Volume 11, Issue 33 August 20, 2019

CDC Science Clips: Volume 11, Issue 33, August 20, 2019

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

  1. CDC Public Health Grand Rounds
    • Adolescent Health
      1. Adolescent and young adult preventive care: comparing national survey ratesexternal icon
        Adams SH, Park MJ, Irwin CE.
        Am J Prev Med. 2015 Aug;49(2):238-47.
        INTRODUCTION: The Affordable Care Act’s preventive healthcare provisions have the potential to increase adolescents’ and young adults’ receipt of recommended preventive services. Assessing whether this potential is realized requires valid monitoring data in several areas, including receipt of an annual preventive visit. The purpose of this study is to describe and compare preventive visit rates across national surveys for adolescents and young adults. METHODS: This study, conducted in 2014: (1) identified national surveys with past-year preventive visit measures; (2) compared survey features, including mode of administration, respondent, response rate, demographic profile (univariate analysis), preventive visit measure wording, and method of construction; and (3) compared preventive visit rates, including rates among sociodemographic subgroups (bivariate analyses). RESULTS: Four 2011 surveys were identified: National Health Interview Survey, National Survey of Children’s Health (2011-2012), and Medical Expenditure Panel Survey (MEPS) for adolescents, and MEPS and Behavioral Risk Factor Surveillance System for young adults. Surveys varied by most assessed features; demographic profiles were similar. Preventive visit rates varied significantly across adolescents (43%-81%) and young adults (26%-58%). The largest differences in visit rates were in comparisons of subjective assessments to a more detailed assessment coded from specific records of visits kept by respondents. Sociodemographic differences in visit rates were consistent across surveys. CONCLUSIONS: Further research is needed to assess reasons for the different estimates of preventive visits across national surveys. Those who monitor trends in receipt of recommended care for adolescents and young adults should take survey differences into account. Monitoring content of care is also needed.

      2. Guide to Community Preventive Servicesexternal icon
        Community Preventive Services Task Force .
        Promoting health equity through education programs and policies: school-based health centers. 2015 .
        The Community Preventive Services Task Force recommends the implementation and maintenance of school-based health centers (SBHCs) in low-income communities, based on sufficient evidence of effectiveness in improving educational and health outcomes. Improved educational outcomes include school performance, grade promotion, and high school completion. Improved health outcomes include the delivery of vaccinations and other recommended preventive services, asthma morbidity, emergency department and hospital admissions, contraceptive use among females, prenatal care and birth weight, and other health risk behaviors. Most evidence derives from studies of SBHCs in low-income populations. As SBHCs are commonly implemented in low-income communities and communities with high proportions of racial and ethnic minority populations, many of whom are low-income, this source of student health care and health education may be a prominent means of advancing health equity.

      3. The Project Connect health systems intervention: linking sexually experienced youth to sexual and reproductive health careexternal icon
        Dittus PJ, De Rosa CJ, Jeffries RA, Afifi AA, Cumberland WG, Chung EQ, Martinez E, Kerndt PR, Ethier KA.
        J Adolesc Health. 2014 Oct;55(4):528-34.
        PURPOSE: To evaluate a health systems intervention to increase adolescents’ receipt of high-quality sexual and reproductive health care services. METHODS: Quasi experimental design. Twelve high schools in a large public school district were matched into pairs. Within each pair, schools were assigned to condition so that no control school shared a geographic border with an intervention school. Five yearly surveys (T1, T2, …, T5) were administered from 2005 to 2009 (N = 29,823) to students in randomly selected classes in grades 9-12. Community-based providers of high-quality sexual and reproductive health care services were listed on a referral guide for use by school nurses to connect adolescents to care. RESULTS: Statistically significant effects were found for intervention school females on three outcomes, relative to controls. Relative to T1, receipt of birth control in the past year was greater at T4 (adjusted odds ratio [AOR] = 1.85; 95% confidence interval [CI], 1.09-3.15) and T5 (AOR = 2.22; 95% CI, 1.32-3.74). Increases in sexually transmitted disease testing and/or treatment in the past year were greater in T1-T3 (AOR = 1.78; 95% CI, 1.05-3.02), T1-T4 (AOR = 1.73; 95% CI, 1.01-2.97), T1-T5 (AOR = 1.97; 95% CI, 1.17-3.31), and T2-T5 (AOR = 1.76; 95% CI, 1.06-2.91). Increases in ever receiving an HIV test were greater in T1-T4 (AOR = 2.14; 95% CI, 1.08-4.26). Among males, no intervention effects were found. CONCLUSIONS: A school-based structural intervention can improve female adolescents’ receipt of services.

      4. PURPOSE: The objective of this study was to examine the relationship between school involvement and connectedness with measures of sexual risk, substance use, and experience of violence among students who had sexual contact with the same sex or with both sexes. METHODS: A sample of middle school and high school students who participated in a study conducted in a large urban school district were selected based on their reported experience of having initiated sexual activity with same-sex partners. In classroom-based surveys, we assessed self-reported involvement in school-based activities and feelings of school connectedness, as well as self-reported sexual risk, substance use, and experience of violence. RESULTS: Significant protective associations were found between school involvement and lifetime alcohol and marijuana use, and between school connectedness and ever having been in a fight, feeling safe at school, and drug use other than marijuana (all p < .05). CONCLUSIONS: Findings suggest that efforts to increase school involvement and connectedness provide a starting point for addressing significant health and safety concerns among students with same-sex sexual activity.

      5. OBJECTIVE: Graduated driver licensing (GDL) systems are designed to reduce the high crash risk of young novice drivers. Almost all states in the United States have some form of a 3-phase GDL system with various restrictions in the intermediate phase. Studies of the effects of GDL in various states show significant reductions in fatal crash involvements of 16- and 17-year-old drivers; however, only a few national studies of GDL effects have been published. The objective of this national panel study was to evaluate the effect of GDL laws on the fatal crash involvements of novice drivers while controlling for possible confounding factors not accounted for in prior studies. METHODS: The Fatality Analysis Reporting System (FARS) was used to examine 16- and 17-year-old driver involvement in fatal crashes (where GDL laws are applied) relative to 2 young driver age groups (19-20, 21-25) where GDL would not be expected to have an effect. Dates when various GDL laws were adopted in the states between 1990 and 2007 were coded from a variety of sources. Covariates in the longitudinal panel regression analyses conducted included 4 laws that could have an effect on 16- and 17-year-old drivers: primary enforcement seat belt laws, zero-tolerance (ZT) alcohol laws for drivers younger than age 21, lowering the blood alcohol concentration limit for driving to 0.08, and so-called use and lose laws where drivers aged 20 and younger lose their licenses for underage drinking violations. RESULTS: The adoption of a GDL law of average strength was associated with a significant decrease in fatal crash involvements of 16- and 17-year-old drivers relative to fatal crash involvements of one of the 2 comparison groups. GDL laws rated as “good” showed stronger relationships to fatal crash reductions, and laws rated as “less than good” showed no reductions in crash involvements relative to the older driver comparison groups. CONCLUSIONS: States that adopt a basic GDL law can expect a decrease of 8 to 14 percent in the proportion of 16- and 17-year-old drivers involved in fatal crashes (relative to 21- to 25-year-old drivers), depending upon their other existing laws that affect novice drivers, such as those used in these analyses. This finding is consistent with recent national studies that used different outcome measures and covariates. The results of this study provide additional support for states to adopt, maintain, and upgrade GDL systems to reduce youthful traffic crash fatalities.

      6. A parent-based intervention to reduce sexual risk behavior in early adolescence: building alliances between physicians, social workers, and parentsexternal icon
        Guilamo-Ramos V, Bouris A, Jaccard J, Gonzalez B, McCoy W, Aranda D.
        J Adolesc Health. 2011 Feb;48(2):159-63.
        PURPOSE: To evaluate the efficacy of a parent-based intervention to prevent sexual risk behavior among Latino and African American young adults. This was delivered to mothers while waiting for their adolescent child to complete an annual physical examination. METHODS: A randomized clinical trial was conducted with 264 mother-adolescent dyads in New York City. Adolescents were eligible for the study only if they were African American or Latino and aged 11-14 years, inclusive. Dyads completed a brief baseline survey and were then randomly assigned to one of the following two conditions: (1) a parent-based intervention (n = 133), or (2) a “standard care” control condition (n = 131). Parents and adolescents completed a follow-up survey nine months later. The primary outcomes included whether the adolescent had ever engaged in vaginal sexual intercourse, the frequency of sexual intercourse, and the frequency of oral sex. RESULTS: Relative to the control group, statistically significant reduced rates of transitioning to sexual activity and frequency of sexual intercourse were observed, with oral sex reductions nearly reaching statistical significance (p < .054). Specifically, sexual activity increased from 6% to 22% for young adults in the “standard of care” control condition, although it remained at 6% among young adults in the intervention condition at the 9-month follow-up. CONCLUSIONS: A parent-based intervention delivered to mothers in a pediatric clinic as they waited for their child to complete a physical examination may be an effective way to reduce sexual risk behaviors among Latino and African American middle-school young adults.

      7. Youth Risk Behavior Surveillance – United States, 2017external icon
        Kann L, McManus T, Harris WA, Shanklin SL, Flint KH, Queen B, Lowry R, Chyen D, Whittle L, Thornton J, Lim C, Bradford D, Yamakawa Y, Leon M, Brener N, Ethier KA.
        MMWR Surveill Summ. 2018 Jun 15;67(8):1-114.
        PROBLEM: Health-risk behaviors contribute to the leading causes of morbidity and mortality among youth and adults in the United States. In addition, significant health disparities exist among demographic subgroups of youth defined by sex, race/ethnicity, and grade in school and between sexual minority and nonsexual minority youth. Population-based data on the most important health-related behaviors at the national, state, and local levels can be used to help monitor the effectiveness of public health interventions designed to protect and promote the health of youth at the national, state, and local levels. REPORTING PERIOD COVERED: September 2016-December 2017. DESCRIPTION OF THE SYSTEM: The Youth Risk Behavior Surveillance System (YRBSS) monitors six categories of priority health-related behaviors among youth and young adults: 1) behaviors that contribute to unintentional injuries and violence; 2) tobacco use; 3) alcohol and other drug use; 4) sexual behaviors related to unintended pregnancy and sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) infection; 5) unhealthy dietary behaviors; and 6) physical inactivity. In addition, YRBSS monitors the prevalence of other health-related behaviors, obesity, and asthma. YRBSS includes a national school-based Youth Risk Behavior Survey (YRBS) conducted by CDC and state and large urban school district school-based YRBSs conducted by state and local education and health agencies. Starting with the 2015 YRBSS cycle, a question to ascertain sexual identity and a question to ascertain sex of sexual contacts were added to the national YRBS questionnaire and to the standard YRBS questionnaire used by the states and large urban school districts as a starting point for their questionnaires. This report summarizes results from the 2017 national YRBS for 121 health-related behaviors and for obesity, overweight, and asthma by demographic subgroups defined by sex, race/ethnicity, and grade in school and by sexual minority status; updates the numbers of sexual minority students nationwide; and describes overall trends in health-related behaviors during 1991-2017. This reports also summarizes results from 39 state and 21 large urban school district surveys with weighted data for the 2017 YRBSS cycle by sex and sexual minority status (where available). RESULTS: Results from the 2017 national YRBS indicated that many high school students are engaged in health-risk behaviors associated with the leading causes of death among persons aged 10-24 years in the United States. During the 30 days before the survey, 39.2% of high school students nationwide (among the 62.8% who drove a car or other vehicle during the 30 days before the survey) had texted or e-mailed while driving, 29.8% reported current alcohol use, and 19.8% reported current marijuana use. In addition, 14.0% of students had taken prescription pain medicine without a doctor’s prescription or differently than how a doctor told them to use it one or more times during their life. During the 12 months before the survey, 19.0% had been bullied on school property and 7.4% had attempted suicide. Many high school students are engaged in sexual risk behaviors that relate to unintended pregnancies and STIs, including HIV infection. Nationwide, 39.5% of students had ever had sexual intercourse and 9.7% had had sexual intercourse with four or more persons during their life. Among currently sexually active students, 53.8% reported that either they or their partner had used a condom during their last sexual intercourse. Results from the 2017 national YRBS also indicated many high school students are engaged in behaviors associated with chronic diseases, such as cardiovascular disease, cancer, and diabetes. Nationwide, 8.8% of high school students had smoked cigarettes and 13.2% had used an electronic vapor product on at least 1 day during the 30 days before the survey. Forty-three percent played video or computer games or used a computer for 3 or more hours per day on an average school day for something that was not school work and 15.4% had not been physically active for a total of at least 60 minutes on at least 1 day during the 7 days before the survey. Further, 14.8% had obesity and 15.6% were overweight. The prevalence of most health-related behaviors varies by sex, race/ethnicity, and, particularly, sexual identity and sex of sexual contacts. Specifically, the prevalence of many health-risk behaviors is significantly higher among sexual minority students compared with nonsexual minority students. Nonetheless, analysis of long-term temporal trends indicates that the overall prevalence of most health-risk behaviors has moved in the desired direction. INTERPRETATION: Most high school students cope with the transition from childhood through adolescence to adulthood successfully and become healthy and productive adults. However, this report documents that some subgroups of students defined by sex, race/ethnicity, grade in school, and especially sexual minority status have a higher prevalence of many health-risk behaviors that might place them at risk for unnecessary or premature mortality, morbidity, and social problems (e.g., academic failure, poverty, and crime). PUBLIC HEALTH ACTION: YRBSS data are used widely to compare the prevalence of health-related behaviors among subpopulations of students; assess trends in health-related behaviors over time; monitor progress toward achieving 21 national health objectives; provide comparable state and large urban school district data; and take public health actions to decrease health-risk behaviors and improve health outcomes among youth. Using this and other reports based on scientifically sound data is important for raising awareness about the prevalence of health-related behaviors among students in grades 9-12, especially sexual minority students, among decision makers, the public, and a wide variety of agencies and organizations that work with youth. These agencies and organizations, including schools and youth-friendly health care providers, can help facilitate access to critically important education, health care, and high-impact, evidence-based interventions.

