Volume 11, Issue 34 August 27, 2019

CDC Science Clips: Volume 11, Issue 34, August 26, 2019

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

  1. Top Articles of the Week

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

    The names of CDC authors are indicated in bold text.
    • Communicable Diseases
      • Association between trends in county-level opioid prescribing and reported rates of gonorrhea cases in the United Statesexternal icon
        Abara WE, Hong J, Dorji T, Bohm MK, Weston EJ, Bernstein KT, Kirkcaldy RD.
        Ann Epidemiol. 2019 Jul 4.
        PURPOSE: We investigated the association between county-level trends in opioid prescribing rates, a proxy for opioid misuse, and rates of reported gonorrhea (GC) among males in the United States. METHODS: We used linear mixed-model regression analyses to evaluate the association between county-level trends in opioid prescribing rates and rates of reported GC among males during 2010-2015. RESULTS: There was a positive association between trends in county-level opioid prescribing rates and rates of GC among males (beta = 0.068, 95% confidence interval [CI] = 0.030, 0.105) during 2010-2015. However, the magnitude of this association decreased significantly over time in counties where opioid prescribing rates decreased (beta = -0.018, 95% CI = -0.030, -0.006) and remained stable (beta = -0.020, 95% CI = -0.038, -0.002) but was unchanged in counties where opioid prescribing rates increased (beta = -0.029, 95% CI = -0.058, 0.001). CONCLUSIONS: During 2010-2015, we found a positive association between increases in county-level opioid prescribing rates, a proxy for opioid misuse, and rates of reported GC among males especially in counties most affected by the opioid crisis. Integrating sexual health with opioid misuse interventions might be beneficial in addressing the GC burden in the United States.

      • Homelessness and hepatitis A – San Diego County, 2016-2018external icon
        Peak CM, Stous SS, Healy JM, Hofmeister MG, Lin Y, Ramachandran S, Foster M, Kao A, McDonald EC.
        Clin Infect Dis. 2019 Aug 15.
        BACKGROUND: Hepatitis A is a vaccine-preventable viral disease transmitted by the fecal-oral route. During 2016-2018, the County of San Diego investigated an outbreak of hepatitis A infections primarily among people experiencing homelessness (PEH) to identify risk factors and support control measures. At the time of the outbreak, homelessness was not recognized as an independent risk factor for the disease. METHODS: We tested the association between homelessness and infection with hepatitis A virus (HAV) using a test-negative study design comparing patients with laboratory-confirmed hepatitis A with control subjects who tested negative for HAV infection. We assessed risk factors for severe hepatitis A disease outcomes, including hospitalization and death, using multivariable logistic regression. We measured the frequency of indications for hepatitis A vaccination according to Advisory Committee on Immunization Practice (ACIP) guidelines. RESULTS: Among 589 outbreak-associated cases reported, 291 (49%) occurred among PEH. Compared with those who were not homeless, PEH were at 3.3 (95% CI: 1.5-7.9) times higher odds of HAV infection, 2.5 (95% CI: 1.7-3.9) times higher odds of hospitalization, and 3.9 (95% CI: 1.1-16.9) times higher odds of death associated with hepatitis A. Among PEH, 212 (73%) patients recorded other ACIP indications for hepatitis A vaccination. CONCLUSIONS: PEH were at higher risk for infection with HAV and higher risk for severe hepatitis A disease outcomes compared with those not experiencing homelessness. Approximately one-fourth of PEH had no other ACIP indication for hepatitis A vaccination. These findings support the recent ACIP recommendation to add homelessness as an indication for hepatitis A vaccination.

      • Impact of inter-partner HIV disclosure patterns in Malawi’s PMTCT program: A mixed-method studyexternal icon
        van Lettow M, Cataldo F, Landes M, Kasende F, Nkhoma P, van Oosterhout JJ, Kim E, Schouten E, Nkhoma E, Nyirenda R, Tippett Barr BA.
        PLoS ONE. 2019 ;14(7).
        Background Evidence suggests that disclosure of HIV status between partners may influence prevention of maternal-to-child transmission of HIV (PMTCT) outcomes. We report partner disclosure in relation to maternal antiretroviral therapy (ART) uptake and adherence, and MTCT among postpartum HIV-infected Malawian women. Methods A cross-sectional mixed-method study was conducted as part of a nationally representative longitudinal cohort study. Between 2014-2016, all (34,637) mothers attending 54 under-5 clinics with their 4-26 week-old infants were approached, of which 98% (33,980) were screened for HIV; infants received HIV-1 DNA testing. HIV-exposure was confirmed in 3,566/33,980 (10.5%). Baseline data from mothers who were known to be HIV-infected at time of screening were included in the current analysis. Guardians (n = 17), newly diagnosed HIV-infected mothers (n = 256) and mothers or infants with undetermined HIV status (n = 30) were excluded. Data collected included socio-demographics, partner disclosure, maternal ART uptake, and adherence. Between 2016-2017, in-depth interviews and focus group discussions were conducted with adult mothers (n = 53) and their spouse/cohabiting partners (n = 19), adolescent mothers (n = 13), lost-to-follow up (LTFU) mothers (n = 22), community leaders (n = 23) and healthcare workers (n = 154). Results Of 3153 known HIV-infected mothers, 2882 (91.4%) reported having a spouse/cohabiting partner. Among 2882 couples, both partners, one partner, and neither partner disclosed to each other in 2090 (72.5%), 622 (21.6%), and 169 (5.9%), respectively. In multivariable models, neither partner disclosing was associated with no maternal ART (aOR 4.7; 95%CI 2.5-8.8), suboptimal treatment adherence (aOR 1.8; 95%CI 1.1-2.8) and MTCT (aOR 2.1; 95%CI 1.1-4.1). Women’s fear of blame by partners was central to decisions not to disclose within couples and when starting new relationships. LTFU mothers struggled to accept and disclose their status, hindering treatment initiation; some were unable to hide ART and feared involuntary disclosure. Conclusion Partner disclosure seems to play an important role in women’s decisions regarding ART initiation and adherence. Inter-partner non-disclosure was associated with no ART uptake, suboptimal treatment adherence and MTCT. Copyright This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

    • Drug Safety
      • A random survey of the prevalence of falsified and substandard antibiotics in the Lao PDRpdf iconexternal icon
        Tabernero P, Swamidoss I, Mayxay M, Khanthavong M, Phonlavong C, Vilayhong C, Yeuchaixiong S, Sichanh C, Sengaloundeth S, Green MD, Newton PN.
        J Antimicrob Chemother. 2019 ;74(8):2417-2425.
        OBJECTIVES: In 2012, a stratified random survey, using mystery shoppers, was conducted to investigate the availability and quality of antibiotics sold to patients in the private sector in five southern provinces of the Lao People’s Democratic Republic (Laos). METHODS: A total of 147 outlets were sampled in 10 districts. The active pharmaceutical ingredient (API) content measurements for 909 samples, including nine APIs (amoxicillin, ampicillin, ceftriaxone, ciprofloxacin, doxycycline, ofloxacin, sulfamethoxazole, tetracycline and trimethoprim), were determined using HPLC. RESULTS: All the analysed samples contained the stated API and we found no evidence for falsification. All except one sample had all the units tested with %API values between 75% and 125% of the content stated on the label. However, we identified the presence of substandard antibiotics: 19.6% (201/1025) of samples had their units outside the 90%-110% content of the label claim and 60.2% (617/1025) of the samples had units outside of the International Pharmacopoeia uniformity of content limit range. Amoxicillin had a high number of samples [67.1% (151)] with units above the limit range, followed by ciprofloxacin [58.8% (10)] and ofloxacin [57.4% (39)]. Ceftriaxone, trimethoprim and sulfamethoxazole had the highest number of samples with low API content: 57.1% (4), 51.6% (64) and 34.7% (43), respectively. Significant differences in %API were found between stated countries of manufacture and stated manufacturers. CONCLUSIONS: With the global threat of antimicrobial resistance to patient outcomes, greater understanding of the role of poor-quality antibiotics is needed. Substandard antibiotics will have reduced therapeutic efficacy, impacting public health and control of bacterial infections.

    • Epidemiology and Surveillance
      • Calls for remedies for the persistent scarcity of accurate, reliable, national, disaggregated health statistics on hard-to-survey populations are common, but solutions are rare. Survey strategies used in community and clinical studies of hard-to-survey populations often cannot be, and generally are not, implemented at the national level.This essay presents a set of approaches, for use in combination with traditional survey methods in large-scale surveys of these populations, to overcome challenges in 2 domains: sampling and motivating respondents to participate. The first approach consists of using the American Community Survey as a frame, and the second consists of implementing a multifaceted community engagement effort.We offer lessons learned from implementing these strategies in a national survey, some of which are relevant to all survey planners. We then present evidence of the quality of the resulting data set. If these approaches were used more widely, hard-to-survey populations could become more visible and accurately represented to those responsible for setting national priorities for health research and services. (Am J Public Health. Published online ahead of print August 15, 2019: e1-e8. doi:10.2105/AJPH.2019.305217).

    • Immunity and Immunization
      • Early impact of 13-valent pneumococcal conjugate vaccine use on invasive pneumococcal disease among adults with and without underlying medical conditions – United Statesexternal icon
        Ahmed SS, Pondo T, Xing W, McGee L, Farley M, Schaffner W, Thomas A, Reingold A, Harrison L, Lynfield R, Rowlands J, Bennett N, Petit S, Barnes M, Smelser C, Beall B, Whitney CG, Pilishvili T.
        Clin Infect Dis. 2019 Aug 12.
        BACKGROUND: The 13-valent pneumococcal vaccine (PCV13) was introduced for U.S. children in 2010, and for immunocompromised adults >/=19 years old in series with the 23-valent polysaccharide vaccine (PPSV23) in 2012. To quantify indirect effects before the 2014 introduction of PCV13 for all adults >/=65 years old, we evaluated PCV13 impact on invasive pneumococcal disease (IPD) among adults with and without PCV13 indications. METHODS: We estimated IPD incidence using Active Bacterial Core surveillance and National Health Interview Survey. We compared incidence in 2013-2014 and 2007-2008, by age and serotype group (PCV13, PPSV23-unique, or types in neither vaccine [NVT]), among adults with and without PCV13 indications. RESULTS: IPD incidence declined among all adults. Among adults 19-64 years, PCV13-type IPD declined 57% (95%CI:-68,-43) in adults with immunocompromising conditions (IC, indication for PCV13 use), 57% (95%CI:-62, -52) in immunocompetent adults with chronic medical conditions (CMC, indications for PPSV23 use alone), and 74% (95%CI:-78,-70) in adults with neither vaccine indication. Among adults >/=65 years, PCV13-type IPD decreased 68% (95%CI:-76,-60) in those with IC, 68% (95%CI:-72,-63) in those with CMC, and 71% (95%CI:-77,-64) in healthy adults. PPSV23-unique types increased in adults 1964 years with CMC, and NVT did not change among adults with or without PCV13 indications. From 2013-2014, non-PCV13 serotypes accounted for nearly 80% of IPD. CONCLUSION: IPD incidence among U.S. adults declined after PCV13 introduction in children. Similar reductions in PCV13-type IPD in those with and without PCV13 indications suggest observed benefits are largely due to indirect effects from pediatric PCV13 use rather than direct use among adults.

