus was not reproductive health, for nurses versus advanced practice clinicians, and for providers working in clinics without Title X funding. For office-based physicians, adolescent medicine providers had higher odds of uncertainty versus obstetrician-gynecologists. Physicians practicing in settings classified as “other” (such as community health centers) had higher odds of considering COCs effective compared with those practicing in hospital or university clinics. CONCLUSIONS: Substantial proportions of surveyed providers had inadequate knowledge of COC effectiveness for women with a history of malabsorptive procedures.

    • Substance Use and Abuse
      1. U.S. adults’ attitudes toward lowering nicotine levels in cigarettesexternal icon
        Ali FR, Al-Shawaf M, Wang TW, King BA.
        Am J Prev Med. 2019 Jul 10.
        INTRODUCTION: This study assessed U.S. adults’ attitudes toward lowering the nicotine levels in cigarettes to make them less addictive. METHODS: Data from the 2018 SummerStyles, a web-based panel survey of U.S. adults aged >/=18 years (n=4,037) fielded in June-July, were analyzed in 2018. Respondents were asked: Do you favor or oppose requiring cigarette makers to lower the nicotine levels in cigarettes so that they are less addictive? Responses were strongly favor, somewhat favor, somewhat oppose, and strongly oppose. Sociodemographic correlates of favorability (strongly favor or somewhat favor) were assessed using multivariable Poisson regression. RESULTS: Eighty-one percent of adults in 2018 strongly or somewhat favored requiring cigarette makers to lower the nicotine levels in cigarettes to make them less addictive, including 80.6% of current cigarette smokers, 84.3% of former smokers, and 81.3% of never smokers. Favorability was 71.5% among current noncigarette tobacco product users and 81.9% among nonusers. Following adjustment, slight variations in favorability existed by sex, age, race/ethnicity, and other tobacco product use. CONCLUSIONS: Most adults favor requiring cigarette makers to lower the nicotine levels in cigarettes, including 8 in 10 current cigarette smokers. These findings can help inform the U.S. Food and Drug Administration’s recent proposal to pursue a nicotine reduction standard for cigarettes.

      2. Changes in reported injection behaviors following the public health response to an HIV outbreak among people who inject drugs: Indiana, 2016external icon
        Dasgupta S, Broz D, Tanner M, Patel M, Halleck B, Peters PJ, Weidle PJ, O’Donnell J, Amlung J, McAlister C, Chapman E, Bailey A, Burnett J, Duwve J.
        AIDS Behav. 2019 Jul 16.
        A syringe services program (SSP) was established following the Indiana HIV outbreak among persons who inject drugs (PWID) in Scott County. Among Indiana-based PWID, we examined injection behaviors associated with HIV status, SSP use after its establishment, and changes in injection behaviors after the outbreak response. During 2016, we interviewed 200 PWID and assessed injection behaviors before the response by HIV status. We reported injection behaviors prior to the response and used Fisher’s exact Chi square tests (P < 0.05) to assess differences by HIV status. Next, among persons who injected both before (July-December 2014) and after (past 30 days) the response, we (1) reported the proportion of persons who used the SSP to obtain sterile syringes, and assessed differences in SSP use by HIV status using Fisher’s exact Chi square tests; and (2) compared distributive and receptive sharing of injection equipment and disposal of syringes before and after the outbreak response, and assessed statistical differences using McNemar’s test. We also compared injection behaviors before and after the response by HIV status. Injecting extended release oxymorphone (Opana(R) ER); receptive sharing of syringes and cookers; and distributive sharing of cookers, filters, or water before the response were associated with HIV infection. SSP use was high (86%), particularly among HIV-positive compared with HIV-negative persons (98% vs. 84%). Injection equipment sharing decreased and safe disposal of used syringes increased after the response, especially among HIV-positive persons. Injection equipment sharing contributed to the outbreak. High SSP use following the response, particularly among HIV-positive persons, contributed to decreased high-risk injection practices.

      3. An Intertemporal Analysis of Post-FCTC Era Household Tobacco Consumption in Pakistanexternal icon
        Datta BK, Husain MJ, Nargis N.
        Int J Environ Res Public Health. 2019 Jul 16;16(14).
        Since the ratification of the WHO Framework Convention on Tobacco Control (FCTC) in 2004, Pakistan has taken various measures of tobacco control. This study examines how these tobacco control measures are associated with change in household-level tobacco consumption patterns in Pakistan over the decade (2005 to 2016) after FCTC ratification. We used multiple waves of the household survey data of Pakistan from 2004-2005 to 2015-2016 for analyzing household-level tobacco use. We find that tobacco consumption remains at a significantly high level (45.5%) in Pakistan despite the recent declining trend in the post-FCTC era. During the preparatory phase of FCTC implementation between 2005 and 2008, the smoking rate was on the rise, and smokeless tobacco use was declining. Over the implementation phase of FCTC policies between 2008 and 2016, the pattern of change in tobacco use reversed-the smoking rate started to decrease while smokeless tobacco use started to rise. However, the decrease in the smoking rate was slower and the increase in smokeless tobacco use at the national level was driven by an increase among the poor and middle-income households. These trends resulted in the growing burden of tobacco expenditure among the poor and middle-income households relative to the wealthier households.

