Volume 11, Issue 37 September 18, 2019

CDC Science Clips: Volume 11, Issue 37, September 18, 2019

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

  1. CDC Public Health Grand Rounds
    • Maternal Immunization: Current Status and Future Directions
      1. 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.

      2. Prevention of pertussis, tetanus, and diphtheria with vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP)external icon
        Liang JL, Tiwari T, Moro P, Messonnier NE, Reingold A, Sawyer M, Clark TA.
        MMWR Recomm Rep. 2018 Apr 27;67(2):1-44.
        This report compiles and summarizes all recommendations from CDC’s Advisory Committee on Immunization Practices (ACIP) regarding prevention and control of tetanus, diphtheria, and pertussis in the United States. As a comprehensive summary of previously published recommendations, this report does not contain any new recommendations and replaces all previously published reports and policy notes; it is intended for use by clinicians and public health providers as a resource. ACIP recommends routine vaccination for tetanus, diphtheria, and pertussis. Infants and young children are recommended to receive a 5-dose series of diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccines, with one adolescent booster dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine. Adults who have never received Tdap also are recommended to receive a booster dose of Tdap. Women are recommended to receive a dose of Tdap during each pregnancy, which should be administered from 27 through 36 weeks’ gestation, regardless of previous receipt of Tdap. After receipt of Tdap, adolescents and adults are recommended to receive a booster tetanus and diphtheria toxoids (Td) vaccine every 10 years to assure ongoing protection against tetanus and diphtheria.

      3. Despite strong evidence that maternal influenza vaccination during pregnancy is safe, uptake of influenza vaccination during pregnancy remains low. We identified studies that assessed outcomes of stillbirth or spontaneous abortion after administration of influenza vaccine during pregnancy. We conducted a literature search in November 2013 that yielded 447 total citations. After removal of duplicates and studies deemed not relevant based on the title and abstract, 36 records underwent a full text review and 7 studies were included in the final review. Where possible, adjusted results were included in the meta-analysis. Women in the influenza vaccine group had a lower likelihood of stillbirth (relative risk [RR], 0.73; 95% confidence interval [CI], .55-.96); this association was similar when restricted to the H1N1pdm09 vaccine (RR, 0.69; 95% CI, .53-.90). The pooled estimate for spontaneous abortion was not significant (RR, 0.91; 95% CI, .68-1.22). These analyses add to the evidence base for the safety of influenza vaccination in pregnancy.

      4. Ethics of maternal vaccinationexternal icon
        Chamberlain AT, Lavery JV, White A, Omer SB.
        Science. 2017 Oct 27;358(6362):452-453.

        [No abstract]

      5. Influenza and Tdap vaccination coverage among pregnant women – United States, April 2018external icon
        Kahn KE, Black CL, Ding H, Williams WW, Lu PJ, Fiebelkorn AP, Havers F, D’Angelo DV, Ball S, Fink RV, Devlin R.
        MMWR Morb Mortal Wkly Rep. 2018 Sep 28;67(38):1055-1059.
        Vaccinating pregnant women with influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines can reduce the risk for influenza and pertussis for themselves and their infants. The Advisory Committee on Immunization Practices (ACIP) recommends that all women who are or might be pregnant during the influenza season receive influenza vaccine, which can be administered any time during pregnancy (1). The ACIP also recommends that women receive Tdap during each pregnancy, preferably from 27 through 36 weeks’ gestation (2). To assess influenza and Tdap vaccination coverage among women pregnant during the 2017-18 influenza season, CDC analyzed data from an Internet panel survey conducted during March 28-April 10, 2018. Among 1,771 survey respondents pregnant during the peak influenza vaccination period (October 2017-January 2018), 49.1% reported receiving influenza vaccine before or during their pregnancy. Among 700 respondents who had a live birth, 54.4% reported receiving Tdap during their pregnancy. Women who reported receiving a provider offer of vaccination had higher vaccination coverage than did women who received a recommendation but no offer and women who did not receive a recommendation. Reasons for nonvaccination included concern about effectiveness of the influenza vaccine and lack of knowledge regarding the need for Tdap vaccination during every pregnancy. Provider offers or referrals for vaccination in combination with patient education could reduce missed opportunities for vaccination and increase vaccination coverage among pregnant women.

      6. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000external icon
        Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, Rudan I, Campbell H, Cibulskis R, Li M, Mathers C, Black RE.
        Lancet. 2012 Jun 9;379(9832):2151-61.
        BACKGROUND: Information about the distribution of causes of and time trends for child mortality should be periodically updated. We report the latest estimates of causes of child mortality in 2010 with time trends since 2000. METHODS: Updated total numbers of deaths in children aged 0-27 days and 1-59 months were applied to the corresponding country-specific distribution of deaths by cause. We did the following to derive the number of deaths in children aged 1-59 months: we used vital registration data for countries with an adequate vital registration system; we applied a multinomial logistic regression model to vital registration data for low-mortality countries without adequate vital registration; we used a similar multinomial logistic regression with verbal autopsy data for high-mortality countries; for India and China, we developed national models. We aggregated country results to generate regional and global estimates. FINDINGS: Of 7.6 million deaths in children younger than 5 years in 2010, 64.0% (4.879 million) were attributable to infectious causes and 40.3% (3.072 million) occurred in neonates. Preterm birth complications (14.1%; 1.078 million, uncertainty range [UR] 0.916-1.325), intrapartum-related complications (9.4%; 0.717 million, 0.610-0.876), and sepsis or meningitis (5.2%; 0.393 million, 0.252-0.552) were the leading causes of neonatal death. In older children, pneumonia (14.1%; 1.071 million, 0.977-1.176), diarrhoea (9.9%; 0.751 million, 0.538-1.031), and malaria (7.4%; 0.564 million, 0.432-0.709) claimed the most lives. Despite tremendous efforts to identify relevant data, the causes of only 2.7% (0.205 million) of deaths in children younger than 5 years were medically certified in 2010. Between 2000 and 2010, the global burden of deaths in children younger than 5 years decreased by 2 million, of which pneumonia, measles, and diarrhoea contributed the most to the overall reduction (0.451 million [0.339-0.547], 0.363 million [0.283-0.419], and 0.359 million [0.215-0.476], respectively). However, only tetanus, measles, AIDS, and malaria (in Africa) decreased at an annual rate sufficient to attain the Millennium Development Goal 4. INTERPRETATION: Child survival strategies should direct resources toward the leading causes of child mortality, with attention focusing on infectious and neonatal causes. More rapid decreases from 2010-15 will need accelerated reduction for the most common causes of death, notably pneumonia and preterm birth complications. Continued efforts to gather high-quality data and enhance estimation methods are essential for the improvement of future estimates. FUNDING: The Bill & Melinda Gates Foundation.

      7. BACKGROUND: Pregnancy is considered to be an important risk factor for severe complications following influenza virus infection. As a consequence, WHO recommendations prioritize pregnant women over other risk groups for influenza vaccination. However, the risk associated with pregnancy has not been systematically quantified. PURPOSE: Systematic review and meta-analysis of observational studies that reported on pregnancy as a risk factor for severe outcomes from influenza virus infection. DATA SOURCE: MEDLINE, EMBASE, CINAHL, and CENTRAL up to April 2014. DATA SELECTION: Studies reporting on outcomes in pregnant women with influenza in comparison to non-pregnant patients with influenza. Outcomes included community-acquired pneumonia, hospitalization, admission to intensive care units (ICU), ventilatory support, and death. DATA EXTRACTION: Two reviewers conducted independent screening and data extraction. A random effects model was used to obtain risk estimates. Ecological studies were summarized descriptively. DATA SYNTHESIS: A total of 142 non-ecological and 10 ecological studies were included. The majority of studies (n=136, 95.8%) were conducted during the 2009 influenza A (pH1N1) pandemic. There was a higher risk for hospitalization in pregnant versus non-pregnant patients infected with influenza (odds ratio [OR] 2.44, 95% CI 1.22-4.87), but no significant difference in mortality (OR 1.04, 95% CI 0.81-1.33) or other outcomes. Ecologic studies confirmed the association between hospitalization risk and pregnancy and 4 of 7 studies reported higher mortality rates in pregnant women. LIMITATIONS: No studies were identified in which follow-up began prior to contact with the healthcare system and lack of adjustment for confounding factors. CONCLUSIONS: We found that influenza during pregnancy resulted in a higher risk of hospital admission than influenza infection in non-pregnant individuals, but that the risk of mortality following influenza was similar in both pregnant and non-pregnant individuals.

      8. Obstetrician-gynecologists’ strategies to address vaccine refusal among pregnant womenexternal icon
        O’Leary ST, Riley LE, Lindley MC, Allison MA, Albert AP, Fisher A, Jiles AJ, Crane LA, Hurley LP, Beaty B, Brtnikova M, Kempe A.
        Obstet Gynecol. 2019 Jan;133(1):40-47.
        OBJECTIVE: To describe 1) obstetrician-gynecologists’ (ob-gyns’) perceptions of the frequency of vaccine refusal among pregnant patients and perceived reasons for refusal and 2) ob-gyns’ strategies used when encountering vaccine refusal and perceived effectiveness of those strategies. METHODS: We conducted an email and mail survey among a nationally representative network of ob-gyns from March 2016 to June 2016. RESULTS: The response rate was 69% (331/477). Health care providers perceived that pregnant women more commonly refused influenza vaccine than tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine: 62% of respondents reported 10% or greater of pregnant women they care for in a typical month refused influenza vaccine compared with 32% reporting this for Tdap vaccine. The most commonly reported reasons for vaccine refusal were patients’ belief that influenza vaccine makes them sick (48%), belief they are unlikely to get a vaccine-preventable disease (38%), general worries about vaccines (32%), desire to maintain a natural pregnancy (31%), and concern that their child could develop autism as a result of maternal vaccination (25%). The most commonly reported strategies ob-gyns used to address refusal were stating that it is safe to receive vaccines in pregnancy (96%), explaining that not getting the vaccine puts the fetus or newborn at risk (90%), or that not getting the vaccine puts the pregnant woman’s health at risk (84%). The strategy perceived as most effective was stating that not getting vaccinated puts the fetus or newborn at risk. CONCLUSION: Ob-gyns perceive vaccine refusal among pregnant women as common and refusal of influenza vaccine as more common than refusal of Tdap vaccine. Emphasizing the risk of disease to the fetus or newborn may be an effective strategy to increase vaccine uptake.

      9. The underrecognized burden of influenza in young childrenexternal icon
        Poehling KA, Edwards KM, Weinberg GA, Szilagyi P, Staat MA, Iwane MK, Bridges CB, Grijalva CG, Zhu Y, Bernstein DI, Herrera G, Erdman D, Hall CB, Seither R, Griffin MR.
        N Engl J Med. 2006 Jul 6;355(1):31-40.
        BACKGROUND: The disease burden of influenza infection among children is not well established. We conducted a population-based surveillance of medical visits associated with laboratory-confirmed influenza. METHODS: Eligible children were younger than five years of age, resided in three U.S. counties, and had a medical visit for an acute respiratory tract infection or fever. Nasal and throat swabs were tested for the influenza virus by viral culture and polymerase-chain-reaction assay. Epidemiologic data were collected from parental surveys and chart reviews. Children who were hospitalized were enrolled prospectively from 2000 through 2004. Population-based rates of hospitalizations associated with influenza were calculated. Children who were seen in selected pediatric clinics and emergency departments during two influenza seasons (2002-2003 and 2003-2004) were systematically enrolled. The rates of visits to clinics and emergency departments associated with influenza were estimated. RESULTS: The average annual rate of hospitalization associated with influenza was 0.9 per 1000 children. The estimated burden of outpatient visits associated with influenza was 50 clinic visits and 6 emergency department visits per 1000 children during the 2002-2003 season and 95 clinic visits and 27 emergency department visits per 1000 children during the 2003-2004 season. Few children who had laboratory-confirmed influenza were given a diagnosis of influenza by the treating physician in the inpatient (28 percent) or outpatient (17 percent) settings. CONCLUSIONS: Among young children, outpatient visits associated with influenza were 10 to 250 times as common as hospitalizations. Few influenza infections were recognized clinically.

      10. Impact of the US maternal tetanus, diphtheria, and acellular pertussis vaccination program on preventing pertussis in infants <2 months of age: A case-control evaluationexternal icon
        Skoff TH, Blain AE, Watt J, Scherzinger K, McMahon M, Zansky SM, Kudish K, Cieslak PR, Lewis M, Shang N, Martin SW.
        Clin Infect Dis. 2017 Nov 29;65(12):1977-1983.
        Background: Infants aged <1 year are at highest risk for pertussis-related morbidity and mortality. In 2012, Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccine was recommended for women during each pregnancy to protect infants in the first months of life; data on effectiveness of this strategy are currently limited. Methods: We conducted a case-control evaluation among pertussis cases <2 months old with cough onset between 1 January 2011 and 31 December 2014 from 6 US Emerging Infection Program Network states. Controls were hospital-matched and selected by birth certificate. Mothers were interviewed to collect information on demographics, household characteristics, and healthcare providers. Provider-verified immunization history was obtained on mothers and infants. Mothers were considered vaccinated during pregnancy if Tdap was received >/=14 days before delivery; trimester was calculated using Tdap date, infant’s date of birth, and gestational age. Odds ratios were calculated using multivariable conditional logistic regression; vaccine effectiveness (VE) was estimated as (1 – odds ratio) x 100%. Results: A total of 240 cases and 535 controls were included; 17 (7.1%) case mothers and 90 (16.8%) control mothers received Tdap during the third trimester of pregnancy. The multivariable VE estimate for Tdap administered during the third trimester of pregnancy was 77.7% (95% confidence interval [CI], 48.3%-90.4%); VE increased to 90.5% (95% CI, 65.2%-97.4%) against hospitalized cases. Conclusions: Vaccination during pregnancy is an effective way to protect infants during the early months of life. With a continuing resurgence in pertussis, efforts should focus on maximizing Tdap uptake among pregnant women.

      11. The epidemiology of nationally reported pertussis in the United States, 2000-2016external icon
        Skoff TH, Hadler S, Hariri S.
        Clin Infect Dis. 2019 May 2;68(10):1634-1640.
        BACKGROUND: Despite successful vaccination programs, pertussis remains endemic in the United States, and increasing incidence has been reported. We used national surveillance data to describe pertussis epidemiology, including patient demographic characteristics, geographic distribution, and temporal trends. METHODS: We included cases reported through the National Notifiable Diseases Surveillance System between 1 January 2000 and 31 December 2016. Differences in case characteristics were compared using Pearson chi2. Average annual incidence (cases per 100 000 population) was calculated overall and by age (<1 year, 1-6 years, 7-10 years, 11-18 years, 19-39 years, 30-64 years, and >/=65 years) and geographic subgroup. Annual percent change was estimated using negative bionomial regression. RESULTS: During 2000-2016, 339 420 pertussis cases were reported. The majority were in white (88.2%) and non-Hispanic (81.3%) persons, 9.9% were hospitalized, and 0.1% were fatal; however, differences existed by age. Infants had the highest incidence (75.3/100 000 population), accounting for 88.8% of deaths. Incidence increased significantly over time (P = .0019), increases were observed for all groups except persons aged <1 year and 19-64 years. Elevated case counts among persons aged 7-10 and 11-18 years coincided with the aging of acellular-primed cohorts. Incidence varied by geographic region, with some similarities in disease cyclicity. CONCLUSIONS: Increasing baseline incidence and changing age distribution of pertussis suggest a central role of the transition to acellular vaccines in the US disease resurgence. Continued monitoring of national data is important to evaluate and optimize pertussis prevention and control strategies.

