Volume 11, Issue 38 September 24, 2019

CDC Science Clips: Volume 11, Issue 38, September 24, 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!

This week Science Clips is pleased to highlight articles from the September 2019 issue of the American Journal of Public Health focusing on Community Preparedness for Public Health Emergenciesexternal icon.

From the introduction: “Preparedness planning must account for and use the multitude of complex organizational and socioeconomic components that contribute to building community resilience following a large-scale tragedy. This supplement samples the broad-ranging topics that comprise the body of scientific and programmatic information available on the subject. . . . Our goal with this publication is to provide a forum for advancing evidence-based practice for analysis, reflection, consideration, and potential implementation. We hope that these articles stimulate continued scientific inquiry of public health emergency preparedness and encourage future investigations focused on improving community preparedness, recovery, and, ultimately, a resilient nation.”

  1. Key Scientific Articles in Featured Topic Areas
    Subject matter experts decide what topic to feature, and articles are selected from the last 3 to 6 months of published literature. Key topic coincides monthly with other CDC products (e.g. Vital Signs).
    • Disaster Control and Emergency Services

      The names of CDC authors are indicated in bold text.
      1. Community preparedness for public health emergencies: Introduction and contents of the volumeexternal icon
        Avchen RN, Kosmos C, LeBlanc TT.
        Am J Public Health. 2019 Sep;109(S4):S253-s255.

        [No abstract]

      2. The PanVax Tool to improve pandemic influenza emergency vaccination program readiness and partnershipexternal icon
        Carias C, Lehnert JD, Greening B, Adhikari BB, Kahn EB, Meltzer MI, Graitcer SB.
        Am J Public Health. 2019 Sep;109(S4):S322-s324.
        Objectives. To show how the Centers for Disease Control and Prevention’s Pandemic Vaccine Campaign Planning Tool (PanVax Tool) can help state and local public health emergency planners demonstrate and quantify how partnerships with community vaccine providers can improve their overall pandemic vaccination program readiness.Methods. The PanVax Tool helps planners compare different strategies to vaccinate their jurisdiction’s population in a severe pandemic by allowing users to customize the underlying model inputs in real time, including their jurisdiction’s size, community vaccine provider types, and how they allocate vaccine to these providers. In this report, we used a case study with hypothetical data to illustrate how jurisdictions can utilize the PanVax Tool for preparedness planning.Results. By using the tool, planners are able to understand the impact of engaging with different vaccine providers in a vaccination campaign.Conclusions. The PanVax Tool is a useful tool to help demonstrate the impact of community vaccine provider partnerships on pandemic vaccination readiness and identify areas for improved partnerships for pandemic response.

      3. Small area estimates of populations with chronic conditions for community preparedness for public health emergenciesexternal icon
        Holt JB, Matthews KA, Lu H, Wang Y, LeClercq JM, Greenlund KJ, Thomas CW.
        Am J Public Health. 2019 Sep;109(S4):S325-s331.
        Objectives. To demonstrate a flexible and practical method to obtain near real-time estimates of the number of at-risk community-dwelling adults with a chronic condition in a defined area potentially affected by a public health emergency.Methods. We used small area estimation with survey responses from the 2016 Behavioral Risk Factor Surveillance System together with a geographic information system to predict the number of adults with chronic obstructive pulmonary disease who lived in the forecasted path of Hurricane Florence in North and South Carolina in 2018.Results. We estimated that a range of 32 002 to 676 536 adults with chronic obstructive pulmonary disease resided between 50 and 200 miles of 3 consecutive daily forecasted landfalls. The number of affected counties ranged from 8 to 10 (at 50 miles) to as many as 119 to 127 (at 200 miles).Conclusions. Community preparedness is critical to anticipating, responding to, and ameliorating these health threats. We demonstrated the feasibility of quickly producing detailed estimates of the number of residents with chronic conditions who may face life-threatening situations because of a natural disaster. These methods are applicable to a range of planning and response scenarios.

      4. Preparing communities to evacuate for major hurricanesexternal icon
        Kruger J, Avchen RN, Purcell P.
        Am J Public Health. 2019 Sep;109(S4):S279-s280.

        [No abstract]

      5. The virtual village: A 21st-century challenge for community preparednessexternal icon
        LeBlanc TT, Ekperi L, Kosmos C, Avchen RN.
        Am J Public Health. 2019 Sep;109(S4):S258-s259.

        [No abstract]

      6. Building children’s preparedness capacity at the Centers for Disease Control and Prevention one event at a time, 2009-2018external icon
        Leeb RT, Franks JL, Dziuban EJ, Ruben W, Bartenfeld M, Hinton CF, Chatham-Stephens K, Peacock G.
        Am J Public Health. 2019 Sep;109(S4):S260-s262.

        [No abstract]

      7. Essential public health services framework: Use for rebuilding communitiesexternal icon
        Mainzer HM, Kruger J, Mahany M.
        Am J Public Health. 2019 Sep;109(S4):S271-s273.

        [No abstract]

      8. Preassessment of community-based organization preparedness in two sectors, human services and faith based: New York City, 2016external icon
        Rivera L, Pagaoa M, Molinari NA, Morgenthau BM, LeBlanc TT.
        Am J Public Health. 2019 Sep;109(S4):S290-s296.
        Objectives. To determine the level of preparedness among New York City community-based organizations by using a needs assessment.Methods. We distributed online surveys to 582 human services and 6017 faith-based organizations in New York City from March 17, 2016 through May 11, 2016. We calculated minimal indicators of preparedness to determine the proportion of organizations with preparedness indicators. We used bivariate analyses to examine associations between agency characteristics and minimal preparedness indicators.Results. Among the 210 human service sector respondents, 61.9% reported emergency management plans and 51.9% emergency communications systems in place. Among the 223 faith-based respondents, 23.9% reported emergency management plans and 92.4% emergency communications systems in place. Only 10.0% of human services and 18.8% of faith-based organizations reported having funds allocated for emergency response. Only 2.9% of human services sector and 39.5% of faith-based sector respondents reported practicing emergency communication alerts.Conclusions. New York City human service and faith-based sector organizations are striving to address emergency preparedness concerns, although notable gaps are evident.Public Health Implications. Our results can inform the development of metrics for community-based organizational readiness.

      9. CDC engagement with community and faith-based organizations in public health emergenciesexternal icon
        Santibanez S, Davis M, Avchen RN.
        Am J Public Health. 2019 Sep;109(S4):S274-s276.

        [No abstract]

      10. Community Assessments for Public Health Emergency Response (CASPERs) – US Virgin Islands, 2017-2018external icon
        Schnall AH, Wolkin AF, Roth JJ, Ellis EM.
        Am J Public Health. 2019 Sep;109(S4):S303-s308.
        Objectives. To assess preparedness levels of communities to help public health and others plan for disasters or emergencies and tailor messaging to increase community preparedness.Methods. US Virgin Islands Department of Health conducted a Community Assessment for Public Health Emergency Response (CASPER) in June 2017, 2 hurricane response CASPERs in November 2017, and a recovery CASPER in February 2018. CASPER is a 2-stage cluster sampling method designed to provide household-based information about a community’s needs in a timely, inexpensive, and representative manner.Results. Roughly the same amount of households reported having a 3-day supply of food and water before and 3 months after the hurricanes. During the response, approximately a third of households resupplied between 3 and 6 days and an additional approximately 40% between days 7 and 14.Conclusions. On the basis of the CASPERs, we were able to track whether households had an emergency preparedness kit, whether they used it during the storms (and what was missing), and if they resupplied their kit in recovery.Public Health Implications. CASPER is a promising tool to measure community preparedness to help state, local, tribal, and territorial jurisdictions plan for disasters or emergencies.

      11. Top-down and bottom-up measurement to enhance community resilience to disastersexternal icon
        Schoch-Spana M, Gill K, Hosangadi D, Slemp C, Burhans R, Zeis J, Carbone E, Links J.
        Am J Public Health. 2019 Sep;109(S4):S265-s267.