    • Parasitic Diseases
      • Use of routine health information system data to evaluate impact of malaria control interventions in Zanzibar, Tanzania from 2000 to 2015external icon
        Ashton RA, Bennett A, Al-Mafazy AW, Abass AK, Msellem MI, McElroy P, Kachur SP, Ali AS, Yukich J, Eisele TP, Bhattarai A.
        EClinicalMedicine. 2019 July;12:11-19.
        Background: Impact evaluations allow countries to assess public health gains achieved through malaria investments. This study uses routine health management information system (HMIS) data from Zanzibar to describe changes in confirmed malaria incidence and impact of case management and vector control interventions during 2000-2015. Method(s): HMIS data from 129 (82%) public outpatient facilities were analyzed using interrupted time series models to estimate the impact of artemisinin-based combination therapy (ACT), indoor residual spray, and long-lasting insecticidal nets. Evaluation periods were defined as pre-intervention (January 2000 to August 2003), ACT-only (September 2003 to December 2005) and ACT plus vector control (2006-2015). Finding(s): After accounting for climate, seasonality, diagnostic testing rates, and outpatient attendance, average monthly incidence of confirmed malaria showed no trend over the pre-intervention period 2000-2003 (incidence rate ratio (IRR) 0.998, 95% CI 0.995-1.000). During the ACT-only period (2003-2005), the average monthly malaria incidence rate declined compared to the pre-intervention period, showing an overall declining trend during the ACT-only period (IRR 0.984, 95% CI 0.978-0.990). There was no intercept change at the start of the ACT-only period (IRR 1.081, 95% CI 0.968-1.208), but a drop in intercept was identified at the start of the ACT plus vector control period (IRR 0.683, 95% CI 0.597-0.780). During the ACT plus vector control period (2006-2015), the rate of decline in average monthly malaria incidence slowed compared to the ACT-only period, but the incidence rate continued to show an overall slight declining trend during 2006-2015 (IRR 0.993, 95% CI 0.992-0.994). Interpretation(s): This study presents a rigorous approach to the use of HMIS data in evaluating the impact of malaria control interventions. Evidence is presented for a rapid decline in malaria incidence during the period of ACT roll out compared to pre-intervention, with a rapid drop in malaria incidence following introduction of vector control and a slower declining incidence trend thereafter.

    • Physical Activity
      • Obesity and lack of physical activity among children and adolescents are public health problems in the United States. This Presidential Youth Fitness Program (PYFP) evaluation measured program implementation in 13 middle schools and its effect on physical education practices, student fitness knowledge, and student physical activity and fitness levels. PYFP, a free program with the potential to positively affect student health and fitness outcomes, was designed to improve fitness education practices that are easily integrated into existing physical education programs. We used a 2-group (13 PYFP and 13 comparison schools) quasi-experimental design to collect FitnessGram assessments, accelerometry data, and surveys of students, physical education teachers, and administrators. Although the program was positively associated with student cardiovascular endurance and physical activity gains during the semester, schools underused professional development courses and fitness recognition resources.

    • Public Health Leadership and Management
      • Background In September 2009, the Machinga Integrated Antenatal Water Hygiene Kit Program began addressing problems of unsafe water, high infant mortality, and low antenatal care (ANC) attendance in Machinga District, Malawi. In March 2011, the supporting international nongovernmental organization transitioned management of the program to the Machinga District Health Office (DHO). We evaluated maternal and HIV service use before and after program transition to the DHO. Methods We compared pre- and post-transition periods by examining data recorded in ANC and maternal registries in 15 healthcare facilities (HCFs) by proportion z-tests. We classified HCFs by size, using the median monthly patient volumes as the split for large or small facilities. We used logistic regression to evaluate changes in the use of ANC, maternal, and HIV services and their interactions with HCF size. Results The percentage of women attending their first ANC visit during the first trimester was similar in the pre-and post-transition periods (9.3% vs 10.2%). Although the percentage of women with 4 ANC visits was similar from pre- to post-transition (26.0% vs 24.8%), the odds increased among women in small facilities (OR: 1.37, 95% CI: 1.24-1.51), and decreased among women in large facilities (OR: 0.80, 95% CI: 0.75-0.85). Although a similar percentages of pregnant women were diagnosed with HIV in all HCFs in the pre- and post-transitions periods (6.4% vs 4.8%), a substantially larger proportion of women were not tested for HIV in large HCFs (OR: 6.34, 95% CI: 5.88-6.84). A larger proportion of women gave birth at both small (OR: 1.30, 95% CI: 1.16-1.45) and large HCFs (OR: 1.55, 95% CI: 1.43-1.67) in the post-transition vs. the pre-transition period. Conclusions The evaluation results suggest that many positive aspects of this donor-supported program continued following transition of program management from a non-governmental organization to a DHO. This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

    • Zoonotic and Vectorborne Diseases
      • Mobile phone-based surveillance for animal disease in rural communities: implications for detection of zoonoses spilloverexternal icon
        Thumbi SM, Njenga MK, Otiang E, Otieno L, Munyua P, Eichler S, Widdowson MA, McElwain TF, Palmer GH.
        Philos Trans R Soc Lond B Biol Sci. 2019 Sep 30;374(1782):20190020.
        Improving the speed of outbreak detection and reporting at the community level are critical in managing the threat of emerging infectious diseases, many of which are zoonotic. The widespread use of mobile phones, including in rural areas, constitutes a potentially effective tool for real-time surveillance of infectious diseases. Using longitudinal data from a disease surveillance system implemented in 1500 households in rural Kenya, we test the effectiveness of mobile phone animal syndromic surveillance by comparing it with routine household animal health surveys, determine the individual and household correlates of its use and examine the broader implications for surveillance of zoonotic diseases. A total of 20 340 animal and death events were reported from the community through the two surveillance systems, half of which were confirmed as valid disease events. The probability of an event being valid was 2.1 times greater for the phone-based system, compared with the household visits. Illness events were 15 times (95% CI 12.8, 17.1) more likely to be reported through the phone system compared to routine household visits, but not death events (OR 0.1 (95% CI 0.09, 0.11)). Disease syndromes with severe presentations were more likely to be reported through the phone system. While controlling for herd and flock sizes owned, phone ownership was not a determinant of using the phone-based surveillance system, but the lack of a formal education, and having additional sources of income besides farming were associated with decreased likelihood of reporting through the phone system. Our study suggests that a phone-based surveillance system will be effective at detecting outbreaks of diseases such as Rift Valley fever that present with severe clinical signs in animal populations, but in the absence of additional reporting incentives, it may miss early outbreaks of diseases such as avian influenza that present primarily with mortality. This article is part of the theme issue ‘Dynamic and integrative approaches to understanding pathogen spillover’.

  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. The Winnebago Tribe of Nebraska implemented interventions to promote the health of their people, focusing on community-selected and culturally adapted policies, systems, and environmental (PSE) improvements to reduce the prevalence of obesity and type 2 diabetes. The interventions were implemented as part of the Centers for Disease Control and Prevention’s (CDC’s) 2014-2019 Good Health and Wellness in Indian Country program. The Winnebago Tribe used CDC’s CHANGE community health assessment tool to prioritize and direct their interventions. They integrated findings from a community health assessment tool with observations from tribal working groups and implemented 6 new evidence-based PSE interventions. Their successful approaches – selected by the Winnebago community, culturally relevant, and driven by scientific assessment -demonstrate the value of flexibility in CDC grant programs.

      2. OBJECTIVES: Research suggests that persons who are aware of the risk factors for cardiovascular disease (CVD) are more likely to engage in healthy behaviors than persons who are not aware of the risk factors. We examined whether patients whose insurance claims included an International Classification of Diseases, Ninth Revision (ICD-9) code associated with hypertension who self-reported high blood pressure were more likely to fill antihypertensive medication prescriptions and less likely to have CVD-related emergency department visits and hospitalizations (hereinafter, CVD-related events) and related medical expenditures than patients with these codes who did not self-report high blood pressure. METHODS: We used a large convenience sample from the MarketScan Commercial Database linked with the MarketScan Health Risk Assessment (HRA) Database to identify patients aged 18-64 in the United States whose insurance claims included an ICD-9 code associated with hypertension and who completed an HRA from 2008 through 2012 (n = 111 655). We used multivariate logistic regression analysis to examine the association between self-reported high blood pressure and (1) filling prescriptions for antihypertensive medications and (2) CVD-related events. Because most patients with hypertension will not have a CVD-related event, we used a 2-part model to analyze medical expenditures. The first part estimated the likelihood of a CVD-related event, and the second part estimated expenditures. RESULTS: Patients with an ICD-9 code of hypertension who self-reported high blood pressure had a significantly higher predicted probability of filling antihypertensive medication prescriptions (26.5%; 95% confidence interval, 25.7-27.3; P < .001), had a significantly lower predicted probability of a CVD-related event (0.6%, P < .001), and on average spent significantly less on CVD-related events ($251, P = .01) than patients who did not self-report high blood pressure. CONCLUSION: This study affirms that self-knowledge of high blood pressure, even among patients who are diagnosed and treated for hypertension, can be improved. Interventions that improve patients’ awareness of their hypertension may improve antihypertensive medication use and reduce adverse CVD-related events.

