Volume 11, Issue 36 September 10, 2019

CDC Science Clips: Volume 11, Issue 36, September 10, 2019

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

  1. Top Articles of the Week

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

    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions
      • Implementation of liver cancer education among health care providers and community coalitions in the Cherokee Nationexternal icon
        Momin B, Mera J, Essex W, Gahn D, Burkhart M, Nielsen D, Mezzo J, Millman AJ.
        Prev Chronic Dis. 2019 Aug 22;16:E112.
        INTRODUCTION: The Cherokee Nation Comprehensive Cancer Control Program collaborated with the Cherokee Nation Hepatitis C Virus (HCV) Elimination Program within Cherokee Nation’s Health Services to plan and implement activities to increase knowledge and awareness of liver cancer prevention among health care providers and the Cherokee Nation community. From August 2017 to April 2018, the 2 programs implemented liver cancer prevention interventions that focused on education of health care providers and community members. We used descriptive statistics to analyze data collected from a brief, retrospective pre-post survey for each intervention. We assessed overall awareness and knowledge of liver cancer and ability and intention to address it on a scale of 1 to 5. Project Extension for Community Healthcare Outcomes didactic sessions resulted in a 1.1-point improvement, provider education workshops resulted in a 1.4-point improvement, and presentations at community coalition meetings resulted in a 1.7-point improvement. Our study shows that HCV interventions can be used by public health and medical professionals interested in controlling HCV and related diseases such as liver cancer.

    • Communicable Diseases
      • BACKGROUND: Understanding tuberculosis epidemiology among children and adolescents informs treatment and prevention efforts, and efforts to eliminate disparities in tuberculosis incidence and mortality. We sought to describe the epidemiology of children and adolescents with tuberculosis disease in the USA, including tuberculosis incidence rates by parental country of birth and for US territories and freely associated states, which have not been previously described. METHODS: We analysed data for children aged younger than 15 years and adolescents aged 15-17 years with tuberculosis disease reported to the National Tuberculosis Surveillance System during 2007-17, and calculated tuberculosis incidence rates using population estimates from the US Census Bureau. FINDINGS: During 2010-17, 6072 tuberculosis cases occurred among children and adolescents; of these, 5175 (85%) of 6072 occurred in the 50 US states or the District of Columbia and 897 (15%) of 6072 in US-affiliated islands. In US states, 3520 (68%) of 5175 cases occurred among US-born people overall, including 2977 (76%) of 3896 children and 543 (42%) of 1279 adolescents. The incidence rate among children and adolescents was 1.0 per 100 000 person-years during 2007-17 and declined 47.8% (95% CI -51.4 to -44.1) during this period. We observed disproportionately high tuberculosis rates among children and adolescents of all non-white racial or ethnic groups, people living in US-affiliated islands, and children born in or with parents from tuberculosis-endemic countries. INTERPRETATION: Overall, tuberculosis incidence among children and adolescents in the USA is low and steadily declining, but additional efforts are needed to eliminate disparities in incidence and mortality. FUNDING: US Centers for Disease Control and Prevention.

      • Comparison of knowledge of HIV status and treatment coverage between non-citizens and citizens: Botswana Combination Prevention Project (BCPP)external icon
        Marukutira T, Block L, Alwano MG, Behel S, Jarvis JN, Chakalisa U, Powis K, Novitsky V, Bapati W, Wang H, Ussery F, Lebelonyane R, Mills LA, Moore J, Bachanas P.
        PLoS One. 2019 ;14(8):e0221629.
        INTRODUCTION: Non-citizens often face barriers to HIV care and treatment. Quantifying knowledge of positive HIV status and antiretroviral therapy (ART) coverage among non-citizens in a high HIV-prevalence country like Botswana that is close to achieving UNAIDS “90-90-90” targets may expose important gaps in achieving universal HIV testing and treatment. METHODS: The Botswana Combination Prevention Project (BCPP) is a pair-matched cluster-randomized trial evaluating the impact of prevention interventions on HIV incidence in 30 rural or peri-urban communities. Community case finding and HIV testing were conducted in home and mobile venues in 15 intervention communities from October 2013-September 2017. In this secondary analysis, we compared HIV positivity, knowledge of positive HIV-status, and ART status among all citizens and non-citizens assessed at intake in the intervention communities. RESULTS: HIV status was assessed in 57,556 residents in the intervention communities; 4% (n = 2,463) were non-citizens. Five communities accounted for 81% of the total non-citizens assessed. A lower proportion of non-citizens were HIV-positive (15%; n = 369) compared to citizens (21%; n = 11,416) [p = 0.026]; however, a larger proportion of non-citizens did not know their HIV-positive status prior to BCPP testing (75%) as compared to citizens (15%) [p = 0.003]. Among residents with knowledge of their HIV-positive status before BCPP, 79% of the non-citizens (72/91) were on ART compared to 86% (8,267/9,652) of citizens (p = 0.137). CONCLUSIONS: Although non-citizens were less likely to know their HIV-positive status compared to citizens, there were no differences in treatment uptake among non-citizens and citizens who knew their status. Designing interventions for non-citizens that provide HIV testing and treatment services commensurate to that of citizens as well as targeting communities with the largest number of non-citizens may help close a meaningful gap in the HIV care cascade and ensure ethical treatment for all HIV-positive persons. TRIAL REGISTRATION: NCT01965470 (Botswana Combination Prevention Project).

      • Non-AIDS comorbidity burden differs by sex, race, and insurance type in aging adults in HIV careexternal icon
        Palella FJ, Hart R, Armon C, Tedaldi E, Yangco B, Novak R, Battalora L, Ward D, Li J, Buchacz K.
        Aids. 2019 Aug 22.
        OBJECTIVE: To understand the epidemiology of non-AIDS-related chronic comorbidities (NACMs) among aging persons with HIV (PWH) DESIGN:: Prospective multicenter observational study to assess, in an age stratified fashion, number and types of NACMs by demographic and HIV factors. METHODS: Eligible participants were seen during 1/1/1997 – 6/30/2015, followed >5.0 years, received antiretroviral therapy (ART), and virally suppressed [HIV viral load (VL) < 200 copies/mL >/=75% of observation time]. Age was stratified (18-40, 41-50, 51-60, >/=61 years). NACMs included cardiovascular disease, cancer, hypertension, diabetes, dyslipidemia, arthritis, viral hepatitis, anemia, and psychiatric illness. RESULTS: Of 1540 patients, 1247 (81%) were men, 406 (26%) non-Hispanic blacks (NHB), 183 (12%) Hispanics/Latinos, 575 (37%) with public insurance, 939 (61%) men who have sex with men (MSM), and 125 (8%) with injection drug use history. By age strata 18-40, 41-50, 51-60, >/=61 years, there were 180, 502, 560, and 298 patients, respectively. Median HIV Outpatient Study (HOPS) observation was 10.8 years (range: min-max = 5.0-18.5). Mean number of NACMs increased with older age category; 1.4, 2.1, 3.0, and 3.9, respectively (P < 0.001), as did prevalence of most NACMs (P < 0.001). Age-related differences NACM number were primarily due to anemia, hepatitis C virus infection, and diabetes. Differences (all P < 0.05) in NACM number existed by sex (women >men, 3.9 vs 3.4), race/ethnicity (NHB >non-NHB, 3.8 vs 3.4), and insurance status (public >private, 4.3 vs 3.1). CONCLUSIONS: Age-related increases existed in prevalence and number of NACMs, with disproportionate burden among women, NHBs, and the publicly insured. These groups should be targeted for screening and prevention strategies aimed at NACM reduction.

    • Disaster Control and Emergency Services
      • Injury-related emergency department visits after hurricane Maria in a southern Puerto Rico hospitalexternal icon
        Frasqueri-Quintana VM, Oliveras Garcia CA, Adams LE, Torres-Figueroa X, Iriarte RI, Ryff K, Sanchez-Gonzalez L, Perez Gomez V, Perez-Rodriguez NM, Alvarado LI, Paz-Bailey G.
        Disaster Med Public Health Prep. 2019 Aug 28:1-8.
        OBJECTIVE: The aim of this study was to describe individuals seeking care for injury at a major emergency department (ED) in southern Puerto Rico in the months after Hurricane Maria on September 20, 2017. METHODS: After informed consent, we used a modified version of the Natural Disaster Morbidity Surveillance Form to determine why patients were visiting the ED during October 16, 2017-March 28, 2018. We analyzed visits where injury was reported as the primary reason for visit and whether it was hurricane-related. RESULTS: Among 5 116 patients, 573 (11%) reported injury as the primary reason for a visit. Of these, 10% were hurricane-related visits. The most common types of injuries were abrasions, lacerations, and cuts (43% of all injury visits and 50% of hurricane-related visits). The most common mechanisms of injury were falls, slips, trips (268, 47%), and being hit by/or against an object (88, 15%). Most injury visits occurred during the first 3 months after the hurricane. CONCLUSIONS: Surveillance after Hurricane Maria identified injury as the reason for a visit for about 1 in 10 patients visiting the ED, providing evidence on the patterns of injuries in the months following a hurricane. Public health and emergency providers can use this information to anticipate health care needs after a disaster.

    • Food Safety
      • Multidrug-resistant Salmonella I 4,[5],12:i:- and Salmonella infantis infections linked to whole roasted pigs from a single slaughter and processing facilityexternal icon
        Kawakami V, Bottichio L, Lloyd J, Carleton H, Leeper M, Olson G, Li Z, Kissler B, Angelo KM, Whitlock L, Sinatra J, Defibaugh-Chavez S, Bicknese A, Kay M, Wise ME, Basler C, Duchin J.
        J Food Prot. 2019 Sep;82(9):1615-1624.
        We describe two outbreaks of multidrug-resistant (MDR) Salmonella I 4,[5],12:i:- infection, occurring in 2015 to 2016, linked to pork products, including whole roaster pigs sold raw from a single Washington slaughter and processing facility (establishment A). Food histories from 80 ill persons were compared with food histories reported in the FoodNet 2006 to 2007 survey of healthy persons from all 10 U.S. FoodNet sites who reported these exposures in the week before interview. Antimicrobial susceptibility testing and whole genome sequencing were conducted on selected clinical, food, and environmental isolates. During 2015, a total of 192 ill persons were identified from five states; among ill persons with available information, 30 (17%) of 180 were hospitalized, and none died. More ill persons than healthy survey respondents consumed pork (74 versus 43%, P < 0.001). Seventeen (23%) of 73 ill persons for which a response was available reported attending an event where whole roaster pig was served in the 7 days before illness onset. All 25 clinical isolates tested from the 2015 outbreak and a subsequent 2016 smaller outbreak (n = 15) linked to establishment A demonstrated MDR. Whole genome sequencing of clinical, environmental, and food isolates (n = 69) collected in both investigations revealed one clade of highly related isolates, supporting epidemiologic and traceback data that establishment A as the source of both outbreaks. These investigations highlight that whole roaster pigs, an uncommon food vehicle for MDR Salmonella I 4,[5],12:i:- outbreaks, will need further attention from food safety researchers and educators for developing science-based consumer guidelines, specifically with a focus on the preparation process.

    • Healthcare Associated Infections
      • Hospital-associated multicenter outbreak of emerging fungus Candida auris, Colombia, 2016external icon
        Armstrong PA, Rivera SM, Escandon P, Caceres DH, Chow N, Stuckey MJ, Diaz J, Gomez A, Velez N, Espinosa-Bode A, Salcedo S, Marin A, Berrio I, Varon C, Guzman A, Perez-Franco JE, Escobar JD, Villalobos N, Correa JM, Litvintseva AP, Lockhart SR, Fagan R, Chiller TM, Jackson B, Pacheco O.
        Emerg Infect Dis. 2019 Jul;25(7).
        Candida auris is an emerging multidrug-resistant fungus that causes hospital-associated outbreaks of invasive infections with high death rates. During 2015-2016, health authorities in Colombia detected an outbreak of C. auris. We conducted an investigation to characterize the epidemiology, transmission mechanisms, and reservoirs of this organism. We investigated 4 hospitals with confirmed cases of C. auris candidemia in 3 cities in Colombia. We abstracted medical records and collected swabs from contemporaneously hospitalized patients to assess for skin colonization. We identified 40 cases; median patient age was 23 years (IQR 4 months-56 years). Twelve (30%) patients were <1 year of age, and 24 (60%) were male. The 30-day mortality was 43%. Cases clustered in time and location; axilla and groin were the most commonly colonized sites. Temporal and spatial clustering of cases and skin colonization suggest person-to-person transmission of C. auris. These cases highlight the importance of adherence to infection control recommendations.