        [No abstract]

      12. Collaboration is key to community preparednessexternal icon
        Telfair LeBlanc T, Kosmos C, Avchen RN.
        Am J Public Health. 2019 Sep;109(S4):S252.

        [No abstract]

  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. Population health, place, and space: Spatial perspectives in chronic disease research and practiceexternal icon
        Casper M, Kramer MR, Peacock JM, Vaughan AS.
        Prev Chronic Dis. 2019 Sep 5;16:E123.

        [No abstract]

      2. Trends in cancer mortality among people with vs without diabetes in the USA, 1988-2015external icon
        Harding JL, Andes LJ, Gregg EW, Cheng YJ, Weir HK, Bullard KM, Burrows NR, Imperatore G.
        Diabetologia. 2019 Sep 12.
        AIMS/HYPOTHESIS: Cancer-related death is higher among people with vs without diabetes. However, it is not known if this excess risk has changed over time or what types of cancer may be driving these changes. METHODS: To estimate rates of site-specific cancer mortality in adults with vs without self-reported diagnosed diabetes, we used data from adults aged >/=18 years at the time of the interview who participated in the 1985-2012 National Health Interview Survey. Participants’ data were linked to the National Death Index by the National Center for Health Statistics to determine vital status and cause of death through to the end of 2015. Cancer deaths were classified according to underlying cause of death. Death rates for five time periods (1988-1994, 1995-1999, 2000-2004, 2005-2009, 2010-2015) were estimated using discrete Poisson regression models adjusted for age, sex and race/ethnicity with p for linear trend reported (ptrend). Site-specific cancer mortality rates were stratified by diabetes status and period, and total cancer mortality rates were additionally stratified by sex, race/ethnicity, education and BMI status. RESULTS: Among adults with diabetes, age-adjusted cancer mortality rates (per 10,000 person-years) declined 25.5% from 39.1 (95% CI 30.1, 50.8) in 1988-1994 to 29.7 (26.6, 33.1) in 2010-2015, ptrend < 0.001. Among adults without diabetes, rates declined 25.2% from 30.9 (28.6, 33.4) in 1988-1994 to 23.2 (22.1, 24.2) in 2010-2015, ptrend < 0.01. Adults with diabetes remained approximately 30% more likely to die from cancer than people without diabetes, and this excess risk did not improve over time. In adults with diabetes, cancer mortality rates did not decline in some population subgroups (including black people, people with lower levels of education and obese people), and the excess risk increased for obese adults with vs without diabetes. Declines in total cancer mortality rates in adults with diabetes appear to be driven by large relative declines in cancers of the pancreas (55%) and breast (65%), while for lung cancer, declines are modest (7%). CONCLUSIONS/INTERPRETATION: Declines in cancer mortality rates were observed in adults with and without diabetes. However, adults with diabetes continue to be more likely to die from cancer than people without diabetes. This study highlights the continued need for greater cancer risk-factor mitigation, especially in adults with diabetes.

      3. Patient navigation in cancer: The business case to support clinical needsexternal icon
        Kline RM, Rocque GB, Rohan EA, Blackley KA, Cantril CA, Pratt-Chapman ML, Burris HA, Shulman LN.
        J Oncol Pract. 2019 Sep 11:Jop1900230.
        PURPOSE: Patient navigation (PN) is an increasingly recognized element of high-quality, patient-centered cancer care, yet PN in many cancer programs is absent or limited, often because of concerns of extra cost without tangible financial benefits. METHODS: Five real-world examples of PN programs are used to demonstrate that in the pure fee-for-service and the alternative payment model worlds of reimbursement, strong cases can be made to support the benefits of PN. RESULTS: In three large programs, PN resulted in increased patient retention and increased physician loyalty within the cancer programs, leading to increased revenue. In addition, in two programs, PN was associated with a reduction in unnecessary resource utilization, such as emergency department visits and hospitalizations. PN also reduces burdens on oncology providers, potentially reducing burnout, errors, and costly staff turnover. CONCLUSION: PN has resulted in improved patient outcomes and patient satisfaction and has important financial benefits for cancer programs in the fee-for-service and the alternative payment model worlds, lending support for more robust staffing of PN programs.

      4. Global hemophilia care: Data for actionexternal icon
        Soucie JM.
        Ann Intern Med. 2019 Sep 10.

        [No abstract]

      5. National survey of primary care physicians’ knowledge, practices, and perceptions of prediabetesexternal icon
        Tseng E, Greer RC, O’Rourke P, Yeh HC, McGuire MM, Albright AL, Marsteller JA, Clark JM, Maruthur NM.
        J Gen Intern Med. 2019 Sep 9.
        BACKGROUND: Despite strong evidence and national policy supporting type 2 diabetes prevention, little is known about type 2 diabetes prevention in the primary care setting. OBJECTIVE: Our objective was to assess primary care physicians’ knowledge and practice regarding perceived barriers and potential interventions to improving management of prediabetes. DESIGN: Cross-sectional mailed survey. PARTICIPANTS: Nationally representative random sample of US primary care physicians (PCPs) identified from the American Medical Association Physician Masterfile. MAIN MEASURES: We assessed PCP knowledge, practice behaviors, and perceptions related to prediabetes. We performed chi-square and Fisher’s exact tests to evaluate the association between PCP characteristics and the main survey outcomes. KEY RESULTS: In total, 298 (33%) eligible participants returned the survey. PCPs had limited knowledge of risk factors for prediabetes screening, laboratory diagnostic criteria for prediabetes, and management recommendations for patients with prediabetes. Only 36% of PCPs refer patients to a diabetes prevention lifestyle change program as their initial management approach, while 43% discuss starting metformin for prediabetes. PCPs believed that barriers to type 2 diabetes prevention are both at the individual level (e.g., patients’ lack of motivation) and at the system level (e.g., lack of weight loss resources). PCPs reported that increased access to and insurance coverage of type 2 diabetes prevention programs and coordination of referral of patients to these resources would facilitate type 2 diabetes preventive efforts. CONCLUSIONS: Addressing gaps in PCP knowledge may improve the identification and management of people with prediabetes, but system-level changes are necessary to support type 2 diabetes prevention in the primary care setting.

      6. PURPOSE: To evaluate the psychometric properties of the Patient-Reported Outcome Measurement Information System(R) Fatigue Short Form 7a (PROMIS F-SF) among people with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). METHODS: Analyses were conducted using data from the Multi-Site Clinical Assessment of ME/CFS study, which recruited participants from seven ME/CFS specialty clinics across the US. Baseline and follow-up data from ME/CFS participants and healthy controls were used. Ceiling/Floor effects, internal consistency reliability, differential item functioning (DIF), known-groups validity, and responsiveness were examined. RESULTS: The final sample comprised 549 ME/CFS participants at baseline, 386 of whom also had follow-up. At baseline, the sample mean of PROMIS F-SF T-score was 68.6 (US general population mean T-score of 50 and standard deviation of 10). The PROMIS F-SF demonstrated good internal consistency reliability (Cronbach’s alpha = 0.84) and minimal floor/ceiling effects. No DIF was detected by age or sex for any item. This instrument also showed good known-groups validity with medium-to-large effect sizes (eta(2) = 0.08-0.69), with a monotonic increase of the fatigue T-score across ME/CFS participant groups with low, medium, and high functional impairment as measured by three different variables (p < 0.01), and with significantly higher fatigue T-scores among ME/CFS participants than healthy controls (p < 0.0001). Acceptable responsiveness was found with small-to-medium effect sizes (Guyatt’s Responsiveness Statistic = 0.28-0.54). CONCLUSIONS: Study findings support the reliability and validity of PROMIS F-SF as a measure of fatigue for ME/CFS and lend support to the drug development tool submission for qualifying this measure to evaluate therapeutic effect in ME/CFS clinical trials.