      12. Infant hospitalizations and mortality after maternal vaccinationexternal icon
        Sukumaran L, McCarthy NL, Kharbanda EO, Vazquez-Benitez G, Lipkind HS, Jackson L, Klein NP, Naleway AL, McClure DL, Hechter RC, Kawai AT, Glanz JM, Weintraub ES.
        Pediatrics. 2018 Mar;141(3).
        BACKGROUND: The Advisory Committee on Immunization Practices currently recommends pregnant women receive influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines. There are limited studies of the long-term safety in infants for vaccines administered during pregnancy. We evaluate whether maternal receipt of influenza and Tdap vaccines increases the risk of infant hospitalization or death in the first 6 months of life. METHODS: We included singleton, live birth pregnancies in the Vaccine Safety Datalink between 2004 and 2014. Outcomes were infant hospitalizations and mortality in the first 6 months of life. We performed a case-control study matching case patients and controls 1:1 and used conditional logistic regression to estimate odds ratios for maternal exposure to influenza and/or Tdap vaccines in pregnancy. RESULTS: There were 413 034 live births in our population. Of these, 25 222 infants had hospitalizations and 157 infants died in the first 6 months of life. We found no association between infant hospitalization and maternal influenza (adjusted odds ratio: 1.00; 95% confidence interval [CI]: 0.96-1.04) or Tdap (adjusted odds ratio: 0.94; 95% CI: 0.88-1.01) vaccinations. We found no association between infant mortality and maternal influenza (adjusted odds ratio: 0.96; 95% CI: 0.54-1.69) or Tdap (adjusted odds ratio: 0.44; 95% CI: 0.17-1.13) vaccinations. CONCLUSIONS: We found no association between vaccination during pregnancy and risk of infant hospitalization or death in the first 6 months of life. These findings support the safety of current recommendations for influenza and Tdap vaccination during pregnancy.

      13. Influenza vaccine effectiveness in preventing influenza-associated hospitalizations during pregnancy: A multi-country retrospective test negative design study, 2010-2016external icon
        Thompson MG, Kwong JC, Regan AK, Katz MA, Drews SJ, Azziz-Baumgartner E, Klein NP, Chung H, Effler PV, Feldman BS, Simmonds K, Wyant BE, Dawood FS, Jackson ML, Fell DB, Levy A, Barda N, Svenson LW, Fink RV, Ball SW, Naleway A.
        Clin Infect Dis. 2019 Apr 24;68(9):1444-1453.
        BACKGROUND: To date, no study has examined influenza vaccine effectiveness (IVE) against laboratory-confirmed influenza-associated hospitalizations during pregnancy. METHODS: The Pregnancy Influenza Vaccine Effectiveness Network (PREVENT) consisted of public health or healthcare systems with integrated laboratory, medical, and vaccination records in Australia, Canada (Alberta and Ontario), Israel, and the United States (California, Oregon, and Washington). Sites identified pregnant women aged 18 through 50 years whose pregnancies overlapped with local influenza seasons from 2010 through 2016. Administrative data were used to identify hospitalizations with acute respiratory or febrile illness (ARFI) and clinician-ordered real-time reverse transcription polymerase chain reaction (rRT-PCR) testing for influenza viruses. Overall IVE was estimated using the test-negative design and adjusting for site, season, season timing, and high-risk medical conditions. RESULTS: Among 19450 hospitalizations with an ARFI discharge diagnosis (across 25 site-specific study seasons), only 1030 (6%) of the pregnant women were tested for influenza viruses by rRT-PCR. Approximately half of these women had pneumonia or influenza discharge diagnoses (54%). Influenza A or B virus infections were detected in 598/1030 (58%) of the ARFI hospitalizations with influenza testing. Across sites and seasons, 13% of rRT-PCR-confirmed influenza-positive pregnant women were vaccinated compared with 22% of influenza-negative pregnant women; the adjusted overall IVE was 40% (95% confidence interval = 12%-59%) against influenza-associated hospitalization during pregnancy. CONCLUSION: Between 2010 and 2016, influenza vaccines offered moderate protection against laboratory-confirmed influenza-associated hospitalizations during pregnancy, which may further inform the benefits of maternal influenza vaccination programs.

  2. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Chronic Diseases and Conditions
      1. The relation between dialysis-requiring acute kidney injury and recovery from end-stage renal disease: a national studyexternal icon
        Chen Z, Lee BJ, McCulloch CE, Burrows NR, Heung M, Hsu RK, Pavkov ME, Powe NR, Saran R, Shahinian V, Hsu CY.
        BMC Nephrol. 2019 Sep 2;20(1):342.
        BACKGROUND: Approximately 4-6% of incident end stage renal disease (ESRD) patients in the U.S. recover enough kidney function to discontinue dialysis but there is considerable geographic variation. We undertook this study to investigate whether state-level variations in renal recovery among incident ESRD patients correlated with state-level variations in incidence of acute kidney injury requiring dialysis (AKI-D). METHODS: We conducted a national cross-sectional ecological study at the state-level using data from State Inpatient Databases and U.S. Renal Data System. All hospital admissions and all ESRD patients in 18 US states (AZ, AR, CA, FL, IA, KY, MA, MD, MI, NJ, NM, NY, NV, OR, RI, SC, VT, and WA) were included. Correlation between AKI-D incidence and rate of renal recovery across states was determined using Pearson’s r (overall and in subgroups). We also calculated partial correlations adjusted for sex and age. RESULTS: AKI-D incidence ranged from 99.0 per million population (pmp) in Vermont to 490.4 pmp in Nevada. Rate of renal recovery among incident ESRD patients ranged from 8.8 pmp in Massachusetts to 29.3 pmp in Florida. A positive correlation between AKI-D incidence and rate of renal recovery among incident ESRD patients at state level was found overall (unadjusted r = 0.67; p = 0.002) and in age, sex, and race subgroups. The overall correlation persisted after adjusting for age (adjusted r = 0.62; p < 0.001) and sex (adjusted r = 0.65; p < 0.001). CONCLUSION: Our findings suggest that AKI-D incidence is an important driver of renal recovery rates among incident ESRD patients.

      2. Calibrating local population-based blood pressure data from NYC HANES 2013-2014external icon
        Kanchi R, Perlman S, Ostchega Y, Chamany S, Shimbo D, Chernov C, Thorpe LE.
        J Urban Health. 2019 Sep 4.
        New York City Health and Nutrition Examination Survey (NYC HANES) was a population-based cross-sectional survey of NYC adults conducted twice, in 2004 and again in 2013-2014, to monitor the health of NYC adults 20 years or older. While blood pressure was measured in both surveys, an auscultatory mercury sphygmomanometer was used to measure blood pressure in clinics in 2004, and an oscillometric LifeSource UA-789AC monitor was used in homes in 2013-2014. To assess comparability of blood pressure results across both surveys, we undertook a randomized study comparing blood pressure (BP) readings by the two devices. Blood pressure measuring protocols followed the 2013 Association for the Advancement in Medical instrumentation guidelines for non-invasive blood pressure device. Data from 167 volunteers were analyzed for this purpose.Paired t tests were used to test for significant difference in mean systolic and diastolic blood pressure between devices for overall and by mid-arm circumference categories. To test for systematic differences between the two devices, we generated Bland-Altman graphs. Sensitivity, specificity, and Kappa statistics were calculated to assess between-device agreement for high (>/= 130/80 mmHg) and not high (< 130/80 mmHg) blood pressure, with mercury set as the reference.Systolic and diastolic blood pressure measured by LifeSource UA-789AC were on average 2.0 and 1.1 mmHg higher, respectively, than those of the mercury sphygmomanometer systolic and diastolic blood pressure readings (P < 0.05). Sensitivity was 81%, specificity was 96%, and the Kappa coefficient was 75%. The Bland-Altman graphs showed that the between-device difference did not vary as a function of the average of the two devices for systolic blood pressure and was larger in the lower and upper ends for diastolic blood pressure. Given the observed differences in systolic and diastolic blood pressure readings between the two blood pressure measurement approaches, we calibrated NYC HANES 2013-2014 blood pressure data by predicting mercury blood pressure values from LifeSource blood pressure values. The mean systolic and diastolic blood pressure in NYC HANES 2013-2014 were lower when data were calibrated.

      3. Small area estimation of cancer risk factors and screening behaviors in US counties by combining two large national health surveysexternal icon
        Liu B, Parsons V, Feuer EJ, Pan Q, Town M, Raghunathan TE, Schenker N, Xie D.
        Prev Chronic Dis. 2019 Aug 29;16:E119.
        BACKGROUND: National health surveys, such as the National Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance System (BRFSS), collect data on cancer screening and smoking-related measures in the US noninstitutionalized population. These surveys are designed to produce reliable estimates at the national and state levels. However, county-level data are often needed for cancer surveillance and related research. METHODS: To use the large sample sizes of BRFSS and the high response rates and better coverage of NHIS, we applied multilevel models that combined information from both surveys. We also used relevant sources such as census and administrative records. By using these methods, we generated estimates for several cancer risk factors and screening behaviors that are more precise than design-based estimates. RESULTS: We produced reliable, modeled estimates for 11 outcomes related to smoking and to screening for female breast cancer, cervical cancer, and colorectal cancer. The estimates were produced for 3,112 counties in the United States for the data period from 2008 through 2010. CONCLUSION: The modeled estimates corrected for potential noncoverage bias and nonresponse bias in the BRFSS and reduced the variability in NHIS estimates that is attributable to small sample size. The small area estimates produced in this study can serve as a useful resource to the cancer surveillance community.

      4. [No abstract]

      5. The Cancer Prevention and Control Research Network (CPCRN): Advancing public health and implementation scienceexternal icon
        White A, Sabatino SA, Vinson C, Chambers D, White MC.
        Prev Med. 2019 Aug 29:105824.
        The Cancer Prevention and Control Research Network (CPCRN) is one of the thematic networks of the United States’ Centers for Disease Control and Prevention’s (CDC) Prevention Research Centers. Network members are academic research centers in the United States who collaborate with public health and community partners to accelerate the use of evidence-based interventions in communities to reduce the burden of cancer, especially among underserved populations. CPCRN studies include geographically dispersed populations, cross-institution partnerships, and opportunities for collaborative learning across network centers. Since its inception in 2002, CPCRN has worked to translate research on community-based intervention strategies into practice to improve cancer screening and reduce cancer risk. This commentary describes CPCRN’s role in contributing to public health and the field of dissemination and implementation science. In addition, CDC and the National Cancer Institute describe how their joint support of the network contributes to each organization’s goals and missions.

    • Communicable Diseases
      1. Impact of public health interventions on drinking water-associated outbreaks of hepatitis A – United States, 1971-2017external icon
        Barrett CE, Pape BJ, Benedict KM, Foster MA, Roberts VA, Rotert K, Mattioli MC, Yoder JS.
        MMWR Morb Mortal Wkly Rep. 2019 Sep 6;68(35):766-770.
        Hepatitis A virus (HAV) is an RNA virus primarily transmitted via the fecal-oral route and, in rare cases, causes liver failure and death in infected persons. Although drinking water-associated hepatitis A outbreaks in the United States are rarely reported (1), HAV was the most commonly reported etiology for outbreaks associated with untreated ground water during 1971-2008 (2), and HAV can remain infectious in water for months (3). This report analyzes drinking water-associated hepatitis A outbreaks reported to the Waterborne Disease and Outbreak Surveillance System (WBDOSS) during 1971-2017. During that period, 32 outbreaks resulting in 857 cases were reported, all before 2010. Untreated ground water was associated with 23 (72%) outbreaks, resulting in 585 (68.3%) reported cases. Reported outbreaks significantly decreased after introduction of Advisory Committee on Immunization Practices (ACIP) hepatitis A vaccination recommendations* and U.S. Environmental Protection Agency’s (USEPA) public ground water system regulations.(dagger) Individual water systems, which are not required to meet national drinking water standards,( section sign) were the only contaminated drinking water systems to cause the last four reported hepatitis A outbreaks during 1995-2009. No waterborne outbreaks were reported during 2009-2017. Water testing and treatment are important considerations to protect persons who use these unregulated systems from HAV infection.

      2. The relationship between previous antimicrobial use, antimicrobial resistance and treatment outcome among Alaskans treated for Helicobacter pylori infectionexternal icon
        Bruce MG, Bruden D, Newbrough D, Hurlburt DA, Hennessy TW, Morris JM, Reasonover AL, Sacco F, McMahon BJ.
        GastroHep. 2019 ;1(4):172-179.
        Background: Helicobacter pylori isolates from Alaska have demonstrated a high prevalence of antimicrobial resistance. Objective(s): To determine treatment failure in three groups, and analyse the relationship between treatment failure and antimicrobial resistance. Method(s): Antimicrobial susceptibility was determined using agar dilution and Etest. Treatment success was determined using the urea breath test 2 months after antimicrobial therapy. Result(s): Among 303 treated adult patients, 103 (34%) failed initial treatment despite a 91% compliance with medication. About 222 (73%) patients were treated with a clarithromycin-based regimen, 55 (18%) with a metronidazole-based regimen, 15 (5%) with a regimen that contained clarithromycin and metronidazole and 11 (4%) with other antimicrobials. Among 260 culture-positive patients, 156 (60%) were infected with metronidazole-resistant isolates, 74 (28%) clarithromycin-resistant, 52 (20%) clarithromycin/metronidazole-resistant, 40 (15%) levofloxacin-resistant, 11 (4%) clarithromycin/metronidazole/levofloxacin-resistant and nine (3%) amoxicillin-resistant. Overall, 34% of patients were treated with at least one antibiotic to which their infecting organism was resistant. Among patients treated with clarithromycin-based regimens, treatment failed in 72% of patients carrying clarithromycin-resistant H pylori vs 20% with clarithromycin-sensitive strains (RR = 3.7, P < 0.001). Among patients treated with metronidazole-based regimens, treatment failed in 19% of patients carrying metronidazole-resistant H pylori vs 24% with metronidazole-sensitive strains (P = 0.72). Conclusion(s): A high proportion of H pylori isolates demonstrate resistance to clarithromycin, metronidazole or levofloxacin. Over one third of H pylori-infected patients were treated with an antibiotic to which their infecting organism demonstrated resistance. Clarithromycin resistance is associated with a greater risk for failure with clarithromycin-based multidrug regimens compared to clarithromycin-sensitive; resistance to metronidazole did not affect treatment failure.

      3. An internet-based HIV self-testing program to increase HIV testing uptake among men who have sex with men in Brazil: Descriptive cross-sectional analysisexternal icon
        De Boni RB, Veloso VG, Fernandes NM, Lessa F, Correa RG, Lima RS, Cruz M, Oliveira J, Nogueira SM, de Jesus B, Reis T, Lentini N, Miranda RL, Bingham T, Johnson CC, Barbosa Junior A, Grinsztejn B.
        J Med Internet Res. 2019 Aug 1;21(8):e14145.
        BACKGROUND: Approximately 30% of people living with HIV worldwide are estimated to be unaware of their infection. HIV self-testing (HIVST) is a strategy recommended by the World Health Organization to increase access to and uptake of testing among key populations who are at high risk for HIV infection. OBJECTIVE: This study aimed to describe the development and feasibility of a free, anonymous, internet-based HIVST strategy designed for men who have sex with men in Curitiba, Brazil (electronic testing [e-testing]). METHODS: The project was developed under the scope of the “A Hora e Agora” (The Time is Now) program. Individuals aiming to request an HIVST package (two tests each) answered an anonymous 5-minute questionnaire regarding inclusion criteria and sexual risk behavior. Eligible individuals could receive one package every 6 months for free. Website analytics, response to online questionnaires, package distribution, and return of test results were monitored via a platform-integrated system. RESULTS: Between February 2015 and January 2016, the website documented 17,786 unique visitors and 3218 completed online questionnaires. Most individuals self-reported being white (77.0%), young (median age: 25 years, interquartile range: 22-31 years), educated (87.3% completed secondary education or more), and previously tested for HIV (62.5%). Overall, 2526 HIVST packages were delivered; of those, 542 (21.4%) reported a result online or by mail (23 reactive and 11 invalid). During the study period, 37 individuals who reported using e-testing visited the prespecified health facility for confirmatory testing (30 positive, 7 negative). CONCLUSIONS: E-testing proved highly feasible and acceptable in this study, thus supporting scale-up to additional centers for men who have sex with men in Brazil.