      3. Healthy contact lens behaviors communicated by eye care providers and recalled by patients – United States, 2018external icon
        Konne NM, Collier SA, Spangler J, Cope JR.
        MMWR Morb Mortal Wkly Rep. 2019 Aug 16;68(32):693-697.
        An estimated 45 million U.S. residents enjoy the benefits of contact lens wear, but many of them might be at increased risk for complications stemming from improper wear and care behaviors (1). One of the most serious complications of contact lens wear is a corneal infection known as microbial keratitis, which can sometimes result in reduced vision or blindness (2). In 2014, 50% of contact lens wearers reported ever sleeping in contact lenses, and 55% reported topping off* their contact lens solutions (3), which put them at greater risk for a contact lens-related eye infection (2,4). Data on communication between eye care providers and contact lens wearers on contact lens wear and care recommendations are limited. Two surveys were conducted to better understand and assess contact lens education about nine recommendations: the first assessed contact lens wearer experiences regarding recommendations received from eye care providers during their most recent appointment; the second evaluated provider-reported practices for communicating contact lens wear and care recommendations to their patients. One third (32.9%) of contact lens wearers aged >/=18 years recalled never hearing any lens wear and care recommendations. Fewer than half (47.9%) recalled hearing their provider recommend not sleeping in lenses at their last visit, and 19.8% recalled being told to avoid topping off their contact lens solution. A majority of providers reported sharing recommendations always or most of the time at initial visits, regular checkups, and complication-related visits. Providers reported sharing nearly all recommendations more frequently at initial and complication-related visits than at regular checkups. Of the nine recommendations for safe contact lens wear and care, eye care providers at regular checkups most often recommend complying with the recommended lens replacement schedules (85% of regular visits), not sleeping in lenses (79.0% of regular visits), and not topping off solutions (64.4% of regular visits). Eye care providers play an important role in the health of their contact lens-wearing patients and can share health communication messages with their patients to help educate them about healthy wear and care habits. These findings can assist in the creation of health communication messages to help encourage eye care providers to communicate more effectively with their patients.

      4. Using a RE-AIM framework to identify promising practices in National Diabetes Prevention Program implementationexternal icon
        Nhim K, Gruss SM, Porterfield DS, Jacobs S, Elkins W, Luman ET, Van Aacken S, Schumacher P, Albright A.
        Implement Sci. 2019 Aug 14;14(1):81.
        BACKGROUND: The National Diabetes Prevention Program (National DPP) is rapidly expanding in an effort to help those at high risk of type 2 diabetes prevent or delay the disease. In 2012, the Centers for Disease Control and Prevention funded six national organizations to scale and sustain multistate delivery of the National DPP lifestyle change intervention (LCI). This study aims to describe reach, adoption, and maintenance during the 4-year funding period and to assess associations between site-level factors and program effectiveness regarding participant attendance and participation duration. METHODS: The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to guide the evaluation from October 2012 to September 2016. Multilevel linear regressions were used to examine associations between participant-level demographics and site-level strategies and number of sessions attended, attendance in months 7-12, and duration of participation. RESULTS: The six funded national organizations increased the number of participating sites from 68 in 2012 to 164 by 2016 across 38 states and enrolled 14,876 eligible participants. By September 2016, coverage for the National DPP LCI was secured for 42 private insurers and 7 public payers. Nearly 200 employers were recruited to offer the LCI on site to their employees. Site-level strategies significantly associated with higher overall attendance, attendance in months 7-12, and longer participation duration included using self-referral or word of mouth as a recruitment strategy, providing non-monetary incentives for participation, and using cultural adaptations to address participants’ needs. Sites receiving referrals from healthcare providers or health systems also had higher attendance in months 7-12 and longer participation duration. At the participant level, better outcomes were achieved among those aged 65+ (vs. 18-44 or 45-64), those who were overweight (vs. obesity), those who were non-Hispanic white (vs. non-Hispanic black or multiracial/other races), and those eligible based on a blood test or history of gestational diabetes mellitus (vs. screening positive on a risk test). CONCLUSIONS: In a time of rapid dissemination of the National DPP LCI the findings of this evaluation can be used to enhance program implementation and translate lessons learned to similar organizations and settings.

    • Communicable Diseases
      1. Evaluating household transmission of invasive group A streptococcus disease in the United States using population-based surveillance data, 2013-2016external icon
        Adebanjo T, Apostol M, Alden N, Petit S, Tunali A, Torres S, Hollick R, Bell A, Muse A, Poissant T, Schaffner W, Van Beneden CA.
        Clin Infect Dis. 2019 Aug 13.
        Using population-based surveillance data, we quantified secondary invasive group A Streptococcus (iGAS) disease risk among household contacts. Disease risk in the 30 days post-exposure to an index case-patient was highest among individuals aged >/=65 years (4,122 cases/100,000 person-years) versus the annual background incidence of 4.0 cases/100,000 population of all ages.

      2. Distinguishing between histoplasmosis, tuberculosis (TB), and co-occurrence of disease is a frequent dilemma for clinical staff treating people with advanced Human Immunodeficiency Virus (HIV) infection. This problem is most frequently observed in clinical settings in countries where both diseases are endemic. It is also a challenge outside these endemic countries in HIV clinics that take care of patients coming from countries with endemic histoplasmosis and TB. The gold standard for diagnosis of both of these diseases is based on conventional laboratory tests (culture, histopathology and special stains). These tests have several limitations, such as lack of laboratory infrastructure for handling isolates (biosafety level 3), shortage of laboratory staff who have appropriate training and experience, variable analytical performance of tests and long turn-around time. Recently, novel rapid assays for the diagnosis of histoplasmosis and TB became available. However, this technology is not yet widely used. Mortality in immunocompromised patients, such as people with advanced HIV, is directly linked with the ability to rapidly diagnose opportunistic diseases. The aim of this review is to synthesize the main aspects of epidemiology, clinical characteristics, diagnosis and treatment of histoplasmosis/TB co-occurrence in people with advanced HIV.

      3. Tracking linkage to care in an anonymous HIV testing context: A field assessment in Mozambiqueexternal icon
        Courtenay-Quirk C, Geller AL, Duran D, Honwana N.
        J Eval Clin Pract. 2019 Aug 14.
        RATIONALE: Effective human immunodeficiency virus (HIV) prevention requires a coordinated continuum of services to foster early diagnosis and treatment. Early linkage to care (LTC) is critical, yet programmes differ in strategies to monitor LTC. METHODS: In 2014, we visited 23 HIV testing and care service delivery points in Mozambique to assess programme strategies for monitoring LTC. We interviewed key informants, reviewed forms, and matched records across service points to identify successful models and challenges. RESULTS: Forms most useful for tracking LTC included individual identifiers, eg, patient name, unique identifier (ie, National Health Identification Number [NID]), sex, and date of birth. The majority (67%) of records matched occurred in the presence of a unique NID. Key informants described challenges related to processes, staffing, and communication between service delivery points to confirm LTC. CONCLUSIONS: While tracking clients from HIV testing to care is possible, programmes with insufficient tracking procedures are likely to underreport LTC. Adoption of additional patient identifiers in testing registers and standardized protocols may improve LTC programme monitoring and reduce underreporting.

      4. Self-reported history of chlamydia or gonorrhea testing among heterosexual women at high risk of HIV infection, National HIV Behavioral Surveillance, 2013external icon
        Johnson Jones ML, Kirkcaldy RD, An Q, Gorwitz R, Bernstein K, Paz-Bailey G.
        Sex Transm Dis. 2019 Sep;46(9):608-616.
        BACKGROUND: The US Preventive Services Task Force recommends annual chlamydia and gonorrhea screening for sexually active women <25 and >/=25 years old with associated risk factors. We sought to determine self-reported chlamydia and gonorrhea testing and diagnosis rates in the past 12 months in a community-based sample of heterosexual women at high risk of HIV infection. METHODS: We used National HIV Behavioral Surveillance data from 2013 when surveillance was conducted in heterosexual adults with low social economic status. Our analysis was restricted to 18- to 44-year-old women who answered questions regarding chlamydia/gonorrhea testing and diagnosis in the previous 12 months. We calculated the percentage reporting testing and diagnosis. Poisson regressions with generalized estimating equations clustered on recruitment chain were used to assess factors associated with testing and diagnosis. RESULTS: Among 18- to 24-year-old women (n = 1017), 61.0% self-reported chlamydia testing and 57.6% gonorrhea testing in the past 12 months. Among 25- to 44-year-old women (n = 2322), 49.0% and 47.0% reported chlamydia and gonorrhea testing, respectively. Among the subset of 25- to 44-year-old women who met screening criteria, 51.2% reported chlamydia testing. Having seen a medical provider and HIV testing (past 12 months) were associated with chlamydia/gonorrhea testing in both age groups. Self-reported chlamydia (18-24 years, 21.4%; 25-44 years, 12.2%) and gonorrhea diagnoses (18-24 years, 8.4%; 25-44 years, 6.6%) were common. CONCLUSIONS: A substantial number of eligible women may not have been screened for chlamydia/gonorrhea. Renewed efforts to facilitate screening may prevent sequelae and support disease control activities.

      5. Rapid response to meningococcal disease cluster in Foya district, Lofa County, Liberia January to February 2018external icon
        Rude JM, Kortimai L, Mosoka F, April B, Nuha M, Katawera V, Nagbe T, Tamba A, Williams D, Mulbah R, Pierre F, Onuche EM, Chukwudi JO, Talisuna A, Yahaya AA, Rajatonirina S, Nyenswah T, Dahn B, Gasasira A, Fall IS.
        Pan Afr Med J. 2019 ;33(Suppl 2):6.
        Introduction: Early detection of disease outbreaks is paramount to averting associated morbidity and mortality. In January 2018, nine cases including four deaths associated with meningococcal disease were reported in three communities of Foya district, Lofa County, Liberia. Due to the porous borders between Lofa County and communities in neighboring Sierra Leone and Guinea, the possibility of epidemic spread of meningococcal disease could not be underestimated. Methods: The county incidence management system (IMS) was activated that coordinated the response activities. Daily meetings were conducted to review response activities progress and challenges. The district rapid response team (DRRT) was the frontline responders. The case based investigation form; case line list and contacts list were used for data collection. A data base was established and analysed daily for action. Tablets Ciprofloxacin were given for chemoprophylaxis. Results: Sixty-seven percent (67%) of the cases were males and also 67% of the affected age range was 3 to 14 years and attending primary school. The attack rate was 7/1,000 population and case fatality rate was 44.4 % with majority of the deaths occurring within 24-48 hours of symptoms onset. Three of the cases tested positive for Neisseria Meningitidis sero-type W while six cases were Epi-linked. None of the cases had recent meningococcal vaccination and no health-worker infections were registered. Conclusion: This cluster of cases of meningococcal disease during the meningitis season in a country that is not traditionally part of the meningitis belt emphasized the need for strengthening surveillance, preparedness and response capacity to meningitis.