    • Immunity and Immunization
      • Creating and sustaining demand for immunization services is a global priority to ensure that vaccine-eligible populations are fully protected from vaccine-preventable diseases. Social mobilization remains a key health promotion strategy used by low- and middle-income countries (LMICs) to promote vaccination demand. In this commentary, we synthesize illustrative evidence on successful social mobilization efforts promoting the uptake of immunization services in select LMICs. The first example focuses on Sierra Leone’s routine immunization program during the Universal Child Immunization initiative in the late 1980s. We then give an example of India’s establishment of a social mobilization network in the early- to mid-2000s to support polio elimination in high-risk communities. Thirdly, we highlight the complexities of social mobilization in a humanitarian emergency during the 2017-2018 diphtheria outbreak among displaced Rohingyas in camps and settlements in Bangladesh. Lastly, we draw upon examples from the introduction of the human papillomavirus vaccine in several countries. We then critically examine recurring challenges faced when implementing social mobilization for immunization in LMICs and offer practical recommendations for improvement.

    • Substance Use and Abuse
      • Prescription opioid misuse associated with risk behaviors among adolescentsexternal icon
        Clayton HB, Bohm MK, Lowry R, Ashley C, Ethier KA.
        Am J Prev Med. 2019 Aug 13.
        INTRODUCTION: With the ongoing opioid overdose epidemic in the U.S., it is important to explore how prescription opioid misuse correlates with health behaviors that increase the risk for adverse health outcomes among adolescents. The objective of this study is to determine if lifetime nonmedical use of prescription opioids is associated with health risk behaviors among adolescents. METHODS: Data from the 2017 nationally representative Youth Risk Behavior Survey (14,765 high school students in Grades 9-12) were used to explore associations between lifetime nonmedical use of prescription opioids and 29 health risk behaviors. Logistic regression models (adjusted for sex, race/ethnicity, grade, and sexual identity) estimated adjusted prevalence ratios and 95% CIs. Analyses were completed in 2018. RESULTS: Nonmedical use of prescription opioids was associated with all but 1 of the health risk behaviors included in the analyses. Substance use ranged from adjusted prevalence ratio=2.46 (current alcohol use) to adjusted prevalence ratio=17.52 (heroin use); violence victimization from adjusted prevalence ratio=1.80 (bullied at school) to adjusted prevalence ratio=3.12 (threatened or injured with a weapon); suicidal thoughts/behaviors from adjusted prevalence ratio=2.23 (considered suicide) to adjusted prevalence ratio=3.45 (attempted suicide); and sexual behavior from adjusted prevalence ratio=1.06 (did not use a dual pregnancy prevention method) to adjusted prevalence ratio=3.42 (4 or more sexual partners). Poor academic performance (adjusted prevalence ratio=1.53), receiving an HIV test (adjusted prevalence ratio=1.77), and having persistent feelings of sadness/hopelessness (adjusted prevalence ratio=1.80) were also associated with nonmedical use of prescription opioids. CONCLUSIONS: Nonmedical use of prescription opioids is associated with many health risk behaviors. Opportunities to reduce nonmedical use of prescription opioids include screening pediatric patients for opioid use disorder, improved prescribing practices, and, from a primary prevention perspective, integrated evidence-based health education programs in schools.

      • Cessation behaviors and treatment use among U.S. smokers by insurance status, 2000-2015external icon
        Zhang L, Babb S, Schauer G, Asman K, Xu X, Malarcher A.
        Am J Prev Med. 2019 Aug 22.
        INTRODUCTION: Variations exist in insurance coverage of smoking-cessation treatments and cigarette smokers’ use of these treatments. Recent trends in cessation behaviors by health insurance status have not been reported. This study examines trends in quit attempts, provider advice to quit, and use of cessation counseling and/or medications among adult cigarette smokers by insurance status. Demographic correlates of these cessation behaviors are also identified. METHODS: Data from the 2000-2015 National Health Interview Surveys were used to estimate the prevalence of and trends in past-year quit attempts, receipt of health professional advice to quit, and use of counseling and/or medication among cigarette smokers aged 18-64 years by insurance status (private, Medicaid, or uninsured). Multivariable logistic regression models were used to identify demographic correlates. The analysis was conducted in 2017. RESULTS: Past-year quit attempts increased linearly among all insurance groups (p<0.05), whereas provider advice to quit remained unchanged. Use of cessation treatment increased linearly among smokers with Medicaid (18.1% [95% CI=13.4%, 22.8%] in 2000 to 34.9% [95% CI=28.5%, 40.5%] in 2015, p<0.05), whereas nonlinear increases were observed among those with private insurance (26.2% [95% CI=24.0%, 28.4%] in 2000 to 32.3% [95% CI=29.0%, 35.6%] in 2015; quadratic trend, p<0.05) and uninsured smokers (13.9% [95% CI=11.0%, 16.8%] in 2000 to 21.8% [95% CI=17.1%, 26.5%] in 2015; quadratic trend, p<0.05). Regardless of insurance status, adults aged 18-24 years had lower odds than older adults of receiving advice to quit and using cessation treatments. CONCLUSIONS: Despite increased use of cessation treatments among Medicaid enrollees, disparities by insurance status persist in adult cessation behaviors. Opportunities exist to increase cessation by making comprehensive, barrier-free cessation coverage available to all smokers.

  2. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Chronic Diseases and Conditions
      1. Objective: Arthritis patients experience the impact of disease beyond routinely assessed clinical measures. We characterized arthritis-attributable interference in four important routine life domains: 1) recreation/leisure/hobbies; 2) household chores; 3) errands/shopping; and 4) social activities. Method(s): Participants were from the Arthritis Conditions Health Effects Survey (2005-2006), a cross-sectional survey of noninstitutionalized US adults 45 years or older with doctor-diagnosed arthritis (n = 1793). We estimated the prevalence of “a lot” of arthritis-attributable interference and quantified the associations between sociodemographic, clinical, and psychological characteristics and “a lot” of arthritis-attributable interference (vs “a little” or “none”) in each domain using prevalence ratios (PRs) in multivariable (MV)-adjusted logistic regression models. Result(s): An estimated 1 in 5 to 1 in 4 adults with arthritis reported “a lot” of arthritis-attributable interference in recreation/leisure/hobbies (27%), household chores (25%), errands/shopping (22%), and social activities (18%). The highest prevalence of “a lot” of arthritis-attributable interference was for those unable to work/disabled or reporting severe arthritis symptoms (pain, stiffness, fatigue), anxiety, depression, or no/low confidence in ability to manage arthritis, across domains. In MV-adjusted models, those unable to work/disabled, currently seeing a doctor, or reporting fair/poor self-rated health, severe joint pain, anxiety, or no/low confidence in ability to manage arthritis were more likely to report arthritis-attributable interference than their respective counterparts. Magnitudes varied by domain but were consistently strongest for those unable to work/disabled (MV PR range = 1.8-2.5) and with fair/poor health (MV PR range = 1.7-2.7). Conclusion(s): Many characteristics associated with arthritis-attributable interference in routine life activities are potentially modifiable, suggesting unmet need for use of existing evidence-based interventions that address these characteristics and reduce interferences to improve quality of life.

    • Communicable Diseases
      1. Changes in tuberculosis epidemiology, United States, 1993-2017external icon
        Armstrong LR, Winston CA, Stewart B, Tsang CA, Langer AJ, Navin TR.
        Int J Tuberc Lung Dis. 2019 Jul 1;23(7):797-804.
        BACKGROUND: After 20 years of steady decline, the pace of decline of tuberculosis (TB) incidence in the United States has slowed.METHODS: Trends in TB incidence rates and case counts since 1993 were assessed using national US surveillance data. Patient characteristics reported during 2014-2017 were compared with those for 2010-2013.RESULTS: TB rates and case counts slowed to an annual decline of respectively 2.2% (95%CI -3.4 to -1.0) and 1.5% (95%CI -2.7 to -0.3) since 2012, with decreases among US-born persons and no change among non-US-born persons. Overall, persons with TB diagnosed during 2014-2017 were older, more likely to have combined pulmonary and extra-pulmonary disease than extra-pulmonary disease alone, more likely to be of non-White race, and less likely to have human immunodeficiency virus infection, or cavitary pulmonary disease. During 2014-2017, non-US-born persons with TB were more likely to have diabetes mellitus, while the US-born were more likely to have smear-positive TB and use non-injecting drugs.CONCLUSION: Changes in epidemiologic trends are likely to affect TB incidence in the coming decades. The Centers for Disease Control and Prevention has called for increased attention to TB prevention through the detection and treatment of latent tuberculous infection.

      2. Facility-associated release of polioviruses into communities-risks for the posteradication eraexternal icon
        Bandyopadhyay AS, Singh H, Fournier-Caruana J, Modlin JF, Wenger J, Partridge J, Sutter RW, Zaffran MJ.
        Emerg Infect Dis. 2019 Jul;25(7):1363-1369.
        The Global Polio Eradication Initiative continues to make progress toward the eradication target. Indigenous wild poliovirus (WPV) type 2 was last detected in 1999, WPV type 3 was last detected in 2012, and over the past 2 years WPV type 1 has been detected only in parts of 2 countries (Afghanistan and Pakistan). Once the eradication of poliomyelitis is achieved, infectious and potentially infectious poliovirus materials retained in laboratories, vaccine production sites, and other storage facilities will continue to pose a risk for poliovirus reintroduction into communities. The recent breach in containment of WPV type 2 in an inactivated poliovirus vaccine manufacturing site in the Netherlands prompted this review, which summarizes information on facility-associated release of polioviruses into communities reported over >8 decades. Successful polio eradication requires the management of poliovirus containment posteradication to prevent the consequences of the reestablishment of poliovirus transmission.

      3. Are missed- and kept-visit measures capturing different aspects of retention in HIV primary care?external icon
        Batey DS, Kay ES, Westfall AO, Zinski A, Drainoni ML, Gardner LI, Giordano T, Keruly J, Rodriguez A, Wilson TE, Mugavero MJ.
        AIDS Care. 2019 Aug 28:1-6.
        The literature recognizes six measures of retention in care, an integral component of the HIV Continuum of Care. Given prior research showing that different retention measures are differentially associated with HIV health outcomes (e.g., CD4 count and viral suppression), we hypothesized that different groups of people living with HIV (PLWH) would also have differential retention outcomes based on the retention measure applied. We conducted a cross-sectional analysis of multisite patient-level medical record data (n = 10,053) from six academically-affiliated HIV clinics using six different measures of retention. Principal component analysis indicated two distinct retention constructs: kept-visit-measures and missed-visit measures. Although black (compared to white) PLWH had significantly poorer retention on the three missed-visit measures, race was not significantly associated with any of the three kept-visit measures. Males performed significantly worse than females on all kept-visit measures, but sex differences were not observed for any missed-visit retention measures. IDU risk transmission group and younger age were associated with poorer retention on both missed- and kept-visit retention measures. Missed- and kept-visit measures may capture different aspects of retention, as indicated in the observed differential associations among race, sex, age, and risk transmission group. Multiple measures are needed to effectively assess retention across patient subgroups.

      4. Sapovirus: an important cause of acute gastroenteritis in childrenexternal icon
        Becker-Dreps S, Bucardo F, Vinje J.
        Lancet Child Adolesc Health. 2019 Aug 19.

        [No abstract]

      5. Pre-exposure prophylaxis (PrEP) has demonstrated high efficacy to reduce HIV infections, however, racial/ethnic HIV disparities continue among black MSM. The purpose of this review was to assess available data to inform interventions to increase PrEP awareness, uptake, and adherence among black MSM. Of the 3024 studies retrieved, 36 met final inclusion criteria and were categorized into the PrEP care continuum: (1) awareness (n = 16), (2) uptake (n = 9), and (3) adherence (n = 12). Only 26 of the studies presented analytical findings by race/ethnicity. Key barrier themes included cost, HIV-related stigma, and fear of potential side effects. A key facilitator theme identified by black MSM included gaining PrEP awareness from social and sexual networks. There are significant gaps in research on black MSM and PrEP utilization, especially regarding PrEP uptake and adherence. These data are needed to inform interventions to address current inequities in PrEP services, to help improve care outcomes for black MSM.