      4. Prenatal HIV testing and the impact of state HIV testing laws, 2004 to 2011external icon
        FitzHarris LF, Johnson CH, Nesheim SR, Oussayef NL, Taylor AW, Harrison AT, Ruffo N, Burley K, House L, Koumans EH.
        Sex Transm Dis. 2018 Sep;45(9):583-587.
        OBJECTIVE: This study aimed to analyze prenatal human immunodeficiency virus (HIV) testing rates over time and describe the impact of state HIV testing laws on prenatal testing. METHODS: During 2004-2011, self-reported prenatal HIV testing data for women with live births in 35 states and New York City were collected. Prevalence of testing was estimated overall and by state and year. An annual percent change was calculated in states with at least 6 years of data to analyze testing changes over time. An attorney-coder used WestlawNext to identify states with laws that direct prenatal care providers to screen all pregnant women or direct all women to be tested for HIV and document changes in laws to meet this threshold. RESULTS: The overall prenatal HIV testing rate for 2004 through 2011 combined was 75.7%. State-level data showed a wide range of testing rates (43.2%-92.8%) for 2004 through 2011 combined. In areas with 6 years of data, 4 experienced an annual drop in testing (Alaska, Arkansas, Colorado, and Illinois). States that changed laws to meet the threshold generally had the highest testing rates, averaging 80%, followed by states with a preexisting law, at approximately 70%. States with no law, or no law meeting the threshold, had an average prenatal testing rate of 65%. CONCLUSIONS: Prenatal HIV testing remained stable between 2004 and 2011 but remained below universal recommendations. Testing varied widely across states and was generally higher in areas that changed their laws to meet the threshold or had preexisting prenatal HIV testing laws, compared with those with no or limited prenatal HIV testing language.

      5. Burkholderia pseudomallei, the causative agent of melioidosis, is rare but ecologically established and widely dispersed in the environment in Puerto Ricoexternal icon
        Hall CM, Jaramillo S, Jimenez R, Stone NE, Centner H, Busch JD, Bratsch N, Roe CC, Gee JE, Hoffmaster AR, Rivera-Garcia S, Soltero F, Ryff K, Perez-Padilla J, Keim P, Sahl JW, Wagner DM.
        PLoS Negl Trop Dis. 2019 Sep 5;13(9):e0007727.
        BACKGROUND: Burkholderia pseudomallei is a soil-dwelling bacterium and the causative agent of melioidosis. The global burden and distribution of melioidosis is poorly understood, including in the Caribbean. B. pseudomallei was previously isolated from humans and soil in eastern Puerto Rico but the abundance and distribution of B. pseudomallei in Puerto Rico as a whole has not been thoroughly investigated. METHODOLOGY/PRINCIPAL FINDINGS: We collected 600 environmental samples (500 soil and 100 water) from 60 sites around Puerto Rico. We identified B. pseudomallei by isolating it via culturing and/or using PCR to detect its DNA within complex DNA extracts. Only three adjacent soil samples from one site were positive for B. pseudomallei with PCR; we obtained 55 isolates from two of these samples. The 55 B. pseudomallei isolates exhibited fine-scale variation in the core genome and contained four novel genomic islands. Phylogenetic analyses grouped Puerto Rico B. pseudomallei isolates into a monophyletic clade containing other Caribbean isolates, which was nested inside a larger clade containing all isolates from Central/South America. Other Burkholderia species were commonly observed in Puerto Rico; we cultured 129 isolates from multiple soil and water samples collected at numerous sites around Puerto Rico, including representatives of B. anthina, B. cenocepacia, B. cepacia, B. contaminans, B. glumae, B. seminalis, B. stagnalis, B. ubonensis, and several unidentified novel Burkholderia spp. CONCLUSIONS/SIGNIFICANCE: B. pseudomallei was only detected in three soil samples collected at one site in north central Puerto Rico with only two of those samples yielding isolates. All previous human and environmental B. pseudomallei isolates were obtained from eastern Puerto Rico. These findings suggest B. pseudomallei is ecologically established and widely dispersed in the environment in Puerto Rico but rare. Phylogeographic patterns suggest the source of B. pseudomallei populations in Puerto Rico and elsewhere in the Caribbean may have been Central or South America.

      6. Tuberculosis Regional Training and Medical Consultation Centers in the United States: Characteristics, outcomes, and quality of medical consultations, June 1, 2010 – May 31, 2014external icon
        Mase SR, Samron R, Ashkin D, Castro KG, Ryan S, Seaworth B, Chen L, Lardizabal A, Tuckey D, Khan A, Posey DL, Chappelle C, Temesgen Z.
        J Clin Tuberc Other Mycobact Dis. 2019 December;17.
        Background: Tuberculosis (TB) Regional Training and Medical Consultation Centers (RTMCCs) were established in 2005 for TB medical consultation, training and education in the United States. A medical consultation database (MCD) captured all consultations provided by RTMCCs; we report on those provided from June 1, 2010 to May 31, 2014. Method(s): All MCD consultations during 2010-2014 were categorized into: provider type, setting, consultation topic, and patient age. We analyzed data frequencies and performed subgroup analyses by RTMCC, by TB incidence for the geographical area, and by year of consultation. End-user satisfaction was assessed by a 2016 telephone evaluation of RTMCC services. Result(s): A total of 11,074 consultations were delivered, with 10,754 (97.1%) in the U.S. and its current or former territories. Of these, 6018 (56%) were for high, 2443 (22.7%) for medium, and 2293 (21.3%) for low TB incidence settings. Most were for adults (81.3%) and answered within 24 h (96.2%). Nearly 2/3 consultations originated from health departments; providers included mostly physicians (44.3%) or nurses (37.6%). Common consult categories included TB disease (47.7%), case management (29.8%), latent TB infection (19.3%), diagnosis (16.1%), pharmacology (14.7%) and adverse side effects (14.3%). Among adverse side effects, hepatotoxicity was most common (39.6%). Volume and nature of consult requests remained relatively stable over the four-year period. Feedback from a 2016 CDC evaluation indicated overall satisfaction with RTMCC medical consultation services. Conclusion(s): RTMCCS were an important source of TB medical consultation over the time-frame of this assessment and provided quality expert consultation within 24 h. RMTCCs represent a reservoir of TB subject-matter expertise in the United States.

      7. Influenza virus seroincidence in a cohort of healthy and high-risk children enrolled in infancy, Bangkok, Thailandexternal icon
        Rungrojcharoenkit K, Kittikraisak W, Ditsungnoen D, Olsen SJ, Suntarattiwong P, Chotpitayasunondh T, Klungthong C, Yoon IK, Dawood FS, Fernandez S, Macareo L, Lindblade KA.
        Int J Infect Dis. 2019 Aug 27.
        BACKGROUND: We measured seroconversion to influenza viruses and incidence of symptomatic influenza virus infection in a cohort of children in Bangkok, Thailand. METHODS: Children aged </=6 months were followed for two years for acute respiratory illness and had serum specimens taken at 6-month intervals and tested by hemagglutination inhibition (HI) assay. Seroconversion was defined as a >4-fold rise in the HI titers between time points with a titer of >40 in the second specimen. Respiratory swabs were tested by rRT-PCR for influenza. Data were analyzed using generalized linear models. RESULTS: Of 350 children, 266 (76%, 147 were healthy and 119 high-risk) had >/=2 serum specimens collected before influenza vaccination. During the 2-year follow-up, 266 children contributed 370 person-years of observation, excluding post-vaccination periods. We identified 32 ARI cases with rRT-PCR-confirmed influenza virus infection (7 infections/100 person-years, 95% confidence interval [CI], 4-11). There were 126 episodes of influenza virus infection, resulting in a seroconversion rate of 35 infections/100 person-years (95% CI, 30-42). Rates in healthy and high-risk children did not differ. CONCLUSIONS: Influenza virus infection is common during the first two years of life among Thai children. A large proportion of infections may not be detected using the ARI case definition.

      8. Water, sanitation, and hygiene characteristics among HIV-positive households participating in the Global Enteric Multicenter Study in Rural Western Kenya, 2008-2012external icon
        Schilling KA, Awuor AO, Rajasingham A, Moke F, Omore R, Amollo M, Farag TH, Nasrin D, Nataro JP, Kotloff KL, Levine MM, Ayers T, Laserson K, Blackstock A, Rothenberg R, Stauber CE, Mintz ED, Breiman RF, O’Reilly CE.
        Am J Trop Med Hyg. 2018 Oct;99(4):905-915.
        Diarrheal illness, a common occurrence among people living with human immunodeficiency virus (PLHIV), is largely preventable through access to safe drinking water quality, sanitation, and hygiene (WASH) facilities. We examined WASH characteristics among households with and without HIV-positive residents enrolled in the Global Enteric Multicenter Study (GEMS) in rural Western Kenya. Using univariable logistic regression, we examined differences between HIV-positive and HIV-negative households in regard to WASH practices. Among HIV-positive households, we explored the relationship between the length of time knowing their HIV status and GEMS enrollment. No statistically significant differences were apparent in the WASH characteristics among HIV-positive and HIV-negative households. However, we found differences in the WASH characteristics among HIV-positive households who were aware of their HIV status >/= 30 days before enrollment compared with HIV-positive households who found out their status < 30 days before enrollment or thereafter. Significantly more households aware of their HIV-positive status before enrollment reported treating their drinking water (odds ratio [OR] confidence interval [CI]: 2.34 [1.12, 4.86]) and using effective water treatment methods (OR [CI]: 9.6 [3.09, 29.86]), and had better drinking water storage practices. This suggests that within this region of Kenya, HIV programs are effective in promoting the importance of practicing positive WASH-related behaviors among PLHIV.

      9. [No abstract]

      10. Community-acquired pneumonia visualized on CT scans but not chest radiographs: Pathogens, severity, and clinical outcomesexternal icon
        Upchurch CP, Grijalva CG, Wunderink RG, Williams DJ, Waterer GW, Anderson EJ, Zhu Y, Hart EM, Carroll F, Bramley AM, Jain S, Edwards KM, Self WH.
        Chest. 2018 Mar;153(3):601-610.
        BACKGROUND: The clinical significance of pneumonia visualized on CT scan in the setting of a normal chest radiograph is uncertain. METHODS: In a multicenter prospective surveillance study of adults hospitalized with community-acquired pneumonia (CAP), we compared the presenting clinical features, pathogens present, and outcomes of patients with pneumonia visualized on a CT scan but not on a concurrent chest radiograph (CT-only pneumonia) and those with pneumonia visualized on a chest radiograph. All patients underwent chest radiography; the decision to obtain CT imaging was determined by the treating clinicians. Chest radiographs and CT images were interpreted by study-dedicated thoracic radiologists blinded to the clinical data. RESULTS: The study population included 2,251 adults with CAP; 2,185 patients (97%) had pneumonia visualized on chest radiography, whereas 66 patients (3%) had pneumonia visualized on CT scan but not on concurrent chest radiography. Overall, these patients with CT-only pneumonia had a clinical profile similar to those with pneumonia visualized on chest radiography, including comorbidities, vital signs, hospital length of stay, prevalence of viral (30% vs 26%) and bacterial (12% vs 14%) pathogens, ICU admission (23% vs 21%), use of mechanical ventilation (6% vs 5%), septic shock (5% vs 4%), and inhospital mortality (0 vs 2%). CONCLUSIONS: Adults hospitalized with CAP who had radiological evidence of pneumonia on CT scan but not on concurrent chest radiograph had pathogens, disease severity, and outcomes similar to patients who had signs of pneumonia on chest radiography. These findings support using the same management principles for patients with CT-only pneumonia and those with pneumonia seen on chest radiography.

      11. HIV prevention goals in the United States include reducing new HIV infections among people in the South Census region (commonly referred as the South). Using data reported to the National HIV Surveillance System, we examined trends in HIV diagnoses in the South, including the Deep South and Other South, during 2012-2017. Although diagnosis rates declined in all regions during the time period, declines were greater in all other regions compared to the Deep South, with the exception of the West region. Moreover, the South continues to have a diagnosis rate 50% higher (65% higher in the Deep South) than that of any other region. Diagnoses in the Deep South increased among some groups, including men who have sex with men, persons aged 25-34 years and Hispanics/Latinos. These findings highlight the need to further strengthen interventions in the South, particularly among communities of color and young adults.

      12. Lessons from an active surveillance pilot to assess the pneumonia of unknown etiology surveillance system in China, 2016: the need to increase clinician participation in the detection and reporting of emerging respiratory infectious diseasesexternal icon
        Xiang N, Song Y, Wang Y, Wu J, Millman AJ, Greene CM, Ding Z, Sun J, Yang W, Guo G, Wang R, Guo P, Ren Z, Gong L, Xu P, Zhou S, Lin D, Ni D, Feng Z, Li Q.
        BMC Infect Dis. 2019 Sep 3;19(1):770.
        BACKGROUND: We sought to assess reporting in China’s Pneumonia of Unknown Etiology (PUE) passive surveillance system for emerging respiratory infections and to identify ways to improve the PUE surveillance system’s detection of respiratory infections of public health significance. METHODS: From February 29-May 29, 2016, we actively identified and enrolled patients in two hospitals with acute respiratory infections (ARI) that met all PUE case criteria. We reviewed medical records for documented exposure history associated with respiratory infectious diseases, collected throat samples that were tested for seasonal and avian influenza, and interviewed clinicians regarding reasons for reporting or not reporting PUE cases. We described and analyzed the proportion of PUE cases reported and clinician awareness of and practices related to the PUE system. RESULTS: Of 2619 ARI admissions in two hospitals, 335(13%) met the PUE case definition; none were reported. Of 311 specimens tested, 18(6%) were seasonal influenza virus-positive; none were avian influenza-positive. < 10% PUE case medical records documented whether or not there were exposures to animals or others with respiratory illness. Most commonly cited reasons for not reporting cases were no awareness of the PUE system (76%) and not understanding the case definition (53%). CONCLUSIONS: Most clinicians have limited awareness of and are not reporting to the PUE system. Exposures related to respiratory infections are rarely documented in medical records. Increasing clinicians’ awareness of the PUE system and including relevant exposure items in standard medical records may increase reporting.

    • Disaster Control and Emergency Services
      1. Evaluation of emergency department-based surveillance systems at 2 healthcare facilities after Hurricane Maria: Puerto Rico, 2017-2018external icon
        Adams LE, Vargas L, Frasqueri-Quintana VM, Torres-Figueroa X, Ryff K, Sanchez-Gonzalez L, Little E, Ciampaglio K, Reyes Claudio JM, Ponton-Cruz E, Santiago W, Paz-Bailey G, Alvarado LI.
        Disaster Med Public Health Prep. 2019 Sep 2:1-9.
        OBJECTIVES: Hurricane Maria caused catastrophic damage in Puerto Rico, increasing the risk for morbidity and mortality in the post-impact period. We aimed to establish a syndromic surveillance system to describe the number and type of visits at 2 emergency health-care settings in the same hospital system in Ponce, Puerto Rico. METHODS: We implemented a hurricane surveillance system by interviewing patients with a short questionnaire about the reason for visit at a hospital emergency department and associated urgent care clinic in the 6 mo after Hurricane Maria. We then evaluated the system by comparing findings with data from the electronic medical record (EMR) system for the same time period. RESULTS: The hurricane surveillance system captured information from 5116 participants across the 2 sites, representing 17% of all visits captured in the EMR for the same period. Most visits were associated with acute illness/symptoms (79%), followed by injury (11%). The hurricane surveillance and EMR data were similar, proportionally, by sex, age, and visit category. CONCLUSIONS: The hurricane surveillance system provided timely and representative data about the number and type of visits at 2 sites. This system, or an adapted version using available electronic data, should be considered in future disaster settings.