    • Environmental Health
      1. Children’s exposure to phthalates and non-phthalate plasticizers in the home: The TESIE studyexternal icon
        Hammel SC, Levasseur JL, Hoffman K, Phillips AL, Lorenzo AM, Calafat AM, Webster TF, Stapleton HM.
        Environ Int. 2019 Aug 7;132:105061.
        BACKGROUND: Phthalates and their potential replacements, including non-phthalate plasticizers, are ubiquitous in home environments due to their presence in building materials, plastics, and personal care products. As a result, exposure to these compounds is universal. However, the primary pathways of exposure and understanding which products in the home are associated most strongly with particular exposures are unclear. OBJECTIVES: We sought to investigate the relationships between phthalates and non-phthalate plasticizers in paired samples of house dust, hand wipes, and their corresponding metabolites in children’s urine samples (n=180). In addition, we compared product use or presence of materials in the household against all compounds to investigate the relationship between product use or presence and exposure. METHODS: Children aged 3-6years provided hand wipe and urine samples. Questionnaires were completed by mothers or legal guardians to capture product use and housing characteristics, and house dust samples were collected from the main living area during home visits. RESULTS: Phthalates and non-phthalate replacements were detected frequently in the environmental matrices. All urine samples had at least 13 of 19 phthalate or non-phthalate replacement metabolites present. Hand wipe mass and dust concentrations of diisobutyl phthalate, benzyl butyl phthalate (BBP), bis(2-ethylhexyl) phthalate, and di-isononyl phthalate were significantly associated with their corresponding urinary metabolites (rs=0.18-0.56, p<0.05). Bis(2-ethylhexyl) terephthalate (DEHTP) in dust was also significantly and positively correlated with its urinary metabolites (rs=0.33, p<0.001). Vinyl flooring was most significantly and positively associated with particular phthalate exposures (indicated by concentrations in environmental matrices and urinary biomarkers). In particular, children who lived in homes with 100% vinyl flooring had urinary concentrations of monobenzyl phthalate, a BBP metabolite, that were 15 times higher than those of children who lived in homes with no vinyl flooring (p<0.0001). Levels of BBP in hand wipes and dust were 3.5 and 4.5 times higher, respectively, in those homes with 100% vinyl flooring (p<0.0001 for both). CONCLUSIONS: This paper summarizes one of the most comprehensive phthalate and non-phthalate plasticizer investigation of potential residential exposure sources conducted in North America to date. The data presented herein provide evidence that dermal contact and hand-to-mouth behaviors are important sources of exposure to phthalates and non-phthalate plasticizers. In addition, the percentage of vinyl flooring is an important consideration when examining residential exposures to these compounds.

      2. Maternal serum concentrations of perfluoroalkyl substances during pregnancy and gestational weight gain: The Avon Longitudinal Study of Parents and Childrenexternal icon
        Marks KJ, Jeddy Z, Flanders WD, Northstone K, Fraser A, Calafat AM, Kato K, Hartman TJ.
        Reprod Toxicol. 2019 Aug 12.
        Perfluoroalkyl substances (PFAS) are chemicals used in the manufacture of consumer products. PFAS may act as endocrine disruptors, influencing metabolic pathways and weight-related outcomes. We analyzed associations of maternal serum pregnancy concentrations of PFAS with gestational weight gain (GWG). We used data from 905 women in a subsample of the Avon Longitudinal Study of Parents and Children. Women were routinely weighed in antenatal check-ups; absolute GWG was determined by subtracting the first weight measurement from the last. Linear regression was used to explore associations of maternal PFAS concentrations with absolute GWG, stratified by pre-pregnancy body mass index. Associations of maternal PFAS concentrations with absolute GWG were null. Ten percent higher perfluorooctane sulfonic acid (PFOS) was associated with GWG of -0.03kg (95% CI: -0.11, 0.06) and -0.12kg (95% CI: -0.30, 0.06) among under-/normal weight and overweight/obese mothers, respectively. Overall, findings suggest no association between maternal PFAS concentrations and GWG.

      3. This report describes the available drinking water quality monitoring data on the Centers for Disease Control and Prevention (CDC) National Environmental Public Health Tracking Network (Tracking Network). This surveillance summary serves to identify the degree to which ten drinking water contaminants are present in finished water delivered to populations served by community water systems (CWS) in 24 states from 2000 to 2010. For each state, data were collected from every CWS. CWS are sampled on a monitoring schedule established by the Environmental Protection Agency (EPA) for each contaminant monitored. Annual mean and maximum concentrations by CWS for ten water contaminants were summarized from 2000 to 2010 for 24 states. For each contaminant, we calculated the number and percent of CWS with mean and maximum concentrations above the maximum contaminant level (MCL) and the number and percent of population served by CWS with mean and maximum concentrations above the MCL by year and then calculated the median number of those exceedances for the 11-year period. We also summarized these measures by CWS size and by state and identified the source water used by those CWS with exceedances of the MCL. The contaminants that occur more frequently in CWS with annual mean and annual maximum concentrations greater than the MCL include the disinfection byproducts, total trihalomethanes (TTHM), and haloacetic acids (HAA5); arsenic; nitrate; radium and uranium. A very high proportion of exceedances based on MCLs occurred mostly in very small and small CWS, which serve a year-round population of 3,300 or less. Arsenic in New Mexico and disinfection byproducts HAA5 and TTHM, represent the greatest health risk in terms of exposure to regulated drinking water contaminants. Very small and small CWS are the systems’ greatest difficulty in achieving compliance.

    • Epidemiology and Surveillance
      1. Estimating the size of key populations in Kampala, Uganda: 3-source capture-recapture studyexternal icon
        Doshi RH, Apodaca K, Ogwal M, Bain R, Amene E, Kiyingi H, Aluzimbi G, Musinguzi G, Serwadda D, McIntyre AF, Hladik W.
        JMIR Public Health Surveill. 2019 Aug 12;5(3):e12118.
        BACKGROUND: Key populations, including people who inject drugs (PWID), men who have sex with men (MSM), and female sex workers (FSW), are disproportionately affected by the HIV epidemic. Understanding the magnitude of, and informing the public health response to, the HIV epidemic among these populations requires accurate size estimates. However, low social visibility poses challenges to these efforts. OBJECTIVE: The objective of this study was to derive population size estimates of PWID, MSM, and FSW in Kampala using capture-recapture. METHODS: Between June and October 2017, unique objects were distributed to the PWID, MSM, and FSW populations in Kampala. PWID, MSM, and FSW were each sampled during 3 independent captures; unique objects were offered in captures 1 and 2. PWID, MSM, and FSW sampled during captures 2 and 3 were asked if they had received either or both of the distributed objects. All captures were completed 1 week apart. The numbers of PWID, MSM, and FSW receiving one or both objects were determined. Population size estimates were derived using the Lincoln-Petersen method for 2-source capture-recapture (PWID) and Bayesian nonparametric latent-class model for 3-source capture-recapture (MSM and FSW). RESULTS: We sampled 467 PWID in capture 1 and 450 in capture 2; a total of 54 PWID were captured in both. We sampled 542, 574, and 598 MSM in captures 1, 2, and 3, respectively. There were 70 recaptures between captures 1 and 2, 103 recaptures between captures 2 and 3, and 155 recaptures between captures 1 and 3. There were 57 MSM captured in all 3 captures. We sampled 962, 965, and 1417 FSW in captures 1, 2, and 3, respectively. There were 316 recaptures between captures 1 and 2, 214 recaptures between captures 2 and 3, and 235 recaptures between captures 1 and 3. There were 109 FSW captured in all 3 rounds. The estimated number of PWID was 3892 (3090-5126), the estimated number of MSM was 14,019 (95% credible interval (CI) 4995-40,949), and the estimated number of FSW was 8848 (95% CI 6337-17,470). CONCLUSIONS: Our population size estimates for PWID, MSM, and FSW in Kampala provide critical population denominator data to inform HIV prevention and treatment programs. The 3-source capture-recapture is a feasible method to advance key population size estimation.

      2. Using ancillary sociodemographic data to identify sexual minority adults among those responding “something else” or “don’t know” to sexual orientation questionsexternal icon
        Elliott MN, Dahlhamer JM, MacCarthy S, Beckett MK, Orr N, Guerino P, Agniel D, Saunders CL, Schuster MA, Ng JH, Martino SC.
        Med Care. 2019 Aug 14.
        BACKGROUND: General population surveys are increasingly offering broader response options for questions on sexual orientation-for example, not only gay or lesbian, but also “something else” (SE) and “don’t know” (DK). However, these additional response options are potentially confusing for those who may not know what the terms mean. Researchers studying sexual orientation-based disparities face difficult methodological trade-offs regarding how best to classify respondents identifying with the SE and DK categories. OBJECTIVES: Develop respondent-level probabilities of sexual minority orientation without excluding or misclassifying the potentially ambiguous SE and DK responses. Compare 3 increasingly inclusive analytic approaches for estimating health disparities using a single item: (a) omitting SE and DK respondents; (b) classifying SE as sexual minority and omitting DK; and (c) a new approach classifying only SE and DK respondents with >50% predicted probabilities of being sexual minorities as sexual minority. MATERIALS AND METHODS: We used the sociodemographic information and follow-up questions for SE and DK respondents in the 2013-2014 National Health Interview Survey to generate predicted probabilities of identifying as a sexual minority adult. RESULTS: About 94% of the 144 SE respondents and 20% of the 310 DK respondents were predicted to identify as a sexual minority adult, with higher probabilities for younger, wealthier, non-Hispanic white, and urban-dwelling respondents. Using a more specific definition of sexual minority orientation improved the precision of health and health care disparity estimates. CONCLUSIONS: Predicted probabilities of sexual minority orientation may be used in this and other surveys to improve representation and categorization of those who identify as a sexual minority adult.