      6. Evaluation of an HIV prevention intervention for women living with HIVexternal icon
        Joshua TG, Williams WO, Benton S, Uhl G.
        AIDS Care. 2019 Aug 28:1-8.
        It is estimated that 23% of the adults and adolescents living with HIV in the United States are female. The Division of HIV/AIDS Prevention at the Centers for Disease Control and Prevention (CDC) funds evidence-based interventions (EBIs) to reduce HIV risk behaviors, including HIV prevention programs for people living with HIV and their partners. While EBIs have been shown to be effective in controlled research environments, there are limited data on intervention implementation in real-world settings. Women Involved in Life Learning from Other Women (WILLOW) is a four-session small-group intervention that targets heterosexual women aged 18-50 who are living with HIV. This evaluation assessed changes in participants’ HIV knowledge, attitudes, beliefs and risk behaviors. A repeated measures design was used to collect participant risk behaviors at baseline, and again at three and six months post-intervention. Changes in attitudes, beliefs, and risk behaviors were assessed using generalized estimating equations. After participation in WILLOW, participants reported increased HIV knowledge, attitudes and beliefs, being more supportive of condom use, and reduced prevalence of HIV risk behaviors. Findings suggest that the WILLOW intervention can be successfully delivered by community-based organizations to reduce HIV risk behaviors among members of this high-risk population.

      7. Granulomatous amoebic encephalitis caused by Acanthamoeba in a patient with AIDS: a challenging diagnosisexternal icon
        Lau HL, De Lima Corvino DF, Guerra FM, Malik AM, Lichtenberger PN, Gultekin SH, Ritter JM, Roy S, Ali IK, Cope JR, Post MJ, Gonzales Zamora JA.
        Acta Clin Belg. 2019 Aug 27:1-5.
        INTRODUCTION: Acanthamoeba spp. is a ubiquitous free-living amoeba that causes human infections affecting predominantly the cornea and central nervous system. The diagnosis and treatment of Acanthamoeba encephalitis is very challenging. CASE SUMMARY: A 53-year-old male with HIV/AIDS was admitted for altered mental status and fever. On initial examination, he had left hemianopia with left-sided weakness and numbness. MRI revealed an inflammatory and enhancing parenchymal mass associated with leptomeningeal enhancement in the occipitoparietal lobe containing multiple punctate hemorrhages. He was treated with empiric antibiotics for presumptive toxoplasmosis, brain abscess, fungal infection and tuberculosis with an unremarkable lymphoma work up. Initial brain biopsy studies were unremarkable except for non-specific granulomas and adjacent necrotic tissue. The patient passed away 2.5 months after initial presentation with no diagnosis. Post-mortem testing by the Centers for Disease Control and Prevention (CDC) confirmed the diagnosis of granulomatous amoebic encephalitis (GAE) by visualization with immunohistochemistry staining and PCR. Recovery is rare from GAE likely due to delay in diagnosis. CONCLUSIONS: This case illustrates the importance of including GAE into the differential diagnosis of brain mass. We advocate early molecular testing of tissue specimen by the CDC to achieve an appropriate diagnosis, and a multidisciplinary approach for the management of this condition.

      8. Notes from the field: Mumps in detention facilities that house detained migrants – United States, September 2018-August 2019external icon
        Leung J, Elson D, Sanders K, Marin M, Leos G, Cloud B, McNall RJ, Hickman CJ, Marlow M.
        MMWR Morb Mortal Wkly Rep. 2019 Aug 30;68(34):749-750.

        [No abstract]

      9. High yield of new HIV diagnoses during active case-finding for tuberculosisexternal icon
        McHembere W, Agaya J, Yuen CM, Okelloh D, Achola M, Opole J, Cowden J, Muttai H, Heilig CM, Borgdorff MW, Cain KP.
        Aids. 2019 Aug 22.
        OBJECTIVE: To evaluate the utility of a broad and non-specific symptom screen for identifying people with undiagnosed HIV infection. DESIGN: Secondary analysis of operational data collected during implementation of a cluster-randomized trial for tuberculosis case detection. METHODS: As part of the trial, adults reporting cough, fever, night sweats, weight loss, or difficulty breathing of any duration in the past month were identified in health facilities and community-based mobile screening units in western Kenya. Adults reporting any symptom were offered HIV testing. We analysed the HIV testing data from this study, using modified Poisson regression to identify predictors of new HIV diagnoses among adults with symptoms and initially unknown HIV status. RESULTS: We identified 3,818 symptomatic adults, referred 1424 (37%) for testing, of whom 1065 (75%) accepted, and 107 (10%) were newly diagnosed with HIV. The prevalence of new HIV diagnoses was 21% (95% CI: 17-25%) among those tested in health facilities and 5% (95% CI 4-7%) among those tested in mobile units. More men were diagnosed with HIV than women despite fewer men being screened. People who reported 4-5 symptoms were over twice as likely to be diagnosed with HIV compared to those reporting 1-3 symptoms (adjusted prevalence ratio [aPR] in health facilities = 2.58, 95% CI, 1.65-4.05; aPR in mobile units = 2.63, 95% CI, 1.37-5.03). CONCLUSION: We observed a high yield of new HIV diagnoses among adults identified by active application of a broad symptom screen. Integrated tuberculosis and HIV screening using could help close the detection gap for both conditions.

      10. Health care worker perspectives on TB case finding and HIV services among pediatric TB patients in Tanzaniaexternal icon
        Ndakidemi E, Emerson C, Medley A, Ngowi B, Ng’eno B, Munuo G, Kohi W, Modi S.
        Int J Tuberc Lung Dis. 2019 Jul 1;23(7):811-816.
        BACKGROUND: Tuberculosis (TB) and human immunodeficiency virus (HIV) infection in children are of concern due to the high morbidity and mortality they engender. Tanzania is working to improve TB and HIV case identification and treatment, as well as linkage of TB and HIV care in pediatric patients.METHODS: In-depth interviews were conducted in March 2016 at 10 high TB burden clinics in five districts of Tanzania to identify the barriers to pediatric TB diagnosis and HIV care. Health care workers (HCWs) at TB clinics who provided informed consent were administered interviews which were analyzed.RESULTS: Of 41 HCWs interviewed, 26 reported receiving pediatric TB training. Barriers to TB diagnosis included low community awareness, stigma and late presentation to the clinic. Barriers to HIV testing included children attending the TB clinic with someone who was not their parent/guardian and shortages of HIV rapid test kits. HCWs stressed the need for improved community education because it was perceived that some caregivers did not understand the importance of prompt TB and HIV treatment in children (although most were eager for a resolution of their child’s illness).CONCLUSIONS: Efforts are needed to ensure effective TB and HIV diagnosis and treatment of children, provision of broader HCW and community education, enhanced TB-HIV contact tracing, and ensuring a continuous supply of HIV rapid test kits.

      11. Reducing the African American HIV disease burden in the deep south: Addressing the role of faith and spiritualityexternal icon
        Nunn A, Jeffries WL, Foster P, McCoy K, Sutten-Coats C, Willie TC, Ransome Y, Lanzi RG, Jackson E, Berkley-Patton J, Keefer M, Coleman JD.
        AIDS Behav. 2019 Aug 23.
        Nearly half of HIV infections in the United States are concentrated among African Americans, and over half of new HIV infections occur in the South. African Americans have poorer outcomes in the entire continua of HIV and PrEP care. Complex social, structural, and behavioral factors contribute to our nation’s alarming racial disparities in HIV infection, particularly in the Deep South. Despite the importance of faith, spirituality and religious practice in the lives of many African Americans, there has been little scientific investment exploring how African Americans’ religious participation, faith and spirituality may impact our nation’s HIV epidemic. This article summarizes the state of the science on this critical issue. We also identify opportunities for new scholarship on how faith, spirituality and religious participation may impact HIV care continuum outcomes in the South and call for greater federal research investment on these issues.

      12. African American men who have sex with men (AAMSM) are vastly overrepresented among people with HIV/AIDS. Using data from 595 AAMSM in Philadelphia, we explored differences in sociodemographics, psychosocial characteristics related to beliefs about ethnicity, sexuality and masculinity, and sexual behavior with men and women by self-reported sexual identity (gay, bisexual, down low, straight). Roughly equivalent numbers identified as gay (40.6 %) and bisexual (41.3 %), while fewer identified as straight (7.6 %) or down low (10.5 %), with significant differences in age, income, history of incarceration, HIV status, alcohol and drug problems, childhood sexual abuse, and connection to the gay community evident among these groups. Analysis of psychosocial characteristics theorized to be related to identity and sexual behavior indicated significant differences in masculinity, homophobia, and outness as MSM. Gay and straight men appeared to be poles on a continuum of frequency of sexual behavior, with bisexual and down low men being sometimes more similar to gay men and sometimes more similar to straight men. The percentage of men having total intercourse of any kind was highest among down low and lowest among gay men. Gay men had less intercourse with women, but more receptive anal intercourse with men than the other identities. There were no significant differences by identity in frequency of condomless insertive anal intercourse with men, but gay men had significantly more condomless receptive anal intercourse. There were significant differences by identity for condomless vaginal and anal intercourse with women. This study demonstrates the importance of exploring differences in types of sex behavior for AAMSM by considering sexual identity.

      13. Introduction of an Alcohol-Related Electronic Screening and Brief Intervention (eSBI) Program to reduce hazardous alcohol consumption in Namibia’s antiretroviral treatment (ART) programexternal icon
        Tang AM, Hamunime N, Adams RA, Kanyinga G, Fischer-Walker C, Agolory S, Prybylski D, Mutenda N, Sughrue S, Walker DD, Rennie T, Zahralban-Steele M, Kerrigan A, Hong SY.
        AIDS Behav. 2019 Aug 23.
        Alcohol is the most widely abused substance in Namibia and is associated with poor adherence and retention in care among people on antiretroviral therapy (ART). Electronic screening and brief interventions (eSBI) are effective in reducing alcohol consumption in various contexts. We used a mixed methods approach to develop, implement, and evaluate the introduction of an eSBI in two ART clinics in Namibia. Of the 787 participants, 45% reported some alcohol use in the past 12 months and 25% reported hazardous drinking levels. Hazardous drinkers were more likely to be male, separated/widowed/divorced, have a monthly household income > $1000 NAD, and report less than excellent ART adherence. Based on qualitative feedback from participants and providers, ART patients using the eSBI for the first time found it to be a positive and beneficial experience. However, we identified several programmatic considerations that could improve the experience and yield in future implementation studies.

      14. Progress toward HIV epidemic control in Lesotho: results from a population-based surveyexternal icon
        Thin K, Frederix K, McCracken S, Letsie M, Low A, Patel H, Parekh B, Motsoane T, Ahmed N, Justman J, Callaghan L, Tembo S, Schwitters A.
        Aids. 2019 Aug 22.
        OBJECTIVE: The Lesotho Population-based HIV Impact Assessment (LePHIA) survey was conducted nationally and designed to measure HIV prevalence, incidence, and viral load suppression (VLS). DESIGN: A nationally representative sample of 9,403 eligible households was surveyed between November 2016 and May 2017; analyses account for study design. Consenting participants provided blood samples, socio-demographic and behavioral information. METHODS: Blood samples were tested using the national rapid HIV testing algorithm. HIV-seropositive results were confirmed with Geenius supplemental assay. Screening for detectable concentrations of antiretroviral (ARV) analytes was conducted on dried blood specimens from all HIV-positive adults using high-resolution liquid chromatography coupled with tandem mass spectrometry. Self-reported and/or ARV biomarker data were used to classify individuals as HIV-positive and on treatment. Viral load testing was performed on all HIV-positive samples at central labs. VLS was defined as HIV RNA < 1000 copies per mL. RESULTS: Overall, 25.6% of adults ages 15-59 were HIV-positive. Among seropositive adults, 81.0% (male: 76.6%, female: 84.0%) reported knowing their HIV status, 91.8% of people living with HIV (male: 91.6%, female: 92.0%) who reported knowing their status reporting taking ARVs, and 87.7% (male and female: 87.7%) of these had VLS. Younger age was significantly associated with being less likely to be aware of HIV status for both sexes. CONCLUSIONS: Findings from this population-based survey provide encouraging data in terms of HIV testing and treatment uptake and coverage. Specific attention to reaching youth to engage them in HIV-related intervention is critical to achieving epidemic control.