      2. Participation in community preparedness programs in human services organizations and faith-based organizations – New York City, 2018external icon
        Rivera L, Pagaoa M, Morgenthau BM, Paquet C, Molinari NA, LeBlanc TT.
        MMWR Morb Mortal Wkly Rep. 2019 Sep 6;68(35):757-761.
        Community-based organizations have a long history of engagement with public health issues; these relationships can contribute to disaster preparedness (1,2). Preparedness training improves response capacity and strengthens overall resilience (1). Recognizing the importance of community-based organizations in community preparedness, the Office of Emergency Preparedness and Response in New York City’s (NYC’s) Department of Health and Mental Hygiene (DOHMH) launched a community preparedness program in 2016 (3), which engaged two community sectors (human services and faith-based). To strengthen community preparedness for public health emergencies in human services organizations and faith-based organizations, the community preparedness program conducted eight in-person preparedness trainings. Each training focused on preparedness topics, including developing plans for 1) continuity of operations, 2) emergency management, 3) volunteer management, 4) emergency communications, 5) emergency notification systems, 6) communication with persons at risk, 7) assessing emergency resources, and 8) establishing dedicated emergency funds (2,3). To evaluate training effectiveness, data obtained through online surveys administered during June-September 2018 were analyzed using multivariate logistic regression. Previously described preparedness indicators among trained human services organizations and faith-based organizations were compared with those of organizations that were not trained (3). Participation in the community preparedness program training was associated with increased odds of meeting preparedness indicators. NYC’s community preparedness program can serve as a model for other health departments seeking to build community preparedness through partnership with community-based organizations.

    • Disease Reservoirs and Vectors
      1. Temporal and spatial distribution of anthrax outbreaks among Kenyan wildlife, 1999-2017external icon
        Gachohi JM, Gakuya F, Lekolool I, Osoro E, Nderitu L, Munyua P, Ngere I, Kemunto N, Bett B, Otieno F, Muturi M, Mwatondo A, Widdowson MA, Kariuki Njenga M.
        Epidemiol Infect. 2019 ;147.
        The burden of anthrax in wildlife is demonstrated through high numbers of sudden mortalities among herbivore species, including endangered animal species. East Africa is home of multiple species of faunal wildlife numbering in the millions but there are limited disease surveillance programmes, resulting in a paucity of information on the role of anthrax and other infectious diseases on declining wildlife populations in the region. We reviewed historical data on anthrax outbreaks from Kenya Wildlife Service (KWS) spanning from 1999 to 2017 in Kenya to determine the burden, characteristics and spatial distribution of anthrax outbreaks. A total of 51 anthrax outbreaks associated with 1014 animal deaths were reported across 20 of 60 wildlife conservation areas located in six of the seven agro-ecological zones. Overall, 67% of the outbreaks were reported during the dry seasons, affecting 24 different wildlife species. Over 90% (22 of 24) of the affected species were herbivore, including 12 grazers, five browsers and five mixed grazers and browsers. Buffaloes (23.5%), black rhinos (21.6%) and elephants (17.6%) were the most frequently affected species. Our findings demonstrate the extensive geographic distribution of wildlife anthrax in the country, making it one of the important infectious diseases that threaten wildlife conservation.

      2. Outbreak of diarrhea in piglets caused by novel rotavirus genotype G4P[49] in northwestern district of Bangladesh, February 2014external icon
        Sarkar S, Dioh Esona M, Gautam R, Castro CJ, Ng TF, Haque W, Khan SU, Hossain ME, Rahman MZ, Gurley ES, Kennedy ED, Bowen MD, Parashar UD, Rahman M.
        Transbound Emerg Dis. 2019 Aug 30.
        Group A rotavirus (RVA) associated diarrhea in piglets represents one of the major causes of morbidity and mortality in pig farms worldwide. A diarrhea outbreak occurred among nomadic piglets in north-western district of Bangladesh in February 2014. Outbreak investigation was performed to identify the cause, epidemiologic and clinical features of the outbreak. Rectal swabs and clinical information were collected from diarrheic piglets (n=36). Rectal swabs were tested for RVA RNA by real time reverse transcription polymerase chain reaction (rRT-PCR) using NSP3-specific primers. The G (VP7) and P (VP4) genes were typed by conventional RT-PCR and sanger sequencing and full genome sequences were determined using next generation sequencing. We found the attack rate was 61% (50/82) among piglets in the nomadic pig herd and the case fatality rate was 20% (10/50) among piglets with diarrhea. All study piglets cases had watery diarrhea, lack of appetite or reluctance to move. A novel RVA strain with a new P[49] genotype combined with G4 was identified among all piglets with diarrhea. The genome constellation of the novel RVA strains was determined to be G4-P [49]-I1-R1-C1-M1-A8-N1-T7-E1-H1. Genetic analysis shows that the novel G4P[49] strain is similar to Indian and Chinese porcine or porcine-like G4 human strains and is genetically distant from Bangladeshi human G4 strains. Identification of this novel RVA strain warrants further exploration for disease severity and zoonotic potential. This article is protected by copyright. All rights reserved.

      3. The American dog tick, Dermacentor variabilis Say, is the principal vector of spotted fever group rickettsiae that cause illness in people. Because the composition and structure of microbial communities in D. variabilis are poorly understood, we conducted high-throughput amplicon sequencing of the 16S rRNA gene to characterize the bacterial communities of adult D. variabilis ticks collected from field populations in North Carolina. Sequence analyses were performed using QIIME 2 with the DADA2 plugin and taxonomic assignments using the Greengenes database. After quality filtering and rarefaction, the bacterial DNA sequences were assigned to 432 operational taxonomic units (OTUs) and were dominated by a single OTU classified as Francisella spp. Subsequent cloning, sequencing and phylogenic analysis of nearly full length 16S rRNA gene fragments revealed that most Francisella were similar to Francisella-like endosymbionts (FLEs) of D. variabilis reported previously. One cloned Francisella, however, was genetically distinct and more related to the FLE of D. occidentalis. The core microbiome of D. variabilis was comprised of Francisella spp., Sphingomonas spp., Delftia spp., and Hymenobacter spp. The taxonomic resolution and detection of less abundant bacterial taxa, including Rickettsia, are discussed. Alpha diversity metrics revealed lower bacterial community diversity in females. Beta-diversity also distinguished the composition of female bacterial communities from those of males. These findings advance current knowledge of the microbial ecology and structure and composition of D. variabilis microbiome and sets the foundation for further studies to determine the influence of microbiota on vector susceptibility to pathogens.

      4. Integrated vector management with additional pre-transmission season thermal fogging is associated with a reduction in dengue incidence in Makassar, Indonesia: Results of an 8-year observational studyexternal icon
        Wahid I, Ishak H, Hafid A, Fajri M, Sidjal S, Nurdin A, Azikin NT, Sudirman R, Hasan H, Yusuf M, Bachtiar I, Hawley WA, Rosenberg R, Lobo NF.
        PLoS Negl Trop Dis. 2019 Aug;13(8):e0007606.
        Dengue virus transmission is endemic in Makassar, Indonesia, with the majority of cases reported soon after the start of the annual rainy season. Before 2006, larval source reduction, larvaciding, and reactive routine, outdoor, insecticide fogging campaigns did not result in a reduction in seasonal dengue incidence. Beginning in 2006, village volunteers conducted comprehensive surveys for immature Aedes during the dry season, when vector populations were at their lowest. Based on this pre-season vector data, a single additional pre-emptive outdoor fogging with Malathion was conducted once annually before the rains began in villages with a pre-defined proportion of sampled houses positive for Aedes immatures. This additional procedure was associated with reduced temporal larval indices as well as an 83% reduction in reported cases during the transmission season over the 8-year period of implementation. Two cities adjacent to Makassar experienced substantial but smaller reductions in dengue incidence; while other cities further from the intervention area did not. This represents the first time an integrated intervention strategy has been coupled with substantially reduced dengue transmission in Indonesia.

    • Environmental Health
      1. Association of urinary concentrations of early pregnancy phthalate metabolites and bisphenol A with length of gestationexternal icon
        Chin HB, Jukic AM, Wilcox AJ, Weinberg CR, Ferguson KK, Calafat AM, McConnaughey DR, Baird DD.
        Environ Health. 2019 Aug 30;18(1):80.
        BACKGROUND: Environmental exposure to phthalates and bisphenol A (BPA) may have endocrine disrupting effects that alter length of gestation. We assessed the association between the urinary concentrations of 11 phthalate metabolites and BPA with length of gestation in a cohort of women followed from before conception with daily 1st-morning urinary hormone measures that identified day of implantation. METHODS: Pre-implantation and post-implantation urinary phthalate metabolites and BPA concentrations were measured in pooled urine samples designed to limit single-measure variability due to the likely episodic nature of these exposures and the short half-life of these compounds. We estimated associations between these exposure biomarkers early in pregnancy with length of gestation from implantation to spontaneous birth. Cox proportional hazards models were used to estimate the hazard of birth among 125 naturally-conceived, singleton live births with censoring for medical interventions that artificially shortened pregnancy. RESULTS: Higher concentrations of mono (2-ethyl-5-hydroxyhexyl) phthalate (a metabolite of di (2-ethylhexyl) phthalate (DEHP)) during the pre-implantation window were associated with reduced probability of birth, i.e., longer gestations (hazard ratio (HR): 0.55, 95% CI: 0.35, 0.86; p = 0.01). The HR for the molar sum of the four DEHP metabolites measured showed a similar association (HR: 0.67, 95% CI: 0.43, 1.05). Higher concentrations of mono (3-carboxypropyl) phthalate (MCPP), a non-specific metabolite of several high molecular-weight phthalates, measured post-implantation were associated with increased risk of earlier birth, i.e. shorter length of gestation, HR: 1.59, CI: 1.02, 2.49. CONCLUSIONS: Early gestational exposure to DEHP and possibly other high-molecular weight phthalates, (as reflected by urinary MCPP concentrations) may influence the length of pregnancy. Such effects could have consequences for neonatal and maternal health.

      2. Differences in heat-related mortality by citizenship status: United States, 2005-2014external icon
        Taylor EV, Vaidyanathan A, Flanders WD, Murphy M, Spencer M, Noe RS.
        Am J Public Health. 2018 Apr;108(S2):S131-s136.
        OBJECTIVES: To determine whether non-US citizens have a higher mortality risk of heat-related deaths than do US citizens. METHODS: We used place of residence reported in mortality data from the National Vital Statistics System from 2005 to 2014 as a proxy for citizenship to examine differences in heat-related deaths between non-US and US citizens. Estimates from the US Census Bureau American Community Survey of self-reported citizenship status and place of birth provided the numbers for the study population. We calculated the standardized mortality ratio and relative risk for heat-related deaths between non-US and US citizens nationally. RESULTS: Heat-related deaths accounted for 2.23% (n = 999) of deaths among non-US citizens and 0.02% (n = 4196) of deaths among US citizens. The age-adjusted standardized mortality ratio for non-US citizens compared with US citizens was 3.4 (95% confidence ratio [CI] = 3.2, 3.6). This risk was higher for Hispanic non-US citizens (risk ratio [RR] = 3.6; 95% CI = 3.2, 3.9) and non-US citizens aged 18 to 24 years (RR = 20.6; 95% CI = 16.5, 25.7). CONCLUSIONS: We found an increased mortality risk among non-US citizens compared with US citizens for heat-related deaths, especially those younger and of Hispanic ethnicity.

    • Genetics and Genomics
      1. Updated classification of norovirus genogroups and genotypesexternal icon
        Chhabra P, de Graaf M, Parra GI, Chan MC, Green K, Martella V, Wang Q, White PA, Katayama K, Vennema H, Koopmans MP, Vinje J.
        J Gen Virol. 2019 Sep 4.
        Noroviruses are genetically diverse RNA viruses associated with acute gastroenteritis in mammalian hosts. Phylogenetically, they can be segregated into different genogroups as well as P (polymerase)-groups and further into genotypes and P-types based on amino acid diversity of the complete VP1 gene and nucleotide diversity of the RNA-dependent RNA polymerase (RdRp) region of ORF1, respectively. In recent years, several new noroviruses have been reported that warrant an update of the existing classification scheme. Using previously described 2x standard deviation (sd) criteria to group sequences into separate clusters, we expanded the number of genogroups to 10 (GI-GX) and the number of genotypes to 49 (9 GI, 27 GII, 3 GIII, 2 GIV, 2 GV, 2 GVI and 1 genotype each for GVII, GVIII, GIX [formerly GII.15] and GX). Viruses for which currently only one sequence is available in public databases were classified into tentative new genogroups (GNA1 and GNA2) and genotypes (GII.NA1, GII.NA2 and GIV.NA1) with their definitive assignment awaiting additional related sequences. Based on nucleotide diversity in the RdRp region, noroviruses can be divided into 60 P-types (14 GI, 37 GII, 2 GIII, 1 GIV, 2 GV, 2 GVI, 1 GVII and 1 GX), 2 tentative P-groups and 14 tentative P-types. Future classification and nomenclature updates will be based on complete genome sequences and will be coordinated and disseminated by the international norovirus classification-working group.

      2. NS2B/NS3 mutations enhance the infectivity of genotype I Japanese encephalitis virus in amplifying hostsexternal icon
        Fan YC, Liang JJ, Chen JM, Lin JW, Chen YY, Su KH, Lin CC, Tu WC, Chiou MT, Ou SC, Chang GJ, Lin YL, Chiou SS.
        PLoS Pathog. 2019 Aug;15(8):e1007992.
        Genotype I (GI) virus has replaced genotype III (GIII) virus as the dominant Japanese encephalitis virus (JEV) in the epidemic area of Asia. The mechanism underlying the genotype replacement remains unclear. Therefore, we focused our current study on investigating the roles of mosquito vector and amplifying host(s) in JEV genotype replacement by comparing the replication ability of GI and GIII viruses. GI and GIII viruses had similar infection rates and replicated to similar viral titers after blood meal feedings in Culex tritaeniorhynchus. However, GI virus yielded a higher viral titer in amplifying host-derived cells, especially at an elevated temperature, and produced an earlier and higher viremia in experimentally inoculated pigs, ducklings, and young chickens. Subsequently we identified the amplification advantage of viral genetic determinants from GI viruses by utilizing chimeric and recombinant JEVs (rJEVs). Compared to the recombinant GIII virus (rGIII virus), we observed that both the recombinant GI virus and the chimeric rJEVs encoding GI virus-derived NS1-3 genes supported higher replication ability in amplifying hosts. The replication advantage of the chimeric rJEVs was lost after introduction of a single substitution from a GIII viral mutation (NS2B-L99V, NS3-S78A, or NS3-D177E). In addition, the gain-of-function assay further elucidated that rGIII virus encoding GI virus NS2B-V99L/NS3-A78S/E177E substitutions re-gained the enhanced replication ability. Thus, we conclude that the replication advantage of GI virus in pigs and poultry is the result of three critical NS2B/NS3 substitutions. This may lead to more efficient transmission of GI virus than GIII virus in the amplifying host-mosquito cycle.