    • Global Health
      1. Emergency care surveillance and emergency care registries in low-income and middle-income countries: conceptual challenges and future directions for researchexternal icon
        Mowafi H, Ngaruiya C, O’Reilly G, Kobusingye O, Kapil V, Rubiano A, Ong M, Puyana JC, Rahman AF, Jooma R, Beecroft B, Razzak J.
        BMJ Glob Health. 2019 ;4(Suppl 6):e001442.
        Despite the fact that the 15 leading causes of global deaths and disability-adjusted life years are from conditions amenable to emergency care, and that this burden is highest in low-income and middle-income countries (LMICs), there is a paucity of research on LMIC emergency care to guide policy making, resource allocation and service provision. A literature review of the 550 articles on LMIC emergency care published in the 10-year period from 2007 to 2016 yielded 106 articles for LMIC emergency care surveillance and registry research. Few articles were from established longitudinal surveillance or registries and primarily composed of short-term data collection. Using these articles, a working group was convened by the US National Institutes of Health Fogarty International Center to discuss challenges and potential solutions for established systems to better understand global emergency care in LMICs. The working group focused on potential uses for emergency care surveillance and registry data to improve the quality of services provided to patients. Challenges included a lack of dedicated resources for such research in LMIC settings as well as over-reliance on facility-based data collection without known correlation to the overall burden of emergency conditions in the broader community. The group outlined potential solutions including incorporating data from sources beyond traditional health records, use of standard clinical forms that embed data needed for research and policy making and structured population-based research to establish clear linkages between what is seen in emergency units and the wider community. The group then identified current gaps in LMIC emergency care surveillance and registry research to form a research agenda for the future.

    • Health Disparities
      1. Racial and ethnic estimates of Alzheimer’s disease and related dementias in the United States (2015-2060) in adults aged >= 65 yearsexternal icon
        Matthews KA, Xu W, Gaglioti AH, Holt JB, Croft JB, Mack D, McGuire LC.
        Alzheimers Dement. 2019 January;15(1):17-24.
        Introduction: Alzheimer’s disease and related dementias (ADRD) cause a high burden of morbidity and mortality in the United States. Age, race, and ethnicity are important risk factors for ADRD. Method(s): We estimated the future US burden of ADRD by age, sex, and race and ethnicity by applying subgroup-specific prevalence among Medicare Fee-for-Service beneficiaries aged >=65 years in 2014 to subgroup-specific population estimates for 2014 and population projection data from the United States Census Bureau for 2015 to 2060. Result(s): The burden of ADRD in 2014 was an estimated 5.0 million adults aged >=65 years or 1.6% of the population, and there are significant disparities in ADRD prevalence among population subgroups defined by race and ethnicity. ADRD burden will double to 3.3% by 2060 when 13.9 million Americans are projected to have the disease. Discussion(s): These estimates can be used to guide planning and interventions related to caring for the ADRD population and supporting caregivers.

    • Immunity and Immunization
      1. Ten years of experience with herpes zoster vaccine in primary care- how attitudes and practices have changed and what it may mean for a new zoster vaccineexternal icon
        Guo A, Lindley MC, Hurley LP, Allen JA, Allison MA, O’Leary ST, Crane LA, Brtnikova M, Beaty BL, Kempe A, Dooling KL.
        Vaccine. 2019 Aug 7.
        Zoster vaccine live (ZVL [Zostavax]) has been recommended for the prevention of herpes zoster (HZ) among immunocompetent adults >/= 60 years in the United States since 2008. To examine changes in healthcare providers’ perceptions and practices related to HZ disease and vaccination, we administered surveys to national networks of primary care physicians in 2005, 2008, and 2016. Ten years after ZVL was first licensed, physicians were more likely to respond that they perceived HZ as a serious disease and more strongly recommended ZVL, and were less likely to report less likely to report several major barriers to HZ vaccination such as patient cost, vaccine effectiveness and competing medical concerns. Overall, physician attitudes appear to be more favorable towards zoster vaccination after a decade of availability of a HZ vaccine. The new recombinant zoster vaccine (RZV [Shingrix]) may benefit from physician’s increased perception of the importance of HZ and HZ vaccination.

      2. Rapid disappearance of poliovirus type 2 (PV2) immunity in young children following withdrawal of oral PV2-containing vaccine in Vietnamexternal icon
        Huyen DT, Mach O, Thanh Trung N, Thai PQ, Thang HV, Weldon WC, Oberste MS, Jeyaseelan V, Sutter RW, Anh DD.
        J Infect Dis. 2019 ;220(3):386-391.
        Due to global shortage of inactivated poliovirus vaccine and withdrawal of oral vaccine containing poliovirus type 2 (PV2), a PV2-containing vaccine was not used in Vietnam May 2016 to October 2018. We assessed the population immunity gap to PV2. Methods: A cross-sectional survey in children aged 1-18 months was carried out in January 2018. One blood sample per child was analyzed for presence of poliovirus neutralizing antibodies. In children with detectable anti-PV2 antibodies, a second sample was analyzed 4 months later to distinguish between passive (maternally derived) and active (induced by secondary transmission or vaccination) immunity. Results: Sera were obtained from 1106/1110 children. Seroprevalence of PV2 antibodies was 87/368 (23.6%) at age 1-7 months, 27/471 (5.7%) at 8-15 months, and 19/267 (7.1%) at 16-18 months. Seroprevalence declined with age in the 1-7 months group; in the 8-18 months group there was no significant change with age. Four months later, 11/87 (14%), 9/27 (32%), and 12/19 (37%) remained seropositive in 1-7, 8-15, and 16-18 months age groups, respectively. Conclusions: We found declining immunity to PV2, suggesting Vietnam is at risk for an outbreak of type 2 vaccine-derived poliovirus following virus importation or new emergence.

      3. Human papillomavirus vaccination for adults: Updated recommendations of the Advisory Committee on Immunization Practicesexternal icon
        Meites E, Szilagyi PG, Chesson HW, Unger ER, Romero JR, Markowitz LE.
        MMWR Morb Mortal Wkly Rep. 2019 Aug 16;68(32):698-702.
        Vaccination against human papillomavirus (HPV) is recommended to prevent new HPV infections and HPV-associated diseases, including some cancers. The Advisory Committee on Immunization Practices (ACIP)* routinely recommends HPV vaccination at age 11 or 12 years; vaccination can be given starting at age 9 years. Catch-up vaccination has been recommended since 2006 for females through age 26 years, and since 2011 for males through age 21 years and certain special populations through age 26 years. This report updates ACIP catch-up HPV vaccination recommendations and guidance published in 2014, 2015, and 2016 (1-3). Routine recommendations for vaccination of adolescents have not changed. In June 2019, ACIP recommended catch-up HPV vaccination for all persons through age 26 years. ACIP did not recommend catch-up vaccination for all adults aged 27 through 45 years, but recognized that some persons who are not adequately vaccinated might be at risk for new HPV infection and might benefit from vaccination in this age range; therefore, ACIP recommended shared clinical decision-making regarding potential HPV vaccination for these persons.

      4. Defining hard-to-reach populations for vaccinationexternal icon
        Ozawa S, Yemeke TT, Evans DR, Pallas SE, Wallace AS, Lee BY.
        Vaccine. 2019 Aug 7.
        Extending the benefits of vaccination to everyone who is eligible requires an understanding of which populations current vaccination efforts have struggled to reach. A clear definition of “hard-to-reach” populations – also known as high-risk or marginalized populations, or reaching the last mile – is essential for estimating the size of target groups, sharing lessons learned based on consistent definitions, and allocating resources appropriately. A literature review was conducted to determine what formal definitions of hard-to-reach populations exist and how they are being used, and to propose definitions to consider for future use. Overall, we found that (1) there is a need to distinguish populations that are hard to reach versus hard to vaccinate, and (2) the existing literature poorly defined these populations and clear criteria or thresholds for classifying them were missing. Based on this review, we propose that hard-to-reach populations be defined as those facing supply-side barriers to vaccination due to geography by distance or terrain, transient or nomadic movement, healthcare provider discrimination, lack of healthcare provider recommendations, inadequate vaccination systems, war and conflict, home births or other home-bound mobility limitations, or legal restrictions. Although multiple mechanisms may apply to the same population, supply-side barriers should be distinguished from demand-side barriers. Hard-to-vaccinate populations are defined as those who are reachable but difficult to vaccinate due to distrust, religious beliefs, lack of awareness of vaccine benefits and recommendations, poverty or low socioeconomic status, lack of time to access available vaccination services, or gender-based discrimination. Further work is needed to better define hard-to-reach populations and delineate them from populations that may be hard to vaccinate due to complex refusal reasons, improve measurement of the size and importance of their impact, and examine interventions related to overcoming barriers for each mechanism. This will enable policy makers, governments, donors, and the vaccine community to better plan interventions and allocate necessary resources to remove existing barriers to vaccination.

      5. Evaluating strategies to improve rotavirus vaccine impact during the second year of life in Malawiexternal icon
        Pitzer VE, Bennett A, Bar-Zeev N, Jere KC, Lopman BA, Lewnard JA, Parashar UD, Cunliffe NA.
        Sci Transl Med. 2019 Aug 14;11(505).
        Rotavirus vaccination has substantially reduced the incidence of rotavirus-associated gastroenteritis (RVGE) in high-income countries, but vaccine impact and estimated effectiveness are lower in low-income countries for reasons that are poorly understood. We used mathematical modeling to quantify rotavirus vaccine impact and investigate reduced vaccine effectiveness, particularly during the second year of life, in Malawi, where vaccination was introduced in October 2012 with doses at 6 and 10 weeks. We fitted models to 12 years of prevaccination data and validated the models against postvaccination data to evaluate the magnitude and duration of vaccine protection. The observed rollout of vaccination in Malawi was predicted to lead to a 26 to 77% decrease in the overall incidence of moderate-to-severe RVGE in 2016, depending on assumptions about waning of vaccine-induced immunity and heterogeneity in vaccine response. Vaccine effectiveness estimates were predicted to be higher among 4- to 11-month-olds than 12- to 23-month-olds, even when vaccine-induced immunity did not wane, due to differences in the rate at which vaccinated and unvaccinated individuals acquire immunity from natural infection. We found that vaccine effectiveness during the first and second years of life could potentially be improved by increasing the proportion of infants who respond to vaccination or by lowering the rotavirus transmission rate. An additional dose of rotavirus vaccine at 9 months of age was predicted to lead to higher estimated vaccine effectiveness but to only modest (5 to 16%) reductions in RVGE incidence over the first 3 years after introduction, regardless of assumptions about waning of vaccine-induced immunity.