      15. Optimizing the efficiency of tuberculosis active case-finding in health facilities and communitiesexternal icon
        Yuen CM, Agaya J, McHembere W, Okelloh D, Achola M, Opole J, Cowden J, Heilig CM, Borgdorff MW, Cain KP.
        Int J Tuberc Lung Dis. 2019 Jul 1;23(7):844-849.
        SETTING: Efficient tuberculosis (TB) active case-finding strategies are important in settings with high TB burdens and limited resources, such as those in western Kenya. OBJECTIVE: To guide efforts to optimize screening efficiency, we identified the predictors of TB among people screened in health facilities and communities. DESIGN: During February 2015-June 2016, adults aged >/=15 years reporting any TB symptom were identified in health facilities and community mobile screening units, and evaluated for TB. We assessed the predictors of TB using a modified Poisson regression with generalized estimating equations to account for clustering according to screening site. RESULTS: TB was diagnosed in 484 (20.3%) of 2394 symptomatic adults in health facilities and 39 (3.4%) of 1424 in communities. In health facilities, >10% of symptomatic adults in all demographic groups had TB, and no predictors were associated with a >/=2-fold increased risk. In communities, the independent predictors of TB were male sex (adjusted prevalence ratio [aPR] = 4.26, 95%CI 2.43-7.45), HIV infection (aPR 2.37, 95%CI 1.18-4.77), and household TB contact in the last 2 years (aPR 2.84, 95%CI 1.62-4.96). CONCLUSION: Our findings support the notion of general TB screening in health facilities and evaluation of the adult household contacts of TB patients.

    • Disaster Control and Emergency Services
      1. A framework for integrating information resources for chemical emergency management and responseexternal icon
        Seaton MG, Maier A, Sachdeva S, Barton C, Ngai E, Lentz TJ, Rane PD, McKernan LT.
        Am J Disaster Med. 2019 Winter;14(1):33-49.
        Effective emergency management and response require appropriate utilization of various resources as an incident evolves. This manuscript describes the information resources used in chemical emergency management and operations and how their utility evolves from the initial response phase to recovery to event close out. The authors address chemical hazard guidance in the context of four different phases of emergency response: preparedness, emergency response (both initial and ongoing), recovery, and mitigation. Immediately following a chemical incident, during the initial response, responders often use readily available, broad-spectrum guidance to make rapid decisions in the face of uncertainties regarding potential exposure to physical and health hazards. Physical hazards are described as the hazards caused by chemicals that can cause harm with or without direct contact. Examples of physical hazards include explosives, flammables, and gases under pressure. This first line of resources may not be chemical-specific in nature, but it can provide guidance related to isolation distances, protective actions, and the most important physical and health threats. During the ongoing response phase, an array of resources can provide detailed information on physical and health hazards related to specific chemicals of concern. Consequently, risk management and mitigation actions evolve as well. When the incident stabilizes to a recovery phase, the types of information resources that facilitate safe and effective incident management evolve. Health and physical concerns transition from acute toxicity and immediate hazards to both immediate and latent health effects. Finally, the information inputs utilized during the preparedness phase include response evaluations of past events, emergency preparedness planning, and chemical-specific guidance about chemicals present. This manuscript details a framework for identifying the effective use of information resources at each phase and provides case study examples from chemical hazard emergencies.

    • Disease Reservoirs and Vectors
      1. Not all surveillance data are created equal – A multi-method dynamic occupancy approach to determine rabies elimination from wildlifeexternal icon
        Davis AJ, Kirby JD, Chipman RB, Nelson KM, Xifara T, Webb CT, Wallace R, Gilbert AT, Pepin KM.
        J Appl Ecol. 2019 .
        A necessary component of elimination programmes for wildlife disease is effective surveillance. The ability to distinguish between disease freedom and non-detection can mean the difference between a successful elimination campaign and new epizootics. Understanding the contribution of different surveillance methods helps to optimize and better allocate effort and develop more effective surveillance programmes. We evaluated the probability of rabies virus elimination (disease freedom) in an enzootic area with active management using dynamic occupancy modelling of 10?years of raccoon rabies virus (RABV) surveillance data (2006?2015) collected from three states in the eastern United States. We estimated detection probability of RABV cases for each surveillance method (e.g. strange acting reports, roadkill, surveillance-trapped animals, nuisance animals and public health samples) used by the USDA National Rabies Management Program. Strange acting, found dead and public health animals were the most likely to detect RABV when it was present, and generally detectability was higher in fall?winter compared to spring?summer. Found dead animals in fall?winter had the highest detection at 0.33 (95% CI: 0.20, 0.48). Nuisance animals had the lowest detection probabilities (~0.02). Areas with oral rabies vaccination (ORV) management had reduced occurrence probability compared to enzootic areas without ORV management. RABV occurrence was positively associated with deciduous and mixed forests and medium to high developed areas, which are also areas with higher raccoon (Procyon lotor) densities. By combining occupancy and detection estimates we can create a probability of elimination surface that can be updated seasonally to provide guidance on areas managed for wildlife disease. Synthesis and applications. Wildlife disease surveillance is often comprised of a combination of targeted and convenience-based methods. Using a multi-method analytical approach allows us to compare the relative strengths of these methods, providing guidance on resource allocation for surveillance actions. Applying this multi-method approach in conjunction with dynamic occupancy analyses better informs management decisions by understanding ecological drivers of disease occurrence.

      2. Seroprevalence of spotted fever group rickettsiae in canines along the United States-Mexico borderexternal icon
        Pieracci EG, De La Rosa JD, Rubio DL, Perales ME, Drexler NA, Nicholson WL, De La Rosa JJ, Chung IH, Kato C, Barton Behravesh C, Enriquez MA, Roldan JF, Villarino ME.
        Zoonoses Public Health. 2019 Aug 23.
        Portions of northern Mexico are experiencing a re-emergence of Rocky Mountain spotted fever (RMSF), a tickborne disease caused by Rickettsia rickettsii, a member of the spotted fever group of rickettsiae (SFGR). Infection with R. rickettsii can result in serious and life-threatening illness in people and dogs. Canine seroprevalence has been used as a sentinel for human RMSF in previous studies. This study aims to quantify SFGR seroprevalence in canines in three northern Mexican states and identify risk factors associated with seropositivity. A total of 1,136 serum samples and 942 ticks were obtained from dogs participating in government sterilization campaigns and from animal control facilities in 14 Mexican cities in three states. SFGR antibodies were detected using indirect immunofluorescence antibody assays at titre values >/=1/64. Six per cent (69 dogs) showed antibodies to SFGR, with the highest seroprevalence reported in Baja California (12%), Coahuila (4%) and Sonora (4%). Dogs from Baja California had three times higher odds of having SFGR antibodies compared to dogs from Sonora (OR = 3.38, 95% CI, 1.81-6.37). Roughly one quarter (25%) of surveyed dogs were parasitized by ticks (Rhipicephalus sanguineus sensu lato) at the time of sample collection. A portion of collected ticks were tested for rickettsial DNA using polymerase chain reaction. Positive samples were then sequenced, showing evidence of SFGR including R. massiliae, R. parkeri and R. rickettsii. Dogs that spent the majority of time on the street, such as free-roaming or community-owned dogs, showed a greater risk of tick infestation, seropositivity, bearing seropositive ticks, and may play a pivotal role in the spread of SFGR among communities. Estimating the seroprevalence of SFGR in the canine population can help public health campaigns target high-risk communities for interventions to reduce human RMSF cases.

      3. Primary amebic meningoencephalomyelitis caused by Naegleria fowleri in a south-central black rhinoceros (Diceros bicornis minor)external icon
        Yaw TJ, O’Neil P, Gary JM, Ali IK, Cowart JR, Wallace RS, Estep JS.
        J Am Vet Med Assoc. 2019 Jul 15;255(2):219-223.
        CASE DESCRIPTION A 20-year-old female south-central black rhinoceros (Diceros bicornis minor) was evaluated because of an acute onset of CNS deficits. CLINICAL FINDINGS The rhinoceros had no history of illness. Clinical signs included acute lethargy, ataxia, and decreased appetite. Hematologic abnormalities included leukocytosis with neutrophilia and a profound left shift. Results of serum biochemical analysis revealed hypophosphatemia but no other abnormalities. Results of a quantitative PCR assay for West Nile virus and an assay for anti-Neosporum caninum antibodies in serum were negative; the patient was seropositive for multiple Leptospira serovars. TREATMENT AND OUTCOME Antimicrobials and anti-inflammatory agents were administered, but the condition of the rhinoceros worsened overnight; despite treatment with additional anti-inflammatory and antimicrobial agents, IV fluids, and thiamine, it became obtunded and died of respiratory arrest </= 24 hours later. Necropsy revealed severe, diffuse, suppurative, and histiocytic meningo-encephalomyelitis involving the cerebrum, cerebellum, and spinal cord. Amebic trophozoites were observed on histologic examination of affected tissue. Infection with Naegleria fowleri was confirmed by results of immuno-histochemical analysis and a multiplex real-time PCR assay. CLINICAL RELEVANCE Findings suggested that south-central black rhinoceros are susceptible to the free-living ameba N fowleri. Ameba-induced meningoencephalomyelitis should be considered as a differential diagnosis for rhinoceros that have an acute onset of neurologic signs. Diagnosis of N fowleri infection in an animal has a profound public health impact because of potential human exposure from the environment and the high fatality rate in people with N fowleri infection.

    • Environmental Health
      1. BACKGROUND: Per- and polyfluoroalkyl substances (PFAS) are a chemical class widely used in industrial and commercial applications because of their unique physical and chemical properties. Between 2013 and 2016 PFAS were detected in public water systems and private wells in El Paso County, Colorado. The contamination was likely due to aqueous film forming foams used at a nearby Air Force base. OBJECTIVE: To cross-sectionally describe the serum concentrations of PFAS in a highly exposed community, estimate associations with drinking water source, and explore potential demographic and behavioral predictors. METHODS: In June 2018, serum PFAS concentrations were quantified and questionnaires administered in 213 non-smoking adult (ages 19-93) participants residing in three affected water districts. Twenty PFAS were quantified and those detected in >50% of participants were analyzed: perfluorohexane sulfonate (PFHxS), perfluorooctane sulfonate (PFOS), perfluorooctanoate (PFOA), perfluorononanoate (PFNA) and perfluoroheptane sulfonate (PFHpS). Unadjusted associations were estimated between serum PFAS concentrations and several predictors, including water consumption, demographics, personal behaviors and employment. A multiple linear regression model estimated adjusted associations with smoking history. RESULTS: Study participants’ median PFHxS serum concentration (14.8ng/mL) was approximately 12 times as high as the U.S. national average. Median serum concentrations for PFOS, PFOA, PFNA and PFHpS were 9.7ng/mL, 3.0ng/mL, 0.4ng/mL and 0.2ng/mL, respectively. Determinants of PFHxS serum concentrations were water district of residence, frequency of bottled water consumption, age, race/ethnicity, and smoking history. Determinants of serum concentrations for the other four PFAS evaluated included: water district of residence, bottled water consumption, age, sex, race/ethnicity, smoking history, and firefighter or military employment. CONCLUSIONS: Determinants of serum concentrations for multiple PFAS, including PFHxS, included water district of residence and frequency of bottled water consumption. Participants’ dominant PFAS exposure route was likely consumption of PFAS-contaminated water, but certain demographic and behavioral characteristics also predicted serum concentrations.

    • Food Safety
      1. Notes from the field: Multistate outbreak of Salmonella agbeni associated with consumption of raw cake mix – five states, 2018external icon
        Ladd-Wilson SG, Morey K, Koske SE, Burkhalter B, Bottichio L, Brandenburg J, Fontana J, Tenney K, Kutumbaka KK, Samadpour M, Kreil K, Cieslak PR.
        MMWR Morb Mortal Wkly Rep. 2019 Aug 30;68(34):751-752.