      4. Monitoring opioid addiction and treatment: Do you know if your population is engaged?external icon
        Prieto JT, McEwen D, Davidson AJ, Al-Tayyib A, Gawenus L, Papagari Sangareddy SR, Blum J, Foldy S, Shlay JC.
        Drug Alcohol Depend. 2019 Jul 6;202:56-60.
        BACKGROUND: Assessment of people affected by opioid-related problems and those receiving care is challenging due to lack of common definitions and scattered information. We sought to fill this gap by demonstrating a method to describe a continuum of opioid addiction care in a large, public safety-net institution. METHODS: Using 2017 clinical and administrative data from Denver Health (DH), we created operational definitions for opioid use disorder (OUD), opioid misuse (OM), and opioid poisoning (OP). Six stages along a continuum of patient engagement in opioid addiction care were developed, and operational definitions assigned patients to stages for a specific time point of analysis. National data was used to estimate the Denver population affected by OUD, OM and OP. RESULTS: In 2017, an estimated 6688 people aged >/=12 years were affected by OUD, OM, or OP in Denver; 48.4% (3238/6688) were medically diagnosed in DH. Of those, 32.5% (1051/3238) were in the medication assisted treatment stage, and, of those, 59.8% (629/1051) in the adhered to treatment stage. Among that latter group, 78.4% (493/629) adhered at least 90 days and 52.3% (329/629) for more than one year. Among patients who received medication assisted treatment, less than one third (31.3%, 329/1051) were adherent for more than one year. CONCLUSIONS: A health-system level view of the continuum of opioid addiction care identified improvement opportunities to better monitor accuracy of diagnosis, treatment capacity, and effectiveness of patient engagement. Applied longitudinally at local, state and national levels, the model could better synergize responses to the opioid crisis.

      5. State-specific prevalence of quit attempts among adult cigarette smokers – United States, 2011-2017external icon
        Walton K, Wang TW, Schauer GL, Hu S, McGruder HF, Jamal A, Babb S.
        MMWR Morb Mortal Wkly Rep. 2019 Jul 19;68(28):621-626.
        From 1965 to 2017, the prevalence of cigarette smoking among U.S. adults aged >/=18 years decreased from 42.4% to 14.0%, in part because of increases in smoking cessation (1,2). Increasing smoking cessation can reduce smoking-related disease, death, and health care expenditures (3). Increases in cessation are driven in large part by increases in quit attempts (4). Healthy People 2020 objective 4.1 calls for increasing the proportion of U.S. adult cigarette smokers who made a past-year quit attempt to >/=80% (5). To assess state-specific trends in the prevalence of past-year quit attempts among adult cigarette smokers, CDC analyzed data from the 2011-2017 Behavioral Risk Factor Surveillance System (BRFSS) surveys for all 50 states, the District of Columbia (DC), Guam, and Puerto Rico. During 2011-2017, quit attempt prevalence increased in four states (Kansas, Louisiana, Virginia, and West Virginia), declined in two states (New York and Tennessee), and did not significantly change in the remaining 44 states, DC, and two territories. In 2017, the prevalence of past-year quit attempts ranged from 58.6% in Wisconsin to 72.3% in Guam, with a median of 65.4%. In 2017, older smokers were less likely than younger smokers to make a quit attempt in most states. Implementation of comprehensive state tobacco control programs and evidence-based tobacco control interventions, including barrier-free access to cessation treatments, can increase the number of smokers who make quit attempts and succeed in quitting (2,3).

      6. Background: Comorbid substance use disorder and mental health conditions are common in women of reproductive age. We sought to understand the prevalence of substance use and substance use disorder by depression and anxiety disorder status and the independent association between depression and anxiety disorder status with receiving substance use treatment. Methods: A sample of 106,142 women ages 18-44 years was drawn from the 2008 to 2014 National Survey on Drug Use and Health. Differences in demographics, substance use, substance use disorders, and treatment by major depressive episode (MDE), and anxiety disorder status, were assessed with chi-squared tests. The independent association between MDE and anxiety disorder with substance use treatment was assessed with adjusted prevalence ratios. Results: Women with MDE and/or anxiety disorder had higher prevalence of substance use and substance use disorder than women with no MDE or anxiety disorder (p < 0.001). Less than a quarter of women with substance use disorders and both MDE and anxiety disorder received mental health and substance use treatment. After adjustment, women with substance use disorder and MDE and anxiety disorder, MDE only, or anxiety disorder only were more likely to receive substance use treatment (respectively, 2.4, 1.6, and 2.2 times) than women with no MDE or anxiety disorder (p < 0.001). Conclusions: Women with MDE and/or anxiety disorder are significantly more likely to suffer from substance use and substance use disorders than their counterparts. Integrating substance use treatment services and mental health services in settings frequently visited by reproductive-aged women may increase receipt of combined treatment.

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

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