      8. Practices That Support and Sustain Health in Schools: An Analysis of SHPPS Dataexternal icon
        Lee SM, Miller GF, Brener N, Michael S, Jones SE, Leroy Z, Merlo C, Robin L, Barrios L.
        J Sch Health. 2019 Apr;89(4):279-299.
        BACKGROUND: The Whole School, Whole Community, Whole Child (WSCC) model provides an organizing framework for schools to develop and implement school health policies, practices, and programs. The purpose of this study was to examine the presence of practices that support school health for each component of the WSCC model in US schools. METHODS: Data from the School Health Policies and Practices Study 2014 were analyzed to determine the percentage of schools with practices in place that support school health for WSCC components. RESULTS: Less than 27% of schools had a school health council that addressed any specific WSCC component, but more than 50% had a coordinator for all but one component. The use of other practices that support school health varied widely across the WSCC components. For example, more than 80% of schools reported family engagement for health education and nutrition environment and services, but less than 50% reported family engagement for other components. CONCLUSIONS: These results indicate that many US schools are using practices that support school health and align with WSCC components, but improvement is needed. These results also highlight discrepancies in the types of practices being used.

      9. OBJECTIVES: Physical education (PE) that allows students to engage in moderate-to-vigorous physical activity (MVPA) can play an important role in health promotion. Unfortunately, MVPA levels in PE lessons are often very low. In this review, we aimed to determine the effectiveness of interventions designed to increase the proportion of PE lesson time that students spend in MVPA. METHODS: In March 2012, we searched electronic databases for intervention studies that were conducted in primary or secondary schools and measured the proportion of lesson time students spent in MVPA. We assessed risk of bias, extracted data, and conducted meta-analyses to determine intervention effectiveness. RESULTS: From an initial pool of 12,124 non-duplicate records, 14 studies met the inclusion criteria. Students in intervention conditions spent 24% more lesson time in MVPA compared with students in usual practice conditions (standardized mean difference=0.62). CONCLUSIONS: Given the small number of studies, moderate-to-high risk of bias, and the heterogeneity of results, caution is warranted regarding the strength of available evidence. However, this review indicates that interventions can increase the proportion of time students spend in MVPA during PE lessons. As most children and adolescents participate in PE, these interventions could lead to substantial public health benefits.

      10. Does delivering preventive services in primary care reduce adolescent risky behavior?external icon
        Ozer EM, Adams SH, Orrell-Valente JK, Wibbelsman CJ, Lustig JL, Millstein SG, Garber AK, Irwin CE.
        J Adolesc Health. 2011 Nov;49(5):476-82.
        PURPOSE: To determine whether the delivery of preventive services changes adolescent behavior. This exploratory study examined the trajectory of risk behavior among adolescents receiving care in three pediatric clinics, in which a preventive services intervention was delivered during well visits. METHODS: The intervention consisted of screening and brief counseling from a provider, followed by a health educator visit. At age 14 (year 1), 904 adolescents had a risk assessment and intervention, followed by a risk assessment 1 year later at age 15 (year 2). Outcomes were changes in adolescent behavior related to seat belt and helmet use; tobacco, alcohol, and drug use; and sexual behavior. Analysis involved age-related comparisons between the intervention and several cross-sectional comparison samples from the age of 14-15 years. RESULTS: The change in helmet use in the intervention sample was 100% higher (p < .05), and the change in seat belt use among males was 50% higher (p = .14); the change in smoking among males was 54% lower (p < .10), in alcohol use was no different, and in drug use was 10% higher (not significant [NS]); and the change in rate of sexual intercourse was 18% and 22% lower than cohort comparison samples (NS). CONCLUSIONS: The intervention had the strongest effect in the area of helmet use, shows promise for increasing seat belt use and reducing smoking among male adolescents, and indicates a nonsignificant trend toward delaying the onset of sexual activity. Participation in the intervention seemed to have no effect on the rates of experimentation with alcohol and drugs between the ages of 14 and 15 years.

      11. Young adult preventive health care guidelines: there but can’t be foundexternal icon
        Ozer EM, Urquhart JT, Brindis CD, Park MJ, Irwin CE.
        Arch Pediatr Adolesc Med. 2012 Mar;166(3):240-7.
        OBJECTIVES: To (1) identify adolescent and adult clinical preventive services guidelines relevant to the young adult age group; (2) review, compare, and synthesize these guidelines, with emphasis on the extent to which professional guidelines are consistent with evidence-based guidelines developed by the US Preventive Services Task Force; and (3) recommend the next steps in the establishment and integration of preventive care guidelines for young adults. DESIGN: Nonexperimental: an Internet search was conducted to identify relevant preventive care guidelines for the young adult group. SETTING: The search included federal agencies and professional organizations that focus on health areas linked to the care of young adults or that provide health care to adolescents and young adults. PARTICIPANTS: National organizations, federal agencies, health professional associations, and medical societies. MAIN OUTCOME MEASURES: Preventive services guidelines for adolescents and adults that intersect with the age range of 18 to 26 years. RESULTS: When the ages of 18 to 26 years are carved out of established professional guidelines across specialty groups, there is a broad number of recommendations, with many supported by sufficient evidence to receive a US Preventive Services Task Force grade of A or B that can inform the care of young adults. CONCLUSIONS: We recommend the establishment of young adult preventive health guidelines that reflect the current evidence-based recommendations that overlap with the young adult age group; we suggest clinician and health care system supports to facilitate the delivery of preventive services to young adults; and we emphasize prioritizing research in prevention areas in which sufficient evidence does not exist.

      12. Adolescence and young adulthood are unique developmental periods that present opportunities and challenges for improving health. Health at this age can affect health throughout the lifespan. This review has two aims: (1) to examine trends in key indicators in outcomes, behaviors, and health care over the past decade for U.S. adolescents and young adults; and (2) to compare U.S. adolescents and young adults on these indicators. The review also assesses sociodemographic differences in trends and current indicators. Guided by our aims, previous reviews, and national priorities, the present review identified 21 sources of nationally representative data to examine trends in 53 areas and comparisons of adolescents and young adults in 42 areas. Most health and health care indicators have changed little over the past decade. Encouraging exceptions were found for adolescents and young adults in unintentional injury, assault, and tobacco use, and, for adolescents, in sexual/reproductive health. Trends in violence and chronic disease and related behaviors were mixed. Review of current indicators demonstrates that young adulthood continues to entail greater risk and worse outcomes than adolescence. Young adults fared worse on about two-thirds of the indicators examined. Differences among sociodemographic subgroups persisted for both trends and current indicators.

      13. Adolescent Connectedness and Adult Health Outcomesexternal icon
        Steiner RJ, Sheremenko G, Lesesne C, Dittus PJ, Sieving RE, Ethier KA.
        Pediatrics. 2019 Jul;144(1).
        BACKGROUND: Because little is known about long-term effects of adolescent protective factors across multiple health domains, we examined associations between adolescent connectedness and multiple health-related outcomes in adulthood. METHODS: We used weighted data from Waves I and IV of the National Longitudinal Study of Adolescent to Adult Health (n = 14 800). Linear and logistic models were used to examine associations between family and school connectedness in adolescence and self-reported health risk behaviors and experiences in adulthood, including emotional distress, suicidal thoughts and attempts, physical violence victimization and perpetration, intimate partner physical and sexual violence victimization, multiple sex partners, condom use, sexually transmitted infection (STI) diagnosis, prescription drug misuse, and other illicit drug use. RESULTS: In multivariable analyses, school connectedness in adolescence had independent protective associations in adulthood, reducing emotional distress and odds of suicidal ideation, physical violence victimization and perpetration, multiple sex partners, STI diagnosis, prescription drug misuse, and other illicit drug use. Similarly, family connectedness had protective effects for emotional distress, all violence indicators, including intimate partner violence, multiple sex partners, STI diagnosis, and both substance use indicators. Compared to individuals with low scores for each type of connectedness, having high levels of both school and family connectedness was associated with 48% to 66% lower odds of health risk behaviors and experiences in adulthood, depending on the outcome. CONCLUSIONS: Family and school connectedness may have long-lasting protective effects across multiple health outcomes related to mental health, violence, sexual behavior, and substance use. Increasing both family and school connectedness during adolescence has the potential to promote overall health in adulthood.

      14. Cost-benefit study of school nursing servicesexternal icon
        Wang LY, Vernon-Smiley M, Gapinski MA, Desisto M, Maughan E, Sheetz A.
        JAMA Pediatr. 2014 Jul;168(7):642-8.
        IMPORTANCE: In recent years, across the United States, many school districts have cut on-site delivery of health services by eliminating or reducing services provided by qualified school nurses. Providing cost-benefit information will help policy makers and decision makers better understand the value of school nursing services. OBJECTIVE: To conduct a case study of the Massachusetts Essential School Health Services (ESHS) program to demonstrate the cost-benefit of school health services delivered by full-time registered nurses. DESIGN, SETTING, AND PARTICIPANTS: Standard cost-benefit analysis methods were used to estimate the costs and benefits of the ESHS program compared with a scenario involving no school nursing service. Data from the ESHS program report and other published studies were used. A total of 477 163 students in 933 Massachusetts ESHS schools in 78 school districts received school health services during the 2009-2010 school year. INTERVENTIONS: School health services provided by full-time registered nurses. MAIN OUTCOMES AND MEASURES: Costs of nurse staffing and medical supplies incurred by 78 ESHS districts during the 2009-2010 school year were measured as program costs. Program benefits were measured as savings in medical procedure costs, teachers’ productivity loss costs associated with addressing student health issues, and parents’ productivity loss costs associated with student early dismissal and medication administration. Net benefits and benefit-cost ratio were calculated. All costs and benefits were in 2009 US dollars. RESULTS: During the 2009-2010 school year, at a cost of $79.0 million, the ESHS program prevented an estimated $20.0 million in medical care costs, $28.1 million in parents’ productivity loss, and $129.1 million in teachers’ productivity loss. As a result, the program generated a net benefit of $98.2 million to society. For every dollar invested in the program, society would gain $2.20. Eighty-nine percent of simulation trials resulted in a net benefit. CONCLUSIONS AND RELEVANCE: The results of this study demonstrated that school nursing services provided in the Massachusetts ESHS schools were a cost-beneficial investment of public money, warranting careful consideration by policy makers and decision makers when resource allocation decisions are made about school nursing positions.

  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. A holistic approach to chronic disease prevention: Good health and wellness in Indian countryexternal icon
        Andrade NS, Espey DK, Hall ME, Bauer UE.
        Prev Chronic Dis. 2019 Aug 1;16:E98.
        The National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention funds the agency’s largest investment in Indian Country, Good Health and Wellness in Indian Country. This 5-year program, launched in 2014, supports American Indian and Alaska Native communities and tribal organizations to address chronic diseases and risk factors simultaneously and in coordination. This article describes the development, funding, and implementation of the program. Dialogue with tribal members and leaders helped shape the program, and unlike previous programs that funded a small number of tribes to work on specific diseases, this program funds multiple tribal entities to reach widely into Indian Country. Implementation included culturally developed and adapted practices and opportunities for peer sharing and problem solving. This program identified approaches useful for the Centers for Disease Control and Prevention, other federal agencies, or other organizations working with American Indians and Alaska Natives.