      7. Projecting burden of hypertension and its management in Turkey, 2015-2030external icon
        Yurekli AA, Bilir N, Husain MJ.
        PLoS One. 2019 ;14(9):e0221556.
        BACKGROUND: In Turkey, hypertension was responsible for 13% of total deaths in 2015. We apply existing research finding regarding the impact of a population-wide reduction in sodium consumption on the decrease of the hypertension prevalence rate among 15+ years population and the gender-age specific reduction in total death rates among 30+ years population, and compare hypertension burden, averted deaths, costs and benefits between two scenarios. METHODS: The first scenario (i.e. status quo) assumes constant hypertension prevalence rate and the death rates between 2015 and 2030. Based on the Framingham Heart Study and INTERSALT Study findings on the impact of salt-reduction strategies on hypertension prevalence rate, the second scenario (Scenario II) assumes a 17% reduction in the prevalence of hypertension in Turkey in 2030, from its 2015 prevalence level. We project hypertension attributable disability adjusted life years (DALYs) in 2030, monetize DALYs using GDP (and income) per capita, and compare the projected economic benefits of DALYs averted and the additional costs associated with the increases in hypertension treatment through antihypertensive medications and physician consultations. RESULTS: The estimated benefits of reducing the economic burden of hypertension deaths outweigh the cost of providing hypertension treatment. A decrease in hypertension prevalence by 17%, attributable to population-wide reduction in salt consumption, is projected to avert 24.3 thousand deaths in 2030. We projected that, compared to status quo, 392 thousand DALYs will be averted in Scenario II in 2030. The economic benefits of reduction in potential hypertension deaths are estimated to be 6.7 to 8.6 folds higher than the additional cost of hypertension treatment. CONCLUSION: Population-wide hypertension prevention and management is a win-win situation for public health and the Turkish health care system as the economic benefits of reducing deaths and disabilities associated with hypertension outweigh the costs significantly.

    • Communicable Diseases
      1. Distributive syringe sharing and use of syringe services programs (SSPs) among persons who inject drugsexternal icon
        Adams M, An Q, Broz D, Burnett J, Wejnert C, Paz-Bailey G.
        AIDS Behav. 2019 Sep 11.
        Monitoring distributive syringe sharing (DSS) and syringe services program (SSP) use among persons who inject drugs (PWID) is important for HIV prevention. PWID aged >/= 18 in 20 US cities were recruited for National HIV Behavioral Surveillance in 2015 using respondent-driven sampling, interviewed and offered HIV testing. Bivariate and multivariable analyses via log-linked Poisson regression with generalized estimating equations were conducted to examine associations between demographic and behavioral variables and DSS. Effect of SSP use on DSS by HIV sero-status was assessed by including an interaction between SSP and sero-status. Analyses were adjusted for sampling design. Among 10,402 PWID, 42% reported DSS. DSS was less likely to be reported among HIV-positive compared to HIV-negative PWID (aPR = 0.51, CI 0.45-0.60), and among those who primarily obtained syringes from SSPs versus those who did not (aPR = 0.82, 95% CI 0.77-0.88). After adjustment, those who primarily used SSPs were less likely to report DSS than those who did not among both HIV-negative PWID (aPR = 0.84, 95% CI 0.78-0.90) and HIV-positive PWID (aPR = 0.54, 95% CI 0.39-0.75). Findings support expansion of SSPs, and referrals to SSPs by providers working with PWID.

      2. Notes from the field: Interventions to reduce measles virus exposures in outpatient health care facilities – New York City, 2018external icon
        Alroy KA, Vora NM, Arciuolo RJ, Asfaw M, Isaac BM, Iwamoto M, Jean A, Benkel DH, Blaney K, Crouch B, Geevarughese A, Graham KA, Lash M, Daskalakis D, Zucker JR, Rosen JB.
        MMWR Morb Mortal Wkly Rep. 2019 Sep 13;68(36):791-792.

        [No abstract]

      3. BACKGROUND: Calculating national rates of HIV diagnosis, incidence, and prevalence can quantify disease burden, and is important for planning and evaluating programs. We calculated HIV rates among MSM, persons who inject drugs (PWID), and heterosexuals in 2010 and 2015. METHODS: We used proportion estimates of the US population classified as MSM, PWID, and heterosexuals along with census data to calculate the population sizes which were used as the denominators for calculating HIV rates. The numerators (HIV diagnosis, incidence, and prevalence) were based on data submitted to the National HIV Surveillance System through June 2017. RESULTS: The estimated HIV diagnosis and incidence rates in 2015 were 574.7 and 583.6 per 100 000 MSM; 34.3 and 32.7 per 100 000 PWID; and 4.1 and 3.8 per 100 000 heterosexuals. The estimated HIV prevalence in 2015 was 12 372.9 per 100 000 MSM; 1937.2 per 100 000 PWID; and 126.7 per 100 000 heterosexuals. The HIV diagnosis rates decreased from 2010 to 2015 in all three transmission categories. Black individuals had the highest HIV diagnosis rates at both time points. The HIV incidence rates decreased among white MSM, MSM aged 13-24 years, PWID overall, and male and female heterosexual individuals; however, it increased among MSM aged 25-34 years. CONCLUSIONS: The estimated HIV diagnosis and HIV infection rates decreased for several transmission categories, and also race/ethnicity and age subgroups. MSM continue to be disproportionately affected. Disparities remain and have widened for some groups. Efforts are needed to strengthen prevention, care, and supportive services for all persons with HIV infection.

      4. The detection of Coccidioides from ambient air in Phoenix, Arizona: Evidence of uneven distribution and seasonalityexternal icon
        Gade L, McCotter OZ, Bowers JR, Waddell V, Brady S, Carvajal JA, Sunenshine R, Komatsu KK, Engelthaler DM, Chiller T, Litvintseva AP.
        Med Mycol. 2019 Sep 10.
        Coccidioidomycosis is a debilitating fungal disease caused by inhalation of arthroconidia. We developed a novel approach for detection of airborne Coccidioides and used it to investigate the distribution of arthroconidia across the Phoenix, Arizona, metropolitan area. Air filters were collected daily from 21 stationary air-sampling units across the area: the first set collected before, during and after a large dust storm on August 25, 2015, and the second over the 45-day period September 25-November 8, 2016. Analysis of DNA extracted from the filters demonstrated that the day of the dust storm was not associated with increase of Coccidioides in air samples, although evidence of the low-level polymerase chain reaction (PCR) inhibition was observed in DNA extracted from samples collected on the day of the dust storm. Testing over 45 days identified uneven geographic distribution suggesting Coccidioides hot spots. In 2016, highest daily concentration of arthroconidia was observed between September 25-October 20, and only sporadic low levels were detected after that. These results provide evidence of seasonality and uneven spatial distribution of Coccidioides in the air. Our results demonstrate that routine air monitoring for arthroconidia is possible and provides an important tool for Coccidioides surveillance, which can address important questions about environmental exposure and human infection.

      5. HIV risk associated with serum medroxyprogesterone acetate levels among women in East and southern Africaexternal icon
        Heffron R, Stalter R, Pyra M, Nanda K, Erikson DW, Hladik F, Blue SW, Davis NL, Mugo N, Kourtis AP, Lingappa JR, Baeten JM.
        Aids. 2019 Mar 15;33(4):735-744.
        BACKGROUND: Some observational studies have found increased HIV risk associated with self-reported use of injectable depot medroxyprogesterone acetate. Testing blood samples for medroxyprogesterone acetate (MPA), the progestin in depot medroxyprogesterone acetate, permits validation of self-reported data, and exploration of whether potential HIV risk is correlated with MPA levels, which are highest soon after injection. METHODS: We conducted a case-control study testing archived serum from women who participated in three longitudinal studies of HIV prevention in East and southern Africa. Case samples, from women who acquired HIV, were from visits that occurred at or immediately prior to the first evidence of HIV infection. Secondary analyses restricted to case samples collected within 15 and 30 days of the estimated date of HIV infection. Matched control samples were from women who remained HIV uninfected. We used multivariable conditional logistic regression to compare exogenous hormone levels, quantified through mass spectrometry, among cases and controls. RESULTS: When restricted to cases with samples collected within 15 days or less of estimated date of HIV infection, MPA detection was more frequent among women who acquired HIV (adjusted odds ratio = 2.75, 95% confidence interval 1.22-6.19). In this subset, the increase in HIV risk was only among samples with MPA detected at a low level of 0.02-0.50 ng/ml: 36.7% of cases and 9.4% of controls, adjusted odds ratio = 6.03, 95% confidence interval 2.50-14.54. CONCLUSION: Detection of MPA at low levels close to the estimated time of HIV acquisition was significantly more frequent among women who acquired HIV. Studies are needed that explore biological mechanisms elicited by any MPA level and HIV risk.