        [No abstract]

    • Health Disparities
      1. Racial disparities in breastfeeding initiation and duration among U.S. infants born in 2015external icon
        Beauregard JL, Hamner HC, Chen J, Avila-Rodriguez W, Elam-Evans LD, Perrine CG.
        MMWR Morb Mortal Wkly Rep. 2019 Aug 30;68(34):745-748.
        Surveillance of U.S. breastfeeding duration and exclusivity has historically reported estimates among all infants, regardless of whether they had initiated breastfeeding. These surveillance estimates have consistently shown that non-Hispanic black (black) infants are less likely to breastfeed, compared with other racial/ethnic groups.* Less is known about disparities in breastfeeding duration when calculated only among infants who had initiated breastfeeding, compared with surveillance estimates based on all infants. CDC analyzed National Immunization Survey-Child (NIS-Child) data for infants born in 2015 to describe breastfeeding duration and exclusivity at ages 3 and 6 months among all black and non-Hispanic white (white) infants, and among only those who had initiated breastfeeding. When calculated among all infants regardless of breastfeeding initiation, breastfeeding differences between black and white infants were 14.7 percentage points (95% confidence interval [CI] = 10.7-18.8) for any breastfeeding at age 3 months and were significantly different for both any and exclusive breastfeeding at both ages 3 and 6 months. Among only infants who had initiated breastfeeding, the magnitude of black-white differences in breastfeeding rates were smaller. This was most notable in rates of any breastfeeding at 3 months, where the percentage point difference between black and white infants was reduced to 1.2 (95% CI = -2.3-4.6) percentage points and was no longer statistically significant. Black-white disparities in breastfeeding duration result, in part, from disparities in initiation. Interventions both to improve breastfeeding initiation and to support continuation among black mothers might help reduce disparities.

    • Healthcare Associated Infections
      1. Whole genome sequencing to identify drivers of carbapenem-resistant Klebsiella pneumoniae transmission within and between regional long-term acute care hospitalsexternal icon
        Han JH, Lapp Z, Bushman F, Lautenbach E, Goldstein EJ, Mattei L, Hofstaedter CE, Kim D, Nachamkin I, Garrigan C, Jain T, Bilker W, Wolford HM, Slayton RB, Wise J, Tolomeo P, Snitkin ES.
        Antimicrob Agents Chemother. 2019 Aug 26.
        Carbapenem-resistant Klebsiella pneumoniae (CRKP) is an antibiotic resistance threat of the highest priority. Given the limited treatment options for this multidrug-resistant organism (MDRO), there is an urgent need for targeted strategies to prevent transmission. Here, we applied whole-genome sequencing to a comprehensive collection of clinical isolates to reconstruct regional transmission pathways, and analyzed this transmission network in the context of statewide patient transfer data and patient-level clinical data to identify drivers of regional transmission. We found that high regional CRKP burden was due to a small number of regional introductions, with subsequent regional proliferation occurring via patient transfers among healthcare facilities. While CRKP was predicted to be imported into each facility multiple times, there was substantial variation in the ratio of intra-facility transmission events per importation, indicating that amplification occurs unevenly across regional facilities. While myriad factors likely influence intra-facility transmission rates, an understudied one is the potential for clinical characteristics of colonized and infected patient to influence their propensity for transmission. Supporting the contribution of high-risk patients to elevated transmission rates, we observed that CRKP colonized and infected patients in high transmission facilities had higher rates of carbapenem use, malnutrition, old age and dialysis. This study highlights the potential for regional infection prevention efforts that are grounded in genomic epidemiology to identify patients and facilities that make the greatest contribution to regional MDRO prevalence, thereby facilitating the design of precision interventions of maximal impact.

      2. Carbapenem-resistant Pseudomonas aeruginosa at US Emerging Infections Program Sites, 2015external icon
        Walters MS, Grass JE, Bulens SN, Hancock EB, Phipps EC, Muleta D, Mounsey J, Kainer MA, Concannon C, Dumyati G, Bower C, Jacob J, Cassidy PM, Beldavs Z, Culbreath K, Phillips WE, Hardy DJ, Vargas RL, Oethinger M, Ansari U, Stanton R, Albrecht V, Halpin AL, Karlsson M, Rasheed JK, Kallen A.
        Emerg Infect Dis. 2019 Jul;25(7):1281-1288.
        Pseudomonas aeruginosa is intrinsically resistant to many antimicrobial drugs, making carbapenems crucial in clinical management. During July-October 2015 in the United States, we piloted laboratory-based surveillance for carbapenem-resistant P. aeruginosa (CRPA) at sentinel facilities in Georgia, New Mexico, Oregon, and Tennessee, and population-based surveillance in Monroe County, NY. An incident case was the first P. aeruginosa isolate resistant to antipseudomonal carbapenems from a patient in a 30-day period from any source except the nares, rectum or perirectal area, or feces. We found 294 incident cases among 274 patients. Cases were most commonly identified from respiratory sites (120/294; 40.8%) and urine (111/294; 37.8%); most (223/280; 79.6%) occurred in patients with healthcare facility inpatient stays in the prior year. Genes encoding carbapenemases were identified in 3 (2.3%) of 129 isolates tested. The burden of CRPA was high at facilities under surveillance, but carbapenemase-producing CRPA were rare.

    • Immunity and Immunization
      1. Standard-dose intradermal influenza vaccine elicits cellular immune responses similar to those of intramuscular vaccine in men with and those without HIV infectionexternal icon
        Amoah S, Mishina M, Praphasiri P, Cao W, Kim JH, Liepkalns JS, Guo Z, Carney PJ, Chang JC, Fernandez S, Garg S, Beacham L, Holtz TH, Curlin ME, Dawood F, Olsen SJ, Gangappa S, Stevens J, Sambhara S.
        J Infect Dis. 2019 Jul 31;220(5):743-751.
        BACKGROUND: Human immunodeficiency virus (HIV)-infected persons are at a higher risk of severe influenza. Although we have shown that a standard-dose intradermal influenza vaccine versus a standard-dose intramuscular influenza vaccine does not result in differences in hemagglutination-inhibition titers in this population, a comprehensive examination of cell-mediated immune responses remains lacking. METHODS: Serological, antigen-specific B-cell, and interleukin 2-, interferon gamma-, and tumor necrosis factor alpha-secreting T-cell responses were assessed in 79 HIV-infected men and 79 HIV-uninfected men. RESULTS: The route of vaccination did not affect the immunoglobulin A and immunoglobulin G (IgG) plasmablast or memory B-cell response, although these were severely impaired in the group with a CD4+ T-cell count of <200 cells/muL. The frequencies of IgG memory B cells measured on day 28 after vaccination were highest in the HIV-uninfected group, followed by the group with a CD4+ T-cell count of >/=200 cells/muL and the group with a CD4+ T-cell count of <200 cells/muL. The route of vaccination did not affect the CD4+ or CD8+ T-cell responses measured at various times after vaccination. CONCLUSIONS: The route of vaccination had no effect on antibody responses, antibody avidity, T-cell responses, or B-cell responses in HIV-infected or HIV-uninfected subjects. With the serological and cellular immune responses to influenza vaccination being impaired in HIV-infected individuals with a CD4+ T-cell count of <200 cells/muL, passive immunization strategies need to be explored to protect this population. CLINICAL TRIALS REGISTRATION: NCT01538940.

      2. This report updates the 2018-19 recommendations of the Advisory Committee on Immunization Practices (ACIP) regarding the use of seasonal influenza vaccines in the United States (MMWR Recomm Rep 2018;67[No. RR-3]). Routine annual influenza vaccination is recommended for all persons aged >/=6 months who do not have contraindications. A licensed, recommended, and age-appropriate vaccine should be used. Inactivated influenza vaccines (IIVs), recombinant influenza vaccine (RIV), and live attenuated influenza vaccine (LAIV) are expected to be available for the 2019-20 season. Standard-dose, unadjuvanted, inactivated influenza vaccines will be available in quadrivalent formulations (IIV4s). High-dose (HD-IIV3) and adjuvanted (aIIV3) inactivated influenza vaccines will be available in trivalent formulations. Recombinant (RIV4) and live attenuated influenza vaccine (LAIV4) will be available in quadrivalent formulations.Updates to the recommendations described in this report reflect discussions during public meetings of ACIP held on October 25, 2018; February 27, 2019; and June 27, 2019. Primary updates in this report include the following two items. First, 2019-20 U.S. trivalent influenza vaccines will contain hemagglutinin (HA) derived from an A/Brisbane/02/2018 (H1N1)pdm09-like virus, an A/Kansas/14/2017 (H3N2)-like virus, and a B/Colorado/06/2017-like virus (Victoria lineage). Quadrivalent influenza vaccines will contain HA derived from these three viruses, and a B/Phuket/3073/2013-like virus (Yamagata lineage). Second, recent labeling changes for two IIV4s, Afluria Quadrivalent and Fluzone Quadrivalent, are discussed. The age indication for Afluria Quadrivalent has been expanded from >/=5 years to >/=6 months. The dose volume for Afluria Quadrivalent is 0.25 mL for children aged 6 through 35 months and 0.5 mL for all persons aged >/=36 months (>/=3 years). The dose volume for Fluzone Quadrivalent for children aged 6 through 35 months, which was previously 0.25 mL, is now either 0.25 mL or 0.5 mL. The dose volume for Fluzone Quadrivalent is 0.5 mL for all persons aged >/=36 months (>/=3 years).This report focuses on the recommendations for use of vaccines for the prevention and control of influenza during the 2019-20 season in the United States. A brief summary of these recommendations and a Background Document containing additional information are available at These recommendations apply to U.S.-licensed influenza vaccines used within Food and Drug Administration-licensed indications. Updates and other information are available from CDC’s influenza website ( Vaccination and health care providers should check this site periodically for additional information.

      3. Timeliness of rotavirus vaccination at sentinel sites in four early-adopter African countriesexternal icon
        Pindyck T, Tate JE, Bonkoungou IJ, Armah G, Mujuru HA, Rugambwa C, Mwenda JM, Parashar U.
        Vaccine. 2019 Aug 24.
        BACKGROUND: The majority of countries with the highest rotavirus-associated death rates are in sub-Saharan Africa. In 2009, the World Health Organization (WHO) recommended routine vaccination against rotavirus worldwide, with unique age recommendations to administer the first dose before 15weeks of age and last dose by 32weeks of age. These age restrictions were relaxed in January 2013, but they may still lead to lower rotavirus vaccine coverage. METHODS: Children age-eligible to have received rotavirus vaccine that were enrolled in Ghana, Zimbabwe, Rwanda or Burkina Faso’s active rotavirus surveillance platforms from 2013 to 2017 and had a stool specimen that tested rotavirus-negative were included in the analysis. Proportion vaccinated and timeliness of rotavirus vaccine versus DTPw-HepB-Hib (pentavalent) first dose and last dose were compared at weeks 15 and 32, respectively, using Chi-square analyses. Odds ratios were calculated using logistic regression. RESULTS: Among children who received rotavirus vaccine dose 1, 96-99% received this dose by 15weeks of age and among children who received the last dose, 98-99% received it by 32weeks of age. In all four countries, there was no significant difference in the proportion of children who received first dose rotavirus versus pentavalent vaccine by week 15, or last dose rotavirus versus concordant pentavalent vaccine by week 32. Delayed administration of first dose pentavalent vaccine was significantly associated with missing first dose of rotavirus vaccine in 3 of the 4 countries studied, although delays in administration were rare (1-4%). CONCLUSIONS: Rotavirus vaccination was timely among sentinel sites in these four early rotavirus vaccine-introducing countries in Africa. Late presentation for vaccination may have resulted in some children with access to care missing first dose of rotavirus vaccine; however, vaccination delays were infrequent and therefore the potential impact of the age restrictions on overall proportion vaccinated was minimal.