    • Health Disparities
      1. Racial/ethnic disparities in pregnancy-related deaths – United States, 2007-2016external icon
        Petersen EE, Davis NL, Goodman D, Cox S, Syverson C, Seed K, Shapiro-Mendoza C, Callaghan WM, Barfield W.
        MMWR Morb Mortal Wkly Rep. 2019 Sep 6;68(35):762-765.
        Approximately 700 women die in the United States each year as a result of pregnancy or its complications, and significant racial/ethnic disparities in pregnancy-related mortality exist (1). Data from CDC’s Pregnancy Mortality Surveillance System (PMSS) for 2007-2016 were analyzed. Pregnancy-related mortality ratios (PRMRs) (i.e., pregnancy-related deaths per 100,000 live births) were analyzed by demographic characteristics and state PRMR tertiles (i.e., states with lowest, middle, and highest PRMR); cause-specific proportionate mortality by race/ethnicity also was calculated. Over the period analyzed, the U.S. overall PRMR was 16.7 pregnancy-related deaths per 100,000 births. Non-Hispanic black (black) and non-Hispanic American Indian/Alaska Native (AI/AN) women experienced higher PRMRs (40.8 and 29.7, respectively) than did all other racial/ethnic groups. This disparity persisted over time and across age groups. The PRMR for black and AI/AN women aged >/=30 years was approximately four to five times that for their white counterparts. PRMRs for black and AI/AN women with at least some college education were higher than those for all other racial/ethnic groups with less than a high school diploma. Among state PRMR tertiles, the PRMRs for black and AI/AN women were 2.8-3.3 and 1.7-3.3 times as high, respectively, as those for non-Hispanic white (white) women. Significant differences in cause-specific proportionate mortality were observed among racial/ethnic populations. Strategies to address racial/ethnic disparities in pregnancy-related deaths, including improving women’s health and access to quality care in the preconception, pregnancy, and postpartum periods, can be implemented through coordination at the community, health facility, patient, provider, and system levels.

    • Health Economics
      1. Long-distance effects of epidemics: Assessing the link between the 2014 West Africa Ebola outbreak and U.S. exports and employmentexternal icon
        Kostova D, Cassell CH, Redd JT, Williams DE, Singh T, Martel LD, Bunnell RE.
        Health Econ. 2019 Aug 28.
        Although the economic consequences of epidemic outbreaks to affected areas are often well documented, little is known about how these might carry over into the economies of unaffected regions. In the absence of direct pathogen transmission, global trade is one mechanism through which geographically distant epidemics could reverberate to unaffected countries. This study explores the link between global public health events and U.S. economic outcomes by evaluating the role of the 2014 West Africa Ebola outbreak in U.S. exports and exports-supported U.S. jobs, 2005-2016. Estimates were obtained using difference-in-differences models where sub-Saharan Africa countries were assigned to treatment and comparison groups based on their Ebola transmission status, with controls for observed and unobserved time-variant factors that may independently influence trends in trade. Multiple model specification checks were performed to ensure analytic robustness. The year of peak transmission, 2014, was estimated to result in $1.08 billion relative reduction in U.S. merchandise exports to Ebola-affected countries, whereas estimated losses in exports-supported U.S. jobs exceeded 1,200 in 2014 and 11,000 in 2015. These findings suggest that remote disruptions in health security might play a role in U.S. economic indicators, demonstrating the interconnectedness between global health and aspects of the global economy and informing the relevance of health security efforts.

      2. Economics of multicomponent interventions to increase breast, cervical, and colorectal cancer screening: A Community Guide Systematic Reviewexternal icon
        Mohan G, Chattopadhyay SK, Ekwueme DU, Sabatino SA, Okasako-Schmucker DL, Peng Y, Mercer SL, Thota AB.
        Am J Prev Med. 2019 Aug 30.
        CONTEXT: The Community Preventive Services Task Force recently recommended multicomponent interventions to increase breast, cervical, and colorectal cancer screening based on strong evidence of effectiveness. This systematic review examines the economic evidence to guide decisions on the implementation of these interventions. EVIDENCE ACQUISITION: A systematic literature search for economic evidence was performed from January 2004 to January 2018. All monetary values were reported in 2016 US dollars, and the analysis was completed in 2018. EVIDENCE SYNTHESIS: Fifty-three studies were included in the body of evidence from a literature search yield of 8,568 total articles. For multicomponent interventions to increase breast cancer screening, the median intervention cost per participant was $26.69 (interquartile interval [IQI]=$3.25, $113.72), and the median incremental cost per additional woman screened was $147.64 (IQI=$32.92, $924.98). For cervical cancer screening, the median costs per participant and per additional woman screened were $159.80 (IQI=$117.62, $214.73) and $159.49 (IQI=$64.74, $331.46), respectively. Two studies reported incremental cost per quality-adjusted life year gained of $748 and $33,433. For colorectal cancer screening, the median costs per participant and per additional person screened were $36.63 (IQI=$7.70, $139.23) and $582.44 (IQI=$91.10, $1,452.12), respectively. Two studies indicated a decline in incremental cost per quality-adjusted life year gained of $1,651 and $3,817. CONCLUSIONS: Multicomponent interventions to increase cervical and colorectal cancer screening were cost effective based on a very conservative threshold. Additionally, multicomponent interventions for colorectal cancer screening demonstrated net cost savings. Cost effectiveness for multicomponent interventions to increase breast cancer screening could not be determined owing to the lack of studies reporting incremental cost per quality-adjusted life year gained. Future studies estimating this outcome could assist implementers with decision making.

    • Healthcare Associated Infections
      1. Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a serious public health problem, compromising the management and control of gonorrhoea globally. Resistance in N. gonorrhoeae to ceftriaxone, the last option for first-line empirical monotherapy of gonorrhoea, has been reported from many countries globally, and sporadic failures to cure especially pharyngeal gonorrhoea with ceftriaxone monotherapy and dual antimicrobial therapies (ceftriaxone plus azithromycin or doxycycline) have been confirmed in several countries. In 2018, the first gonococcal isolates with ceftriaxone resistance plus high-level azithromycin resistance were identified in England and Australia. The World Health Organization (WHO) Global Gonococcal Antimicrobial Surveillance Program (GASP) is essential to monitor AMR trends, identify emerging AMR and provide evidence for refinements of treatment guidelines and public health policy globally. Herein we describe the WHO GASP data from 67 countries in 2015-16, confirmed gonorrhoea treatment failures with ceftriaxone with or without azithromycin or doxycycline, and international collaborative actions and research efforts essential for the effective management and control of gonorrhoea. In most countries, resistance to ciprofloxacin is exceedingly high, azithromycin resistance is present and decreased susceptibility or resistance to ceftriaxone has emerged. Enhanced global collaborative actions are crucial for the control of gonorrhoea, including improved prevention, early diagnosis, treatment of index patient and partner (including test-of-cure), improved and expanded AMR surveillance (including surveillance of antimicrobial use and treatment failures), increased knowledge of correct antimicrobial use and the pharmacokinetics and pharmacodynamics of antimicrobials and effective drug regulations and prescription policies (including antimicrobial stewardship). Ultimately, rapid, accurate and affordable point-of-care diagnostic tests (ideally also predicting AMR and/or susceptibility), new therapeutic antimicrobials and, the only sustainable solution, gonococcal vaccine(s) are imperative.

    • Immunity and Immunization
      1. The effect of preexisting immunity on virus detection and immune responses in a phase ii, randomized trial of a Russian-backbone, live, attenuated influenza vaccine in Bangladeshi childrenexternal icon
        Brickley EB, Wright PF, Khalenkov A, Neuzil KM, Ortiz JR, Rudenko L, Levine MZ, Katz JM, Brooks WA.
        Clin Infect Dis. 2019 Aug 16;69(5):786-794.
        BACKGROUND: In a 2012 Phase II clinical trial, 300 Bangladeshi children aged 24 to 59 months with no prior influenza vaccine exposure were randomized to receive a single intranasally-administered dose of either trivalent, Russian-backbone, live, attenuated influenza vaccine (LAIV) or placebo. Protocol-defined analyses, presented in the companion manuscript, demonstrate decreased viral detection and immunogenicity for A/H1N1pdm09, relative to the A/H3N2 and B strains. This post hoc analysis of the trial data aims to investigate the LAIV strain differences by testing the hypothesis that preexisting humoral and mucosal immunity may influence viral recovery and immune responses after LAIV receipt. METHODS: We used logistic regressions to evaluate the relations between markers of preexisting immunity (ie, hemagglutination inhibition [HAI], microneutralization, and immunoglobulin G and immunoglobulin A (both serum and mucosal antibodies) and LAIV viral recovery in the week post-vaccination. We then tested for potential effect modification by baseline HAI titers (ie, <10 versus >/=10) and week 1 viral recovery on the LAIV-induced serum and mucosal immune responses, measured between days 0 and 21 post-vaccination. RESULTS: Higher levels of preexisting immunity to influenza A/H3N2 and B were strongly associated with strain-specific prevention of viral shedding upon LAIV receipt. While evidence of LAIV immunogenicity was observed for all 3 strains, the magnitudes of immune responses were most pronounced in children with no evidence of preexisting HAI and in those with detectable virus. CONCLUSIONS: The results provide evidence for a bidirectional association between viral replication and immunity, and underscore the importance of accounting for preexisting immunity when evaluating virologic and immunologic responses to LAIVs. CLINICAL TRIALS REGISTRATION: NCT01625689.

      2. Primary ovarian insufficiency and human papilloma virus vaccines: A review of the current evidenceexternal icon
        Christianson MS, Wodi P, Talaat K, Halsey N.
        Am J Obstet Gynecol. 2019 Aug 31.
        Human papilloma virus is the primary causative agent for cervical cancer, and vaccination is the primary means of preventing anogenital cancers caused by human papilloma virus infection. Despite the availability of human papilloma virus vaccines for over a decade, coverage rates lag behind the other vaccines. Public concerns regarding safety of human papilloma virus vaccines have been identified as an important barrier to vaccination, including concerns that the human papilloma virus vaccine causes primary ovarian insufficiency, driven in part by isolated reports of ovarian failure following the human papilloma virus vaccine. We summarize published peer-reviewed literature on human papilloma virus vaccines and primary ovarian insufficiency reviewing information contained in the case reports and series. Health care providers should address any patient concerns about primary ovarian insufficiency and the human papilloma virus vaccine by acknowledging the case reports but noting the lack of association found in a recently published epidemiologic study of approximately 60,000 females. Current evidence is insufficient to suggest or support a causal relationship between human papilloma virus vaccination and primary ovarian insufficiency.

      3. Background We conducted a matched case control study in China during the 2013/14-2015/16 influenza seasons to estimate influenza vaccine effectiveness (VE) by dose among children aged 6 months to 8 years. Methods Cases were laboratory-confirmed influenza infections identified through the influenza-like illness sentinel surveillance network in Guangzhou. Age and sex matched community controls were randomly selected through the expanded immunization program database. We defined priming as receipt of >/=1 dose of influenza vaccine during the immediate prior season. Results In total, 4,185 case-control pairs were analyzed. Among children 6-35 months, VE for current season dose(s) across the three seasons during 2013/14-2015/16 were 59% (95% Confidence Interval: 44-71%), 12% (-11%,30%), 54% (32-69%); among unprimed children 6-35 months, VE for 1 vs 2 current season doses were 45% (8-67%) vs 65% (46-78%), -2% (-53%,32%) vs 19% (-11%,40%), and 37% (-24%,68%) vs 61% (32-78%). Among children aged 3-8 years, VE for current season dose(s) across study seasons were 62% (36-78%), 43% (22-58%), 32% (1-53%). VE for unprimed children receiving 1 dose only in current season was insignificant or lower than among all children. Conclusion Findings support utility of providing second dose (“booster dose”) of seasonal influenza vaccine to unprimed children aged 6-35 months, and the need to study further dose effect of a booster dose among unprimed children aged 3-8 years in China.

      4. Immunogenicity and viral shedding of Russian-backbone, seasonal, trivalent, live, attenuated influenza vaccine in a phase II, randomized, placebo-controlled trial among preschool-aged children in urban Bangladeshexternal icon
        Lewis KD, Ortiz JR, Rahman MZ, Levine MZ, Rudenko L, Wright PF, Katz JM, Dally L, Rahman M, Isakova-Sivak I, Ilyushina NA, Matyushenko V, Fry AM, Lindstrom SE, Bresee JS, Brooks WA, Neuzil KM.
        Clin Infect Dis. 2019 Aug 16;69(5):777-785.
        BACKGROUND: We evaluated a Russian-backbone, live, attenuated influenza vaccine (LAIV) for immunogenicity and viral shedding in a randomized, placebo-controlled trial among Bangladeshi children. METHODS: Healthy children received a single, intranasal dose of LAIV containing the 2011-2012 recommended formulation or placebo. Nasopharyngeal wash (NPW) specimens were collected on days 0, 2, 4, and 7. Reverse transcription polymerase chain reactions and sequencing identified the influenza virus (vaccine or wild-type). On days 0 and 21, blood specimens were collected to assess immunogenicity using hemagglutination inhibition, microneutralization, and immunoglobulin A (IgA) and G enzyme-linked immunosorbent assays (ELISAs); NPW specimens were also collected to assess mucosal immunogenicity using kinetic IgA ELISA. RESULTS: We enrolled 300 children aged 24 through 59 months in the immunogenicity and viral shedding analyses. Among children receiving LAIV, 45% and 67% shed A/H3N2 and B vaccine strains, respectively. No child shed A/H1N1 vaccine strain. There were significantly higher day 21 geometric mean titers (GMTs) for the LAIV, as compared to the placebo groups, in all immunoassays for A/H3N2 and B (log10 titer P < .0001; GMT Ratio >2.0). Among immunoassays for A/H1N1, only the mucosal IgA GMT was significantly higher than placebo at day 21 (log10 titer P = .0465). CONCLUSIONS: Children vaccinated with LAIV had serum and mucosal antibody responses to A/H3N2 and B, but only a mucosal IgA response to A/H1N1. Many children shed A/H3N2 and B vaccine strains, but none shed A/H1N1. More research is needed to determine the reason for decreased LAIV A/H1N1 immunogenicity and virus shedding. CLINICAL TRIALS REGISTRATION: NCT01625689.

      5. Seasonal influenza vaccination coverage trends among adult populations, U.S., 2010-2016external icon
        Lu PJ, Hung MC, O’Halloran AC, Ding H, Srivastav A, Williams WW, Singleton JA.
        Am J Prev Med. 2019 Aug 29.
        INTRODUCTION: Influenza is a major cause of morbidity and mortality among adults. The most effective strategy for preventing influenza is annual vaccination. However, vaccination coverage has been suboptimal among adult populations. The purpose of this study is to assess trends in influenza vaccination among adult populations. METHODS: Data from the 2010-2016 National Health Interview Survey were analyzed in 2018 to estimate vaccination coverage during the 2010-2011 through 2015-2016 seasons. Trends of vaccination in recent years were assessed. Vaccination coverage by race/ethnicity within each group was examined. Multivariable logistic regression and predictive marginal models were conducted to identify factors associated with vaccination, and interactions between race/ethnicity and other demographic and access-to-care characteristics were assessed. RESULTS: Vaccination coverage among adults aged >/=18 years increased from 38.3% in the 2010-2011 season to 43.4% in the 2015-2016 season, with an average increase of 1.3 percentage points annually. From the 2010-2011 through 2015-2016 seasons, coverage was stable for adults aged >/=65 years and changed by -0.1 to 9.9 percentage points for all other examined subgroups. Coverage in 2015-2016 was 70.4% for adults aged >/=65 years, 46.4% for those aged 50-64 years, and 32.3% for those aged 18-49 years; 47.9% for people aged 18-64 years with high-risk conditions; 64.8% for healthcare personnel; and 50.3% for pregnant women. Among adults aged >/=18 years for the 2015-2016 season, coverage was significantly lower among non-Hispanic blacks and Hispanics compared with non-Hispanic whites. CONCLUSIONS: Overall, influenza vaccination coverage among adults aged >/=18 years increased during 2010-2016, but it remained below the national target of 70%. Vaccination coverage varied by age, risk status, race/ethnicity, healthcare personnel, and pregnancy status. Targeted efforts are needed to improve coverage and reduce disparities.