      6. HPTN 067/ADAPT: Correlates of sex-related pre-exposure prophylaxis adherence, thai men who have sex with men, and transgender women, 2012-2013external icon
        Holtz TH, Chitwarakorn A, Hughes JP, Curlin ME, Varangrat A, Li M, Amico KR, Mock PA, Grant RM.
        J Acquir Immune Defic Syndr. 2019 Oct 1;82(2):e18-e26.
        BACKGROUND: We identified correlates of sex-related pre-exposure prophylaxis (PrEP) adherence in HPTN067/ADAPT, a phase 2, open-label feasibility study of daily and nondaily regimens of emtricitabine/tenofovir disoproxil fumarate (FTC/TDF)-based PrEP, among Thai men who have sex with men (MSM), and transgender women (TGW), Bangkok. METHODS: Participants were randomly assigned to one of three self-administered dosing regimens for 24 weeks: daily, time-driven, or event-driven. Demographic and behavioral information was obtained at screening. Pill-container opening was recorded with electronic dose monitoring, and self-reported information on PrEP use, sex events, and substance use was obtained during weekly interviews to confirm dose data. Sex-related PrEP adherence was calculated as the proportion of sex events covered by PrEP use (at least one tablet taken within 4 days before sex and at least one tablet taken within 24 hours after sex) to total sex events. We used multivariate modeling with sex event as the unit of analysis to evaluate correlates associated with sex-related PrEP adherence. RESULTS: Among 178 MSM and TGW, sex-related PrEP adherence was similar in the daily and time-driven arms (P = 0.79), both significantly greater than the event-driven arm (P = 0.02 compared to daily). Sex-related PrEP adherence by those reporting stimulant use (74.2%) was similar to those reporting other nonalcohol drug use (76.3%, P = 0.80), but lower than those reporting no substance use (84.6%, P = 0.04). In a multivariable model, randomization to the event-driven arm, a higher prestudy number of reported sex events, and use of stimulant drugs were associated with significantly lower sex-related PrEP adherence. CONCLUSION: Adherence was influenced by treatment schedule and adversely affected by nonalcoholic substance use. Regardless of these factors, Thai MSM and TGW maintained high adherence levels to oral PrEP dosing regimens and coverage of sexual exposures.

      7. Development of new TB regimens: Harmonizing trial design, product registration requirements, and public health guidanceexternal icon
        Lienhardt C, Vernon AA, Cavaleri M, Nambiar S, Nahid P.
        PLoS Med. 2019 Sep;16(9):e1002915.
        Christian Lienhardt and colleagues discuss the importance of communication and coordination between regulators, researchers, and policy makers to ensure tuberculosis trials provide high-quality evidence for policy decisions.

      8. Cascade of care for Alaska Native people with chronic hepatitis C virus infection: Statewide program with high linkage to careexternal icon
        McMahon BJ, Townshend-Bulson L, Homan C, Gounder P, Barbour Y, Hewitt A, Bruden D, Espera H, Plotnik J, Gove J, Stevenson TJ, Luna SV, Simons BC.
        Clin Infect Dis. 2019 Aug 28.
        Most persons with chronic HCV infection in the United States are undiagnosed or linked to care. We describe a program for the management of Alaska Native patients with HCV infection utilizing a computerized registry and statewide liver clinics resulting in higher linkage to care (86%) compared to national estimates (approximately 25%).

      9. Pediatric bacterial meningitis surveillance in the World Health Organization African Region using the Invasive Bacterial Vaccine-Preventable Disease Surveillance Network, 2011-2016external icon
        Mwenda JM, Soda E, Weldegebriel G, Katsande R, Biey JN, Traore T, de Gouveia L, du Plessis M, von Gottberg A, Antonio M, Kwambana-Adams B, Worwui A, Gierke R, Schwartz S, van Beneden C, Cohen A, Serhan F, Lessa FC.
        Clin Infect Dis. 2019 Sep 5;69(Supplement_2):S49-s57.
        BACKGROUND: Bacterial meningitis is a major cause of morbidity and mortality in sub-Saharan Africa. We analyzed data from the World Health Organization’s (WHO) Invasive Bacterial Vaccine-preventable Diseases Surveillance Network (2011-2016) to describe the epidemiology of laboratory-confirmed Streptococcus pneumoniae (Spn), Neisseria meningitidis, and Haemophilus influenzae meningitis within the WHO African Region. We also evaluated declines in vaccine-type pneumococcal meningitis following pneumococcal conjugate vaccine (PCV) introduction. METHODS: Reports of meningitis in children <5 years old from sentinel surveillance hospitals in 26 countries were classified as suspected, probable, or confirmed. Confirmed meningitis cases were analyzed by age group and subregion (South-East and West-Central). We described case fatality ratios (CFRs), pathogen distribution, and annual changes in serotype and serogroup, including changes in vaccine-type Spn meningitis following PCV introduction. RESULTS: Among 49 844 reported meningitis cases, 1670 (3.3%) were laboratory-confirmed. Spn (1007/1670 [60.3%]) was the most commonly detected pathogen; vaccine-type Spn meningitis cases declined over time. CFR was the highest for Spn meningitis: 12.9% (46/357) in the South-East subregion and 30.9% (89/288) in the West-Central subregion. Meningitis caused by N. meningitidis was more common in West-Central than South-East Africa (321/954 [33.6%] vs 110/716 [15.4%]; P < .0001). Haemophilus influenzae (232/1670 [13.9%]) was the least prevalent organism. CONCLUSIONS: Spn was the most common cause of pediatric bacterial meningitis in the African region even after reported cases declined following PCV introduction. Sustaining robust surveillance is essential to monitor changes in pathogen distribution and to inform and guide vaccination policies.

      10. Low disclosure of PrEP nonadherence and HIV-risk behaviors associated with poor HIV PrEP adherence in the HPTN 067/ADAPT Studyexternal icon
        Ojeda VD, Amico KR, Hughes JP, Wilson E, Li M, Holtz TH, Chitwarakorn A, Grant RM, Dye BJ, Bekker LG, Mannheimer S, Marzinke M, Hendrix CW.
        J Acquir Immune Defic Syndr. 2019 Sep 1;82(1):34-40.
        OBJECTIVE: We evaluated the relationship between 2 types of social relationships, ie, (1) external support for use of HIV pre-exposure prophylaxis (PrEP) and related study supplies and (2) participants’ disclosure of PrEP use and condom use and HIV PrEP adherence among daily-dosing regimen participants in HIV Prevention Trials Network (HPTN) 067, an open-label trial of oral tenofovir (TFV) disoproxil fumarate (TDF) 300 mg/emtricitabine (FTC) 200 mg. METHODS: Using HPTN 067 survey data, we developed scales examining (1) Low Perceived External Support for PrEP: low perceived support by others for PrEP use or perceived negative reactions to the pill case (scoring ranges from 0 to 2) and (2) Participant-Staff Disclosure Challenges Scale, which identifies challenges to sharing nonuse of PrEP or condoms to study staff (scoring ranges from 0 to 4); these scales are the primary independent variables. Adherence, the dependent variable, was determined using log-transformed plasma TFV concentrations. generalized estimating equation (GEE) linear regression was used to assess the association between both scales and adherence. RESULTS: Participants (n = 161) included HIV-uninfected women in South Africa, and men who have sex with men and transgender women, in Thailand and the United States. In multivariable analyses, higher scores in the Participant-Staff Disclosure Challenges Scale were significantly associated with lower PrEP adherence [exp(beta) = 0.62, 95% CI: (0.46 to 0.84); P = 0.002] as were increased days since the last PrEP dose [exp(beta) = 0.73, 95% CI: (0.65 to 0.83); P </= 0.001]. CONCLUSIONS: Given the association with adherence, study staff-participant interactions and participants’ disclosure of PrEP challenges may be worthwhile intervention targets for improving PrEP adherence in confirmatory studies.