      2. Public health approaches to type 2 diabetes prevention: The US National Diabetes Prevention Program and beyondexternal icon
        Gruss SM, Nhim K, Gregg E, Bell M, Luman E, Albright A.
        Curr Diab Rep. 2019 Aug 5;19(9):78.
        PURPOSE OF REVIEW: This article highlights foundational evidence, translation studies, and current research behind type 2 diabetes prevention efforts worldwide, with focus on high-risk populations, and whole-population approaches as catalysts to global prevention. RECENT FINDINGS: Continued focus on the goals of foundational lifestyle change program trials and their global translations, and the targeting of those at highest risk through both in-person and virtual modes of program delivery, is critical. Whole-population approaches (e.g., socioeconomic policies, healthy food promotion, environmental/systems changes) and awareness raising are essential complements to efforts aimed at high-risk populations. Successful type 2 diabetes prevention strategies are being realized in the USA through the National Diabetes Prevention Program and elsewhere in the world. A multi-tiered approach involving appropriate risk targeting and whole-population efforts is essential to curb the global diabetes epidemic.

      3. Disparities in the prevalence of excess heart age among women with a recent live birthexternal icon
        Mpofu JJ, Smith RA, Patel D, Gillespie C, Cox S, Ritchey M, Yang Q, Morrow B, Barfield W.
        J Womens Health (Larchmt). 2019 Aug 8.
        Background: Understanding and addressing cardiovascular disease (CVD) risk has implications for maternal and child health outcomes. Heart age, the modeled age of an individual’s cardiovascular system based on risk level, and excess heart age, the difference between a person’s heart age and chronological age, are alternative simplified ways to communicate CVD risk. Among women with a recent live birth, we predicted heart age, calculated prevalence of excess heart age (>/=5 years), and examined factors associated with excess heart age. Materials and Methods: Data were analyzed in 2017 from 2009 to 2014 Pregnancy Risk Assessment Monitoring System (PRAMS). To calculate heart age we used maternal age, prepregnancy body mass index, systolic blood pressure, smoking status, and diabetic status. Weighted prevalence and prevalence ratios compared the likelihood of excess heart age across racial/ethnic groups by selected factors. Results: Prevalence of excess heart age was higher in non-Hispanic black women (11.8%) than non-Hispanic white women (7.3%, prevalence ratio [PR], 95% confidence interval [CI]: 1.62, 1.49-1.76) and Hispanic women (4.9%, PR, 95% CI: 2.39, 2.10-2.72). Prevalence of excess heart age was highest among women who were without health insurance, obese or overweight, engaged in physical activity less than thrice per week, or were smokers in the prepregnancy period. Among women with less than high school education, non-Hispanic black women had a higher prevalence of excess heart age than Hispanic women (PR, 95% CI: 4.01, 3.15-5.10). Conclusions: Excess heart age may be an important tool for decreasing disparities and encouraging CVD risk reduction among certain groups of women.

      4. Using inside knowledge campaign materials to improve gynecologic cancer knowledge in underserved womenexternal icon
        Puckett M, Townsend J, Patterson JR, Shaw D, Wasilewski Y, Stewart SL.
        J Womens Health (Larchmt). 2019 Aug 2.
        Purpose: About 30,000 U.S. women die each year from gynecologic cancer, which disproportionately affects underserved and minority populations. This project aimed at increasing and assessing awareness of risk, symptoms, and recommended screenings and prevention activities in underserved women, through unique collaboration between the Centers for Disease Control and Prevention’s (CDC) Inside Knowledge (IK) campaign, which was designed to educate women about gynecologic cancer, and the CDC’s national network of organizations to reduce cancer-related disparities. Methods: CDC’s national network and the IK campaign partnered to deliver tailored educational sessions about gynecologic cancer to three populations of women served by the participant organizations. Participant organizations included the National Behavioral Health Network (NBHN), Nuestras Voces (NV), and SelfMade. Pre- and post-session questionnaires were administered to assess knowledge changes. Results: Knowledge changes for risk factors, screening, and HPV vaccination varied by network organization, but all sessions increased correct identification of some symptoms. Baseline knowledge also varied among organization participants. Conclusions: Sessions were effective in increasing awareness of gynecologic cancer among underserved women; however, organizational information uptake differed. Additional resources containing specific interventions appropriate to particular underserved populations may be beneficial in increasing healthy behaviors, leading to a reduction in gynecologic cancer disparities.

      5. The misdiagnosis of interstitial cystitis/bladder pain syndrome in a VA populationexternal icon
        Skove SL, Howard LE, Senechal J, De Hoedt A, Bresee C, Cunningham TJ, Barbour KE, Kim J, Freedland SJ, Anger JT.
        Neurourol Urodyn. 2019 Jul 14.
        AIMS: The complexity of Interstitial Cystitis/bladder Pain Syndrome (IC/BPS) has led to a great deal of uncertainty around the diagnosis and prevalence of the condition. Under the hypothesis that IC/BPS is frequently misdiagnosed, we sought to assess the accuracy of the ICD-9/ICD-10 code for IC/BPS using a national data set. METHODS: Using the Veterans Affairs Informatics and Computing Infrastructure, we identified a random sample of 100 patients with an ICD-9/ICD-10 diagnosis of IC/BPS (595.1/N30.10) by querying all living patients in the Veterans Affairs (VA) system. We purposely sampled men and women equally to better understand gender-specific practice patterns. Patients were considered a correct IC/BPS diagnosis if they had two visits complaining of bladder-centric pain in the absence of positive urine culture at least 6 weeks apart. Patients were considered not to have IC/BPS if they had a history of pelvic radiation, systemic chemotherapy, metastatic cancer, or bladder cancer. RESULTS: Of the 100 patients, 48 were female and 52 were male. Five had prior radiation, one had active cancer, and 10 had bladder cancer (all male), and an additional fifteen had insufficient records. Of the remaining 69 patients, 43% did not have IC/BPS. Of these patients who did not have IC/BPS, 43% complained only of overactive bladder (OAB) symptoms, which was more common in women (63%) than men (21%), P = .003. CONCLUSIONS: In our small sample from a nationwide VA system, results indicate that IC/BPS has a high misdiagnosis rate. These findings shed light on the gender-specific diagnostic complexity of IC/BPS.

      6. Objective: We examined walking limitations and associated characteristics among middle-aged and older US adults with arthritis, overall, and by sex. Method(s): Using 2005-2006 Arthritis Conditions and Health Effects Survey (ACHES) data (n = 1793), we estimated “a lot” and “any” (“a lot” or “a little” combined) walking limitation for more than 1 mile (1.6 km) among US adults 45 years or older with arthritis and examined associations (sociodemographics, arthritis symptoms and effects, psychosocial measures, and physical health) with walking limitations in unadjusted and multivariable (MV) adjusted logistic regression models using prevalence ratios (PRs) and 95% confidence intervals, accounting for the complex survey design. Result(s): Respondents frequently reported “a lot” (48%) and “any” (72%) limitation for more than 1 mile. Women reported higher prevalence of all levels of walking limitation versus men (eg, 51% vs 42% for “a lot” overall); additionally, the gap for walking limitations between women and men widened with age. Limitation was high for both sexes at all ages, affecting 1-in-3 to 4-in-5, depending on level of walking limitation. The strongest MV associations for “a lot” of walking limitation among all respondents included substantial and modest arthritis-attributable life interference (PR = 2.5 and 1.6, respectively), age 75 years or older (PR = 1.5), and physical inactivity and fair/poor self-rated health (PR = 1.4 for both). Conclusion(s): Walking limitations among middle-aged and older adults are substantial. Existing proven interventions that improve walking ability and physical function may help this population to reduce and delay disability.

      7. Suicide timing varies across several psychiatric disorders, which may share common underlying pathophysiological mechanisms with epilepsy. We investigated suicide timing in people with epilepsy. Using cross-sectional, population-based U.S. National Violent Death Reporting System data from 2003 through 2014 in 18 States, we identified 1310 suicides with epilepsy and 102,582 suicides without epilepsy among those 10years and older. We compared patterns of suicide mortality ratios between those with and without epilepsy by month of year, week of month, day of week, time of day, and overall by age, sex, and race/ethnicity. As the suicide patterns seen among persons without epilepsy, suicides in persons with epilepsy occurred significantly more often during the morning, afternoon, and evening hours than at night in all subgroups except females. Compared to Sundays, suicides in persons with epilepsy were only significantly increased on Mondays and Tuesdays in those aged >/=45years and only on Mondays in men. This pattern differs from persons without epilepsy whose suicides significantly increased on Mondays and significantly decreased on Saturdays in nearly all study subgroups. Suicides in persons with epilepsy did not exhibit the timing patterns of persons without epilepsy by week of month (significant decreases from the third to fifth weeks compared to the first week among those aged >/=45years, males, and Non-Hispanic whites) and month of year (significant increases from January to November peaking from June to September compared to December in all study groups). Compared to the general population or people without epilepsy, previous and current studies suggest that in people with epilepsy, suicide timing differs from and suicide rates significantly exceed those in people without epilepsy. Preventing suicide in people with epilepsy should focus not only on the peak times of occurrence but also across all time periods.

      8. Estimating prevalence of type I and type II diabetes using incidence rates: the SEARCH for Diabetes in Youth Studyexternal icon
        Tonnies T, Imperatore G, Hoyer A, Saydah SH, D’Agostino RB, Divers J, Isom S, Dabelea D, Lawrence JM, Mayer-Davis EJ, Pihoker C, Dolan L, Brinks R.
        Ann Epidemiol. 2019 Jul 12.
        PURPOSE: Most surveillance efforts in childhood diabetes have focused on incidence, whereas prevalence is rarely reported. This study aimed to assess whether a mathematical illness-death model accurately estimated future prevalence from baseline prevalence and incidence rates in children. METHODS: SEARCH for Diabetes in Youth is an ongoing population-based surveillance study of prevalence and incidence of diabetes and its complications among youth in the United States. We used age-, sex-, and race/ethnicity-specific SEARCH estimates of the prevalence of type I and type II diabetes in 2001 and incidence from 2002 to 2008. These data were used in a partial differential equation to estimate prevalence in 2009 with 95% bootstrap confidence intervals. Model-based prevalence was compared with the observed prevalence in 2009. RESULTS: Most confidence intervals for the difference between estimated and observed prevalence included zero, indicating no evidence for a difference between the two methods. The width of confidence intervals indicated high precision for the estimated prevalence when considering all races/ethnicities. In strata with few cases, precision was reduced. CONCLUSIONS: Future prevalence of type I and type II diabetes in youth may be accurately estimated from baseline prevalence and incidence. Diabetes surveillance could benefit from potential cost savings of this method.

    • Communicable Diseases
      1. Outbreak of influenza A in a boarding school in South Africa, 2016external icon
        Kleynhans J, Treurnicht FK, Cohen C, Vedan T, Seleka M, Maki L, von Gottberg A, McCarthy K, Ramkrishna W, McMorrow M, Walaza S.
        Pan Afr Med J. 2019 ;33:42.
        Introduction: We investigated an outbreak of influenza-like illness (ILI) at a boarding school in Eastern Cape Province, South Africa. We aimed to confirm the etiological agent, estimate attack rates and identify risk factors for illness. Methods: We conducted a retrospective cohort study including senior school boarders (n=308). Students with ILI (cough and fever) were identified through school medical records. We also conducted a questionnaire-based cross-sectional study among senior students including boarders (n=107) and day students (n=45). We collected respiratory specimens for respiratory pathogen testing by real-time polymerase chain reaction from a subset of symptomatic students. We calculated attack rates of medically attended ILI (medILI) and identified factors associated with medILI using logistic regression. We calculated seasonal influenza vaccine effectiveness (VE) against medILI. Results: Influenza A (H3N2) virus was detected in 61% (23/38) of specimens. Attack rate for medILI was 13% among boarders (39/308) in the cohort study and 20% in both day students (9/45) and boarders (21/107) in the cross-sectional study. Playing squash was associated with medILI (aOR 5.35, 95% confidence interval [95% CI]: 1.68-17.07). Of the boarders, 19% (57/308) were vaccinated before the outbreak. The adjusted VE against medILI was 18% (aOR 0.82, 95% CI 0.38-1.78). The outbreak led to cancellation of several events and the need for academic remedial sessions. Conclusion: We confirmed an influenza A (H3N2) virus outbreak with a high attack rate. The outbreak affected academic and sports activities. Participation in sports and social gatherings while experiencing ILI should be discouraged to reduce viral transmission and impact on school activities.

      2. OBJECTIVE: To compare medroxyprogesterone acetate (MPA) concentrations between HIV-infected women on antiretroviral therapy (ART) and HIV-negative women initiating depot medroxyprogesterone (DMPA) injectable. STUDY DESIGN: Secondary analysis of 28 HIV-positive women on non-nucleoside reverse transcriptase inhibitor-containing ART regimens and 10 HIV-negative women randomized to initiate DMPA in a clinical trial of progestin contraception in Malawi. RESULTS: MPA concentrations were significantly lower among HIV-positive women on ART, compared with HIV-negative women, at week 4 and week 13 (p=.03 for both), but not at day 3 or week 26 post-DMPA initiation. CONCLUSIONS: Antiretroviral medications may affect MPA metabolism in HIV-positive African women.