      6. Transmission of vaccine-strain varicella-zoster virus: A systematic reviewexternal icon
        Marin M, Leung J, Gershon AA.
        Pediatrics. 2019 Sep;144(3).
        CONTEXT: Live vaccines usually provide robust immunity but can transmit the vaccine virus. OBJECTIVE: To assess the characteristics of secondary transmission of the vaccine-strain varicella-zoster virus (Oka strain; vOka) on the basis of the published experience with use of live varicella and zoster vaccines. DATA SOURCES: Systematic review of Medline, Embase, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and Scopus databases for articles published through 2018. STUDY SELECTION: Articles that reported original data on vOka transmission from persons who received vaccines containing the live attenuated varicella-zoster virus. DATA EXTRACTION: We abstracted data to describe vOka transmission by index patient’s immune status, type (varicella or herpes zoster) and severity of illness, and whether transmission was laboratory confirmed. RESULTS: Twenty articles were included. We identified 13 patients with vOka varicella after transmission from 11 immunocompetent varicella vaccine recipients. In all instances, the vaccine recipient had a rash: 6 varicella-like and 5 herpes zoster. Transmission occurred mostly to household contacts. One additional case was not considered direct transmission from a vaccine recipient, but the mechanism was uncertain. Transmission from vaccinated immunocompromised children also occurred only if the vaccine recipient developed a rash postvaccination. Secondary cases of varicella caused by vOka were mild. LIMITATIONS: It is likely that other vOka transmission cases remain unpublished. CONCLUSIONS: Healthy, vaccinated persons have minimal risk for transmitting vOka to contacts and only if a rash is present. Our findings support the existing recommendations for routine varicella vaccination and the guidance that persons with vaccine-related rash avoid contact with susceptible persons at high risk for severe varicella complications.

      7. Universities’ experience with mumps outbreak response and use of a third dose of MMR vaccineexternal icon
        Marlow M, Even S, Hoban MT, Moore K, Patel M, Marin M.
        J Am Coll Health. 2019 Sep 3:1-6.
        Objective: During January 2016-June 2017, 75 mumps outbreaks occurred in US universities, despite high vaccine coverage among students. We evaluated universities’ experiences with mumps outbreaks to inform policy deliberations on use of a third dose of MMR vaccine and CDC guidance. Participants: American College Health Association members in September 2017. Methods: Online survey assessing mumps outbreak characteristics and response measures distributed to 980 members. Results: Administrators from 251 (26%) universities from 47 states responded. Seventy-nine (31%) universities had mumps cases on campus during August 2014-August 2017; 17 (22%) recommended a third MMR dose. The main challenges reported in outbreak response were exclusion of persons without presumptive immunity and isolation of students with mumps. Universities’ advice on addressing challenges is described. Conclusion: We identified common challenges faced by universities during mumps outbreaks, and lessons learned. These findings informed the October 2017 recommendation for use of a third MMR dose.

      8. Decreased humoral immunity to mumps in young adults immunized with MMR vaccine in childhoodexternal icon
        Rasheed MA, Hickman CJ, McGrew M, Sowers SB, Mercader S, Hopkins A, Grimes V, Yu T, Wrammert J, Mulligan MJ, Bellini WJ, Rota PA, Orenstein WA, Ahmed R, Edupuganti S.
        Proc Natl Acad Sci U S A. 2019 Sep 3.
        In the past decade, multiple mumps outbreaks have occurred in the United States, primarily in close-contact, high-density settings such as colleges, with a high attack rate among young adults, many of whom had the recommended 2 doses of mumps-measles-rubella (MMR) vaccine. Waning humoral immunity and the circulation of divergent wild-type mumps strains have been proposed as contributing factors to mumps resurgence. Blood samples from 71 healthy 18- to 23-year-old college students living in a non-outbreak area were assayed for antibodies and memory B cells (MBCs) to mumps, measles, and rubella. Seroprevalence rates of mumps, measles, and rubella determined by IgG enzyme-linked immunosorbent assay (ELISA) were 93, 93, and 100%, respectively. The index standard ratio indicated that the concentration of IgG was significantly lower for mumps than rubella. High IgG avidity to mumps Enders strain was detected in sera of 59/71 participants who had sufficient IgG levels. The frequency of circulating mumps-specific MBCs was 5 to 10 times lower than measles and rubella, and 10% of the participants had no detectable MBCs to mumps. Geometric mean neutralizing antibody titers (GMTs) by plaque reduction neutralization to the predominant circulating wild-type mumps strain (genotype G) were 6-fold lower than the GMTs against the Jeryl Lynn vaccine strain (genotype A). The majority of the participants (80%) received their second MMR vaccine >/=10 years prior to study participation. Additional efforts are needed to fully characterize B and T cell immune responses to mumps vaccine and to develop strategies to improve the quality and durability of vaccine-induced immunity.

      9. Sequential, within-season infection with influenza A (H3N2) in a usually healthy vaccinated childexternal icon
        Temte JL, Uzicanin A, Goss M, Comp L, Temte E, Barlow S, Reisdorf E, Shult P, Wedig M, Florek K.
        Influenza Other Respir Viruses. 2019 ;13(5):528-531.
        Cocirculation of varying influenza types, strains, and lineages allows coinfection and intra-season sequential infection, although a same-strain sequential infection has not been previously described. This case report describes the first known case of sequential laboratory-confirmed influenza A (H3N2) infections in a child within one season.

      10. Poliopolis: pushing boundaries of scientific innovations for disease eradicationexternal icon
        Van Damme P, Coster I, Bandyopadhyay AS, Suykens L, Rudelsheim P, Neels P, Oberste MS, Weldon WC, Clemens R, Revets H.
        Future Microbiol. 2019 Sep 4.
        Although global polio eradication is within reach, sustained eradication of all polioviruses requires cessation of oral poliovirus vaccine use to mitigate against vaccine-derived poliovirus circulation and vaccine-associated paralytic poliomyelitis. The first step in this direction was the WHO-recommended global withdrawal of live attenuated type 2 Sabin poliovirus from routine immunisation in May 2016, with future use restricted to outbreak response, and handling controlled by strict containment provisions (GAPIII). This creates unique challenges for development and testing of novel type 2 poliovirus vaccines. We describe the creation of a novel purpose-built containment facility, Poliopolis, to study new monovalent OPV2 vaccine candidates in healthy adult volunteers, which may be a model for future endeavors in vaccine development for emergency use.

    • Informatics
      1. Technology to advance infectious disease forecasting for outbreak managementexternal icon
        George DB, Taylor W, Shaman J, Rivers C, Paul B, O’Toole T, Johansson MA, Hirschman L, Biggerstaff M, Asher J, Reich NG.
        Nat Commun. 2019 Sep 2;10(1):3932.

        [No abstract]

    • Injury and Violence
      1. Self-reported lifetime concussion among adults: Comparison of 3 different survey questionsexternal icon
        Daugherty J, DePadilla L, Sarmiento K, Breiding MJ.
        J Head Trauma Rehabil. 2019 Aug 29.
        OBJECTIVE: Because of limitations in current national data sets, respondent self-report may be critical to obtaining concussion prevalence estimates. We examined whether self-report of lifetime concussion among adults varies with the provision of a concussion definition and by the content of that definition. SETTING AND PARTICIPANTS: A convenience sample of 6427 American adults who participated in the 2018 Porter Novelli SpringStyles survey. DESIGN: Cross-sectional. MAIN MEASURES: Frequency of self-reported concussion by variation in concussion definition. RESULTS: A quarter of respondents (28.9%) reported experiencing a concussion in their lifetime. While concussion prevalence varied by demographic characteristics, it did not vary significantly by concussion definition. Variation in concussion definition did not result in differences related to recency of last concussion, mechanism of injury, or respondent activity engaged in during which they sustained their most recent concussion. CONCLUSION: The current study suggested that in this sample of adults, the percentage reporting a concussion did not significantly vary by whether a concussion definition was provided or by the content of the definition. However, research suggests that prompting about mechanism of injury, listing symptoms individually, and considering only athletic populations may affect estimates and these factors should be included in future question comparisons.

      2. Massive fatal overdose of abrin with progressive encephalopathyexternal icon
        Horowitz BZ, Castelli R, Hughes A, Hendrickson RG, Johnson RC, Thomas JD.
        Clin Toxicol (Phila). 2019 Aug 28:1-4.
        Introduction: The jequirity bean (Abrus precatorius) seed contains abrin, a toxalbumin, that irreversibly binds the 60-s ribosomal subunit inhibiting protein synthesis. Neurologic manifestations of ingestions are rare. Case details: We present a case of a 20-year-old man with 24 h of vomiting, diarrhea and 2 h of hematemesis and hematochezia. He admitted to purchasing 1000 jequirity beans online, crushing and ingesting them 26 h prior to presentation in a suicide attempt. Over the next 2 days, he developed hallucinations, incomprehensible mumbling and grunting, disconjugate gaze with abnormal roving eye movements and a left gaze preference with his right eye deviated medially. There was a fine tremor of the upper extremities and he had brief episodes of choreoathetoid movements of his legs. A head CT was normal with no cerebral edema. He progressed to minimally responsive to noxious stimuli, and was unable to converse or follow commands and displayed increased choreoathetoid movements of his extremities. An electroencephalogram (EEG) showed only mild background slowing. Magnetic resonance imaging (MRI) was performed showing bilaterally symmetric signal abnormalities in the basal ganglia, brainstem, corpus callosum and corona radiata with diffuse leptomeningeal enhancement. The patient developed a tonic-clonic seizure followed by pulseless electrical activity, from which he was resuscitated. He was provided comfort care and died just under 5 days after his ingestion. Results: Urine analysis using liquid chromatography coupled to tandem mass spectrometry was positive for 8.84 ng/ml of l-abrine (4.96 ng l-abrine/mg creatinine) 61 h after admission to the hospital (approximately 87 h post-ingestion). Serum concentrations for l-abrine and ricinine were both below the limits of detection. Discussion: Ingestion of 1000 crushed jequirity beans purchased on the internet resulted in progressive encephalopathy and death.

      3. Coerced and forced sexual initiation and its association with negative health outcomes among youth: Results from the Nigeria, Uganda, and Zambia Violence Against Children Surveysexternal icon
        Nguyen KH, Padilla M, Villaveces A, Patel P, Atuchukwu V, Onotu D, Apondi R, Aluzimbi G, Chipimo P, Kancheya N, Kress H.
        Child Abuse Negl. 2019 Aug 21;96:104074.
        INTRODUCTION: Coerced and forced sexual initiation (FSI) can have detrimental effects on children and youth. Understanding health outcomes that are associated with experiences of FSI is important for developing appropriate strategies for prevention and treatment of FSI and its consequences. METHODS: The Violence Against Children Surveys were conducted in Nigeria, Uganda, and Zambia in 2014 and 2015. We examined the prevalence of FSI and its consequences (sexual high-risk behaviors, violence experiences, mental health outcomes, and sexually transmitted infections (STI)) associated with FSI among youth aged 13-24 years in three countries in sub-Saharan Africa. RESULTS: Over one in ten youth aged 13-24 years who had ever had sex experienced FSI in Nigeria, Uganda, and Zambia. In multivariable logistic regression, FSI was significantly associated with infrequent condom use (OR=1.4, 95%CI=1.1-2.1), recent experiences of sexual violence (OR=1.6, 95%CI: 1.1-2.3), physical violence (OR=2.2, 95%CI: 1.6-3.0), and emotional violence (OR=2.0, 95%CI: 1.3-2.9), moderate/serious mental distress (OR=1.5, 95%CI: 1.1-2.0), hurting oneself (OR=2.0, 95%CI: 1.3-3.1), and thoughts of suicide (OR=1.5, 95%CI: 1.1-2.3), after controlling for demographic characteristics. FSI was not statistically associated with engaging in transactional sex, having multiple sex partners, or having a STI. CONCLUSION: FSI is associated with infrequent condom use, recent experiences of violence and mental health outcomes among youth in sub-Saharan Africa, which may increase the risk for HIV and other consequences. Developing strategies for prevention is important for reducing the prevalence of FSI and its effects on children and youth.

      4. Sexual minority youth (SMY) report more substance use and experience more physical and sexual dating violence victimization than heterosexual youth; however, few studies have explored the relationship between substance use and disparities in teen dating violence and victimization (TDVV) using national-level estimates, and examined if these relationships vary by sexual minority subgroups. Data from the nationally representative 2015 and 2017 national Youth Risk Behavior Surveys were used to examine differences in TDVV and substance use by sexual identity, and to determine if substance use was associated with TDVV disparities between SMY and heterosexual high school students who dated 12 months prior to the survey (n = 18,704). Sex-stratified logistic regression models generated prevalence ratios adjusted for demographic characteristics and substance use behaviors to determine if substance use mediated the relationship between sexual identity and TDVV. Compared with their heterosexual peers, SMY experienced higher rates of TDVV and were more likely to report using most types of substances, although differences were more pronounced among female students compared with male students. Disparities in TDVV were reduced for male gay and bisexual students as well as for female bisexual students once substance use was entered into the model, suggesting that there is a relationship between substance use and some of gay and bisexual students’ risk for experiences of TDVV. Comprehensive efforts for violence prevention among sexual minority students may benefit from incorporating substance use prevention, given its relationship to disparities in TDVV.

    • Laboratory Sciences
      1. A competency framework for developing global laboratory leadersexternal icon
        Albetkova A, Chaignat E, Gasquet P, Heilmann M, Isadore J, Jasir A, Martin B, Wilcke B.
        Front Public Health. 2019 ;7:199.
        Building sustainable national health laboratory systems requires laboratory leaders who can address complex and changing demands for services and build strong collaborative networks. Global consensus on laboratory leadership competencies is critically important to ensure the harmonization of learning approaches for curriculum development across relevant health sectors. The World Health Organization (WHO), the Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (OIE), the European Centre for Disease Prevention and Control (ECDC), the U.S. Centers for Disease Control and Prevention (CDC), and the Association of Public Health Laboratories (APHL) have partnered to develop a Laboratory Leadership Competency Framework (CF) that provides a foundation for the Global Laboratory Leadership Programme (GLLP). The CF represents the first global consensus from multiple disciplines on laboratory leadership competencies and provides structure for the development of laboratory leaders with the knowledge, skills and abilities to build bridges, enhance communication, foster collaboration and develop an understanding of existing synergies between the human, animal, environmental, and other relevant health sectors.

      2. In vitro activity of ibrexafungerp, a novel glucan synthase inhibitor against Candida glabrata isolates with FKS mutationsexternal icon
        Nunnally NS, Etienne KA, Angulo D, Lockhart SR, Berkow EL.
        Antimicrob Agents Chemother. 2019 Sep 3.
        Ibrexafungerp is a first in class glucan-synthase inhibitor. In vitro activity was determined for 89 Candida glabrata isolates with molecularly identified FKS1 or FKS2 mutations conferring resistance to the echinocandins. All isolates were resistant to at least one echinocandin (i.e., anidulafungin, caspofungin, and micafungin) by broth microdilution. Results for ibrexafungerp were compared to those for each echinocandin. Ibrexafungerp had good activity against all echinocandin-resistant Candida glabrata isolates.

      3. The NDV-3A vaccine protects mice from multidrug resistant Candida auris infectionexternal icon
        Singh S, Uppuluri P, Mamouei Z, Alqarihi A, Elhassan H, French S, Lockhart SR, Chiller T, Edwards JE, Ibrahim AS.
        PLoS Pathog. 2019 Aug;15(8):e1007460.
        Candida auris is an emerging, multi-drug resistant, health care-associated fungal pathogen. Its predominant prevalence in hospitals and nursing homes indicates its ability to adhere to and colonize the skin, or persist in an environment outside the host-a trait unique from other Candida species. Besides being associated globally with life-threatening disseminated infections, C. auris also poses significant clinical challenges due to its ability to adhere to polymeric surfaces and form highly drug-resistant biofilms. Here, we performed bioinformatic studies to identify the presence of adhesin proteins in C. auris, with sequence as well as 3-D structural homologies to the major adhesin/invasin of C. albicans, Als3. Anti-Als3p antibodies generated by vaccinating mice with NDV-3A (a vaccine based on the N-terminus of Als3 protein formulated with alum) recognized C. auris in vitro, blocked its ability to form biofilms and enhanced macrophage-mediated killing of the fungus. Furthermore, NDV-3A vaccination induced significant levels of C. auris cross-reactive humoral and cellular immune responses, and protected immunosuppressed mice from lethal C. auris disseminated infection, compared to the control alum-vaccinated mice. The mechanism of protection is attributed to anti-Als3p antibodies and CD4+ T helper cells activating tissue macrophages. Finally, NDV-3A potentiated the protective efficacy of the antifungal drug micafungin, against C. auris candidemia. Identification of Als3-like adhesins in C. auris makes it a target for immunotherapeutic strategies using NDV-3A, a vaccine with known efficacy against other Candida species and safety as well as efficacy in clinical trials. Considering that C. auris can be resistant to almost all classes of antifungal drugs, such an approach has profound clinical relevance.