    • Informatics
      1. Identification of important features in mobile health applications for surgical site infection surveillanceexternal icon
        Chernetsky Tejedor S, Sharma J, Lavallee DC, Lober WB, Evans HL.
        Surg Infect (Larchmt). 2019 Aug 29.
        Background: A landscape analysis of mobile health (mHealth) applications and published literature related to their use in surgical site infection (SSI) detection and surveillance was conducted by the Assessing Surgical Site Infection Surveillance Technologies (ASSIST) investigators. Methods: The literature review focused on post-discharge SSI detection or tracking by caregivers or patients using mHealth technology. This report is unique in its review across both commercial and research-based mHealth apps. Apps designed for long-term wound tracking and those focused on care coordination and scheduling were excluded. A structured evaluation framework was used to assess the operational, technical, and policy features of the apps. Results: Of the 10 apps evaluated, only two were in full clinical use. A variety of data were captured by the apps including wound photographs (eight apps), wound measurements (three apps), dressing assessments (two apps), physical activity metrics (three apps), medication adherence (three apps) as well as structured surveys, signs, and symptoms. Free-text responses were permitted by at least two apps. The extent of integration with the native electronic health record system was variable. Conclusion: The examination of rapidly evolving technologies is challenged by lack of standard evaluative methods, such as those more commonly used in clinical research. This review is unique in its application of a structured evaluation framework across both commercial and research-based mHealth apps.

    • Injury and Violence
      1. Background: Intimate partner violence (IPV) is a leading cause of injury for reproductive-aged women. Clinical guidelines exist to assist providers in counseling women for IPV, but information on provider counseling among pregnant women from population-based sources is limited. Methods: Data for 2009-2015 from 37 states and New York City participating in the Pregnancy Risk Assessment Monitoring System (PRAMS) were analyzed (n = 258,263). We compared prevalence estimates overall and by site, of physical IPV occurring before and/or during pregnancy, and prenatal counseling on physical IPV. Multivariable logistic regression was used to identify factors associated with receiving prenatal counseling on physical IPV. Results: Overall, 3.8% of women reported experiencing any physical IPV in the 12 months before and/or during pregnancy (range: 1.5% [Connecticut] to 7.2% [Mississippi]). Prevalence of prenatal IPV counseling was 51.0% (range: 30.2% [Utah] to 63.1% [New Mexico]). Receipt of prenatal counseling on depression predicted a fourfold increase in prevalence of receiving counseling on physical IPV (adjusted prevalence ratio [aPR] = 4.20, 95% confidence interval [CI]: 4.06-4.34). In addition, non-Hispanic black race versus non-Hispanic white race, and having less than a high school education were associated with higher prevalence of receipt of IPV counseling ([aPR = 1.16, 95% CI: 1.14-1.18] and [aPR = 1.11, 95% CI: 1.08-1.13], respectively). Conclusion: Almost 4% of women with a recent live birth reported physical IPV before and/or during pregnancy. Only half of women received counseling on IPV during prenatal care, with counseling rates varying widely among states. Increased adherence to guidelines for universal screening and counseling of women could ensure all women are offered appropriate support and referral.

    • Laboratory Sciences
      1. Many laboratory studies in cryptosporidial research require a source of purified oocysts. Sources can include experimentally infected laboratory animals or from samples collected from naturally infected animals and from clinical cases of human cryptosporidiosis. Purification of oocysts can be accomplished with readily available laboratory equipment including tabletop centrifuges and microcentrifuges. Following purification, oocysts can be stored in antibiotic-supplemented buffers or in 2.5% aqueous potassium dichromate for over 6 months. Ultimately, oocyst viability and infectivity decline to less than 10% after 1 year, so if isolates are expected to be maintained, serial passage in a suitable host at </=6-month intervals is recommended. Oocysts purified as described in this chapter are suitable for animal infection studies, cell culture studies, and a wide range of molecular biological studies, environmental studies, drug testing, and disinfection studies.

      2. Development of a UPLC-ESI-MS/MS method to measure urinary metabolites of selected VOCs: Benzene, cyanide, furfural, furfuryl alcohol, 5-hydroxymethylfurfural, and N-methyl-2-pyrrolidoneexternal icon
        Bhandari D, McCarthy D, Biren C, Movassaghi C, Blount BC, De Jesus VR.
        J Chromatogr B Analyt Technol Biomed Life Sci. 2019 Aug 14;1126-1127:121746.
        We report on the development of an ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method for simultaneously measuring eight biomarkers of volatile organic compound (VOC) exposure, with potential application to e-cigarette aerosol biomonitoring. Phenylmercapturic acid (PMA) and trans, trans-muconic acid (tt-MA) are metabolites of benzene; 2-aminothiazoline-4-carboxylic acid (ATCA) is a metabolite of cyanide; N-2-furoylglycine (N2FG) is a metabolite of furfural and furfuryl alcohol; 5-hydroxymethylfuroic acid (HMFA), 5-hydroxymethyl-2-furoylglycine (HMFG), and 2,5-furandicarboxylic acid (FDCA) are metabolites of 5-hydroxymethylfurfural; and 5-hydroxy-N-methylpyrrolidone (5HMP) is a metabolite of N-methyl-2-pyrrolidone. A pentafluorophenyl-modified silica column was used for chromatographic separation. The overall run time for the method is about 6min per sample injection. The method has low to sub-nanograms per milliliter sensitivity, linearity over 3 orders of magnitude, and precision and accuracy within 15%. The method was used to measure human urine samples. Results showed that people with known benzene exposure (daily cigarette smokers) had higher levels of tt-MA and PMA compared with non-smokers. The method is advantageous for high-throughput analysis of selected VOC metabolites in large-scale, population-based studies such as the National Health and Nutrition Examination Survey (NHANES). Quantifying these urinary biomarkers is important to public health efforts to understand human exposure to VOCs from various sources, including tobacco products and electronic nicotine delivery systems.

      3. Early breast development in overweight girls: does estrogen made by adipose tissue play a role?external icon
        Carlson L, Flores Poccia V, Sun BZ, Mosley B, Kirste I, Rice A, Sridhar R, Kangarloo T, Vesper HW, Duke L, Botelho JC, Filie AC, Adams JM, Shaw ND.
        Int J Obes (Lond). 2019 Aug 28.
        BACKGROUND: Girls who are overweight/obese (OB) develop breast tissue but do not undergo menarche (the first menstrual period) significantly earlier than girls of normal weight (NW). It has been proposed that estrogen synthesized by adipose tissue may be contributory, yet OB do not have higher serum estrogen levels than NW matched on breast stage. We hypothesized that estrogen synthesized locally, in mammary fat, may contribute to breast development. This hypothesis would predict that breast development would be more advanced than other estrogen-sensitive tissues as a function of obesity and body fat. METHODS: Eighty premenarchal girls (26 OB, 54 NW), aged 8.2-14.7 years, underwent dual-energy x-ray absorptiometry to calculate percent body fat (%BF), Tanner staging of the breast, breast ultrasound for morphological staging, trans-abdominal pelvic ultrasound, hand x-ray (bone age, BA), a blood test for reproductive hormones, and urine collection to determine the vaginal maturation index (VMI), an index of estrogen exposure in urogenital epithelial cells. RESULTS: When controlling for breast morphological stage determined by ultrasound, %BF was not associated with serum estrogen or gonadotropin (LH and FSH) levels or with indices of systemic estrogen action (uterine volume, endometrial thickness, BA advancement, and VMI). Tanner breast stage did not correlate with breast morphological stage and led to misclassification of chest fatty tissue as breast tissue in some OB. CONCLUSIONS: These studies do not support the hypothesis that estrogen derived from total body fat or local (mammary) fat contributes to breast development in OB girls.

      4. Mathematical model of thrombin generation and bleeding phenotype in Amish carriers of Factor IX:C deficiency vs. controlsexternal icon
        Gupta S, Bravo MC, Heiman M, Nakar C, Brummel-Ziedins K, Miller CH, Shapiro A.
        Thromb Res. 2019 Aug 8;182:43-50.
        INTRODUCTION: Factor IX:C (FIX:C) levels vary in hemophilia B carriers even in pedigrees with a unifying genetic defect. Analyzing the balance between pro-and anticoagulants might increase our understanding of carriers’ bleeding potential. AIM: In this research study, we evaluated bleeding scores (BS) and a novel mathematical model of thrombin generation (TG) in Amish FIX:C deficient carriers and controls. METHODS: Blood samples and BS were obtained from post-menarchal females, including 59 carriers and 57 controls from the same extended pedigree. Factors II, V, VII, VIII, IX, X, antithrombin, tissue factor pathway inhibitor and protein C were assayed to generate mathematical models of TG in response to 5pM tissue factor (TF) and for TF+thrombomodulin. BS was based on a modification of the MCMDM-1VWD scoring system. RESULTS: Carriers had a lower mean FIX:C (68% vs. 119%), von Willebrand factor antigen (108 vs.133) and Tissue activatable fibrinolysis inhibitor (103 vs. 111) compared to controls; both groups had a similar mean BS. Carriers demonstrated significantly lower TG parameters on both mathematical models compared to controls. Carriers with FIX:C</=50% had lower TG curves than those >50% but similar BS. CONCLUSION: Thrombin generation showed significant differences between carriers and controls, between low (</=50%) and high (>50%) FIX:C carriers, and specifically in the TF+thrombomodulin model, between high FIX:C carriers and controls, although the BS were not different.

      5. The procedure described here provides instructions for detection of Cryptosporidium recovered from large-volume water samples. Water samples are collected by dead-end ultrafiltration in the field and ultrafilters are processed in a laboratory. Microbes recovered from the filters are further concentrated and subjected to Cryptosporidium isolation or nucleic acid extraction methods for the detection of Cryptosporidium oocysts or Cryptosporidium DNA.

      6. Frequency and characteristics of biologic false positive tests for syphilis, reported in Florida and New York City, 2013-2017external icon
        Matthias J, Klingler EJ, Schillinger JA, Keller G, Wilson C, Peterman TA.
        J Clin Microbiol. 2019 Aug 28.
        BACKGROUND: Discordant syphilis test results, with a reactive non-treponemal test and non-reactive treponemal test are usually considered biological false positive test results (BFP), which can be attributed to other conditions. Syphilis surveillance laws mandate laboratory reporting of reactive syphilis tests which include many BFPs. We describe the frequency of BFP, titer distributions, and titer increases from reported test results in Florida and New York City (NYC). METHODS: Reactive non-treponemal tests for individuals with at least one non-reactive treponemal test and no reactive treponemal test, were extracted from STD surveillance systems in Florida and NYC from 2013 through 2017. Characteristics of individuals with BFPs were analyzed after selecting the observation with the highest titer from each individual. We next considered all results from individuals to characterize persons who had a four-fold titer increase between successive non-treponemal tests. RESULTS: Among 526,540 reactive non-treponemal tests, there were 57,580 BFPs (11%) from 39,920 individuals. Over 90% (n=52,330) of BFPs were low titer (</=1:4), but 654 (1%) were high-titer BFPs (>/=1:32). Very high-titer (>/=1:128) BFPs were more common among individuals over 60 years of age (OR 2.68 95%CI 1.22-5.91). A four-fold increase in titer was observed among 1,863 (14%) individuals with more than one reported BFP. CONCLUSIONS: Most BFPs detected by surveillance were low-titer but some were high-titer and some had a four-fold increase in titer. Review of patient histories might identify underlying conditions contributing to these high and rising titers.

      7. This chapter provides a detailed protocol to assess disinfection efficacy of chlorine against Cryptosporidium oocysts including the core chlorine disinfection assay, the in vitro cell culture infectivity assay, and microscopy analysis and data interpretation.

      8. Measuring cryptosporidium serologic responses by multiplex bead assayexternal icon
        Priest JW, Moss DM.
        Methods Mol Biol. 2020 ;2052:61-85.
        For more than 35 years, various assay formats have been used to detect Cryptosporidium-specific antibodies in human and animal sera. Cryptosporidium parvum 17- and 27-kDa antigens, identified from invasive sporozoites, have been used in serologic antibody assays to identify individuals infected in outbreaks of diarrheal disease caused by this protozoan parasite and to monitor exposures in communities. During infection, immunoglobulin (Ig) A, IgM, and IgG responses are elicited by these immunodominant antigens, and the parasite-specific Ig responses diminish following the resolution of infection. Using the recombinant forms of the 17- and 27-kDa C. parvum antigens and the relatively recently developed multiplex bead assay (MBA), data from serologic antibody responses can be economically and efficiently acquired, especially when the Cryptosporidium assays are integrated with assays for antibody responses to antigens from other pathogens monitored in community-wide or nation-wide serosurveys. Here we describe the coupling of the C. parvum recombinant antigens to carboxylated polystyrene beads, the data acquisition and analysis of IgG antibodies bound to the coupled beads, and the quality control methods required for data validation using the Luminex/MBA system.