      3. Cognitive testing of an instrument to evaluate acceptability and use of pre-exposure prophylaxis products among womenexternal icon
        Zissette S, Atujuna M, Tolley EE, Okumu E, Auerbach JD, Hodder SL, Aral SO, Adimora AA.
        Appl Cogn Psychol. 2019 .
        Given the range of pre-exposure prophylaxis (PrEP) products currently being tested to prevent HIV in women, a standardized Acceptability and Use of PrEP Products Among Women Tool may facilitate comparisons of product acceptability and use across different geographies, trials, and users. We conducted three rounds of cognitive interviewing over 2 months in 2016, with 28 South African women who had experience participating in a range of PrEP product trials. The final instrument contained 41 items, including five new items that improved construct validity and 22 items modified for clarity. Changes were made due to unclear wording, difficulty answering, participant embarrassment, low response variability, and administrative formatting. Cognitive interviewing provided a means to address issues that would have inhibited this tool’s ability to accurately collect data otherwise. This rapid, low-cost study provided valuable insight into participants’ understanding of questions and demonstrated the utility of cognitive interviewing in international clinical trials.

    • Disaster Control and Emergency Services
      1. An evaluation of the literacy demands of online natural disaster preparedness materials for familiesexternal icon
        So M, Franks JL, Cree RA, Leeb RT.
        Disaster Med Public Health Prep. 2019 Aug 6:1-10.
        OBJECTIVE: Natural disasters are becoming increasingly common, but it is unclear whether families can comprehend and use available resources to prepare for such emergencies. The objective of this study was to evaluate the literacy demands of risk communication materials on natural disasters for US families with children. METHODS: In January 2018, we assessed 386 online self-directed learning resources related to emergency preparedness for natural disasters using 5 literacy assessment tools. Assessment scores were compared by information source, audience type, and disaster type. RESULTS: One-in-three websites represented government institutions, and 3/4 were written for a general audience. Nearly 1-in-5 websites did not specify a disaster type. Assessment scores suggest a mismatch between the general population’s literacy levels and literacy demands of materials in the areas of readability, complexity, suitability, web usability, and overall audience appropriateness. Materials required more years of education beyond the grade level recommended by prominent health organizations. Resources for caregivers of children generally and children with special health care needs possessed lower literacy demands than materials overall, for most assessment tools. CONCLUSIONS: Risk communication and public health agencies could better align the literacy demands of emergency preparedness materials with the literacy capabilities of the general public.

    • Disease Reservoirs and Vectors
      1. Models of effectiveness of interventions against malaria transmitted by Anopheles albimanusexternal icon
        Briet OJ, Impoinvil DE, Chitnis N, Pothin E, Lemoine JF, Frederic J, Smith TA.
        Malar J. 2019 Aug 1;18(1):263.
        BACKGROUND: Most impact prediction of malaria vector control interventions has been based on African vectors. Anopheles albimanus, the main vector in Central America and the Caribbean, has higher intrinsic mortality, is more zoophilic and less likely to rest indoors. Therefore, relative impact among interventions may be different. Prioritizing interventions, in particular for eliminating Plasmodium falciparum from Haiti, should consider local vector characteristics. METHODS: Field bionomics data of An. albimanus from Hispaniola and intervention effect data from southern Mexico were used to parameterize mathematical malaria models. Indoor residual spraying (IRS), insecticide-treated nets (ITNs), and house-screening were analysed by inferring their impact on the vectorial capacity in a difference-equation model. Impact of larval source management (LSM) was assumed linear with coverage. Case management, mass drug administration and vaccination were evaluated by estimating their effects on transmission in a susceptible-infected-susceptible model. Analogous analyses were done for Anopheles gambiae parameterized with data from Tanzania, Benin and Nigeria. RESULTS: While LSM was equally effective against both vectors, impact of ITNs on transmission by An. albimanus was much lower than for An. gambiae. Assuming that people are outside until bedtime, this was similar for the impact of IRS with dichlorodiphenyltrichloroethane (DDT) or bendiocarb, and impact of IRS was less than that of ITNs. However, assuming people go inside when biting starts, IRS had more impact on An. albimanus than ITNs. While house-screening had less impact than ITNs or IRS on An. gambiae, it had more impact on An. albimanus than ITNs or IRS. The impacts of chemoprevention and chemotherapy were comparable in magnitude to those of strategies against An. albimanus. Chemo-prevention impact increased steeply as coverage approached 100%, whilst clinical-case management impact saturated because of remaining asymptomatic infections. CONCLUSIONS: House-screening and repellent IRS are potentially highly effective against An. albimanus if people are indoors during the evening. This is consistent with historical impacts of IRS with DDT, which can be largely attributed to excito-repellency. It also supports the idea that housing improvements have played a critical role in malaria control in North America. For elimination planning, impact estimates need to be combined with feasibility and cost-analysis.

      2. Introduction of ticks into the United States that can carry disease-causing pathogens to humans, companion animals, and wildlife has accelerated in recent years, mostly due to globalization, frequency of travel, and a rise in legal and illegal animal trades. We hereby report for the first time introduction of a live fully engorged Amblyomma coelebs feeding on a human into the United States from Central America. Amblyomma coelebs is geographically distributed in the Neotropical region and reaches the southern states of Mexico. This species is capable of transmitting a number of pathogens of public health and veterinary importance including spotted fever group rickettsiae, raising concern that A. coelebs, if it became established in the United States, might also be able to carry these pathogens. Considering the risks of exotic ticks as vectors of numerous pathogens and their potential to establish new populations under conducive climatic and habitat conditions, rigorous inspection practices of imported livestock and pet animals at ports of entry are vital. It is also important for travelers and practitioners to develop a heightened awareness of the public health risks associated with the unintended importation of exotic ticks and the potential such parasites have for breaching United States biosecurity defenses.

    • Environmental Health
      1. Longitudinal study of age of menarche in association with childhood concentrations of persistent organic pollutantsexternal icon
        Attfield KR, Pinney SM, Sjodin A, Voss RW, Greenspan LC, Biro FM, Hiatt RA, Kushi LH, Windham GC.
        Environ Res. 2019 Jun 21;176:108551.
        BACKGROUND: Age at female puberty is associated with adult morbidities, including breast cancer and diabetes. Hormonally active chemicals are suspected of altering pubertal timing. We examined whether persistent organic pollutants (POPs) are associated with age at menarche in a longitudinal study. METHODS: We analyzed data for females enrolled at age 6-8 years in the Breast Cancer and Environment Research Program from California and Ohio. Participants were followed annually 2004-2013 and provided serum (mean age 7.8 years) for measurement of polychlorinated biphenyl (PCB), organochlorine pesticide (OCP), and polybrominated diphenyl ether (PBDE) concentrations. Age of menarche was assigned based on parental and participant reported dates and ages of menarche. Adjusted hazard ratios (aHRs) for menarchal onset were calculated with Cox proportional regression. Body mass index (BMI), potentially on the causal pathway, was added to parallel analyses. RESULTS: Age of menarche was later with higher summed PCB levels (median 11.9 years in quartile 1 [Q1] versus 12.7 in quartile 4 [Q4]) and OCP levels (12.1 years versus 12.4, respectively). When adjusting for all covariates except BMI, higher POP concentrations were associated with later age at menarche (Q4 versus Q1 aHRs: PBDEs 0.75 [95% CI 0.58, 0.97], PCBs 0.67 [95% CI 0.5, 0.89], and OCPs 0.66 [95% CI 0.50, 0.89]). Additional adjustment for BMI attenuated aHRs; PCB aHR approached the null. CONCLUSION: Findings revealed later onset of menarche with higher concentrations of certain POPs, possibly through an association with BMI. Altered pubertal timing may have long lasting effects on reproductive health and disease risk, so continued attention is important for understanding the biological processes affected by hormonally active chemicals.

      2. Concerns are heightened from detecting environmentally persistent man-made per- and polyfluoroalkyl substances (PFAS) in drinking water systems around the world. Many PFAS, including perfluorooctane sulfonate (PFOS) and perfluorooctanoate (PFOA), remain in the human body for years. Since 1999-2000, assessment of exposure to PFOS, PFOA, and other select PFAS in the U.S. general population has relied on measuring PFAS serum concentrations in participants of the National Health and Nutrition Examination Survey (NHANES). Manufacturers have replaced select chemistries (“legacy” PFAS) with PFAS with shorter biological half-lives (e.g., GenX, perfluorobutanoate [PFBA]) which may efficiently eliminate in urine. However, knowledge regarding exposure to these compounds is limited. We analyzed 2682 urine samples for 17 legacy and alternative PFAS in 2013-2014 NHANES participants >/=6years of age. Concentrations of some of these PFAS, measured previously in paired serum samples from the same NHANES participants, suggested universal exposure to PFOS and PFOA, and infrequent or no exposure to two short-chain PFAS, perfluorobutane sulfonate and perfluoroheptanoate. Yet, in urine, PFAS were seldom detected; the frequency of not having detectable concentrations of any of the 17 PFAS was 67.5%. Only two were detected in >1.5% of the population: PFBA (13.3%) and perfluorohexanoate (PFHxA, 22.6%); the 90th percentile urine concentrations were 0.1mug/L (PFBA), and 0.3mug/L (PFHxA). These results suggest that exposures to short-chain PFAS are infrequent or at levels below those that would result in detectable concentrations in urine. As such, these findings do not support biomonitoring of short-chain PFAS or fluorinated alternatives in the general population using urine, and highlight the importance of selecting the adequate biomonitoring matrix.

      3. Evidence indicates that in utero environmental exposures could influence reproduction in female offspring. Perfluoroalkyl substances (PFAS) are synthetic, ubiquitous endocrine disrupting chemicals that can cross the placental barrier. Lower levels of anti-Mullerian hormone (AMH), a biomarker of ovarian reserve, are associated with reduced fertility. We investigated the association between in utero PFAS exposure and AMH levels in female adolescents using data from the Avon Longitudinal Study of Parents and Children, a British pregnancy cohort recruited between 1991 and 1992. Maternal serum samples were collected during pregnancy and analyzed for concentrations of commonly found PFAS-perfluorooctane sulfonate (PFOS), perfluorooctanoic acid (PFOA), perfluorohexane sulfonate (PFHxS), and perfluorononanoic acid (PFNA). AMH levels were measured in serum of female offspring (mean age, 15.4 years) and log-transformed for analyses. We used a sample of 446 mother-daughter dyads for multivariable linear regression analyses, controlling for maternal age at delivery, pre-pregnancy body-mass index, and maternal education. Multiple imputation was utilized to impute missing values of AMH (61.2%) and covariates. Median PFAS concentrations (ng/mL) were as follows: PFOS 19.8 (IQR:15.1, 24.9), PFOA 3.7 (IQR: 2.8, 4.8), PFHxS 1.6 (IQR: 1.2, 2.2), PFNA 0.5 (IQR: 0.4, 0.7). The geometric mean AMH concentration was 3.9ng/mL (95% CI: 3.8, 4.0). After controlling for confounders, mean differences in AMH per one ng/mL higher PFOA, PFOS, PFHxS, and PFNA were 3.6% (95% CI: 1.4%, 8.6%), 0.7% (95% CI: 0.2%, 1.5%), 0.9% (95% CI: 0.4%, 2.2%), and 12.0% (95% CI: 42.8%, 66.8%) respectively. These findings suggest there is no association between in utero PFAS exposure and AMH levels in female adolescents.