      4. Putative novel cps loci in a large global collection of pneumococciexternal icon
        van Tonder AJ, Gladstone RA, Lo SW, Nahm MH, du Plessis M, Cornick J, Kwambana-Adams B, Madhi SA, Hawkins PA, Benisty R, Dagan R, Everett D, Antonio M, Klugman KP, von Gottberg A, Breiman RF, McGee L, Bentley SD.
        Microb Genom. 2019 Jul;5(7).
        The pneumococcus produces a polysaccharide capsule, encoded by the cps locus, that provides protection against phagocytosis and determines serotype. Nearly 100 serotypes have been identified with new serotypes still being discovered, especially in previously understudied regions. Here we present an analysis of the cps loci of more than 18 000 genomes from the Global Pneumococcal Sequencing (GPS) project with the aim of identifying novel cps loci with the potential to produce previously unrecognized capsule structures. Serotypes were assigned using whole genome sequence data and 66 of the approximately 100 known serotypes were included in the final dataset. Closer examination of each serotype’s sequences identified nine putative novel cps loci (9X, 11X, 16X, 18X1, 18X2, 18X3, 29X, 33X and 36X) found in ~2.6 % of the genomes. The large number and global distribution of GPS genomes provided an unprecedented opportunity to identify novel cps loci and consider their phylogenetic and geographical distribution. Nine putative novel cps loci were identified and examples of each will undergo subsequent structural and immunological analysis.

      5. Probing the effects of pyrimidine functional group switches on acyclic fleximer analogues for antiviral activityexternal icon
        Yates MK, Chatterjee P, Flint M, Arefeayne Y, Makuc D, Plavec J, Spiropoulou CF, Seley-Radtke KL.
        Molecules. 2019 Sep 2;24(17).
        Due to their ability to inhibit viral DNA or RNA replication, nucleoside analogues have been used for decades as potent antiviral therapeutics. However, one of the major limitations of nucleoside analogues is the development of antiviral resistance. In that regard, flexible nucleoside analogues known as “fleximers” have garnered attention over the years due to their ability to survey different amino acids in enzyme binding sites, thus overcoming the potential development of antiviral resistance. Acyclic fleximers have previously demonstrated antiviral activity against numerous viruses including Middle East Respiratory Syndrome coronavirus (MERS-CoV), Ebola virus (EBOV), and, most recently, flaviviruses such as Dengue (DENV) and Yellow Fever Virus (YFV). Due to these interesting results, a Structure Activity Relationship (SAR) study was pursued in order to analyze the effect of the pyrimidine functional group and acyl protecting group on antiviral activity, cytotoxicity, and conformation. The results of those studies are presented herein.

      6. The effect of sputum quality and volume on the yield of bacteriologically-confirmed tb by xpert mtb/rif and smearexternal icon
        Zimba O, Tamuhla T, Basotli J, Letsibogo G, Pals S, Mathebula U, Mathoma A, Serumola C, Ramogale K, Boyd R, Tran T, Finlay A, Auld A, Date A, Alexander H, Chihota V, Agizew T.
        Pan Afr Med J. 2019 ;33.
        Introduction: the World Health Organization endorsed (2010) the use of Xpert MTB/RIF and countries are shifting from smear microscopy (smear)-based to Xpert MTB/RIF-based tuberculosis (TB) diagnostic algorithms. As with smear, sputum quality may predict the likelihood of obtaining a bacteriologically-confirmed TB when using Xpert MTB/RIF. Methods: from 08/12-11/2014, all people living with HIV were recruited at 22 clinics. For patients screened positive using the four TB symptoms their sputa were tested by Xpert MTB/RIF and smear. Laboratorians assessed and recorded sputum appearance and volume. The yield of bacteriologically-positive sputum evaluated using Xpert MTB/RIF and smear, likelihood-ratios were calculated. Results: among 6,041 patients enrolled 2,296 were presumptive TB, 1,305 (56.8%) had > 1 sputa collected and 644/1,305 (49.3%) had both Xpert MTB/RIF and smear results. Since >1 sputa collected from 644 patients 954 sputa were tested by Xpert MTB/RIF and smear. Bacteriologically-positive sputum was two-fold higher with Xpert MTB/RIF 11.4% versus smear 5.3%, p < 0.001. Sputum appearance and quantity were not predictive of bacteriologically-positive results, except volume of 2ml to < 3ml, tested by Xpert MTB/RIF LR+= 1.26 (95% CI, 1.05-1.50). Conclusion: Xpert MTB/RIF test yield to bacteriologically-positive sputum was superior to smear. Sputum quality and quantity, however, were not consistently predictive of bacteriologically-positive results by Xpert MTB/RIF or smear.

    • Occupational Safety and Health
      1. Exposures and health effects of bioaerosols in seafood processing workers – a position statementexternal icon
        Bonlokke JH, Bang B, Aasmoe L, Rahman AM, Syron LN, Andersson E, Dahlman-Hoglund A, Lopata AL, Jeebhay M.
        J Agromedicine. 2019 Aug 27:1-8.
        Occupational hazards exist in the processing of seafood both in land-based facilities as well as on board vessels. Recent findings on occupational injury and respiratory health risks among seafood processing workers were presented and discussed at the IFISH5 conference. Particular emphasis was put on the challenges that im/migrant workers encounter, the greater risks onboard factory vessels, especially where processing machinery are retrofitted to older vessels not primarily designed for this purpose, and the difficulties in assessing and preventing bioaerosol exposures and associated respiratory health risks despite recent advances in characterising agents responsible for allergic and non-allergic reactions. Based on appraisal of existing knowledge in the published literature and new findings presented at the conference, recommendations for immediate actions as well as for future research have been proposed. Among these include the importance of improving extraction ventilation systems, optimising machinery performance, enclosure of bioaerosol sources, improved work organization, and making special efforts to identify and support the needs of im/migrant workers to ensure they also benefit from such improvements. There is a need for studies that incorporate longitudinal study designs, have improved exposure and diagnostic methods, and that address seafood processing in countries with high seafood processing activities such as Asia and those that involve im/migrant workers worldwide. The medical and scientific community has an important role to play in prevention but cannot do this in isolation and should cooperate closely with hygienists, engineers, and national and international agencies to obtain better health outcomes for workers in the seafood industry.

      2. Severe lung disease characterized by lymphocytic bronchiolitis, alveolar ductitis, and emphysema (BADE) in industrial machine-manufacturing workersexternal icon
        Cummings KJ, Stanton ML, Nett RJ, Segal LN, Kreiss K, Abraham JL, Colby TV, Franko AD, Green FH, Sanyal S, Tallaksen RJ, Wendland D, Bachelder VD, Boylstein RJ, Park JH, Cox-Ganser JM, Virji MA, Crawford JA, Green BJ, LeBouf RF, Blaser MJ, Weissman DN.
        Am J Ind Med. 2019 Aug 28.
        BACKGROUND: A cluster of severe lung disease occurred at a manufacturing facility making industrial machines. We aimed to describe disease features and workplace exposures. METHODS: Clinical, functional, radiologic, and histopathologic features were characterized. Airborne concentrations of thoracic aerosol, metalworking fluid, endotoxin, metals, and volatile organic compounds were measured. Facility airflow was assessed using tracer gas. Process fluids were examined using culture, polymerase chain reaction, and 16S ribosomal RNA sequencing. RESULTS: Five previously healthy male never-smokers, ages 27 to 50, developed chest symptoms from 1995 to 2012 while working in the facility’s production areas. Patients had an insidious onset of cough, wheeze, and exertional dyspnea; airflow obstruction (mean FEV1 = 44% predicted) and reduced diffusing capacity (mean = 53% predicted); and radiologic centrilobular emphysema. Lung tissue demonstrated a unique pattern of bronchiolitis and alveolar ductitis with B-cell follicles lacking germinal centers, and significant emphysema for never-smokers. All had chronic dyspnea, three had a progressive functional decline, and one underwent lung transplantation. Patients reported no unusual nonoccupational exposures. No cases were identified among nonproduction workers or in the community. Endotoxin concentrations were elevated in two air samples; otherwise, exposures were below occupational limits. Air flowed from areas where machining occurred to other production areas. Metalworking fluid primarily grew Pseudomonas pseudoalcaligenes and lacked mycobacterial DNA, but 16S analysis revealed more complex bacterial communities. CONCLUSION: This cluster indicates a previously unrecognized occupational lung disease of yet uncertain etiology that should be considered in manufacturing workers (particularly never-smokers) with airflow obstruction and centrilobular emphysema. Investigation of additional cases in other settings could clarify the cause and guide prevention.

      3. Aerodynamic behavior of airborne fibers including high-aspect ratio particles plays an important role in aerosol filtration and lung deposition. Fiber length is considered to be an important parameter in causing toxicological responses of elongate mineral particles, including asbestos, as well as one of the factors affecting lung deposition. In order to estimate the toxicity of fibers as a function of fiber length, it is required to separate fibers by length and understand mechanisms related to fiber separation for use in toxicology studies. In this study, we used nylon mesh screens with different pore sizes as a separation method to remove long fibers and measured screen collection efficiency of glass fibers (a surrogate for asbestos) as a function of aerodynamic diameter with the aim to prepare toxicology samples free of long fibers and/or harvest long fibers from the screen. Two screen configurations ([i] without a laminar flow entrance length, and [ii] with the entrance length) were tested to investigate the effect of screen pore size (10, 20, and 60 micro m) and screen configuration on collection efficiency of fibers. Screen collection efficiency (eta) was obtained based on measurements of downstream concentrations of a test chamber either without or with a screen. The results showed that screen collection efficiency increases as screen pore size decreases from 60 to 10 micro m for both cases with and without entrance lengths. For the screen configuration without entrance length, higher collection efficiency was obtained than the case with entrance length probably due to increased impaction caused by the close proximity of inlet to screen. In addition, the difference between the collection efficiencies for the different configurations was small in the aerodynamic size range below 3 micro m while it increased in the size range from 3 to about 7 micro m, indicating that as large aerodynamic diameter is associated with longer fibers, some differential selection of fibers is possible. Modified model collection efficiency for 10 and 20 micro m screens based on the interception predicts well the measured data for the case with entrance length, indicating that the fiber deposition on these screens occurs dominantly through the interception mechanism in the micrometer size range under a given flow condition.

      4. N95 respirators vs medical masks for preventing influenza among health care personnel: A randomized clinical trialexternal icon
        Radonovich LJ, Simberkoff MS, Bessesen MT, Brown AC, Cummings DA, Gaydos CA, Los JG, Krosche AE, Gibert CL, Gorse GJ, Nyquist AC, Reich NG, Rodriguez-Barradas MC, Price CS, Perl TM.
        Jama. 2019 Sep 3;322(9):824-833.
        Importance: Clinical studies have been inconclusive about the effectiveness of N95 respirators and medical masks in preventing health care personnel (HCP) from acquiring workplace viral respiratory infections. Objective: To compare the effect of N95 respirators vs medical masks for prevention of influenza and other viral respiratory infections among HCP. Design, Setting, and Participants: A cluster randomized pragmatic effectiveness study conducted at 137 outpatient study sites at 7 US medical centers between September 2011 and May 2015, with final follow-up in June 2016. Each year for 4 years, during the 12-week period of peak viral respiratory illness, pairs of outpatient sites (clusters) within each center were matched and randomly assigned to the N95 respirator or medical mask groups. Interventions: Overall, 1993 participants in 189 clusters were randomly assigned to wear N95 respirators (2512 HCP-seasons of observation) and 2058 in 191 clusters were randomly assigned to wear medical masks (2668 HCP-seasons) when near patients with respiratory illness. Main Outcomes and Measures: The primary outcome was the incidence of laboratory-confirmed influenza. Secondary outcomes included incidence of acute respiratory illness, laboratory-detected respiratory infections, laboratory-confirmed respiratory illness, and influenzalike illness. Adherence to interventions was assessed. Results: Among 2862 randomized participants (mean [SD] age, 43 [11.5] years; 2369 [82.8%]) women), 2371 completed the study and accounted for 5180 HCP-seasons. There were 207 laboratory-confirmed influenza infection events (8.2% of HCP-seasons) in the N95 respirator group and 193 (7.2% of HCP-seasons) in the medical mask group (difference, 1.0%, [95% CI, -0.5% to 2.5%]; P = .18) (adjusted odds ratio [OR], 1.18 [95% CI, 0.95-1.45]). There were 1556 acute respiratory illness events in the respirator group vs 1711 in the mask group (difference, -21.9 per 1000 HCP-seasons [95% CI, -48.2 to 4.4]; P = .10); 679 laboratory-detected respiratory infections in the respirator group vs 745 in the mask group (difference, -8.9 per 1000 HCP-seasons, [95% CI, -33.3 to 15.4]; P = .47); 371 laboratory-confirmed respiratory illness events in the respirator group vs 417 in the mask group (difference, -8.6 per 1000 HCP-seasons [95% CI, -28.2 to 10.9]; P = .39); and 128 influenzalike illness events in the respirator group vs 166 in the mask group (difference, -11.3 per 1000 HCP-seasons [95% CI, -23.8 to 1.3]; P = .08). In the respirator group, 89.4% of participants reported “always” or “sometimes” wearing their assigned devices vs 90.2% in the mask group. Conclusions and Relevance: Among outpatient health care personnel, N95 respirators vs medical masks as worn by participants in this trial resulted in no significant difference in the incidence of laboratory-confirmed influenza. Trial Registration: Identifier: NCT01249625.

    • Occupational Safety and Health – Mining
      1. Since 2016, electromagnetic interference (EMI) of personal dust monitors (PDMs) with magnetic proximity detection systems (PDSs) has been observed in underground coal mines. The EMI causes the magnetic field measurements of a PDS to change, which, in turn, alters the calculated location of the miner relative to the machine. Any altered location calculation can potentially cause the PDS to fail to warn a worker who is at an unsafe distance from the machine, arousing a serious concern on safety hazard caused by EMI in underground mines. The search for EMI mitigation strategies led to the development and use of large shielding pouches and boxes to hold the entire PDM to reduce its magnetic emission. Research on these pouches and boxes found that although they were able to reduce the emitted radiation from the PDM, they also disturbed the magnetic field of the PDS, affecting its performance. Researchers from the National Institute for Occupational Safety and Health (NIOSH) have focused on shielding internal PDM components rather than shielding the entire PDM. The PDM air pump motor is one of the PDM components that has been identified as a major source of electromagnetic radiation and has been selected for further study and tests. The measurements show that a small copper or aluminum foil enclosure can effectively reduce the magnetic emission of the motor by between 50 and 85% at 73?kHz. This study compares the test results of the air pump motor with various cost-effective shielding materials. The data provided in this paper can serve as a reference for shielding enclosure design of the PDM air pump motor to reduce its electromagnetic emission as one form of EMI mitigation strategy.