    • Informatics
      1. Use of electronic health records from a statewide health information exchange to support public health surveillance of diabetes and hypertensionexternal icon
        Horth RZ, Wagstaff S, Jeppson T, Patel V, McClellan J, Bissonette N, Friedrichs M, Dunn AC.
        BMC Public Health. 2019 Aug 14;19(1):1106.
        BACKGROUND: Electronic health record (EHR) data, collected primarily for individual patient care and billing purposes, compiled in health information exchanges (HIEs) may have a secondary use for population health surveillance of noncommunicable diseases. However, data compilation across fragmented data sources into HIEs presents potential barriers and quality of data is unknown. METHODS: We compared 2015 patient data from a mid-size health system (Database A) to data from System A patients in the Utah HIE (Database B). We calculated concordance of structured data (sex and age) and unstructured data (blood pressure reading and A1C). We estimated adjusted hypertension and diabetes prevalence in each database and compared these across age groups. RESULTS: Matching resulted in 72,356 unique patients. Concordance between Database A and Database B exceeded 99% for sex and age, but was 89% for A1C results and 54% for blood pressure readings. Sensitivity, using Database A as the standard, was 57% for hypertension and 55% for diabetes. Age and sex adjusted prevalence of diabetes (8.4% vs 5.8%, Database A and B, respectively) and hypertension (14.5% vs 11.6%, respectively) differed, but this difference was consistent with parallel slopes in prevalence over age groups in both databases. CONCLUSIONS: We identified several gaps in the use of HIE data for surveillance of diabetes and hypertension. High concordance of structured data demonstrate some promise in HIEs capacity to capture patient data. Improving HIE data quality through increased use of structured variables may help make HIE data useful for population health surveillance in places with fragmented EHR systems.

    • Laboratory Sciences
      1. Identification of Candida auris using the updated 8.01 VITEK(R)2 yeast identification system: a multi-laboratory evaluation studyexternal icon
        Ambaraghassi G, Dufresne PJ, Dufresne SF, Vallieres E, Munoz JF, Cuomo CA, Berkow EL, Lockhart SR, Luong ML.
        J Clin Microbiol. 2019 Aug 14.
        IntroductionCandida auris is an emerging multidrug-resistant yeast that has been systematically incorrectly identified by phenotypic methods in clinical microbiology laboratories. VITEK(R)2 automated identification system (bioMerieux) recently included C. auris in its database (version 8.01).Material and methodsWe evaluated the performance of VITEK(R)2 (YST ID Card) to identify C. auris and related species. A panel of 44 isolates of Candida species (C. auris, n=35; C. haemulonii, n=5; C. duobushaemulonii, n=4) were tested by three different hospital-based microbiology laboratories.ResultsAmong 35 isolates of C. auris, VITEK(R)2 yielded correct identification in an average of 52% of tested samples. Low discrimination results were obtained in an average of 27% with inability to distinguish between C. auris, C. duobushaemulonii and C. famata. Incorrect identification results were obtained in an average of 21%, the majority (91%) of which were reported as C duobushaemulonii and 9% as C. lusitaniae/C. duobushaemulonii. Proportion of correct identification was not statistically different across different centers (p=0,78). Stratification by genetic clades demonstrated that 100% (n=8) of the strains of the South American clade were correctly identified, compared to 7% (n=10) and 0% (n=4) from the African and East Asian clade respectively. None of the non-auris Candida strains (n=9) were incorrectly identified as C. aurisConclusionOur results show that VITEK(R)2 (version 8.01) yeast identification system has a limited ability to correctly identify C. auris This data suggests that an identification result for C. duobushaemulonii should warrant further testing to rule out C. auris Overall performance of VITEK(R)2 seems to differ according to C. auris genetic clade with the South American isolates yielding the most accurate result.

      2. Feasibility of hepatitis B vaccination by microneedle patch: Cellular and humoral immunity studies in rhesus macaquesexternal icon
        Choi YH, Perez-Cuevas MB, Kodani M, Zhang X, Prausnitz MR, Kamili S, O’Connor SM.
        J Infect Dis. 2019 Aug 13.
        BACKGROUND: Dissolvable microneedle patches (dMNPs) provide ease of deployment and eliminate need for hypodermic needle disposal after conventional vaccinations. In this study, immunogenicity of dMNP delivery of adjuvant-free monovalent hepatitis B surface antigen (HBsAg) vaccine (AFV) to standard intramuscular (IM) injection of monovalent aluminum-adjuvanted monovalent hepatitis B vaccine (AAV) were compared in rhesus macaques. METHODS: Sixteen macaques were immunized twice in 4 groups: dMNP delivery of 24 +/- 8microg (n=4) or 48 +/- 14microg (n=4) AFV; IM injection of 10microg AFV (IM AFV, n=4); and IM injection of 10microg AAV (IM AAV, n=4). Levels of hepatitis B surface antibody and HBsAg-specific T-cell responses were analyzed. RESULTS: Six of 8 animals with dMNP delivery of AFV had anti-HBs levels >/=10 mIU/ml after the first vaccine dose. After dMNP delivery of AFV, IFN-gamma, IL-2, and IL-4 production by HBsAg-specific T-cells were detected. A statistically significant positive correlation was detected between anti-HBs levels and HBsAg-specific IFN-gamma and IL-2 (Th1-type cytokine) and IL-4 (Th2-type cytokine) producing cells in all anti-HBs positive animals. CONCLUSIONS: dMNP delivery of AFV can elicit seroprotective anti-HBs levels in rhesus macaques that correlate in human seroprotection, and could be particularly promising for hepatitis B vaccine birth dose delivery in resource-constrained regions.

      3. Characterization of reference materials for genetic testing of CYP2D6 Alleles: A GeT-RM Collaborative Projectexternal icon
        Gaedigk A, Turner A, Everts RE, Scott SA, Aggarwal P, Broeckel U, McMillin GA, Melis R, Boone EC, Pratt VM, Kalman LV.
        J Mol Diagn. 2019 Aug 8.
        Pharmacogenetic (PGx) testing is increasingly available from clinical and research laboratories. However, only a limited number of quality control and other reference materials (RMs) are currently available for the complex rearrangements and rare variants that occur in the CYP2D6 gene. To address this need, the Division of Laboratory Systems, Centers for Disease Control and Prevention based Genetic Testing Reference Material Coordination Program (GeT-RM), in collaboration with members of the pharmacogenetic testing and research communities and the Coriell Cell Repositories, has characterized 179 DNA samples derived from Coriell cell lines. Testing included the re-characterization of 137 genomic DNAs that were genotyped in previous GeT-RM studies and 42 additional samples that had not been previously characterized. DNA samples were distributed to volunteer testing laboratories for genotyping using a variety of commercially available and laboratory developed tests. These publicly available samples will support the quality assurance and quality control programs of clinical laboratories performing CYP2D6 testing.

      4. Investigating effects of cold water hand immersion on selective attention in normobaric hypoxiaexternal icon
        Gerhart HD, Seo Y, Kim JH, Followay B, Vaughan J, Quinn T, Gunstad J, Glickman EL.
        Int J Environ Res Public Health. 2019 Aug 10;16(16).
        This study investigated the effect of cold-water hand immersion on selective attention as measured by the Stroop Color Word Test in nomorbaric normoxia and hypoxia. Ten healthy men rested for 60 min, after which they immersed their non-dominant hand into 5 degrees C water for 15 min. The interference score of the Stroop Color Word Test and thermal sensation were measured at baseline in the final 5 min of resting and in the final 5 min of cold water hand immersion. The interference score was not influenced by hypoxia but was found to be significantly improved compared to resting in both conditions during cold water hand immersion. Selective attention improved during 15 min of cold-water hand immersion, with increased thermal sensations rated as “very cool” of the immersed arm. Cold-water hand immersion may be helpful in improving cognitive function in normoxia and normobaric hypoxia.

      5. Strengthening quality of tuberculosis laboratories toward accreditation in Viet Namexternal icon
        Gumma V, Bennett DL, Nguyen Thi Phong L, Duong Ngoc C, Bond KB, Nguyen Thi Hoang Y, Erni D, Nguyen Van N, Nguyen Van H, Albert H.
        Am J Clin Pathol. 2019 Aug 15.
        OBJECTIVES: Early diagnosis of tuberculosis (TB) and multidrug-resistant TB (MDR-TB) is a priority for Viet Nam’s National TB Control Programme. In many laboratories, quality systems are weak; few have attained accreditation. We implemented a structured training and mentoring program for TB laboratories and measured impact on quality. METHODS: Six TB culture laboratories implemented the Strengthening TB Laboratory Management Towards Accreditation (TB SLMTA) program, consisting of three training workshops and on-site mentoring between workshops to support improvement projects. Periodic audits, using standardized checklists, monitored laboratories’ progress toward accreditation readiness. RESULTS: At baseline, all six laboratories achieved a zero-star level. At exit, five laboratories attained three stars and another one star. Overall checklist scores increased by 44.2% on average, from 29.8% to 74.0%; improvements occurred across all quality system essentials. CONCLUSIONS: The program led to improved quality systems. Sites should be monitored to ensure sustainability of improvements and country capacity expanded for national scaleup.

      6. Enhancing laboratory capacity during Ebola virus disease (EVD) heightened surveillance in Liberia: lessons learned and recommendationsexternal icon
        Katawera V, Kohar H, Mahmoud N, Raftery P, Wasunna C, Humrighouse B, Hardy P, Saindon J, Schoepp R, Makvandi M, Hensley L, Condell O, Durski K, Singaravelu S, Gahimbare L, Olinger G, Kateh F, Naidoo D, Nsubuga P, Formenty P, Nyenswah T, Coulibaly SO, Okeibunor JC, Talisuna A, Yahaya AA, Rajatonirina S, Williams D, Dahn B, Gasasira A, Fall IS.
        Pan Afr Med J. 2019 ;33(Suppl 2):8.
        Introduction: Following a declaration by the World Health Organization that Liberia had successfully interrupted Ebola virus transmission on May 9th, 2015; the country entered a period of enhanced surveillance. The number of cases had significantly reduced prior to the declaration, leading to closure of eight out of eleven Ebola testing laboratories. Enhanced surveillance led to an abrupt increase in demand for laboratory services. We report interventions, achievements, lessons learned and recommendations drawn from enhancing laboratory capacity. Methods: Using archived data, we reported before and after interventions that aimed at increasing laboratory capacity. Laboratory capacity was defined by number of laboratories with Ebola Virus Disease (EVD) testing capacity, number of competent staff, number of specimens tested, specimen backlog, daily and surge testing capacity, and turnaround time. Using Stata 14 (Stata Corporation, College Station, TX, USA), medians and trends were reported for all continuous variables. Results: Between May and December 2015, interventions including recruitment and training of eight staff, establishment of one EVD laboratory facility, implementation of ten Ebola GeneXpert diagnostic platforms, and establishment of working shifts yielded an 8-fold increase in number of specimens tested, a reduction in specimens backlog to zero, and restoration of turn-around time to 24 hours. This enabled a more efficient surveillance system that facilitated timely detection and containment of two EVD clusters observed thereafter. Conclusion: Effective enhancement of laboratory services during high demand periods requires a combination of context-specific interventions. Building and ensuring sustainability of local capacity is an integral part of effective surveillance and disease outbreak response efforts.