      4. Urinary bisphenol S concentrations: Potential predictors of and associations with semen quality parameters among men attending a fertility centerexternal icon
        Ghayda RA, Williams PL, Chavarro JE, Ford JB, Souter I, Calafat AM, Hauser R, Minguez-Alarcon L.
        Environ Int. 2019 Jul 31;131:105050.
        BACKGROUND: Bisphenol S (BPS) was introduced in the market as a potentially safer alternative to bisphenol A (BPA). However, there are limited studies on health effects of BPS and no epidemiologic studies on its relationship with male reproductive health outcomes, specifically semen quality. OBJECTIVE: To investigate predictors of urinary BPS concentrations and its association with semen parameters among men attending a fertility center. METHODS: This cross-sectional analysis included 158 men of couples seeking fertility treatment (2011-2017) contributing 338 paired semen and urine samples. At the time of sample collection, men completed a questionnaire on self-reported use of household products and food intake within the previous 24h. Urinary concentrations of BPA, BPS and bisphenol F were quantified using isotope-dilution tandem mass spectrometry. Semen samples were analyzed following WHO guidelines. Multivariable mixed models were used to investigate predictors of urinary BPS concentrations and to evaluate associations between urinary BPS concentrations and semen parameters, using random intercept to account for correlation in outcomes across multiple observations per man and adjusting for abstinence time, specific gravity, age, body mass index (BMI), year of sample collection and BPA concentrations. Analyses were also stratified by BMI (>/=25 vs <25kg/m(2)). RESULTS: Median (IQR) urinary BPS concentration was 0.30 (0.20, 0.90) mug/L, and 76% of samples had detectable (>0.1mug/L) concentrations. Self-reported fabric softener and paint/solvent use as well as intake of beef and cheese within 24h before urine collection were positively associated with BPS concentrations. Men with higher BPS concentrations also had significantly higher BMI. Lower semen parameters were found among men with detectable BPS concentrations, compared to men with non-detectable BPS [2.66 vs. 2.91mL for volume (p=0.03), 30.7 vs. 38.3 mil/mL for concentration (p=0.03), 76.8 vs. 90.0 mil for total count (p=0.09), 43.7 vs. 47.0% for motility (p=0.06), and 5.42 vs. 6.77% for morphologically normal sperm (p=0.24)]. Some associations of BPS with lower semen parameters were only found among men with a BMI>/=25kg/m(2). CONCLUSIONS: We identified dietary and lifestyle factors associated with BPS exposure, suggesting potential avenues for reducing exposures. We also observed negative associations between BPS and semen parameters, especially among overweight and obese men.

    • Food Safety
      1. Noninfectious foodborne exposures reported to 2 national reporting systems, United States, 2000-2010external icon
        Law RK, Kisselburgh H, Roblin D, Choudhary E, Schier J, Fraser M, Taylor E.
        Public Health Rep. 2019 Aug 6:33354919862690.
        OBJECTIVES: Foodborne disease is a pervasive problem caused by consuming food or drink contaminated by infectious or noninfectious agents. The 55 US poison centers receive telephone calls for advice on foodborne disease cases that may be related to a foodborne disease outbreak (FBDO). Our objective was to assess whether poison center call records uploaded to the National Poison Data System (NPDS) can be used for surveillance of noninfectious FBDOs in the United States. METHODS: We matched NPDS records on noninfectious FBDO agents in the United States with records in the Foodborne Disease Outbreak Surveillance System (FDOSS) for 2000-2010. We conducted multivariable logistic regression analysis comparing NPDS matched and unmatched records to assess features of NPDS records that may indicate a confirmed noninfectious FBDO. RESULTS: During 2000-2010, FDOSS recorded 491 noninfectious FBDOs of known etiology and NPDS recorded 8773 calls for noninfectious foodborne disease exposures. Of 8773 NPDS calls, 469 (5.3%) were matched to a noninfectious FBDO reported to FDOSS. Multivariable logistic regression indicated severity of medical outcome, whether the call was made by a health care professional, and etiology as significant predictors of NPDS records matching an FDOSS noninfectious FBDO. CONCLUSIONS: NPDS may complement existing surveillance systems and response activities by providing timely information about single cases of foodborne diseases or about a known or emerging FBDO. Prioritizing NPDS records by certain call features could help guide public health departments in the types of noninfectious foodborne records that most warrant public health follow-up.

    • Genetics and Genomics
      1. Genome of Alaskapox virus, a novel orthopoxvirus isolated from Alaskaexternal icon
        Gigante CM, Gao J, Tang S, McCollum AM, Wilkins K, Reynolds MG, Davidson W, McLaughlin J, Olson VA, Li Y.
        Viruses. 2019 Aug 1;11(8).
        Since the eradication of smallpox, there have been increases in poxvirus infections and the emergence of several novel poxviruses that can infect humans and domestic animals. In 2015, a novel poxvirus was isolated from a resident of Alaska. Diagnostic testing and limited sequence analysis suggested this isolate was a member of the Orthopoxvirus (OPXV) genus but was highly diverged from currently known species, including Akhmeta virus. Here, we present the complete 210,797 bp genome sequence of the Alaska poxvirus isolate, containing 206 predicted open reading frames. Phylogenetic analysis of the conserved central region of the genome suggested the Alaska isolate shares a common ancestor with Old World OPXVs and is diverged from New World OPXVs. We propose this isolate as a member of a new OPXV species, Alaskapox virus (AKPV). The AKPV genome contained host range and virulence genes typical of OPXVs but lacked homologs of C4L and B7R, and the hemagglutinin gene contained a unique 120 amino acid insertion. Seven predicted AKPV proteins were most similar to proteins in non-OPXV Murmansk or NY_014 poxviruses. Genomic analysis revealed evidence suggestive of recombination with Ectromelia virus in two putative regions that contain seven predicted coding sequences, including the A-type inclusion protein.

    • Healthcare Associated Infections
      1. Multicenter outbreak of gram-negative bloodstream infections in hemodialysis patientsexternal icon
        Novosad SA, Lake J, Nguyen D, Soda E, Moulton-Meissner H, Pho MT, Gualandi N, Bepo L, Stanton RA, Daniels JB, Turabelidze G, Van Allen K, Arduino M, Halpin AL, Layden J, Patel PR.
        Am J Kidney Dis. 2019 Jul 26.
        RATIONALE & OBJECTIVE: Contaminated water and other fluids are increasingly recognized to be associated with health care-associated infections. We investigated an outbreak of Gram-negative bloodstream infections at 3 outpatient hemodialysis facilities. STUDY DESIGN: Matched case-control investigations. SETTING & PARTICIPANTS: Patients who received hemodialysis at Facility A, B, or C from July 2015 to November 2016. EXPOSURES: Infection control practices, sources of water, dialyzer reuse, injection medication handling, dialysis circuit priming, water and dialysate test findings, environmental reservoirs such as wall boxes, vascular access care practices, pulsed-field gel electrophoresis, and whole-genome sequencing of bacterial isolates. OUTCOMES: Cases were defined by a positive blood culture for any Gram-negative bacteria drawn July 1, 2015 to November 30, 2016 from a patient who had received hemodialysis at Facility A, B, or C. ANALYTICAL APPROACH: Exposures in cases and controls were compared using matched univariate conditional logistic regression. RESULTS: 58 cases of Gram-negative bloodstream infection occurred; 48 (83%) required hospitalization. The predominant organisms were Serratia marcescens (n=21) and Pseudomonas aeruginosa (n=12). Compared with controls, cases had higher odds of using a central venous catheter for dialysis (matched odds ratio, 54.32; lower bound of the 95% CI, 12.19). Facility staff reported pooling and regurgitation of waste fluid at recessed wall boxes that house connections for dialysate components and the effluent drain within dialysis treatment stations. Environmental samples yielded S marcescens and P aeruginosa from wall boxes. S marcescens isolated from wall boxes and case-patients from the same facilities were closely related by pulsed-field gel electrophoresis and whole-genome sequencing. We identified opportunities for health care workers’ hands to contaminate central venous catheters with contaminated fluid from the wall boxes. LIMITATIONS: Limited patient isolates for testing, on-site investigation occurred after peak of infections. CONCLUSIONS: This large outbreak was linked to wall boxes, a previously undescribed source of contaminated fluid and biofilms in the immediate patient care environment.

    • Immunity and Immunization
      1. Selective hepatitis B birth-dose vaccination in Sao Tome and Principe: A program assessment and cost-effectiveness studyexternal icon
        Hagan JE, Carvalho E, Souza V, Queresma Dos Anjos M, Abimbola TO, Pallas SW, Tevi Benissan MC, Shendale S, Hennessey K, Patel MK.
        Am J Trop Med Hyg. 2019 Aug 5.
        Sao Tome and Principe (STP) uses a selective hepatitis B birth-dose vaccination (HepB-BD) strategy targeting infants born to mothers who test positive for hepatitis B virus (HBV) surface antigen. We conducted a field assessment and economic analysis of the HepB-BD strategy to provide evidence to guide development of cost-effective policies to prevent perinatal HBV transmission in STP. We interviewed national stakeholders and key informants to understand policies, knowledge, and practices related to HepB-BD, vaccine management, and data recording/reporting. Cost-effectiveness of the existing strategy was compared with an alternate approach of universal HepB-BD to all newborns using a decision analytic model. Incremental cost-effectiveness ratios (ICERs) were calculated in 2015 USD per HBV-associated death and per chronic HBV case prevented, from the STP health-care system perspective. We found that STP lacked national or facility-specific written policies and procedures related to HepB-BD. Timely HepB-BD to eligible newborns was considered a high priority, although timeliness of HepB-BD was not monitored. Compared with the existing selective vaccination strategy, universal HepB-BD would result in a 19% decrease in chronic HBV infections per year at overall cost savings of approximately 44% (savings of USD 5,441 each year). We estimate an ICER of USD 5,012 saved per HBV-associated death averted. The existing selective HepB-BD strategy in STP could be improved through documentation of policies, procedures, and timeliness of HepB-BD. Expansion to universal newborn HepB-BD without maternal screening is feasible and could result in cost savings if actual implementation costs and effectiveness fall within the ranges modeled.

    • Injury and Violence
      1. Objectives: The objective of this study is to assess the prevalence of sexual violence, stalking, and intimate partner violence (IPV) across sexual orientation groups among U.S. adults. Method: From 2010 to 2012, national probability samples (n = 41,174) of English- or Spanish-speaking noninstitutionalized U.S. adults were interviewed to assess the prevalence of violence and injury as part of the National Intimate Partner and Sexual Violence Survey. National estimates across sexual orientation groups were compared. Results: Compared with heterosexual women, both bisexual women and lesbians experienced more contact sexual violence (CSV) and noncontact unwanted sexual violence by any perpetrator. In addition, bisexual women experienced more stalking by any perpetrator, IPV, and IPV-related impact than did heterosexual women. Compared with lesbians, bisexual women reported more CSV and stalking by any perpetrator, IPV, and IPV-related impact. Compared with heterosexual men, both bisexual and gay men experienced more CSV and noncontact unwanted sexual violence, and gay men experienced more stalking. Although there were no detected statistically significant differences in the prevalence of IPV overall, gay men did report more IPV-related impacts compared with heterosexual men. Conclusion: Results reveal a significantly elevated burden of violence experienced by certain sexual minorities.

      2. Introduction: In 2017, unintentional injuries were the seventh leading cause of death among older adults (age >/= 65), resulting in over 55,000 deaths. Falls accounted for more than half of these deaths. Given that older adults are the fastest growing age group in the United States, we can anticipate that injuries will become an even greater health concern in the near future. Methods: Aging without injury is possible. There are evidence-based strategies that can reduce falls. However, older adults may not realize that falls can be prevented or they may be afraid to admit their fear of falling or difficulty with walking as these issues may signal their inability to live independently. Results: In this commentary, we will highlight what the Centers for Disease Control and Prevention is doing to prevent older adult falls. We also highlight the importance of broadening older adults’ awareness about falls to successfully empower them to begin contemplating and preparing to adopt fall prevention strategies that can help them age in place. Conclusions: Older adult falls are common and can result in severe injury and death but they can be prevented. Broadening older adults’ awareness about falls can empower them to take the actions necessary to reduce their fall risk. Practical applications: Increasing awareness about falls can help older adults, healthcare providers, and local and state health departments take steps to reduce fall risk.

      3. Safety culture across culturesexternal icon
        Yorio PL, Edwards J, Hoeneveld D.
        Saf Sci. 2019 ;120:402-410.
        National culture colors nearly every aspect of human behavior (Javidan et al., 2006). Despite this truism, the concept has yet to be integrated into organizational safety culture theory. The purpose of this article is to bring awareness as to how national culture can influence organizational safety culture. We do so by theorizing that the shared organizational beliefs, assumptions, and values related to safety (i.e., the anthropologic component of safety culture) are a reflection of the national culture in which the organization’s workers are embedded. These organizational values, beliefs, and assumptions directly influence worker perceptions of organizational life and their behavioral choices. Given this prospectively strong direct influence on organizational behavior, we reason that the effectiveness of different organizational structure designs, safety management practices, and leadership characteristics (i.e., safety culture’s normative component) can depend on characteristics of the national culture within which the organization resides. We conclude by providing a few key practical suggestions and directions for future research.