      11. Decreased HIV-associated mortality rates during scale-up of antiretroviral therapy, 2011-2016: a population-based cohort studyexternal icon
        Otieno G, Whiteside YO, Achia T, Kwaro D, Zielinski-Gutierrez E, Ojoo S, Sewe M, Musingila P, Akelo V, Obor D, Nyaguara A, de Cock KM, Borgdorff MW.
        Aids. 2019 Sep 3.
        OBJECTIVE: HIV-associated mortality rates in Africa decreased by 10%-20% annually in 2003-2011, after the introduction of antiretroviral therapy (ART). We sought to document HIV-associated mortality rates in the general population in Kenya after 2011 in an era of expanded access to ART. DESIGN: We obtained data on mortality rates and migration from a health and demographic surveillance system (HDSS) in Gem, western Kenya, and data for HDSS residents aged 15-64 years from home-based HIV-counseling and testing (HBCT) rounds in 2011, 2012, 2013, and 2016. METHODS: Mortality trends were determined among a closed cohort of residents who participated in at least the 2011 round of HBCT. RESULTS: Of 32,467 eligible HDSS residents, 22,688 (70%) participated in the 2011 round and comprised the study cohort. All-cause mortality rates declined from 10.0 (95% confidence interval [CI] 8.4-11.7) per 1000 in 2011 to 7.4 (95% CI 5.7-9.0) in 2016, while the mortality rate was stable among HIV-uninfected residents, at 5.7 per 1000 person-years. Among HIV-infected residents, mortality rates declined from 30.5 per 1000 in 2011 to 15.9 per 1000 in 2016 (average decline, 6% per year). The HIV-infected group receiving ART had higher mortality rates than the HIV-uninfected group (adjusted rate ratio (aRR), 2.8; 95% CI 2.2-3.4), as did the HIV-infected group who did not receive ART (aRR, 5.3; 95% CI 4.5-6.2). CONCLUSIONS: Mortality rates among HIV-infected individuals declined substantially during ART expansion between 2011 and 2016, though less than during early ART introduction. Mortality trends among HIV-infected populations are critical to understanding epidemic dynamics.

      12. Burden of influenza-associated respiratory hospitalizations in the Americas, 2010-2015external icon
        Palekar RS, Rolfes MA, Arriola CS, Acosta BO, Guidos PA, Vargas XB, Bancej C, Ramirez JB, Baumeister E, Bruno A, Cabello MA, Chen J, Couto P, Junior FJ, Fasce R, Ferreira de Almeida W, Solorzano VE, Ramirez CF, Goni N, Isaza de Molto Y, Lara J, Malo DC, Medina Osis JL, Mejia H, Castillo LM, Mustaquim D, Nwosu A, Ojeda J, Samoya AP, Pulido PA, Ramos Hernandez HM, Lopez RR, Rodriguez A, Saboui M, Bolanos HS, Santoro A, Silvera JE, Sosa P, Sotomayor V, Suarez L, Von Horoch M, Azziz-Baumgartner E.
        PLoS One. 2019 ;14(9):e0221479.
        BACKGROUND: Despite having influenza vaccination policies and programs, countries in the Americas underutilize seasonal influenza vaccine, in part because of insufficient evidence about severe influenza burden. We aimed to estimate the annual burden of influenza-associated respiratory hospitalizations in the Americas. METHODS: Thirty-five countries in the Americas with national influenza surveillance were invited to provide monthly laboratory data and hospital discharges for respiratory illness (International Classification of Diseases 10th edition J codes 0-99) during 2010-2015. In three age-strata (<5, 5-64, and >/=65 years), we estimated the influenza-associated hospitalizations rate by multiplying the monthly number of respiratory hospitalizations by the monthly proportion of influenza-positive samples and dividing by the census population. We used random effects meta-analyses to pool age-group specific rates and extrapolated to countries that did not contribute data, using pooled rates stratified by age group and country characteristics found to be associated with rates. RESULTS: Sixteen of 35 countries (46%) contributed primary data to the analyses, representing 79% of the America’s population. The average pooled rate of influenza-associated respiratory hospitalization was 90/100,000 population (95% confidence interval 61-132) among children aged <5 years, 21/100,000 population (13-32) among persons aged 5-64 years, and 141/100,000 population (95-211) among persons aged >/=65 years. We estimated the average annual number of influenza-associated respiratory hospitalizations in the Americas to be 772,000 (95% credible interval 716,000-829,000). CONCLUSIONS: Influenza-associated respiratory hospitalizations impose a heavy burden on health systems in the Americas. Countries in the Americas should use this information to justify investments in seasonal influenza vaccination-especially among young children and the elderly.

      13. Incidence of Campylobacter-associated Guillain-Barre syndrome estimated from health insurance dataexternal icon
        Scallan Walter EJ, Crim SM, Bruce BB, Griffin PM.
        Foodborne Pathog Dis. 2019 Sep 11.
        Guillain-Barre syndrome (GBS) is sometimes preceded by Campylobacter infection. We estimated the cumulative incidence of Campylobacter-associated GBS in the United States using a retrospective cohort design. We identified a cohort of patients with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code of “intestinal infection due to Campylobacter” (008.43) using MarketScan Research Databases for 2004-2013. Campylobacter patients with an encounter for “acute infective polyneuritis” (AIP; ICD-9-CM 357.0) were identified. Patients with an inpatient encounter having AIP as the principal diagnosis were considered probable GBS cases. Patients with probable GBS </=8 weeks after the Campylobacter encounter were considered probable Campylobacter-associated GBS cases. For comparison, we repeated this analysis for patients with “other Salmonella infections” (ICD-9-CM: 003). Among 9315 Campylobacter patients, 16 met the case definition for probable GBS. Two were hospitalized with probable GBS </=8 weeks after the encounter listing a Campylobacter diagnosis (9 and 54 days) and were considered probable cases of Campylobacter-associated GBS; this results in an estimated cumulative incidence of 21.5 per 100,000 Campylobacter patients (95% confidence interval [CI]: 3.7-86.6), or 5% of all estimated GBS cases. The remaining 14 patients were diagnosed with probable GBS on the same encounter (n = 12) or 1-3 days (n = 2), before the encounter listing the Campylobacter diagnosis. Including these cases increased the cumulative incidence to 172 per 100,000 Campylobacter cases (95% CI: 101.7-285.5), 41% of estimated GBS cases. This study, using a method not previously applied to United States data, supports other data that Campylobacter is an important contributor to GBS, accounting for at least 5% and possibly as many as 41% of all GBS cases. These data can be used to inform estimates of the burden of Campylobacter infections, including economic cost.