    • Parasitic Diseases
      1. Mitochondrial junction region as genotyping marker for Cyclospora cayetanensisexternal icon
        Nascimento FS, Barta JR, Whale J, Hofstetter JN, Casillas S, Barratt J, Talundzic E, Arrowood MJ, Qvarnstrom Y.
        Emerg Infect Dis. 2019 Jul;25(7):1314-1319.
        Cyclosporiasis is an infection caused by Cyclospora cayetanensis, which is acquired by consumption of contaminated fresh food or water. In the United States, cases of cyclosporiasis are often associated with foodborne outbreaks linked to imported fresh produce or travel to disease-endemic countries. Epidemiologic investigation has been the primary method for linking outbreak cases. A molecular typing marker that can identify genetically related samples would be helpful in tracking outbreaks. We evaluated the mitochondrial junction region as a potential genotyping marker. We tested stool samples from 134 laboratory-confirmed cases in the United States by using PCR and Sanger sequencing. All but 2 samples were successfully typed and divided into 14 sequence types. Typing results were identical among samples within each epidemiologically defined case cluster for 7 of 10 clusters. These findings suggest that this marker can distinguish between distinct case clusters and might be helpful during cyclosporiasis outbreak investigations.

    • Reproductive Health
      1. Access to long-acting reversible contraception among US publicly funded health centersexternal icon
        Bornstein M, Carter M, Zapata L, Gavin L, Moskosky S.
        Contraception. 2018 May;97(5):405-410.
        OBJECTIVES: Access to a full range of contraceptive methods, including long-acting reversible contraception (LARC), is central to providing quality family planning services. We describe health center-related factors associated with LARC availability, including staff training in LARC insertion/removal and approaches to offering LARC, whether onsite or through referral. STUDY DESIGN: We analyzed nationally representative survey data collected during 2013-2014 from administrators of publicly funded U.S. health centers that offered family planning. The response rate was 49.3% (n=1615). In addition to descriptive statistics, we used multivariable logistic regression to identify health center characteristics associated with offering both IUDs and implants onsite. RESULTS: Two-thirds (64%) of health centers had staff trained in all three LARC types (hormonal IUD, copper IUD, implant); 21% had no staff trained in any of those contraceptive methods. Half of health centers (52%) offered IUDs (any type) and implants onsite. After onsite provision, informal referral arrangements were the most common way LARC methods were offered. In adjusted analyses, Planned Parenthood (AOR=9.49) and hospital-based (AOR=2.35) health centers had increased odds of offering IUDs (any type) and implants onsite, compared to Health Departments, as did Title X-funded (AOR=1.55) compared to non-Title X-funded health centers and centers serving a larger volume of family planning clients. Centers serving mostly rural areas compared to those serving urbans areas had lower odds (AOR 0.60) of offering IUD (any type) and implants. CONCLUSIONS: Variation in LARC access remains among publicly funded health centers. In particular, Health Departments and rural health centers have relatively low LARC provision. IMPLICATIONS: For more women to be offered a full range of contraceptive methods, additional efforts should be made to increase availability of LARC in publicly-funded health centers, such as addressing provider training gaps, improving referrals mechanisms, and other efforts to strengthen the health care system.

      2. OBJECTIVE: As diabetes is increasing among women of reproductive age in the United States, access to effective contraception is important to allow time for optimal glycemic control which may mitigate complications in future pregnancies. This study sought to describe contraceptive use and compare the effectiveness of contraceptive methods among postpartum women with and without diabetes. STUDY DESIGN: This study used data from the Pregnancy Risk Assessment Monitoring System and included women with recent live births during 2012-2015 (N=93,574). Women were asked about pre-gestational or recent gestational diabetes and their postpartum contraceptive method. Chi-square and multivariate logistic regression analyses were used to compare contraceptive methods between women with and without diabetes. RESULTS: Contraceptive prevalence was similar between women with (82%) and without (83%) diabetes; women with diabetes were more likely to use the most effective methods. This was driven by higher use of female sterilization among women with diabetes (15%) compared to women without diabetes (9%) (p<.001). In multivariate analysis, odds of use of female sterilization versus reversible prescription methods was higher among women with diabetes than women without diabetes (adjusted odds ratio 1.29, 95% confidence interval 1.19-1.39). CONCLUSIONS: Although overall postpartum contraceptive use was high, only 1/3 of women with or without diabetes were using the most effective methods. Furthermore, women with diabetes were more likely to use female sterilization than women without diabetes. It is important all postpartum women, particularly those with high risk pregnancies such as women with diabetes, receive counseling about and access to all contraceptive methods.

      3. Referral transit time between sending and first-line receiving health facilities: a geographical analysis in Tanzaniaexternal icon
        Schmitz MM, Serbanescu F, Arnott GE, Dynes M, Chaote P, Msuya AA, Chen YN.
        BMJ Glob Health. 2019 ;4(Suppl 5):e001568.
        Background: Timely, high-quality obstetric services are vital to reduce maternal and perinatal mortality. We spatially modelled referral pathways between sending and receiving health facilities in Kigoma Region, Tanzania, identifying communication and transportation delays to timely care and inefficient links within the referral system. Methods: We linked sending and receiving facilities to form facility pairs, based on information from a 2016 Health Facility Assessment. We used an AccessMod cost-friction surface model, incorporating road classifications and speed limits, to estimate direct travel time between facilities in each pair. We adjusted for transportation and communications delays to create a total travel time, simulating the effects of documented barriers in this referral system. Results: More than half of the facility pairs (57.8%) did not refer patients to facilities with higher levels of emergency obstetric care. The median direct travel time was 25.9 min (range: 4.4-356.6), while the median total time was 106.7 min (22.9-371.6) at the moderate adjustment level. Total travel times for 30.7% of facility pairs exceeded 2 hours. All facility pairs required some adjustments for transportation and communication delays, with 94.0% of facility pairs’ total times increasing. Conclusion: Half of all referral pairs in Kigoma Region have travel time delays nearly exceeding 1 hour, and facility pairs referring to facilities providing higher levels of care also have large travel time delays. Combining cost-friction surface modelling estimates with documented transportation and communications barriers provides a more realistic assessment of the effects of inter-facility delays on referral networks, and can inform decision-making and potential solutions in referral systems within resource-constrained settings.

      4. OBJECTIVE: To systematically review the literature around the safety and effectiveness of hormonal contraception for women who use opioids. Our specific research questions are: 1) Among women who use opioids, do those who use hormonal contraception have increased adverse health events compared with those who do not use hormonal contraception? 2) Are there drug interactions between hormonal contraception and opioids that cause decreased effectiveness or increased toxicity from either drug? METHODS: We searched Medline, Embase, PsychInfo, CINAHL, the Cochrane Library, and through August 2018. We considered randomized controlled trials, cohort studies, and case-control studies, as well as pharmacokinetic and pharmacodynamic studies. We planned to use standard frameworks to assess risk of bias of included studies. RESULTS: The search identified 1852 articles. The full text of 66 articles was reviewed, and none met inclusion criteria. CONCLUSIONS: Because we found no direct evidence on the safety and effectiveness of hormonal contraception for women who use opioids, we considered theoretical concerns. While women with OUD have a high prevalence of co-morbidities, such as viral hepatitis, generally women with medical conditions can safely use most contraceptive methods. When considering the pharmacokinetics and pharmacodynamics of hormonal contraception and opioids, there is little theoretical concern for interactions. Therefore, future research efforts could focus on improving access to the full range of contraceptive methods for women who use opioids, reducing unnecessary barriers to initiating and using contraception, while ensuring voluntary choice related to contraceptive use.

    • Social and Behavioral Sciences
      1. Recent legal and social changes in marriage equality, parenting among same-sex couples, and fatherhood discourses may prompt more US gay and bisexual men to desire fatherhood. However, scholars know little about fatherhood desires among these men. Therefore, we investigated temporal changes in fatherhood desires and perceptions of being bothered by future childlessness among US gay, bisexual, and heterosexual men. The sample included childless men participating in 5 cycles of the National Survey of Family Growth. Adjusted Wald tests and Pearson?s chi-square tests examined temporal changes in future fatherhood desires and being bothered by future childlessness, and they compared the men along these outcomes. We used logistic regression for multivariable analyses. The proportion of gay, bisexual, and heterosexual men who desired fatherhood remained stable from 2002 to 2013-2015. Most gay, bisexual, and heterosexual men desired fatherhood, but gay men had the lowest likelihood of doing so. Gay and bisexual men were less likely than heterosexual men to be bothered by future childlessness. Although the prevalence of fatherhood desires among these men did not increase during 2002-2015, the relatively high prevalence of fatherhood desires warrants research and data collection to understand factors influencing these desires, especially among gay and bisexual men.

    • Statistics as Topic
      1. Cumulative receiver operator characteristic (ROC) curve analysis extends classic ROC curve analysis to discriminate three or more ordinal outcome levels on a shared continuous scale. The procedure combines cumulative logit regression with a cumulative extension to the ROC curve and performs as expected with ternary (three-level) ordinal outcomes under a variety of simulated conditions (unbalanced data, proportional and non-proportional odds, areas under the ROC curve [AUCs] from 0.70 to 0.95). Simulations also compared several criteria for selecting cutpoints to discriminate outcome levels: the Youden Index, Matthews Correlation Coefficient, Total Accuracy, and Markedness. Total Accuracy demonstrated the least absolute percent-bias. Cutpoints computed from maximum likelihood regression parameters demonstrated bias that was often negligible. The procedure was also applied to publicly available data related to computer imaging and biomarker exposure science, yielding good to excellent AUCs, as well as cutpoints with sensitivities and specificities of commensurate quality. Implementation of cumulative ROC curve analysis and extension to more than three outcome levels are straightforward. The author’s programs for ternary ordinal outcomes are publicly available.

      2. INTRODUCTION: Reproducible research is increasingly gaining interest in the research community. Automating the production of research manuscript tables from statistical software can help increase the reproducibility of findings. Logistic regression is used in studying disease prevalence and associated factors in epidemiological studies and can be easily performed using widely available software including SAS, SUDAAN, Stata or R. However, output from these software must be processed further to make it readily presentable. There exists a number of procedures developed to organize regression output, though many of them suffer limitations of flexibility, complexity, lack of validation checks for input parameters, as well as inability to incorporate survey design. METHODS: We developed a SAS macro, %svy_logistic_regression, for fitting simple and multiple logistic regression models. The macro also creates quality publication-ready tables using survey or non-survey data which aims to increase transparency of data analyses. It further significantly reduces turn-around time for conducting analysis and preparing output tables while also addressing the limitations of existing procedures. In addition, the macro allows for user-specific actions to handle missing data as well as use of replication-based variance estimation methods. RESULTS: We demonstrate the use of the macro in the analysis of the 2013-2014 National Health and Nutrition Examination Survey (NHANES), a complex survey designed to assess the health and nutritional status of adults and children in the United States. The output presented here is directly from the macro and is consistent with how regression results are often presented in the epidemiological and biomedical literature, with unadjusted and adjusted model results presented side by side. CONCLUSIONS: The SAS code presented in this macro is comprehensive, easy to follow, manipulate and to extend to other areas of interest. It can also be incorporated quickly by the statistician for immediate use. It is an especially valuable tool for generating quality, easy to review tables which can be incorporated directly in a publication.

    • Substance Use and Abuse
      1. [No abstract]

    • Zoonotic and Vectorborne Diseases
      1. Knowledge and prevention of tickborne diseases among Hispanic and non-Hispanic residents of Maryland and Virginiaexternal icon
        Hu SY, Starr JA, Gharpure R, Mehta SP, Feldman KA, Nelson CA.
        Zoonoses Public Health. 2019 Sep 3.
        Tickborne diseases (TBDs) such as Lyme disease (LD), babesiosis, ehrlichiosis and Rocky Mountain spotted fever cause substantial morbidity and even mortality in the USA. Data indicate that Hispanic populations may be at greater risk for occupational exposure to ticks and disseminated LD; however, information on knowledge and practices of Hispanic populations regarding TBDs is limited. We surveyed 153 Hispanic and 153 non-Hispanic residents of Maryland and Virginia to assess awareness of TBDs, prevention practices and risk of tick encounters. Hispanic respondents were less likely than non-Hispanics to report familiarity with LD symptoms (21% vs. 53%, p < 0.001) and correctly identify ticks as vectors of LD (40% vs. 85%, p < 0.001). Although there was no significant difference in overall proportion of respondents who routinely take one or more preventive measures to prevent tick bites (59% vs. 61%, p = 0.65), Hispanics were more likely to report showering after coming indoors (36% vs. 25%, p = 0.04) but less likely to conduct daily tick checks compared with non-Hispanics (17% vs. 35%, p < 0.001). History of tick bite or finding a tick crawling on oneself or a household member in the past year did not significantly differ between Hispanics and non-Hispanics (19% vs. 24%, p = 0.26). Notably, after controlling for Hispanic/non-Hispanic ethnicity, primary language (English vs. Spanish) was a significant predictor of whether an individual had knowledge of LD symptoms, correctly identified ticks as vectors for LD and performed daily tick checks. These results provide guidance for future development of more targeted and effective TBD prevention education for both Hispanic and non-Hispanic communities.

      2. Overview of rabies post-exposure prophylaxis access, procurement and distribution in selected countries in Asia and Africa, 2017-2018external icon
        Sreenivasan N, Li A, Shiferaw M, Tran CH, Wallace R, Blanton J, Knopf L, Abela-Ridder B, Hyde T.
        Vaccine. 2019 Aug 27.
        BACKGROUND: Rabies is a neglected zoonotic disease with a global burden of approximately 59,000 human deaths a year. Once clinical symptoms appear, rabies is almost invariably fatal; however, with timely and appropriate post-exposure prophylaxis (PEP) consisting of wound washing, vaccine, and in some cases rabies immunoglobulin (RIG), the disease is almost entirely preventable. Access to PEP is limited in many countries, and when available, is often very expensive. METHODS: We distributed a standardized assessment tool electronically to a convenience sample of 25 low- and middle-income countries in Asia and Africa to collect information on rabies PEP procurement, forecasting, distribution, monitoring and reporting. Information was collected from national rabies focal points, focal points at the World Health Organization (WHO) country offices, and others involved in procurement, logistics and distribution of PEP. Because RIG was limited in availability or unavailable in many countries, the assessment focused on vaccine. Data were collected between January 2017 and May 2018. RESULTS: We received responses from key informants in 23 countries: 11 countries in Asia and 12 countries in Africa. In 9 of 23 (39%) countries, rabies vaccine was provided for free in the public sector and was consistently available. In 10 (43%) countries, all or some patients were required to pay for the vaccine in the public sector, with the cost of a single dose ranging from US$ 6.60 to US$ 20/dose. The primary reason for the high cost of the vaccine for patients was a lack of funding at the central level to subsidize vaccine costs. In the remaining 4 (17%) countries, vaccine was provided for free but was often unavailable so patients were required to purchase it instead. The majority of countries used the intramuscular route for vaccine administration and only 5 countries exclusively used the dose-sparing intradermal (ID) route. Half (11/22; 50%) of all countries assessed had a standardized distribution system for PEP, separate from the systems used for routine childhood vaccines, and almost half used separate storage facilities at both central and health facility levels. Approximately half (9/22; 41%) of all countries assessed reported having regular weekly, monthly or quarterly reporting on rabies vaccination. CONCLUSIONS: While all countries in our assessment had rabies vaccines available in the public sector to some extent, barriers to access include the high cost of the vaccine to the government as well as to patients. Countries should be encouraged to use ID administration as this would provide access to rabies vaccine for many more people with the same number of vaccine vials. In addition, standardized monitoring and reporting of vaccine utilization should be encouraged, in order to improve data on PEP needs.

      3. Notes from the field: Hantavirus pulmonary syndrome – Denver, Colorado, 2018external icon
        Tobolowsky F, Burakoff A, House J, Marzec N, Neumeier A, Sparks P, McLees M.
        MMWR Morb Mortal Wkly Rep. 2019 Sep 6;68(35):771-772.

        [No abstract]

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