    • Laboratory Sciences
      1. Clinical validation of the FluChip-8G Influenza A+B Assay for influenza type and subtype identificationexternal icon
        Blair RH, Dawson ED, Taylor AW, Johnson JE, Slinskey AH, O’Neil K, Smolak AW, Toth E, Liikanen K, Stoughton RS, Smith CB, Talbot S, Rowlen KL.
        J Clin Virol. 2019 Jul 26;118:20-27.
        BACKGROUND: The FluChip-8G Influenza A+B Assay is a multiplexed influenza RT-PCR and microarray-based assay with same day turnaround time, developed to subtype seasonal A viruses (H1N1pdm2009 and H3N2), distinguish B viruses as Yamagata or Victoria lineage, and is the only FDA cleared assay capable of positive identification of a wide variety of A subtypes as “non-seasonal” A viruses from human nasal specimens. OBJECTIVE: To evaluate clinical performance of the FluChip-8G Influenza A+B Assay for detection of seasonal influenza viruses in nasal and nasopharyngeal swab specimens, and to evaluate performance for detection of non-seasonal influenza viruses using contrived samples. STUDY DESIGN: For seasonal viruses, a multisite study of the FluChip-8G Influenza A+B Assay using prospectively and retrospectively collected nasal and nasopharyngeal swabs was performed using the FDA-cleared CDC Human Flu Dx Panel as the comparator assay. For non-seasonal viruses, testing was performed at a single site using contrived samples from 100 unique non-seasonal strains representing 41 subtypes. RESULTS: Sensitivity (95% CI) and specificity (95% CI) for each target group, respectively, from results of 1689 clinical specimens were: seasonal H1N1pdm2009: 96.4% (87.9-99.0), 99.3% (98.8-99.6), seasonal H3N2: 91.8% (87.7-94.7), 99.7% (99.2-99.9), Influenza B Victoria: 100% (94.0-100.0), 99.9% (99.6-100.0), and Influenza B Yamagata: 95.6% (89.2-98.3), 99.9% (99.6-100.0). The sensitivity and specificity from contrived influenza A non-seasonal viruses was determined to be 99.0% (94.6-99.8) and 100% (96.7-100.0). CONCLUSION: The FluChip-8G Influenza A+B Assay has robust sensitivity and specificity for detecting and identifying all target virus groups, including non-seasonal influenza A, with same day results.

      2. BACKGROUND: Two species complexes (SC) cause the majority of human Cryptococcus infections: Cryptococcus neoformans SC and Cryptococcus gattii SC. Infection is typically thought to be acquired following environmental exposure. In an urban setting, parks and other public spaces are a likely source of contact with C. gattii SC. OBJECTIVES: The goals of this study were to describe the genetic diversity of C. gattii SC in the California environment, to determine the extent of environmental exposure in publicly accessed areas, and to correlate the genotypes of environmental C. gattii SC isolates with those from patients in Southern California. METHODS: Specimens from trees and soil from 13 parks and public areas of seven California counties were examined for C. gattii SC isolates. Isolates were sequence typed and compared to sequence types from human clinical isolates from the same area. RESULTS: Multilocus sequence typing identified C. gattii sensu stricto (VGI molecular type) as well as C. bacillisporus (VGIII molecular type). Several C. bacillisporus but none of the C. gattii sensu stricto isolates shared sequence types with human clinical isolates from Southern California. CONCLUSIONS: C. gattii SC colonies exist in some California public parks. The presence of identical STs in environmental and human isolates of C. bacillisporus is suggestive of an arboreal origin of human infections. Two new tree species were documented as hosts for C. gattii SC in California, adding to the four species previously identified. This article is protected by copyright. All rights reserved.

      3. Quality standards as part of an effective quality management system (QMS) are the cornerstone for generating high-quality test results. Next-generation sequencing (NGS) has the potential to improve both clinical diagnostics and public health surveillance efforts in multiple areas, including infectious diseases. However, the laboratories adopting NGS methods face significant challenges due to the complex and modular process design. This document summarizes the first phase of quality system guidance developed by the Centers for Disease Control and Prevention (CDC) NGS Quality Workgroup. The quality system essentials of personnel, equipment, and process management (quality control and validation) were prioritized based on a risk assessment using information gathered from participating CDC laboratories. Here, we present a prioritized QMS framework, including procedures and documentation tools, to assist laboratory implementation and maintenance of quality practices for NGS workflows.

      4. Analgesia during monkeypox virus experimental challenge studies in prairie dogs (Cynomys ludovicianus)external icon
        Hutson CL, Gallardo-Romero N, Carroll DS, Salzer JS, Ayers JD, Doty JB, Hughes CM, Nakazawa Y, Hudson P, Patel N, Keckler MS, Olson VA, Nagy T.
        J Am Assoc Lab Anim Sci. 2019 Jul 1;58(4):485-500.
        Because human patients with monkeypox virus (MPXV) infection report painful symptoms, it is reasonable to assume that animals infected with MPXV experience some degree of pain. Understanding whether and how analgesics affect MPXV disease progression is crucial when planning in vivo challenge experiments. In the current study, we challenged prairie dogs with a low dose (4 x10(3) pfu) of MPXV and treated with meloxicam (NSAID) or buprenorphine (opioid); control animals did not receive analgesia or received analgesia without MPXV challenge. Subsets of animals from each group were serially euthanized during the course of the study. Disease progression and viral kinetics were similar between groups, but MXPVinfected, meloxicam-treated animals showed increasing trends of morbidity and mortality compared with other groups. Differences between no-analgesia MPXV-infected control animals and MPXV-infected animals treated with buprenorphine were minimal. The findings in the current study allow more informed decisions concerning the use of analgesics during experimental MPXV challenge studies, thereby improving animal welfare. In light of these findings, we have modified our pain scale for this animal model to include the use of buprenorphine for pain relief when warranted after MPXV challenge.

      5. Commensal Neisseria kill Neisseria gonorrhoeae through a DNA-dependent mechanismexternal icon
        Kim WJ, Higashi D, Goytia M, Rendon MA, Pilligua-Lucas M, Bronnimann M, McLean JA, Duncan J, Trees D, Jerse AE, So M.
        Cell Host Microbe. 2019 Jul 31.
        The mucosa is colonized with commensal Neisseria. Some of these niches are sites of infection for the STD pathogen Neisseria gonorrhoeae (Ngo). Given the antagonistic behavior of commensal bacteria toward their pathogenic relatives, we hypothesized that commensal Neisseria may negatively affect Ngo colonization. Here, we report that commensal species of Neisseria kill Ngo through a mechanism based on genetic competence and DNA methylation state. Specifically, commensal-triggered killing occurs when the pathogen takes up commensal DNA containing a methylation pattern that it does not recognize. Indeed, any DNA will kill Ngo if it can enter the cell, is differentially methylated, and has homology to the pathogen genome. Consistent with these findings, commensal Neisseria elongata accelerates Ngo clearance from the mouse in a DNA-uptake-dependent manner. Collectively, we propose that commensal Neisseria antagonizes Ngo infection through a DNA-mediated mechanism and that DNA is a potential microbicide against this highly drug-resistant pathogen.

      6. Exposure to graphene nanoparticles induces changes in measures of vascular/renal function in a load and form-dependent manner in miceexternal icon
        Krajnak K, Waugh S, Stefaniak A, Schwegler-Berry D, Roach K, Barger M, Roberts J.
        J Toxicol Environ Health A. 2019 Aug 1:1-16.
        Graphenes isolated from crystalline graphite are used in several industries. Employees working in the production of graphenes may be at risk of developing respiratory problems attributed to inhalation or contact with particulate matter (PM). However, graphene nanoparticles might also enter the circulation and accumulate in other organs. The aim of this study was to examine how different forms of graphene affect peripheral vascular functions, generation of reactive oxygen species (ROS) and changes in gene expression that may be indicative of cardiovascular and/or renal dysfunction. In the first investigation, different doses of graphene nanoplatelets were administered to mice via oropharyngeal aspiration. These effects were compared to those of dispersion medium (DM) and carbon black (CB). Gene expression alterations were observed in the heart for CB and graphene; however, only CB produced changes in peripheral vascular function. In the second study, oxidized forms of graphene were administered. Both oxidized forms increased the sensitivity of peripheral blood vessels to adrenoreceptor-mediated vasoconstriction and induced changes in ROS levels in the heart. Based upon the results of these investigations, exposure to graphene nanoparticles produced physiological and alterations in ROS and gene expression that may lead to cardiovascular dysfunction. Evidence indicates that the effects of these particles may be dependent upon dose and graphene form to which an individual may be exposed to.

      7. Effect of time of day of infection on chlamydia infectivity and pathogenesisexternal icon
        Lundy SR, Ahmad T, Simoneaux T, Benyeogor I, Robinson Y, George Z, Ellerson D, Kirlin W, Omosun T, Eko FO, Black CM, Blas-Machado U, DeBruyne JP, Igietseme JU, He Q, Omosun YO.
        Sci Rep. 2019 Aug 6;9(1):11405.
        Genital chlamydia infection in women causes complications such as pelvic inflammatory disease and tubal factor infertility, but it is unclear why some women are more susceptible than others. Possible factors, such as time of day of chlamydia infection on chlamydial pathogenesis has not been determined. We hypothesised that infections during the day, will cause increased complications compared to infections at night. Mice placed under normal 12:12 light: dark (LD) cycle were infected intravaginally with Chlamydia muridarum either at zeitgeber time 3, ZT3 and ZT15. Infectivity was monitored by periodic vaginal swabs and chlamydiae isolation. Blood and vaginal washes were collected for host immunologic response assessments. The reproductive tracts of the mice were examined histopathologically, and fertility was determined by embryo enumeration after mating. Mice infected at ZT3 shed significantly more C. muridarum than mice infected at ZT15. This correlated with the increased genital tract pathology observed in mice infected at ZT3. Mice infected at ZT3 were less fertile than mice infected at ZT15. The results suggest that the time of day of infection influences chlamydial pathogenesis, it indicates a possible association between complications from chlamydia infection and host circadian clock, which may lead to a better understanding of chlamydial pathogenesis.

      8. Neuroinflammation is a condition characterized by the elaboration of proinflammatory mediators within the central nervous system. Neuroinflammation has emerged as a dominant theme in contemporary neuroscience due to its association with neurodegenerative disease states such as Alzheimer’s disease, Parkinson’s disease and Huntington’s disease. While neuroinflammation often is associated with damage to the CNS, it also can occur in the absence of neurodegeneration, e. g., in association with systemic infection. The “acute phase” inflammatory response to tissue injury or infections instigates neuroinflammation-driven “sickness behavior,” i. e. a constellation of symptoms characterized by loss of appetite, fever, muscle pain, fatigue and cognitive problems. Typically, sickness behavior accompanies an inflammatory response that resolves quickly and serves to restore the body to homeostasis. However, recurring and sometimes chronic sickness behavior disorders can occur in the absence of an underlying cause or attendant neuropathology. Here, we review myalgic enchepalomyelitis/chronic fatigue syndrome (ME/CFS), Gulf War Illness (GWI), and chemobrain as examples of such disorders and propose that they can be exacerbated and perhaps initiated by a variety of environmental stressors. Diverse environmental stressors may disrupt the hypothalamic pituitary adrenal (HPA) axis and contribute to the degree and duration of a variety of neuroinflammation-driven diseases.

      9. Comparison of multi-wall carbon nanotube and nitrogen-doped multi-wall carbon nanotube effects on lung function and airway reactivity in ratsexternal icon
        Russ KA, Thompson JA, Kashon M, Porter DW, Friend SA, McKinney W, Fedan JS.
        Toxicol Appl Pharmacol. 2019 Feb 1;364:153-163.
        Incorporation of multi-wall carbon nanotubes (MWCNT) into materials has raised concerns about their potential hazards to manufacturing workers. In animal models, airway inflammation and lung fibrosis follow aspiration, instillation, and inhalation exposures to MWCNT. However, the effects of MWCNT on pulmonary function, airway reactivity and airway epithelium function following inhalation exposure has not been studied. We investigated whether inhaled MWCNT affects lung resistance (RL) and dynamic compliance (Cdyn), reactivity to inhaled methacholine (MCh), epithelial regulation of airway reactivity to MCh in vitro, and airway epithelial ion transport. Male rats were exposed by whole body inhalation for 6h to air or aerosolized MWCNT (0.5, 1 or 5mg/m(3)) for one or nine days. Eighteen h after 1 d exposure to 5mg/m(3) MWCNT, basal RL was increased and basal Cdyn was decreased; changes did not persist for 7 d. Reactivity to MCh (RL) was increased and Cdyn responses were decreased at 18h, but not 7 d after exposure to 1 and 5mg/m(3) MWCNT. The effects of i.t.-instilled MWCNT and nitrogen-doped MWCNT (N-MWCNT) on pulmonary function and reactivity to MCh at doses comparable to deposition after inhalation of 5mg/m(3) at 1 d and 0.5, 1, and 5mg/m(3) MWCNT 9 d-exposures were compared. Both nanoparticles increased airway reactivity (RL); N-MWCNT did not affect Cdyn responses. Lung function and airway reactivity are altered following a single MWCNT inhalation and generally subside over time. Given i.t., MWCNT’s and N-MWCNT’s effects were comparable, but N-MWCNT evoke smaller changes in Cdyn responses.