      14. Factors associated with HIV antiretroviral therapy among men who have sex with men in 20 US cities, 2014external icon
        Stein R, Xu S, Williams W, Marano M, Eke A, Finlayson T, Paz-Bailey G, Wejnert C.
        J Urban Health. 2019 Sep 11.
        Reducing HIV among men who have sex with men (MSM) is a national goal, and early diagnosis, timely linkage to HIV medical care, and ongoing care and treatment are critical for improving health outcomes for MSM with HIV and preventing transmission to others. We assessed demographic, social, and economic factors associated with HIV antiretroviral treatment among HIV-infected MSM. Data are from the National HIV Behavioral Surveillance (NHBS) collected in 2014 among MSM. We estimated prevalence ratios and 95% confidence intervals using average marginal predictions from logistic regression. Overall, 89% of HIV-positive MSM reported currently taking antiretroviral therapy (ART). After controlling for other variables, we found that higher perceived community stigma and not having health insurance were significant risk factors for not taking ART. We also found that high socioeconomic status (SES) was associated with taking ART. Race/ethnicity was not significantly associated with taking ART in either the unadjusted or adjusted analyses. Findings suggest that to increase ART use for MSM with HIV, we need to move beyond individual-level approaches and move towards the development, dissemination, and evaluation of structural and policy interventions that respond to these important social and economic factors.

      15. Treatment adherence among persons receiving concurrent multidrug-resistant tuberculosis and HIV treatment in KwaZulu-Natal, South Africaexternal icon
        Stephens F, Gandhi NR, Brust JC, Mlisana K, Moodley P, Allana S, Campbell A, Shah S.
        J Acquir Immune Defic Syndr. 2019 Oct 1;82(2):124-130.
        BACKGROUND: Success in multidrug-resistant tuberculosis (MDR-TB) and HIV treatment requires high medication adherence despite high pill burdens, frequent adverse events, and long treatment duration, which may jeopardize adherence. We prospectively compared MDR-TB/HIV-coinfected persons to those with MDR-TB alone to determine the impact of concurrent treatment on adherence and outcomes. METHODS: We assessed medication adherence monthly using 3-day recall, 30-day recall, and visual analog scale and examined adherence to monthly study visits (months 0-12). We determined the proportion of participants fully adherent (no reported missed doses) to MDR-TB vs. HIV treatment by each measure. We assessed the association of medication and clinic visit adherence with MDR-TB treatment success (cure or completion, 18-24 months) and HIV virologic suppression. RESULTS: Among 200 patients with MDR-TB, 63% were women, median age was 33 years, 144 (72%) were HIV-infected, and 81% were receiving antiretroviral therapy (ART) at baseline. Adherence to medications (81%-98% fully adherent across all measures) and clinic visits (80% missed </=1 visit) was high, irrespective of HIV status. Adherence to ART was significantly higher than to MDR-TB treatment by all self-reported measures (3-day recall: 92% vs. 84%, respectively; P = 0.003). In multivariable analysis, the adjusted risk ratio of unsuccessful MDR-TB treatment increased with every missed visit: 1.50, 2.25, and 3.37 for unsuccessful treatment, for 1, 2, and >/=3 missed visits. CONCLUSIONS: Adherence to ART was higher than to MDR-TB treatment among persons with MDR-TB/HIV coinfection. Missed clinic visits may be a simple measure for identifying patients at risk of unsuccessful MDR-TB treatment outcome.

      16. Underdetection of laboratory-confirmed influenza-associated hospital admissions among infants: a multicentre, prospective studyexternal icon
        Thompson MG, Levine MZ, Bino S, Hunt DR, Al-Sanouri TM, Simoes EA, Porter RM, Biggs HM, Gresh L, Simaku A, Khader IA, Tallo VL, Meece JK, McMorrow M, Mercado ES, Joshi S, DeGroote NP, Hatibi I, Sanchez F, Lucero MG, Faouri S, Jefferson SN, Maliqari N, Balmaseda A, Sanvictores D, Holiday C, Sciuto C, Owens Z, Azziz-Baumgartner E, Gordon A.
        Lancet Child Adolesc Health. 2019 Sep 3.
        BACKGROUND: Since influenza often presents non-specifically in infancy, we aimed to assess the extent to which existing respiratory surveillance platforms might underestimate the frequency of severe influenza disease among infants. METHODS: The Influenza and Respiratory Syncytial Virus in Infants (IRIS) study was a prospective observational study done at four hospitals in Albania, Jordan, Nicaragua, and the Philippines. We included acutely ill infants aged younger than 1 year admitted to hospital within 10 days or less of illness onset during two influenza seasons (2015-16 and 2016-17) in Albania, Jordan, and Nicaragua, and over a continuous 34 week period (2015-16) in the Philippines. We assessed the frequency of influenza virus infections by real-time RT-PCR (rRT-PCR) and serology. The main study outcome was seroconversion, defined as convalescent antibody titres more than or equal to four-fold higher than acute sera antibody titres, and convalescent antibody titres of 40 or higher. Seroconverison was confirmed by haemagglutination inhibition assay for influenza A viruses, and by hemagglutination inhibition assay and microneutralisation for influenza B viruses. FINDINGS: Between June 27, 2015, and April 21, 2017, 3634 acutely ill infants were enrolled, of whom 1943 were enrolled during influenza seasons and had complete acute-convalescent pairs and thus were included in the final analytical sample. Of the 1943 infants, 94 (5%) were influenza-positive by both rRT-PCR and serology, 58 (3%) were positive by rRT-PCR-only, and 102 (5%) were positive by serology only. Seroconversion to at least one of the influenza A or B viruses was observed among 196 (77%) of 254 influenza-positive infants. Of the 254 infants with influenza virus, 84 (33%) only had non-respiratory clinical discharge diagnoses (eg, sepsis, febrile seizures, dehydration, or other non-respiratory viral illness). A focus on respiratory diagnoses and rRT-PCR-confirmed influenza underdetects influenza-associated hospital admissions among infants by a factor of 2.6 (95% CI 2.0-3.6). Findings were unchanged when syndromic severe acute respiratory infection criteria were applied instead of clinical diagnosis. INTERPRETATION: If the true incidence of laboratory-confirmed influenza-associated hospital admissions among infants is at least twice that of previous estimates, this substantially increases the global burden of severe influenza and expands our estimates of the preventive value of maternal and infant influenza vaccination programmes. FUNDING: US Centers for Disease Control and Prevention.

      17. A prospective comparative study of children with gastroenteritis: emergency department compared with symptomatic care at homeexternal icon
        Vanderkooi OG, Xie J, Lee BE, Pang XL, Chui L, Payne DC, MacDonald J, Ali S, MacDonald S, Drews S, Osterreicher L, Kim K, Freedman SB.
        Eur J Clin Microbiol Infect Dis. 2019 Sep 9.
        Little is known about the epidemiology and severity of gastroenteritis among children treated at home. We sought to compare illness severity and etiology between children brought for emergency department (ED) care to those managed at home (i.e., community). Prospective cohort study of children enrolled between December 2014 and December 2016 in two pediatric EDs in Alberta, Canada along with children treated at home after telephone triage (i.e., community). Primary outcomes were maximal frequency of vomiting and diarrhea in the 24-h pre-enrollment period; secondary outcomes included etiologic pathogens, dehydration severity, future healthcare visits, and treatments provided. A total of 1613 patients (1317 ED, 296 community) were enrolled. Median maximal frequency of vomiting was higher in the ED cohort (5 (3, 10) vs. 5 (2, 8); P < 0.001). Proportion of children with diarrhea and its 24-h median frequency were lower in the ED cohort (61.3 vs. 82.8% and 2 (0, 6) vs. 4 (1, 7); P < 0.001, respectively). In regression analysis, the ED cohort had a higher maximum number of vomiting episodes pre-enrollment (incident rate ratio (IRR) 1.25; 95% CI 1.12, 1.40) while the community cohort had higher maximal 24-h period diarrheal episodes (IRR 1.20; 95% CI 1.01, 1.43). Norovirus was identified more frequently in the community cohort (36.8% vs. 23.6%; P < 0.001). Children treated in the ED have a greater number of vomiting episodes; those treated at home have more diarrheal episodes. Norovirus is more common among children treated symptomatically at home and thus may represent a greater burden of disease than previously thought.