      9. Comparing QuantiFERON-TB Gold Plus with other tests to diagnose Mycobacterium tuberculosis infectionexternal icon
        Venkatappa TK, Punnoose R, Katz DJ, Higgins MP, Banaei N, Graviss EA, Belknap RW, Ho CS.
        J Clin Microbiol. 2019 Aug 28.
        The fourth generation QuantiFERON test for tuberculosis infection, QuantiFERON-TB Gold Plus (QFT-Plus) has replaced the earlier version, QuantiFERON-TB Gold In-Tube (QFT-GIT). A clinical need exists for information about agreement between QFT-Plus and other tests.We conducted this study to assess agreement of test results for QFT-Plus with those of QuantiFERON-TB Gold In-Tube (QFT-GIT), T-SPOT.TB (T-SPOT) and the tuberculin skin test (TST).Persons at high risk of LTBI and/or progression to TB disease were enrolled at the 10 sites of the Tuberculosis Epidemiologic Studies Consortium from October 2016 through May 2017; each participant received all four tests. Cohen’s kappa (kappa) and Wilcoxon signed rank test compared qualitative and quantitative results of QFT-Plus with the other tests.Test results for 506 participants showed 94% agreement between QFT-Plus and QFT-GIT, with 19% positive and 75% negative results. When the tests disagreed, it was most often in the direction of QFT-GIT negative/QFT-Plus positive. QFT-Plus had similar concordance as QFT-GIT with TST (77% and 77%) and T-SPOT (92% and 91%), respectively.Conclusions: The study showed high agreement between QFT-GIT and QFT-Plus in a direct comparison. Both tests had similar agreement with TST and T-SPOT.

      10. Substrate stiffness-dependent carbon nanotube-induced lung fibrogenesisexternal icon
        Wang K, Shi L, Linthicum W, Man K, He X, Wen Q, Rojanasakul LW, Rojanasakul Y, Yang Y.
        Nano Lett. 2019 Aug 14;19(8):5443-5451.
        Most living tissues exhibit the specific stiffness, which has been known to have profound influence on cell behaviors, yet how the stiffness affects cellular responses to engineered nanomaterials has not been elucidated. Particularly, discrepancies exist between in vitro and in vivo nanotoxicological studies. Here, we investigated the effects of substrate stiffness on the fibrogenic responses of normal human lung fibroblasts (NHLFs) to multiwalled carbon nanotubes (MWCNTs). NHLFs were grown on polyacrylamide (PAAm) hydrogels with the stiffness comparable to that of human normal and fibrotic lung tissues, and treated with MWCNTs for various time. The fibrogenic responses, including cell proliferation, reactive oxygen species production, and collagen I expression, of NHLFs to MWCNTs were observed to be regulated by substrate stiffness in a time-dependent manner. NHLFs generally were rounded on soft hydrogels and required a long treatment time to exhibit fibrogenic responses, while on stiff hydrogels the cells were well-spread with defined stress fibers and short-time MWCNTs treatment sufficiently induced the fibrogenic responses. Mechanistic studies showed that MWCNTs induced fibrogenesis of NHLFs through promoting expression and phosphorylation of focal adhesion kinase (FAK), while attenuating intracellular tension in the cells on stiff gels could increase MWCNTs uptake and thus elevate the induced fibrogenic responses. Moreover, we proposed a time-stiffness superposition principle to describe the equivalent effects of treatment time and substrate stiffness on nanomaterials-induced fibrogenesis, which suggested that increasing substrate stiffness expedited fibrogenesis and shed light on the rational design of in vitro models for nanotoxicological study.

    • Maternal and Child Health
      1. Specific birth defects in pregnancies of women with diabetes – National Birth Defects Prevention Study, 1997-2011external icon
        Tinker SC, Gilboa SM, Moore CA, Waller DK, Simeone RM, Kim SY, Jamieson DJ, Botto LD, Reefhuis J.
        Am J Obstet Gynecol. 2019 Aug 24.
        BACKGROUND: Diabetes is associated with an increased risk for many birth defects and is likely to have an increasing impact on birth defect prevalence due to the rise in diabetes in the United States in recent decades. One of the first analyses in which specific birth defects were assessed for their relationship with both pregestational and gestational diabetes used data from the initial six years of the National Birth Defects Prevention Study. That analysis reported strong associations for pregestational diabetes with several birth defects, but few exposures among some of the less common birth defects led to unstable estimates with wide confidence intervals. Since that analysis, the study continued to collect data for another eight years, including information on approximately 19,000 additional cases and 6,900 additional controls. OBJECTIVES: Our objective was to use data from the National Birth Defects Prevention Study, the largest population-based birth defects case-control study in the United States, to provide updated and more precise estimates of the association between diabetes and birth defects, including some defects not previously assessed. STUDY DESIGN: We analyzed data on deliveries from October 1997 through December 2011. Mothers of case and control infants were interviewed about their health conditions and exposures during pregnancy, including diagnosis of pregestational (type 1 or type 2) diabetes before the index pregnancy or gestational diabetes during the index pregnancy. Using logistic regression, we separately assessed the association between pregestational and gestational diabetes with specific categories of structural birth defects for which there were at least three exposed case infants. For birth defect categories for which there were at least five exposed case infants, we calculated odds ratios adjusted for maternal body mass index, age, education, race/ethnicity, and study site; for defect categories with three or four exposed cases we calculated crude odds ratios. RESULTS: Pregestational diabetes was reported by 0.6 percent of mothers of control infants (71 / 11,447) and 2.5 percent of mothers of case infants (775 / 31,007). Gestational diabetes during the index pregnancy was reported by 4.7 percent of mothers of control infants (536 / 11,447) and 5.3 percent of mothers of case infants (1,653 / 31,007). Pregestational diabetes was associated with strong, statistically significant odds ratios (range: 2.5 to 80.2) for 46 of 50 birth defects considered. The largest odds ratio was observed for sacral agenesis (adjusted OR [aOR]: 80.2; 95% CI: 46.1, 139.3). A greater than 10-fold increased risk was also observed for holoprosencephaly (aOR: 13.1; 95% CI: 7.0, 24.5), longitudinal limb deficiency (aOR: 10.1; 95% CI: 6.2, 16.5), heterotaxy (aOR: 12.3; 95% CI: 7.3, 20.5), truncus arteriosus (aOR: 14.9; 95% CI: 7.6, 29.3), atrioventricular septal defect (aOR: 10.5; 95% CI: 6.2, 17.9), and single ventricle complex (aOR: 14.7; 95% CI: 8.9, 24.3).For gestational diabetes, statistically significant odds ratios were fewer (12 of 56) and of smaller magnitude (range: 1.3 to 2.1; 0.5 for gastroschisis). CONCLUSIONS: Pregestational diabetes is associated with markedly increased risk for many specific births defects. Because glycemic control before pregnancy is associated with a reduced risk for birth defects, ongoing quality care for persons with diabetes is an important opportunity for prevention.

    • Nutritional Sciences
      1. Distance and percent distance from median BMI as alternatives to BMI z-scoreexternal icon
        Freedman DS, Woo JG, Ogden CL, Xu JH, Cole TJ.
        Br J Nutr. 2019 Aug 23:1-25.
        Body mass index z-score (BMIz) based on the CDC growth charts is widely used, but it is inaccurate above the 97th percentile. We explored the performance of alternative metrics based on the absolute distance or % distance of a child’s BMI from the median BMI for sex and age. We used longitudinal data from 5628 children who were first examined < 12 y to compare the tracking of three BMI metrics: distance from median, % distance from median, and % distance from median on a log scale. We also explored the effects of adjusting these metrics for age differences in the distribution of BMI. The intra-class correlation coefficient (ICC) was used to compare tracking of the metrics.

      2. BACKGROUND: Children with uncomplicated severe acute malnutrition (SAM) are treated at home with ready-to-use therapeutic foods (RUTFs). The current RUTF dose is prescribed according to the weight of the child to fulfil 100% of their nutritional needs until discharge. However, there is doubt concerning the dose, as it seems to be shared, resulting in suboptimal cost-efficiency of SAM treatment. We investigated the efficacy of a reduced RUTF dose in community-based treatment of uncomplicated SAM. METHODS AND FINDINGS: We undertook a randomised trial testing the non-inferiority of weight gain velocity of children with SAM receiving (a) a standard RUTF dose for two weeks, followed by a reduced dose thereafter (reduced), compared with (b) a standard RUTF dose throughout the treatment (standard). A mean difference of 0.0 g/kg/day was expected, with a non-inferiority margin fixed at -0.5 g/kg/day. Linear and logistic mixed regression analyses were performed, with study site and team as random effects. Between October 2016 and July 2018, 801 children with uncomplicated SAM aged 6-59 months were enrolled from 10 community health centres in Burkina Faso. At admission, the mean age (+/- standard deviation [SD]) was 13.4 months (+/-8.7), 49% were male, and the mean weight was 6.2 kg (+/-1.3). The mean weight gain velocity from admission to discharge was 3.4 g/kg/day and did not differ between study arms (Delta 0.0 g/kg/day; 95% CI -0.4 to 0.4; p = 0.92) confirming non-inferiority (p = 0.013). However, after two weeks, the weight gain velocity was significantly lower in the reduced dose with a mean of 2.3 g/kg/day compared with 2.7 g/kg/day in the standard dose (Delta -0.4 g/kg/day; 95% CI -0.8 to -0.02; p = 0.041). The length of stay (LoS) was not different (p = 0.73) between groups with a median of 56 days (interquartile range [IQR] 35-91) in both arms. No differences were found between reduced and standard arm in recovery (52.7% and 55.4%; p = 0.45), referral (19.2% and 20.1%; p = 0.80), defaulter (12.2% and 8.5%; p = 0.088), non-response (12.7% and 12.5%; p = 0.95), and relapse (2.4% and 1.8%; p = 0.69) rates, respectively. However, the reduced RUTF dose had a small 0.2 mm/week (95% CI 0.04 to 0.4; p = 0.015) negative effect on height gain velocity with a mean height gain of 2.6 mm/week with reduced and 2.8 mm/week with standard RUTF dose. The impact was more pronounced in children under 12 months of age (interaction, p = 0.019) who gained 2.8 mm/week with reduced and 3.1 mm/week with standard dose (Delta -0.4 mm/week; 95% CI -0.6 to -0.2; p < 0.001). Limitations include not blinding participants to the RUTF dose received and excluding all children with negative appetite test. The results are generalisable for relatively food secure contexts with a young SAM population. CONCLUSIONS: Reducing the RUTF dose provided to children with SAM after two weeks of treatment did not reduce overall weight or mid-upper arm circumference (MUAC) gain velocity nor affect recovery or lengthen treatment time. However, it led to a small but significant negative effect on linear growth, especially among the youngest. The potential effect of reducing the RUTF dose in a routine program on treatment outcomes should be evaluated before scaling up. TRIAL REGISTRATION: ISRCTN registry ISRCTN50039021.