      7. Antibodies to enteroviruses in cerebrospinal fluid of patients with acute flaccid myelitisexternal icon
        Mishra N, Ng TF, Marine RL, Jain K, Ng J, Thakkar R, Caciula A, Price A, Garcia JA, Burns JC, Thakur KT, Hetzler KL, Routh JA, Konopka-Anstadt JL, Nix WA, Tokarz R, Briese T, Oberste MS, Lipkin WI.
        MBio. 2019 Aug 13;10(4).
        Acute flaccid myelitis (AFM) has caused motor paralysis in >560 children in the United States since 2014. The temporal association of enterovirus (EV) outbreaks with increases in AFM cases and reports of fever, respiratory, or gastrointestinal illness prior to AFM in >90% of cases suggest a role for infectious agents. Cerebrospinal fluid (CSF) from 14 AFM and 5 non-AFM patients with central nervous system (CNS) diseases in 2018 were investigated by viral-capture high-throughput sequencing (VirCapSeq-VERT system). These CSF and serum samples, as well as multiple controls, were tested for antibodies to human EVs using peptide microarrays. EV RNA was confirmed in CSF from only 1 adult AFM case and 1 non-AFM case. In contrast, antibodies to EV peptides were present in CSF of 11 of 14 AFM patients (79%), significantly higher than controls, including non-AFM patients (1/5 [20%]), children with Kawasaki disease (0/10), and adults with non-AFM CNS diseases (2/11 [18%]) (P = 0.023, 0.0001, and 0.0028, respectively). Six of 14 CSF samples (43%) and 8 of 11 sera (73%) from AFM patients were immunoreactive to an EV-D68-specific peptide, whereas the three control groups were not immunoreactive in either CSF (0/5, 0/10, and 0/11; P = 0.008, 0.0003, and 0.035, respectively) or sera (0/2, 0/8, and 0/5; P = 0.139, 0.002, and 0.009, respectively).IMPORTANCE The presence in cerebrospinal fluid of antibodies to EV peptides at higher levels than non-AFM controls supports the plausibility of a link between EV infection and AFM that warrants further investigation and has the potential to lead to strategies for diagnosis and prevention of disease.

      8. Comparison of respiratory pathogen yields from Nasopharyngeal/Oropharyngeal swabs and sputum specimens collected from hospitalized adults in rural Western Kenyaexternal icon
        Nyawanda BO, Njuguna HN, Onyango CO, Makokha C, Lidechi S, Fields B, Winchell JM, Katieno JS, Nyaundi J, Ade F, Emukule GO, Mott JA, Otieno N, Widdowson MA, Chaves SS.
        Scientific Reports. 2019 ;9(1).
        Molecular diagnostic methods are becoming increasingly available for assessment of acute lower respiratory illnesses (ALRI). However, nasopharyngeal/oropharyngeal (NP/OP) swabs may not accurately reflect etiologic agents from the lower respiratory tract where sputum specimens are considered as a more representative sample. The pathogen yields from NP/OP against sputum specimens have not been extensively explored, especially in tropical countries. We compared pathogen yields from NP/OP swabs and sputum specimens from patients >/=18 years hospitalized with ALRI in rural Western Kenya. Specimens were tested for 30 pathogens using TaqMan Array Cards (TAC) and results compared using McNemar’s test. The agreement for pathogen detection between NP/OP and sputum specimens ranged between 85-100%. More viruses were detected from NP/OP specimens whereas Klebsiella pneumoniae and Mycobacterium tuberculosis were more common in sputum specimens. There was no clear advantage in using sputum over NP/OP specimens to detect pathogens of ALRI in adults using TAC in the context of this tropical setting.

      9. The neuraminidase of A(H3N2) influenza viruses circulating since 2016 is antigenically distinct from the A/Hong Kong/4801/2014 vaccine strainexternal icon
        Wan H, Gao J, Yang H, Yang S, Harvey R, Chen YQ, Zheng NY, Chang J, Carney PJ, Li X, Plant E, Jiang L, Couzens L, Wang C, Strohmeier S, Wu WW, Shen RF, Krammer F, Cipollo JF, Wilson PC, Stevens J, Wan XF, Eichelberger MC, Ye Z.
        Nat Microbiol. 2019 Aug 12.
        A(H3N2) virus predominated recent influenza seasons, which has resulted in the rigorous investigation of haemagglutinin, but whether neuraminidase (NA) has undergone antigenic change and contributed to the predominance of A(H3N2) virus is unknown. Here, we show that the NA of the circulating A(H3N2) viruses has experienced significant antigenic drift since 2016 compared with the A/Hong Kong/4801/2014 vaccine strain. This antigenic drift was mainly caused by amino acid mutations at NA residues 245, 247 (S245N/S247T; introducing an N-linked glycosylation site at residue 245) and 468. As a result, the binding of the NA of A(H3N2) virus by some human monoclonal antibodies, including those that have broad reactivity to the NA of the 1957 A(H2N2) and 1968 A(H3N2) reference pandemic viruses as well as contemporary A(H3N2) strains, was reduced or abolished. This antigenic drift also reduced NA-antibody-based protection against in vivo virus challenge. X-ray crystallography showed that the glycosylation site at residue 245 is within a conserved epitope that overlaps the NA active site, explaining why it impacts antibody binding. Our findings suggest that NA antigenic drift impacts protection against influenza virus infection, thus highlighting the importance of including NA antigenicity for consideration in the optimization of influenza vaccines.

      10. Interventions to prevent iatrogenic anemia: a Laboratory Medicine Best Practices systematic reviewexternal icon
        Whitehead NS, Williams LO, Meleth S, Kennedy SM, Ubaka-Blackmoore N, Geaghan SM, Nichols JH, Carroll P, McEvoy MT, Gayken J, Ernst DJ, Litwin C, Epner P, Taylor J, Graber ML.
        Crit Care. 2019 Aug 9;23(1):278.
        BACKGROUND: As many as 90% of patients develop anemia by their third day in an intensive care unit (ICU). We evaluated the efficacy of interventions to reduce phlebotomy-related blood loss on the volume of blood lost, hemoglobin levels, transfusions, and incidence of anemia. METHODS: We conducted a systematic review and meta-analysis using the Laboratory Medicine Best Practices (LMBP) systematic review methods for rating study quality and assessing the body of evidence. Searches of PubMed, Embase, Cochrane, Web of Science, PsychINFO, and CINAHL identified 2564 published references. We included studies of the impact of interventions to reduce phlebotomy-related blood loss on blood loss, hemoglobin levels, transfusions, or anemia among hospital inpatients. We excluded studies not published in English and studies that did not have a comparison group, did not report an outcome of interest, or were rated as poor quality. Twenty-one studies met these criteria. We conducted a meta-analysis if > 2 homogenous studies reported sufficient information for analysis. RESULTS: We found moderate, consistent evidence that devices that return blood from flushing venous or arterial lines to the patient reduced blood loss by approximately 25% in both neonatal ICU (NICU) and adult ICU patients [pooled estimate in adults, 24.7 (95% CI = 12.1-37.3)]. Bundled interventions that included blood conservation devices appeared to reduce blood loss by at least 25% (suggestive evidence). The evidence was insufficient to determine if these devices reduced hemoglobin decline or risk of anemia. The evidence suggested that small volume tubes reduced the risk of anemia, but was insufficient to determine if they affected the volume of blood loss or the rate of hemoglobin decline. CONCLUSIONS: Moderate, consistent evidence indicated that devices that return blood from testing or flushing lines to the patient reduce the volume of blood loss by approximately 25% among ICU patients. The results of this systematic review support the use of blood conservation systems with arterial or venous catheters to eliminate blood waste when drawing blood for testing. The evidence was insufficient to conclude the devices impacted hemoglobin levels or transfusion rates. The use of small volume tubes may reduce the risk of anemia.

    • Maternal and Child Health
      1. Surveillance for emerging threats to pregnant women and infantsexternal icon
        Frey MT, Meaney-Delman D, Bowen V, Yazdy MM, Watkins SM, Thorpe PG, Honein MA.
        J Womens Health (Larchmt). 2019 Aug;28(8):1031-1036.
        Recent public health emergencies have highlighted the unique vulnerabilities of pregnant women and infants to emerging health threats and the critical role of public health surveillance. Surveillance systems can collect critical data to measure the impact of a disease or disaster and can be used to inform clinical guidance and prevention strategies. These systems can also be tailored to collect data on vulnerable populations, such as pregnant women and their infants. Novel surveillance systems to assess risks and outcomes of pregnant women and infants have been established during public health emergencies but typically cease data collection once the public health response has ended, limiting our ability to collect data to understand longer-term outcomes. State-based birth defects surveillance systems are not available in all states, and no national surveillance system linking pregnancy exposure data to longitudinal outcomes for infants and children exists. In this report, we describe ongoing surveillance efforts to monitor congenital syphilis, Zika virus infection during pregnancy, and neonatal abstinence syndrome. We describe the need and rationale for an ongoing integrated surveillance system to monitor pregnant women and their infants and to detect emerging threats. We also discuss how data collected through this type of system can better position federal, state, and local health departments to more rapidly and comprehensively respond to the next public health emergency.

      2. Male partner antenatal clinic attendance is associated with increased uptake of maternal health services and infant BCG immunization: a national survey in Kenyaexternal icon
        Odeny B, McGrath CJ, Langat A, Pintye J, Singa B, Kinuthia J, Katana A, Ng’ang’a L, John-Stewart G.
        BMC Pregnancy Childbirth. 2019 Aug 8;19(1):284.
        BACKGROUND: Male partner antenatal clinic (ANC) attendance may improve maternal uptake of maternal child health (MCH) services. METHODS: We conducted a cross-sectional survey of mother-infant pairs attending week-6 or month-9 infant immunizations at 120 high-volume MCH clinics throughout Kenya. Clinics were selected using probability proportionate to size sampling. Women were interviewed using structured questionnaires and clinical data was verified using MCH booklets. Among married women, survey-weighted logistic regression models accounting for clinic-level clustering were used to compare outcomes by male ANC attendance and to identify its correlates. RESULTS: Among 2521 women attending MCH clinics and had information on male partner ANC attendance, 2141 (90%) were married of whom 806 (35%) had male partners that attended ANC. Among married women, male partner ANC attendance was more frequent among women with higher education, women who requested their partners to attend ANC, had male partners with higher education, did not report partner violence, and had disclosed their HIV status (p < 0.001 for each). Additionally, male ANC attendance was associated with higher uptake of ANC visits [adjusted Odds Ratio (AOR) = 1.67, 95% confidence interval (CI) 1.36-2.05,], skilled delivery (AOR = 2.00, 95% CI 1.51-2.64), exclusive breastfeeding (AOR = 1.70, 95% CI 1.00-2.91), infant Bacille Calmette Guerin (BCG) immunization (AOR = 3.59, 95% CI 1.00-12.88), and among HIV-infected women, antiretroviral drugs (aOR = 6.16, 95% CI 1.26-30.41). CONCLUSION: Involving male partners in MCH activities amplifies benefits of MCH services by engaging partner support for maternal uptake of services.