      18. Notes from the Field: Fatal Naegleria fowleri meningoencephalitis after swimming in hot spring water – California, 2018external icon
        Vugia DJ, Richardson J, Tarro T, Vareechon C, Pannaraj PS, Traub E, Cope JR, Balter S.
        MMWR Morb Mortal Wkly Rep. 2019 Sep 13;68(36):793-794.

        [No abstract]

    • Disaster Control and Emergency Services
      1. The call for articles on the long term health effects of the 11 September 2001 terrorist attacks (9/11) has resulted in twenty-three papers that add a significant amount of information to the growing body of research on the effects of the World Trade Center (WTC) disaster almost two decades later […].

    • Disease Reservoirs and Vectors
      1. The need for a national strategy to address vector-borne disease threats in the United Statesexternal icon
        Beard CB, Visser SN, Petersen LR.
        J Med Entomol. 2019 Sep 3;56(5):1199-1203.
        Vector-borne diseases (VBDs) cause significant morbidity and mortality each year in the United States. Over the last 14 yr, over 700,000 cases of diseases carried by ticks, mosquitoes, and fleas have been reported from U.S. states and territories to the Centers for Disease Control and Prevention. The number of reported cases has been increasing annually with two major trends: a steady increase in tick-borne diseases and increasing intermittent outbreaks of mosquito-borne arboviruses. The factors that are driving VBD introduction and emergence vary among diseases but are not likely to disappear, indicating that current trends will continue and probably worsen in the absence of effective prevention and control tools and implementation capacity. There are a number of challenges to preventing VBDs, including the lack of vaccines and effective vector control tools, insecticide resistance, and eroding technical capacities in public health entomology at federal, state, and local levels. For these reasons, a national strategy is needed to address VBD threats and to reverse the alarming trend in morbidity and mortality associated with these diseases.

      2. The theme of the 2018 Entomological Society of America, Entomological Society of Canada, and Entomological Society of British Columbia Joint Annual Meeting was Crossing Borders: Entomology in a Changing World. Following the theme of the meeting, papers selected for the 2018 ‘Highlights of Medical Entomology’ included reports of expanded ranges for Aedes albopictus (Skuse) (Diptera: Culicidae), Aedes japonicus japonicus (Theobald) (Diptera: Culicidae), Culex coronator Dyar and Knab (Diptera: Culicidae), Mansonia titillans (Walker) (Diptera: Culicidae), and Wyeomyia mitchellii (Theobald) (Diptera: Culicidae); a first report of mosquito feeding on earthworms and leeches; Cache Valley virus detection in Ae. j. japonicus; surveillance in high-risk areas of Canada for Lyme Disease; and increasing lone-star tick detections in Connecticut. The selection of papers served as a reminder of the increasingly difficult challenge of sustaining vector surveillance programs. Fluctuating funding and a decline in vector taxonomists and identification expertise contribute to the erosion of vector surveillance.

      3. Detection of ‘Candidatus Ehrlichia khabarensis’ in rodents and ticks removed from rodents in British Columbia, Canadaexternal icon
        Morshed MG, Hojgaard A, Lee MK, Osikowicz LM, Eisen L.
        Ticks Tick Borne Dis. 2019 Aug 24:101277.
        ‘Candidatus Ehrlichia khabarensis’ was first described from rodents and insectivores in the Far East territory of Khabarovsk on the Russian Pacific Coast. Here we report the detection of DNA from this microorganism in rodents and fed ticks collected from rodents in British Columbia, Canada in 2013-2014. ‘Candidatus Ehrlichia khabarensis’ was detected in (i) a female Ixodes angustus tick collected from a Peromyscus maniculatus; (ii) a female Dermacentor andersoni tick collected from a Perognathus parvus; (iii) a pool of 2 larval Ixodes pacificus ticks collected from a single P. maniculatus; and (iv) a pool of 3 nymphal I. pacificus ticks collected from a single P. maniculatus. Three of these four rodents (2 P. maniculatus and 1 P. parvus) with infected ticks also had evidence of ‘Candidatus Ehrlichia khabarensis’ in at least one tissue type. The infected P. maniculatus and Ixodes ticks came from the Vancouver area in western British Columbia and the P. parvus and Dermacentor tick from an inland site in central British Columbia. Although it remains to be determined whether ‘Candidatus Ehrlichia khabarensis’ has any negative impacts on wildlife, domestic animals or humans, we note that all three tick species found to contain the DNA of this microorganism are known to bite humans. Future detection of this microorganism either in ticks collected from rodents and allowed to molt to the next life stage prior to being tested, or from host-seeking ticks, is required to determine if it can survive the tick’s molt after being ingested via an infectious blood meal.

    • Environmental Health
      1. Background: People living in coastal communities are at risk for exposure to environmental hazards, including legacy chemicals. We can use databases such as NHANES to assess whether contaminants in coastal communities are present in higher levels than in the United States overall. We can use information from studies of local animal populations to assess which of these contaminants could have been transferred to people from their shared environment. Objective(s): Our objectives were to examine the POP profiles in human populations in areas where there are published POP profiles in resident dolphins and to compare our results with data from NHANES and the dolphin studies. Method(s): We identified three areas where POPs have been analyzed in local resident dolphin populations (total N = 73). We identified human communities in the same areas, and asked 27 eligible adults to read and sign a consent form, complete a questionnaire about demographics and seafood consumption, provide nine 10-mL blood samples, and provide one sample of seafood (N = 33). Blood and seafood were analyzed for a suite of POPs similar to those analyzed in published dolphin population studies. We compared the results from human blood analyses with NHANES and with data from the published reports of dolphin studies. Result(s): Levels and proportions of specific POPs found in people and animals reflect POPs found in the local environment. Compared with the nationally representative data reported in NHANES, the levels of many POPs found in high levels in dolphins were also higher in the corresponding human communities. Conclusion(s): Contaminants measured in marine animals, such as dolphins, can be used to identify the types and relative levels of environmental contaminants expected to occur in people sharing the same environment. Likewise, contaminants measured in coastal human populations can provide insight into which contaminants may be found in nearby animal populations.

      2. Ambient air pollution and in vitro fertilization treatment outcomesexternal icon
        Boulet SL, Zhou Y, Shriber J, Kissin DM, Strosnider H, Shin M.
        Hum Reprod. 2019 Sep 4.
        STUDY QUESTION: Is air pollution associated with IVF treatment outcomes in the USA? SUMMARY ANSWER: We did not find clear evidence of a meaningful association between reproductive outcomes and average daily concentrations of particulate matter with an aerodynamic diameter </=2.5 mum (PM2.5) and ozone (O3). WHAT IS KNOWN ALREADY: Maternal exposure to air pollution such as PM2.5, nitrogen oxides, carbon monoxide or O3 may increase risks for adverse perinatal outcomes. Findings from the few studies using data from IVF populations to investigate associations between specific pollutants and treatment outcomes are inconclusive. STUDY DESIGN, SIZE AND DURATION: Retrospective cohort study of 253 528 non-cancelled fresh, autologous IVF cycles including 230 243 fresh, autologous IVF cycles with a transfer of >/=1 embryo was performed between 2010 and 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS: We linked 2010-2012 National ART Surveillance System data for fresh, autologous IVF cycles with the ambient air pollution data generated using a Bayesian fusion model available through the Centers for Disease Control and Prevention’s Environmental Public Health Tracking Network. We calculated county-level average daily PM2.5 and O3 concentrations for three time periods: cycle start to oocyte retrieval (T1), oocyte retrieval to embryo transfer (T2) and embryo transfer +14 days (T3). Multivariable predicted marginal proportions from logistic and log-linear regression models were used to estimate adjusted risk ratios (aRR) and 95% CI for the association between reproductive outcomes (implantation rate, pregnancy and live birth) and interquartile increases in PM2.5 and O3. The multipollutant models were also adjusted for patients and treatment characteristics and accounted for clustering by clinic and county of residence. MAIN RESULTS AND THE ROLE OF CHANCE: For all exposure periods, O3 was weakly positively associated with implantation (aRR 1.01, 95% CI 1.001-1.02 for T1; aRR 1.01, 95% CI 1.001-1.02 for T2 and aRR 1.01, 95% CI 1.001-1.02 for T3) and live birth (aRR 1.01, 95% CI 1.002-1.02 for T1; aRR 1.01, 95% CI 1.004-1.02 for T2 and aRR 1.02, 95% CI 1.004-1.03 for T3). PM2.5 was not associated with any of the reproductive outcomes assessed. LIMITATIONS, REASONS FOR CAUTION: The main limitation of this study is the use of aggregated air pollution data as proxies for individual exposure. The weak positive associations found in this study might be related to confounding by factors that we were unable to assess and may not reflect clinically meaningful differences. WIDER IMPLICATIONS OF THE FINDINGS: More research is needed to assess the impact of air pollution on reproductive function. STUDY FUNDING/COMPETING INTEREST(S): None.