      3. The evaluation of IDEAL-REACH Program to improve nutrition among Asian American community members in the Philadelphia metropolitan areaexternal icon
        Ma GX, Zhu L, Shive SE, Zhang G, Senter YR, Topete P, Seals B, Zhai S, Wang M, Tan Y.
        Int J Environ Res Public Health. 2019 Aug 23;16(17).
        Objective Asian Americans’ food purchasing, cooking, and eating patterns are not well understood. Greater insight into these behaviors is urgently needed to guide public health interventions of dietary behaviors in this population. The present study aims to examine the effects of a community-level intervention on food purchasing and preparation, nutrition knowledge, and health awareness in Asian Americans. Methods From 2015 to 2017, we conducted the Improving Diets with an Ecological Approach for Lifestyle (IDEAL-REACH) intervention to increase access to healthy food or beverage options for the Asian-American population in the Philadelphia metropolitan area. Participants (1110 at pre- and 1098 at post-assessment) were recruited from 31 community-based organizations (CBOs). We assessed Asian Americans’ dietary behaviors, nutrition knowledge, and awareness of heart health. Results The results of pre-post intervention comparisons showed that the IDEAL-REACH intervention was successful in promoting whole grains consumption, reducing sodium consumption, and raising knowledge and awareness related to nutrition and heart health. Conclusions To our knowledge, this is one of the first initiatives in the U.S. to engage CBOs to promote healthier dietary behaviors. The findings show that CBOs serve as a powerful platform for community-level interventions to improve healthy nutrition behaviors in Asian-American communities.

      4. Foods and beverages obtained at worksites in the United Statesexternal icon
        Onufrak SJ, Zaganjor H, Pan L, Lee-Kwan SH, Park S, Harris DM.
        J Acad Nutr Diet. 2019 Jun;119(6):999-1008.
        BACKGROUND: Nutrition interventions are a common component of worksite wellness programs and have been recognized as an effective strategy to change employee dietary behaviors. However, little is known about worksite food behaviors or the foods that are obtained at workplaces at the national level. OBJECTIVE: The aims were to examine the frequency of and the amount of money spent obtaining foods at work among employed US adults, to determine the foods most commonly obtained at work, and to assess the dietary quality of these foods. DESIGN: This is a cross-sectional analysis of data from the US Department of Agriculture Food Acquisition and Purchasing Survey, a nationally representative household survey conducted from April 2012 through January 2013 on food purchases and acquisitions during a 7-day study period. PARTICIPANTS: The study included 5,222 employed adult Americans. MAIN OUTCOME MEASURES: The study assessed the prevalence of obtaining any foods at work overall and according to sociodemographic subgroups, number of acquisitions and calories obtained, most commonly obtained foods and leading food sources of calories, and 2010 Healthy Eating Index (HEI) scores that represent dietary quality. STATISTICAL ANALYSES PERFORMED: Prevalence estimates of obtaining >/=1 foods at work were compared according to sociodemographic characteristic using chi(2) tests. RESULTS: Nearly a quarter (23.4%) of working adults obtained foods at work during the week, and the foods they obtained averaged 1,292 kcal per person per week. The leading food types obtained included foods typically high in solid fat, added sugars, or sodium, such as pizza, regular soft drinks, cookies or brownies, cakes and pies, and candy. HEI scores suggest that work foods are high in empty calories, sodium, and refined grains and low in whole grains and fruit. CONCLUSIONS: Working adults commonly obtain foods at work, and the foods they obtain have limited dietary quality. Future research should examine the role worksites can play to help ensure access to and promote healthier options.

    • Occupational Safety and Health
      1. Workplace violence prevention for nursesexternal icon
        Hartley D, Ridenour M, Wassell JT.
        Am J Nurs. 2019 Sep;119(9):19-20.
        An online NIOSH course raises awareness of workplace violence and offers preventive strategies.

      2. Influence of obesity on work ability, respiratory symptoms, and lung function in adults with asthmaexternal icon
        Klepaker G, Svendsen MV, Hertel JK, Holla OL, Henneberger PK, Kongerud J, Fell AK.
        Respiration. 2019 Aug 28:1-9.
        BACKGROUND: Asthma is defined by variable respiratory symptoms and lung function, and may influence work ability. Similarly, obesity may contribute to respiratory symptoms, affect lung function, and reduce work ability. Thus, assessment of the influence of obesity on work ability, respiratory symptoms, and lung function in adults with asthma is needed. OBJECTIVES: We hypothesized that patients with obesity and asthma have more respiratory symptoms and reduced work ability and lung function compared with normal-weight patients with asthma. METHODS: We examined 626 participants with physician-diagnosed asthma, aged 18-52 years, recruited from a cross-sectional general population study using a comprehensive questionnaire including work ability score, the asthma control test (ACT), height and weight, and spirometry with reversibility testing. RESULTS: Participants with a body mass index (BMI) >/=30 kg/m2 (i.e., obese) had a higher symptom score (OR 1.78, 95% CI 1.14-2.80), current use of asthma medication (1.60, 1.05-2.46), and incidence of ACT scores </=19 (poor asthma control) (1.81, 1.03-3.18) than participants with BMI </=24.9 kg/m2 (i.e., normal weight). Post-bronchodilator forced vital capacity (FVC) as a percentage of predicted (beta coefficient -4.5) and pre-bronchodilator forced expiratory volume in 1 s as a percentage of predicted (FEV1) (beta coefficient -4.6) were negatively associated with BMI >/=30 kg/m2. We found no statistically significant association of BMI >30 kg/m2 (compared to BMI <24.9 kg/m2) with sick leave (1.21, 0.75-1.70) or reduced work ability (1.23, 0.74-2.04). CONCLUSIONS: There were indications that patients with obesity had a higher symptom burden, poorer asthma control, higher consumption of asthma medication, and reduced lung function, in particular for FVC, compared with normal-weight patients.

    • Parasitic Diseases
      1. BACKGROUND: Malaria remains a very important public health problem in Ethiopia. Currently, only Plasmodium falciparum and Plasmodium vivax are considered in the malaria diagnostic and treatment policies. However, the existence and prevalence of Plasmodium ovale spp. and Plasmodium malariae in Ethiopia have not been extensively investigated. The objective of this study was to use a multiplex IgG antibody detection assay to evaluate evidence for exposure to any of these four human malaria parasites among asymptomatic individuals. METHODS: Dried blood spots (DBS) were collected from 180 healthy study participants during a 2016 onchocerciasis survey in the Jimma Zone, southwest Ethiopia. IgG antibody reactivity was detected using a multiplex bead assay for seven Plasmodium antigens: P. falciparum circumsporozoite protein (CSP), P. falciparum apical membrane antigen-1 (AMA1), P. falciparum liver stage antigen-1 (LSA1), and homologs of the merozoite surface protein-1 (MSP1)-19kD antigens that are specific for P. falciparum, P. vivax, P. ovale spp. and P. malariae. RESULTS: One hundred six participants (59%) were IgG seropositive for at least one of the Plasmodium antigens tested. The most frequent responses were against P. falciparum AMA1 (59, 33%) and P. vivax (55, 28%). However, IgG antibodies against P. ovale spp. and P. malariae were detected in 19 (11%) and 13 (7%) of the participants, respectively, providing serological evidence that P. malariae and P. ovale spp., which are rarely reported, may also be endemic in Jimma. CONCLUSION: The findings highlight the informative value of multiplex serology and the need to confirm whether P. malariae and P. ovale spp. are aetiologies of malaria in Ethiopia, which is critical for proper diagnosis and treatment.

      2. Dosing pole recommendations for lymphatic filariasis elimination: A height-weight quantile regression modeling approachexternal icon
        Goss CW, O’Brian K, Dubray C, Fischer PU, Hardy M, Jambulingam P, King CL, Laman M, Lemoine JF, Robinson LJ, Samuela J, Subramanian S, Supali T, Weil GJ, Schechtman KB.
        PLoS Negl Trop Dis. 2019 Jul;13(7):e0007541.
        BACKGROUND: The World Health Organization (WHO) currently recommends height or age-based dosing as alternatives to weight-based dosing for mass drug administration lymphatic filariasis (LF) elimination programs. The goals of our study were to compare these alternative dosing strategies to weight-based dosing and to develop and evaluate new height-based dosing pole scenarios. METHODOLOGY/PRINCIPAL FINDINGS: Age, height and weight data were collected from >26,000 individuals in five countries during a cluster randomized LF clinical trial. Weight-based dosing for diethylcarbamazine (DEC; 6 mg/kg) and ivermectin (IVM; 200 ug/kg) with tablet numbers derived from a table of weight intervals was treated as the “gold standard” for this study. Following WHO recommended age-based dosing of DEC and height-based dosing of IVM would have resulted in 32% and 27% of individuals receiving treatment doses below those recommended by weight-based dosing for DEC and IVM, respectively. Underdosing would have been especially common in adult males, who tend to have the highest LF prevalence in many endemic areas. We used a 3-step modeling approach to develop and evaluate new dosing pole cutoffs. First, we analyzed the clinical trial data using quantile regression to predict weight from height. We then used weight predictions to develop new dosing pole cutoff values. Finally, we compared different dosing pole cutoffs and age and height-based WHO dosing recommendations to weight-based dosing. We considered hundreds of scenarios including country- and sex-specific dosing poles. A simple dosing pole with a 6-tablet maximum for both DEC and IVM reduced the underdosing rate by 30% and 21%, respectively, and was nearly as effective as more complex pole combinations for reducing underdosing. CONCLUSIONS/SIGNIFICANCE: Using a novel modeling approach, we developed a simple dosing pole that would markedly reduce underdosing for DEC and IVM in MDA programs compared to current WHO recommended height or age-based dosing.

    • Substance Use and Abuse
      1. From 2013 to 2017, the number of opioid-involved overdose deaths (opioid deaths) in the United States increased 90%, from 25,052 to 47,600.* This increase was primarily driven by substantial increases in deaths involving illicitly manufactured fentanyl (IMF) or fentanyl analogs(dagger) mixed with heroin, sold as heroin, or pressed into counterfeit prescription pills (1-3). Methamphetamine-involved and cocaine-involved deaths that co-involved opioids also substantially increased from 2016 to 2017 (4). Provisional 2018( section sign) estimates of the number of opioid deaths suggest a small decrease from 2017. Investigating the extent to which decreases occurred broadly or were limited to a subset of opioid types (e.g., prescription opioids versus IMF) and drug combinations (e.g., IMF co-involving cocaine) can assist in targeting of intervention efforts. This report describes opioid deaths during January-June 2018 and changes from July-December 2017 in 25( paragraph sign) of 32 states and the District of Columbia participating in CDC’s State Unintentional Drug Overdose Reporting System (SUDORS).** Opioid deaths were analyzed by involvement (opioid determined by medical examiner or coroner to contribute to overdose death) of prescription or illicit opioids,(daggerdagger) as well as by the presence (detection of the drug in decedent) of co-occurring nonopioid drugs (cocaine, methamphetamine, and benzodiazepines). Three key findings emerged regarding changes in opioid deaths from July-December 2017 to January-June 2018. First, overall opioid deaths decreased 4.6%. Second, decreases occurred in prescription opioid deaths without co-involved illicit opioids and deaths involving non-IMF illicit synthetic opioids (fentanyl analogs and U-series drugs) (5). Third, IMF deaths, especially those with multiple illicit opioids and common nonopioids, increased. Consequently, IMF was involved in approximately two-thirds of opioid deaths during January-June 2018. Notably, during January-June 2018, 62.6% of all opioid deaths co-occurred with at least one common nonopioid drug. To maintain and accelerate reductions in opioid deaths, efforts to prevent IMF-involved deaths and address polysubstance misuse with opioids must be enhanced. Key interventions include broadening outreach to groups at high risk for IMF or fentanyl analog exposure and overdose. Improving linkage to and engagement in risk-reduction services and evidence-based treatment for persons with opioid and other substance use disorders with attention to polysubstance use or misuse is also needed.

    • Zoonotic and Vectorborne Diseases
      1. Swine-origin (variant) H1 influenza A viruses associated with numerous human infections in North America in recent years have been extensively studied in vitro and in mammalian models to determine their pandemic potential. However, limited information is available on Eurasian avian-like lineage variant H1 influenza viruses. In 2015, A/Hunan/42443/2015 virus was isolated from a child in China with a severe infection. Molecular analysis revealed that this virus possessed several key virulence and human adaptation markers. Similar to what was previously observed in C57BL/6J mice, we report here that in the BALB/c mouse model, A/Hunan/42443/2015 virus caused more severe morbidity and higher mortality than did North American variant H1 virus isolates. Furthermore, the virus efficiently replicated throughout the respiratory tract of ferrets and exhibited a capacity for transmission in this model, underscoring the need to monitor zoonotic viruses that cross the species barrier as they continue to pose a pandemic threat.

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CDC Science Clips Production Staff

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Page last reviewed: September 3, 2019, 12:00 AM