      3. BACKGROUND: Many public health surveillance programs utilize hospital discharge data in their estimation of disease prevalence. These databases commonly use the International Classification of Diseases (ICD) coding scheme, which transitioned from the ICD-9 clinical modification (ICD-9-CM) to ICD-10-CM on October 1, 2015. This study examined this transition’s impact on the prevalence of major birth defects among infant hospitalizations. METHODS: Using data from the Agency for Health Care Research and Quality-sponsored National Inpatient Sample, hospitalizations during the first year of life with a discharge date between January 1, 2012 and December 31, 2016 were used to estimate the monthly national hospital prevalence of 46 birth defects for the ICD-9-CM and ICD-10-CM timeframes separately. Survey-weighted Poisson regression was used to estimate 95% confidence intervals for each hospital prevalence. Interrupted time series framework and corresponding segmented regression was used to estimate the immediate change in monthly hospital prevalence following the ICD-9-CM to ICD-10-CM transition. RESULTS: Between 2012 and 2016, over 21 million inpatient hospitalizations occurred during the first year of life. Among the 46 defects studied, statistically significant decreases in the immediate hospital prevalence of five defects and significant increases in the immediate hospital prevalence of eight defects were observed after the ICD-10-CM transition. CONCLUSIONS: Changes in prevalence were expected based on changes to ICD-10-CM. Observed changes for some conditions may result from variation in monthly hospital prevalence or initial unfamiliarity of coders with ICD-10-CM. These findings may help birth defects surveillance programs evaluate and interpret changes in their data related to the ICD-10-CM transition.

    • Nutritional Sciences
      1. PURPOSE: To examine associations of adolescent sugar-sweetened beverage (SSB) intake with parent SSB intake and parent and adolescent attitudes about limiting SSB and junk food (SSB/JF) intake. DESIGN: Quantitative, cross-sectional study. SETTING: The 2014 Family Life, Activity, Sun, Health, and Eating study. SAMPLE: Parent-adolescent dyads (N = 1555). MEASURES: The outcome was adolescent SSB intake. Exposure variables were parent SSB intake, sociodemographics, and parent and adolescent attitudes about SSB/JF intake (responses: agree, neither, or disagree). ANALYSIS: Multinomial logistic regressions estimated adjusted odds ratios (aOR) and 95% confidence intervals (CIs). RESULTS: Half (49.5%) of adolescents and 33.7% of parents consumed SSB >/=1 time/day. Parent daily SSB intake was associated with adolescent daily SSB intake (aOR = 8.9; CI = 4.6-17.3) [referent: no consumption]. Adolescents who disagreed on having confidence to limit SSB/JF intake had higher odds of daily SSB intake (aOR = 3.5; CI = 1.8-6.8), as did those who disagreed they felt bad about themselves if they did not limit SSB/JF intake (aOR = 1.9; CI=1.1-3.3), compared to adolescents who agreed with these attitudes. No parental attitudes were significant. CONCLUSION: Higher odds of daily SSB intake among adolescents was associated with parent SSB intake and adolescent attitudes about confidence in, and feeling bad about, limiting SSB/JF intake. Parent attitudes were not associated with daily adolescent SSB intake. Efforts to reduce adolescent SSB intake could consider strategies geared toward improving adolescent attitudes and dietary behaviors and parental SSB intake.

    • Occupational Safety and Health
      1. Effects of aerial ladder rung spacing on firefighter climbing biomechanicsexternal icon
        Simeonov P, Hsiao H, Armstrong T, Fu Q, Woolley C, Kau T.
        Applied Ergonomics. 2020 ;82.
        This study investigated the effects of aerial ladder rung spacing on firefighter climbing biomechanics. Ten female and 9 male firefighters ascended and descended instrumented ladders with rungs spaced at 356 mm (current design) and 305 mm in a laboratory setup. The climbing tests were performed at five ladder slope and handrail conditions: 30 with low (305 mm) and high (914 mm) handrails, 52.5 with and without a low handrail, and 75 without a handrail. Foot and hand forces and body movements were recorded and used to calculate joint moments of the upper and lower body. Reduced rung spacing resulted in reduced foot forces, reduced hand forces, and reduced ankle transverse moment. It was also associated with increased climbing speed for female climbers, and increased ankle vertical overshoot. The results indicate that reduced rung spacing on aerial ladders may lead to lower biomechanical stress; better climbing efficiency and safety; and reduced climbing speed disparity across sexes.

    • Parasitic Diseases
      1. The WHO recommends mass treatment with praziquantel as the primary approach for Schistosoma mansoni-related morbidity control in endemic populations. The Schistosomiasis Consortium for Operational Research and Evaluation implemented multi-country, cluster-randomized trials to compare effectiveness of community-wide and school-based treatment (SBT) regimens on prevalence and intensity of schistosomiasis. To assess the impact of two different treatment schedules on S. mansoni-associated morbidity in children, cohort studies were nested within the randomized trials conducted in villages in Kenya and Tanzania having baseline prevalence >/= 25%. Children aged 7-8 years were enrolled at baseline and followed to ages 11-12 years. Infection intensity and odds of infection were reduced both in villages receiving four years of annual community-wide treatment (CWT) and those who received biennial SBT over 4 years. These regimens were also associated with reduced odds of undernutrition and reduced odds of portal vein dilation at follow-up. However, neither hemoglobin levels nor the prevalence of the rare abnormal pattern C liver scores on ultrasound improved. For the combined cohorts, growth stunting worsened in the areas receiving biennial SBT, and maximal oxygen uptake as estimated by fitness testing scores declined under both regimens. After adjusting for imbalance in starting prevalence between study arms, children in villages receiving annual CWT had significantly greater decreases in infection prevalence and intensity than those villages receiving biennial SBT. Although health-related quality-of-life scores improved in both study arms, children in the CWT villages gained significantly more. We conclude that programs using annual CWT are likely to achieve better overall S. mansoni morbidity control than those implementing only biennial SBT.

    • Public Health Leadership and Management
      1. Factors of success for transitioning from a scientific role to a supervisory leadership role in a federal public health agency, 2016external icon
        Flores AL, Risley K, Zanoni J, Welter C, Hawkins D, Pinsker E, Quintana K.
        Public Health Rep. 2019 Aug 14.

        [No abstract]

    • Substance Use and Abuse
      1. [No abstract]

    • Zoonotic and Vectorborne Diseases
      1. Notes from the field: A multipartner response to prevent a binational rabies outbreak – Anse-a-Pitre, Haiti, 2019external icon
        Adrien J, Georges Y, Augustin PD, Monroe B, Gibson AD, Fenelon N, Fleurinord L, Crowdis K, Mandra A, Joseph HC, Etheart MD, Wallace RM.
        MMWR Morb Mortal Wkly Rep. 2019 Aug 16;68(32):707-709.

        [No abstract]

      2. Strengthening healthcare workforce capacity during and post Ebola outbreaks in Liberia: an innovative and effective approach to epidemic preparedness and responseexternal icon
        Bemah P, Baller A, Cooper C, Massaquoi M, Skrip L, Rude JM, Twyman A, Moses P, Seifeldin R, Udhayashankar K, Enrique K, Niescierenko M, Owen C, Brown L, Boukare B, Williams D, Nyenswah T, Kateh F, Dahn B, Gasasira A, Fall IS.
        Pan Afr Med J. 2019 ;33(Suppl 2):9.
        Introduction: The 2014-2016 Ebola virus disease (EVD) outbreak in Liberia highlighted the importance of robust preparedness measures for a well-coordinated response; the initially delayed response contributed to the steep incidence of cases, infections among health care workers, and a collapse of the health care system. To strengthen local capacity and combat disease transmission, various healthcare worker (HCW) trainings, including the Ebola treatment unit (ETU) training, safe & quality services (SQS) training and rapid response team (RRT), were developed and implemented between 2014 and 2017. Methods: Data from the ETU, SQS and RRT trainings were analyzed to determine knowledge and confidence gained. Results: The ETU, SQS and RRT training were completed by a total of 21,248 participants. There were improvements in knowledge and confidence, an associated reduction in HCWs infection and reduced response time to subsequent public health events. Conclusion: No infections were reported by healthcare workers in Liberia since the completion of these training programs. HCW training programmes initiated during and post disease outbreak can boost public trust in the health system while providing an entry point for establishing an Epidemic Preparedness and Response (EPR) framework in resource-limited settings.

      3. Notes from the Field: Rabies outbreak investigation – Pedernales, Dominican Republic, 2019external icon
        Mandra A, Moran D, Santana PV, Marrero MC, Diaz E, Gil M, Nolasco RR, Capellan R, Acosta X, Perez R, Cespedes C, Baez B, Condori RE, Smith T, Ellison J, Greenberg L, Monroe B, Gibson A, Wallace RM, Petersen B.
        MMWR Morb Mortal Wkly Rep. 2019 Aug 16;68(32):704-706.

        [No abstract]

      4. Updated CDC recommendation for serologic diagnosis of Lyme diseaseexternal icon
        Mead P, Petersen J, Hinckley A.
        MMWR Morb Mortal Wkly Rep. 2019 Aug 16;68(32):703.
        Lyme disease is a tickborne zoonosis for which serologic testing is the principal means of laboratory diagnosis. In 1994, the Association of State and Territorial Public Health Laboratory Directors, CDC, the Food and Drug Administration (FDA), the National Institutes of Health (NIH), the Council of State and Territorial Epidemiologists, and the National Committee for Clinical Laboratory Standards convened the Second National Conference on Serologic Diagnosis of Lyme Disease.

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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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