      10. Heterologous protection against Crimean-Congo hemorrhagic fever in mice after a single dose of replicon particle vaccineexternal icon
        Spengler JR, Welch SR, Scholte FE, Coleman-McCray JD, Harmon JR, Nichol ST, Bergeron E, Spiropoulou CF.
        Antiviral Res. 2019 Aug 1;170:104573.
        No vaccines are currently licensed to prevent Crimean-Congo hemorrhagic fever virus (CCHFV) infection, which can cause mild self-limiting clinical signs or severe, often fatal hemorrhagic fever disease. Here we continued investigations into the utility of a single-dose virus replicon particle (VRP) vaccine regimen by assessing protection against Turkey or Oman strains of CCHFV. We found that all mice were completely protected from disease, supporting broad applicability of this platform for CCHFV prevention.

      11. An empirical validation of the within-subject biospecimens pooling approach to minimize exposure misclassification in biomarker-based studiesexternal icon
        Vernet C, Philippat C, Agier L, Calafat AM, Ye X, Lyon-Caen S, Hainaut P, Siroux V, Schisterman EF, Slama R.
        Epidemiology. 2019 Sep;30(5):756-767.
        BACKGROUND: Within-subject biospecimens pooling can theoretically reduce bias in dose-response functions from biomarker-based studies when exposure assessment suffers from classical-type error. However, collecting many urine voids each day is cumbersome. We evaluated the empirical validity of a within-subject pooling approach and compared several options to avoid sampling each void. METHODS: In 16 pregnant women who collected a spot of each urine void over several nonconsecutive weeks, we compared concentrations of 10 phenols in daily, weekly, and pregnancy within-subject pools. We pooled either three or all daily samples. In a simulation study using these data, we quantified bias in dose-response functions when using one to 20 urine samples per subject to assess methylparaben (a compound with moderate within-subject variability) and bisphenol A (high variability) exposures. RESULTS: Correlations between exposure estimates from pools of all and of only three voids per day were above 0.80 for all time windows and compounds, except for benzophenone-3 and triclosan in the daily time window (correlations, 0.57-0.68). With one spot sample to assess pregnancy exposure, correlations were all below 0.74. Using only one biospecimen led to attenuation bias in the dose-response functions of 29% (methylparaben) and 69% (bisphenol A); four samples for methylparaben and 18 for bisphenol A decreased bias to 10%. CONCLUSIONS: For nonpersistent chemicals, collecting and pooling three samples per day instead of all daily samples efficiently estimates exposures over a week or more. Collecting around 20 biospecimens can strongly limit attenuation bias for nonpersistent chemicals such as bisphenol A.

      12. Strengthening laboratory capacity for detection of respiratory viral pathogens through the Global Health Security Agenda (GHSA) frameworkexternal icon
        Whitaker B, Alroy KA, Guthrie E, Schildecker S, Hiers S, Woodard J, Balajee SA.
        Afr J Lab Med. 2019 ;8(1):861.
        Background: Endemic and emerging respiratory viruses are a threat to public health, and a robust public health laboratory system is essential to ensure global health security. Objective: This program sought to expand molecular laboratory testing capacity to detect a broad range of respiratory pathogens in clinical respiratory specimens collected during disease surveillance and outbreak investigations. Methods: As a part of the Global Health Security Agenda (GHSA), the United States Centers for Disease Control and Prevention utilised the equipment and training infrastructure already in place at the World Health Organization National Influenza Centers to expand testing capacity for respiratory viruses in laboratories in GHSA partner countries. This was done through the provision of quality assured reagents, including multiplex platforms and technical guidance for laboratory staff, as well as the assessment of laboratory testing accuracy. Conclusion: Early findings illustrated that GHSA laboratories have been able to expand testing capacity using specimens from routine surveillance, as well as from outbreak situations.

    • Maternal and Child Health
      1. Neonatal jaundice in association with autism spectrum disorder and developmental disorderexternal icon
        Cordero C, Schieve LA, Croen LA, Engel SM, Maria Siega-Riz A, Herring AH, Vladutiu CJ, Seashore CJ, Daniels JL.
        J Perinatol. 2019 Aug 6.
        OBJECTIVE: To examine the association between neonatal jaundice and autism spectrum disorder (ASD) and non-ASD developmental disorder (DD). STUDY DESIGN: We analyzed data from the Study to Explore Early Development, a US multisite, case-control study conducted from 2007 to 2011. Developmental assessment classified children aged 2-5 years into: ASD (n = 636), DD (n = 777), or controls (POP; n = 926). Neonatal jaundice (n = 1054) was identified from medical records and maternal interviews. We examined associations between neonatal jaundice and ASD and DD using regression models to obtain adjusted odds ratios (aOR). RESULTS: Our results showed interaction between gestational age and neonatal jaundice. Neonatal jaundice was associated with ASD at 35-37 weeks (aOR = 1.83, 95%CI 1.05, 3.19), but not >/=38 weeks gestation (aOR = 0.97, 95%CI 0.76, 1.24). Similar results were observed with DD. CONCLUSIONS: Further exploration of timing and severity of neonatal jaundice and ASD/DD is warranted.

    • Nutritional Sciences
      1. The first 2 y of life are characterized by several transitions that can affect growth, development, and eating patterns long term. These include a shift from a primarily milk-based eating pattern to introduction of complementary foods at approximately 4-6 mo of age, and passage to family-meal patterns in toddler years. Recognizing the importance of this critical period, the Dietary Guidelines for Americans from 2020 onwards will include guidance for children aged birth to 24 mo (B-24). Few large-scale surveys provide comprehensive, nationally representative, quantitative, recent data on infant and toddler nutrition in the United States. The continuous NHANES has collected data relevant to this initiative since 1999 using standardized interview and examination protocols. These include data on infant feeding practices, dietary intakes (foods, beverages, and supplements), anthropometry, and blood-based nutritional status on nationally representative samples of infants and toddlers. NHANES data can be used to describe large group-level consumption patterns, as well as trends over time for B-24 children overall, and by demographic groups (e.g., race-ethnic and income groups). In addition, NHANES data can be analyzed to examine adherence to nutrition-related recommendations, such as those from the American Academy of Pediatrics (AAP), and to track Healthy People 2020 objectives. This paper provides an update on NHANES nutrition monitoring in B-24 children since our previous publication (which provided details through NHANES 2009-2010) and describes data collection since 2010 and plans for upcoming cycles. It also describes key NHANES-based findings published in the last 5 y on infant feeding practices, dietary intakes and supplement use, and nutritional status of US children aged <2 y. Findings related to existing recommendations, such as from the AAP, are presented when available. This information can inform researchers and policymakers on the state of nutrition in the US B-24 population and its subgroups of interest.

      2. Food service guideline policies on local government-controlled propertiesexternal icon
        Zaganjor H, Bishop Kendrick K, Onufrak S, Ralston Aoki J, Whitsel LP, Kimmons J.
        Am J Health Promot. 2019 Aug 1:890117119865146.
        PURPOSE: Local governments can implement food service guideline (FSG) policies, which, in large cities, may reach millions of people. This study identified FSG policies among the 20 largest US cities and analyzed them for key FSG policy attributes. DESIGN: Quantitative research. SETTING: Local government facilities. PARTICIPANTS: Twenty largest US cities. MEASURES: Frequency of FSG policies and percent alignment to tool. ANALYSIS: Using municipal legal code libraries and other data sources, FSG policies enacted as of December 31, 2016, were identified. Full-text reviews were conducted of identified policies to determine whether they met inclusion criteria. Included policies were analyzed for key policy attributes specific to nutrition, behavioral design, implementation, and facility efficiency. RESULTS: Searches identified 469 potential FSG policies, of which 6 policies across 5 cities met inclusion criteria. Five policies met a majority of criteria assessed by the classification tool. Overall alignment to the tool ranged from 17% to 88%. Of the 6 policies, 5 met a majority of the nutrition attributes and 5 met at least 50% of attributes associated with implementation. No policies met the attributes associated with facility efficiency. CONCLUSION: The FSG policies were identified in 5 of the 20 US cities. Policy alignment was high for nutrition and implementation attributes. This analysis suggests that when cities adopt FSG policies, many develop policies that align with key policy attributes. These policies can serve as models for other jurisdictions to create healthier food access through FSGs.

    • Occupational Safety and Health
      1. The impact of a crash prevention program in a large law enforcement agencyexternal icon
        Tiesman HM, Gwilliam M, Rojek J, Hendricks S, Montgomery B, Alpert G.
        Am J Ind Med. 2019 Aug 5.
        BACKGROUND: Motor vehicle crashes (MVCs) remain a leading cause of death for US law enforcement officers. One large agency implemented a crash prevention program with standard operating policy changes, increased training, and a marketing campaign. This was a scientific evaluation of that crash prevention program. METHODS: MVC and motor vehicle injury (MVI) data for law enforcement officers were compared using an autoregressive integrated moving average (ARIMA) model. Two law enforcement agencies who had not implemented a crash prevention program were controls. RESULTS: After program implementation, overall, MVC rates significantly decreased 14% from 2.2 MVCs per 100 000 miles driven to 1.9 (P = .008). MVC rates did not decrease in the control agencies. Overall, MVI rates significantly decreased 31% from 3.4 per 100 officers to 2.1 (P = .0002). MVC rates did not decrease in the control agencies. MVC rates for patrol officers significantly decreased 21% from 3.1 per 100 000 miles to 2.4. MVI rates for patrol officers significantly decreased 48% from 3.2 per 100 officers to 1.6 (P < .0001). CONCLUSIONS: Crash and injury rates can be reduced after implementation of a crash prevention program and the largest impacts were seen in patrol officers.

    • Occupational Safety and Health – Mining
      1. A field study of longwall mine ventilation using tracer gas in a trona mineexternal icon
        Gangrade V, Schatzel SJ, Harteis SP.
        Min Metall Explor. 2019 .
        A ventilation research study was conducted by the National Institute for Occupational Safety and Health and a cooperating trona mine in the Green River basin of Wyoming, USA. The mine operation uses the longwall mining method in trona bed 17, a commonly mined unit in the region. The longwall face length is 228 m (750 ft), and caving on the face occurred up to the back of the longwall shields. The mine is ventilated using a main blowing fan and a bleeder shaft. For this study, sulfur hexafluoride (SF6) tracer gas was released in two separate monitoring experiments. For the first experiment, tracer gas was released on the face, this test focused on airflow along the longwall face of the active panel. Face test showed the airflow patterns to be more complex than just head-to-tail flow in the main ventilation air stream on the active panel. For the second experiment, tracer gas was released 2 crosscuts inby the face on the headgate side, this test focused on gas transport in the mined-out portion of the same active panel. Gob test showed a pathway of movement through the front of the active panel gob that moved outby from the tailgate corner. The primary pathway of tracer gas movement in the active panel gob was towards the headgate and tailgate bleeders and out of a bleeder shaft. The rate of movement towards the back of the gob was measured to be 0.19 m/s (37 fpm).

    • Reproductive Health
      1. Comparison of self-reported female condom failure and biomarker-confirmed semen exposureexternal icon
        Walsh TL, Snead MC, St Claire BJ, Schwartz JL, Mauck CK, Frezieres RG, Blithe DL, Archer DF, Barnhart KT, Jensen JT, Nelson AL, Thomas MA, Wan LS, Weaver MA.
        Contraception. 2019 Aug 2.
        OBJECTIVE: To investigate whether rates of self-reported Woman’s Condom (WC) clinical failure and semen exposure from a functionality study are comparable to results from a contraceptive efficacy substudy. STUDY DESIGN: We structured our comparative analysis to assess whether functionality studies might credibly supplant contraceptive efficacy studies when evaluating new female condom products. Couples not at risk of pregnancy in the functionality (breakage/slippage/invagination/penile misdirection) study and women in the contraceptive efficacy study completed condom self-reports and collected pre and postcoital vaginal samples for up to four uses of the WC. Both studies used nearly identical self-report questions and the same self-sampling procedures and laboratory for prostatic specific antigen (PSA), a well-studied semen biomarker. We compared condom failure and semen exposure proportions using generalized estimating equations methods accounting for within-couple correlation. RESULTS: Ninety-five (95) efficacy substudy participants used 334 WC and 408 functionality participants used 1572 WC. Based on self-report, 19.2% WC (64 condoms) clinically failed in the efficacy substudy compared to 12.3% WC (194 condoms) in the functionality study (p-value=0.030). Of the 207 WC efficacy uses with evaluable post-coital PSA levels, 14.5% (30 uses) resulted in semen exposure compared to 14.2% (184 uses) of the 1293 evaluable WC functionality study uses. CONCLUSIONS: When evaluating the ability of an experimental condom to prevent semen exposure, the rate of clinical condom failure reported by participants risking pregnancy in an efficacy substudy was significantly higher than the rate reported by participants not risking pregnancy in a functionality study. The rate of semen exposure, assessed by an objective biomarker was nearly identical for the two studies. IMPLICATIONS: Our results suggest that an objective marker of semen exposure in functionality studies could provide a reasonable alternative to contraceptive efficacy studies in evaluating risk of unintended pregnancy and inferring protection from sexually transmitted infection than condom failure rates based on self-report.

    • Statistics as Topic
      1. Bayesian model averaging: Improved variable selection for matched case-control studiesexternal icon
        Mu Y, See I, Edwards JR.
        Epidemiol Biostat Public Health. 2019 ;16(2).
        Background: The problem of variable selection for risk factor modeling is an ongoing challenge in statistical practice. Classical methods that select one subset of exploratory risk factors dominate the medical research field. However, this approach has been criticized for not taking into account the uncertainty of the model selection process itself. This limitation can be addressed by a Bayesian model averaging approach: Instead of focusing on a single model and a few factors, Bayesian model averaging considers all the models with non-negligible probabilities to make inference. Methods: This paper reports on a simulation study designed to emulate a matched case-control study and compares classical versus Bayesian model averaging selection methods. We used Matthews’s correlation coefficient to measure the quality of binary classifications. Both classical and Bayesian model averaging were also applied and compared for the analysis of a matched case-control study of patients with methicillin-resistant Staphylococcus aureus infections after hospital discharge 2011-2013. Results: Bayesian model averaging outperformed the classical approach with much lower false positive rates and higher Matthew’s correlation scores. Bayesian model averaging also produced more reliable and robust effect estimates. Conclusion: Bayesian model averaging is a conceptually simple, unified approach that produces robust results. It can be used to replace controversial P-values for case-control study in medical research.

    • Substance Use and Abuse
      1. Surveillance, epidemiology, and estimated burden of neonatal abstinence syndrome, Tennessee, 2013-2016external icon
        Brennan J, Wiedeman C, Dunn JR, Schaffner W, Jones TF.
        Public Health Rep. 2019 Aug 7.
        OBJECTIVES: Between 2003 and 2013, the rate of neonatal abstinence syndrome (NAS)-a postnatal drug withdrawal syndrome-in Tennessee increased approximately 10-fold. NAS surveillance is relatively new, and underestimation associated with surveillance has not been described. We compared data from the Tennessee NAS public health surveillance system (TNSS) with a second source of NAS data, hospital discharge data system (HDDS), and estimated the true number of infants with NAS using capture-recapture methods. METHODS: We obtained NAS data on cases of NAS among Tennessee infants from TNSS and HDDS from January 1, 2013, through December 31, 2016. We matched cases of NAS identified in TNSS to cases identified in HDDS. We estimated the true number of infants with NAS by using the Lincoln-Peterson estimator capture-recapture methodology. RESULTS: During the study period, 4070 infants with NAS were reported to TNSS, and 5321 infants with NAS were identified in HDDS; 2757 were in both data sets. Using capture-recapture methods, the total estimated number of infants with NAS during the study period was 7855 (annual mean = 1972; estimated range = 1531-2427), which was 93% more than in TNSS and 48% more than in HDDS. Drugs used for the medication-assisted treatment of substance use disorder were the most commonly reported substances associated with NAS (n = 2389, 59%). CONCLUSIONS: TNSS underestimated the total burden of NAS based on the capture-recapture estimate. Case-based public health surveillance is important for monitoring the burden of and risk factors for NAS and helping guide public health interventions.

      2. The roots of the remarkably lethal U.S. opioid crisis are complex and inextricably entangled with healthcare, especially in its treatment of another serious health problem: pain. Failures of the healthcare system-including lack of both training in pain management and caution in using an addictive class of medications-precipitated the rise in opioid misuse and addiction over the past two decades, but a wider range of social and economic forces has helped perpetuate the crisis and altered its character. The classic epidemiologic host-agent-environment triad can be augmented for the purpose of elucidating the current opioid crisis by addition of the “vector” to emphasize the importance of purveyors of opioids (licit and illicit), leading to our proposing an expanded host-agent-vector-environment model. Interventions addressing multiple components are needed, including solutions that account for behaviors of all vectors associated with the crisis. For prescription opioids, the vectors include clinicians and pharmaceutical-related companies involved in marketing, prescribing, distributing, and dispensing opioid medications; for illicit opioids, they include drug manufacturing and distribution networks. Attending to the vectors of opioids, while simultaneously implementing a full range of public health, clinical, law enforcement, and other approaches to ending the opioid crisis, may help to improve public health outcomes.

      3. Vital Signs: Pharmacy-based naloxone dispensing – United States, 2012-2018external icon
        Guy GP, Haegerich TM, Evans ME, Losby JL, Young R, Jones CM.
        MMWR Morb Mortal Wkly Rep. 2019 Aug 9;68(31):679-686.
        BACKGROUND: The CDC Guideline for Prescribing Opioids for Chronic Pain recommends considering prescribing naloxone when factors that increase risk for overdose are present (e.g., history of overdose or substance use disorder, opioid dosages >/=50 morphine milligram equivalents per day [high-dose], and concurrent use of benzodiazepines). In light of the high numbers of drug overdose deaths involving opioids, 36% of which in 2017 involved prescription opioids, improving access to naloxone is a public health priority. CDC examined trends and characteristics of naloxone dispensing from retail pharmacies at the national and county levels in the United States. METHODS: CDC analyzed 2012-2018 retail pharmacy data from IQVIA, a health care, data science, and technology company, to assess U.S. naloxone dispensing by U.S. Census region, urban/rural status, prescriber specialty, and recipient characteristics, including age group, sex, out-of-pocket costs, and method of payment. Factors associated with naloxone dispensing at the county level also were examined. RESULTS: The number of naloxone prescriptions dispensed from retail pharmacies increased substantially from 2012 to 2018, including a 106% increase from 2017 to 2018 alone. Nationally, in 2018, one naloxone prescription was dispensed for every 69 high-dose opioid prescriptions. Substantial regional variation in naloxone dispensing was found, including a twenty-fivefold variation across counties, with lowest rates in the most rural counties. A wide variation was also noted by prescriber specialty. Compared with naloxone prescriptions paid for with Medicaid and commercial insurance, a larger percentage of prescriptions paid for with Medicare required out-of-pocket costs. CONCLUSION: Despite substantial increases in naloxone dispensing, the rate of naloxone prescriptions dispensed per high-dose opioid prescription remains low, and overall naloxone dispensing varies substantially across the country. Naloxone distribution is an important component of the public health response to the opioid overdose epidemic. Health care providers can prescribe or dispense naloxone when overdose risk factors are present and counsel patients on how to use it. Efforts to improve naloxone access and distribution work most effectively with efforts to improve opioid prescribing, implement other harm-reduction strategies, promote linkage to medications for opioid use disorder treatment, and enhance public health and public safety partnerships.

      4. [No abstract]

      5. PURPOSE: Tobacco advertising influences youth smoking behavior. Electronic cigarette (E-cigarette) advertising appears to encourage e-cigarette use among youth. Our aim was to explore the combined effect of exposure to both traditional tobacco advertising and e-cigarette advertising on youth’s current use of traditional tobacco products and e-cigarettes. METHODS: Data were obtained from the 2015 National Youth Tobacco Survey (N = 17,711) in the U.S. Three levels of advertising exposure were assessed: none, traditional tobacco-only advertisements, and traditional tobacco and e-cigarette advertisements. Multivariable logistic regression models were used to explore the association between the three advertising exposure categories and current use of tobacco products. RESULTS: Young people reported frequent exposure to traditional tobacco advertising (64.4%) and e-cigarette advertising (38.7%) in 2015. Exposure to any advertising was associated with significantly increased odds of traditional tobacco product use and e-cigarette use. Compared with no exposure to traditional tobacco or e-cigarette advertising, exposure to both (adjusted odds ratio [aOR]: 1.51) and exposure to traditional tobacco-only advertising (aOR: 1.34) were associated with significantly higher odds of current use of cigarettes, cigars/cigarillos/little cigars (aOR: 1.62 vs. 1.27) and dual/poly use (aOR: 1.91 vs. 1.31); exposure to both was also associated with significantly higher odds of current e-cigarette (aOR: 1.56) and waterpipe with tobacco (aOR: 1.54) use. CONCLUSIONS: E-cigarette advertising in addition to existing traditional tobacco advertising seems to be associated with the use of tobacco and nicotine products among youth. These findings suggest that stricter regulations for e-cigarette advertising may contribute toward reducing the use of tobacco products among youth.

      6. Patterns of nicotine concentrations in electronic cigarettes sold in the United States, 2013-2018external icon
        Romberg AR, Miller Lo EJ, Cuccia AF, Willett JG, Xiao H, Hair EC, Vallone DM, Marynak K, King BA.
        Drug Alcohol Depend. 2019 Jul 19;203:1-7.
        INTRODUCTION: Considerable declines in cigarette smoking have occurred in the U.S. over the past half century. Yet emerging tobacco products, including e-cigarettes, have increased in popularity among U.S. youth and adults in recent years. Nicotine content is an important factor in weighing the potential benefits and risks of e-cigarettes on individual and population level health. This study examined how nicotine concentrations of e-cigarette products sold have changed from 2013 to 2018. METHODS: E-cigarette sales data aggregated in 4-week periods from March 2, 2013 to September 8, 2018 (66 months total) from convenience store and mass market channels were obtained from Nielsen. Internet and vape shop sales were not available. Internet searches were used to supplement information for nicotine concentration and flavor. Products were categorized by nicotine concentration, flavor, type (disposable or rechargeable), and brand. Dollar sales, unit sales, and average nicotine concentration were assessed. RESULTS: During 2013-2018, the average nicotine concentration in e-cigarettes sold increased overall, for all flavor categories, and for rechargeable e-cigarettes. The proportion of total dollar sales comprised of higher nicotine concentration e-cigarettes (>4% mg/mL) increased from 12.3% to 74.7% during 2013-2018, with a similar increase in unit share. Zero-nicotine products accounted for less than 1% of dollar market share across all years analyzed. CONCLUSIONS: E-cigarettes with higher nicotine concentrations comprise a substantial and increasing portion of U.S. e-cigarette sales. Higher nicotine concentrations may influence patterns of e-cigarette use, including harms from e-cigarette initiation among youth and potential health benefits for adult smokers switching completely to e-cigarettes.

    • Zoonotic and Vectorborne Diseases
      1. West Nile virus and other domestic nationally notifiable arboviral diseases – United States, 2018external icon
        McDonald E, Martin SW, Landry K, Gould CV, Lehman J, Fischer M, Lindsey NP.
        MMWR Morb Mortal Wkly Rep. 2019 Aug 9;68(31):673-678.
        Arthropodborne viruses (arboviruses) are transmitted to humans primarily through the bites of infected mosquitoes and ticks. West Nile virus (WNV) is the leading cause of domestically acquired arboviral disease in the continental United States (1). Other arboviruses, including eastern equine encephalitis, Jamestown Canyon, La Crosse, Powassan, and St. Louis encephalitis viruses, cause sporadic cases of disease and occasional outbreaks. This report summarizes surveillance data reported to CDC for 2018 on nationally notifiable arboviruses. It excludes dengue, chikungunya, and Zika viruses because they are primarily nondomestic viruses typically acquired through travel. In 2018, 48 states and the District of Columbia (DC) reported 2,813 cases of domestic arboviral disease, including 2,647 (94%) WNV disease cases. Of the WNV disease cases, 1,658 (63%) were classified as neuroinvasive disease (e.g., meningitis, encephalitis, and acute flaccid paralysis), for a national incidence of 0.51 cases of WNV neuroinvasive disease per 100,000 population. Because arboviral diseases continue to cause serious illness and have no definitive treatment, maintaining surveillance is important to direct and promote prevention activities. Health care providers should consider arboviral infections in patients with aseptic meningitis or encephalitis, perform appropriate diagnostic testing, and report cases to public health authorities.

      2. Human monkeypox in Sierra Leone after 44-year absence of reported casesexternal icon
        Reynolds MG, Wauquier N, Li Y, Satheshkumar PS, Kanneh LD, Monroe B, Maikere J, Saffa G, Gonzalez JP, Fair J, Carroll DS, Jambai A, Dafae F, Khan SH, Moses LM.
        Emerg Infect Dis. 2019 May;25(5):1023-1025.
        We note the reemergence of human monkeypox in Sierra Leone following a 44-year absence of reported disease. The persons affected were an 11-month-old boy and, several years later, a 35-year-old man. The reappearance of monkeypox in this country suggests a need for renewed vigilance and awareness of the disease and its manifestations.

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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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