      3. Biomonitoring of populations in Western New York at risk for exposure to Great Lakes contaminantsexternal icon
        Savadatti SS, Liu M, Caglayan C, Reuther J, Lewis-Michl EL, Aldous KM, Parsons PJ, Kannan K, Rej R, Wang W, Palmer CD, Steuerwald AJ, Wattigney WA, Irvin-Barnwell E, Hwang SA.
        Environ Res. 2019 Aug 27;179(Pt A):108690.
        The New York State Department of Health conducted the Healthy Fishing Communities Program in collaboration with the Agency for Toxic Substances and Disease Registry to assess human exposure to contaminants common to Lake Ontario, Lake Erie and surrounding rivers and waterways among populations in western New York State who eat locally caught fish. The program enrolled licensed anglers and Burmese refugees and immigrants, living near four designated Great Lakes Areas of Concern: Buffalo River, Niagara River, Eighteenmile Creek, and the Rochester Embayment. These target populations were sampled and enrolled independently into the program between February and October of 2013. A core set of contaminants were measured in blood and urine of 409 licensed anglers and 206 Burmese refugees and immigrants which included lead, cadmium, mercury, PCBs, PBDEs, organochlorine pesticides (hexachlorobenzene, mirex, DDT, DDE, and chlordane and its metabolites oxychlordane and trans-Nonachlor), and PFOS and PFOA. Biomonitoring results showed that both groups had higher geometric means for blood lead, total blood mercury, and serum PFOS compared to the 2013-2014 NHANES reference levels. The Burmese refugee group also showed higher geometric means for creatinine-adjusted urine mercury and lipid-adjusted serum DDE compared to national levels. Licensed angler participants reported eating a median of 16 locally caught fish meals in the past year. Burmese participants consumed local fish throughout the year, and most frequently in the summer (median 39 fish meals or 3 times a week). The study results provide valuable information on populations at high risk of exposure to contaminants in the Great Lakes Basin of western New York. The results provide the foundation for developing and implementing public health actions to reduce potential exposures to Great Lakes pollutants.

    • Food Safety
      1. Multistate outbreaks of Salmonella infections linked to imported Maradol papayas – United States, December 2016-September 2017external icon
        Hassan R, Whitney B, Williams DL, Holloman K, Grady D, Thomas D, Omoregie E, Lamba K, Leeper M, Gieraltowski L.
        Epidemiol Infect. 2019 Sep 10;147:e265.
        Foodborne salmonellosis causes approximately 1 million illnesses annually in the United States. In the summer of 2017, we investigated four multistate outbreaks of Salmonella infections associated with Maradol papayas imported from four Mexican farms. PulseNet initially identified a cluster of Salmonella Kiambu infections in June 2017, and early interviews identified papayas as an exposure of interest. Investigators from Maryland, Virginia and Food and Drug Administration (FDA) collected papayas for testing. Several strains of Salmonella were isolated from papayas sourced from Mexican Farm A, including Salmonella Agona, Gaminara, Kiambu, Thompson and Senftenberg. Traceback from two points of service associated with illness sub-clusters in two states identified Farm A as a common source of papayas, and three voluntary recalls of Farm A papayas were issued. FDA sampling isolated four additional Salmonella strains from papayas sourced from Mexican Farms B, C and D. In total, four outbreaks were identified, resulting in 244 cases with illness onset dates from 20 December 2016 to 20 September 2017. The sampling of papayas and the collaborative work of investigative partners were instrumental in identifying the source of these outbreaks and preventing additional illnesses. Evaluating epidemiological, laboratory and traceback evidence together during investigations is critical to solving and stopping outbreaks.

      2. Produce is recognized as a source of Salmonella-related foodborne outbreaks in the United States. Identifying produce as a source of foodborne outbreaks is challenging given short product shelf lives and durations of many produce-associated outbreaks. Investigators consider produce a plausible source when illnesses occur over a short time period and disproportionately affect middle-aged or female individuals. We reviewed characteristics of past Salmonella produce outbreaks and their consistency with principles used by epidemiologists when generating hypotheses about an outbreak source. We queried the Foodborne Disease Outbreak Surveillance System for multistate, produce-associated Salmonella outbreaks reported to the Centers for Disease Control and Prevention from 2009 to 2015. All produce-associated outbreaks were classified as fruit outbreaks or vegetable outbreaks using an established classification scheme. We then compared fruit and vegetable outbreaks by characteristics of size, gender, age, age groups, geographic spread, duration, and velocity measures using Wilcoxon rank-sum tests. Epidemic curves were created to display visual representations of outbreak duration and velocity. We identified 14 fruit outbreaks and 24 vegetable outbreaks. The median number of illnesses for all produce-associated outbreaks was 30 and a high median percentage of illnesses were in females (61.9%). Median age was 34 years, with a median of 53.2% of illnesses affecting the 18-59 age group. For all outbreaks, median duration was 77 d and median time to the 50th percentile of illnesses was 32.5 d. Fruit and vegetable outbreaks differed only in the age groups affected. We used outbreak data to verify common indicators of produce-associated Salmonella outbreaks. Outbreaks affected females and middle-aged individuals more commonly, while fruit and vegetable outbreaks impacted different age groups. Although median outbreak duration was less than 12 weeks for both fruit and vegetable outbreaks, there was considerable variation, decreasing its utility as an indicator of produce as a source of the outbreak.

      3. Multistate outbreak of Salmonella Poona infections associated with imported cucumbers, 2015-2016external icon
        Laughlin M, Bottichio L, Weiss J, Higa J, McDonald E, Sowadsky R, Fejes D, Saupe A, Provo G, Seelman S, Concepcion-Acevedo J, Gieraltowski L.
        Epidemiol Infect. 2019 Sep 12;147:e270.
        We investigated a large multistate outbreak that occurred in the United States in 2015-2016. Epidemiologic, laboratory, and traceback studies were conducted to determine the source of the infections. We identified 907 case-patients from 40 states with illness onset dates ranging from July 3, 2015 to March 2, 2016. Sixty-three percent of case-patients reported consuming cucumbers in the week before illness onset. Ten illness sub-clusters linked to events or purchase locations were identified. All sub-clusters investigated received cucumbers from a single distributor which were sourced from a single grower in Mexico. Seventy-five cucumber samples were collected, 19 of which yielded the outbreak strain. Whole genome sequencing performed on 154 clinical isolates and 19 cucumber samples indicated that the sequenced isolates were closely related genetically to one another. This was the largest US foodborne disease outbreak in the last ten years and the third largest in the past 20 years. This was at least the fifth multistate outbreak caused by contaminated cucumbers since 2010. The outbreak is noteworthy because a recall was issued only 17 days after the outbreak was identified, which allowed for the removal of the contaminated cucumbers still available in commerce, unlike previous cucumber associated outbreaks. The rapid identification and response of multiple public health agencies resulted in preventing this from becoming an even larger outbreak.

    • Health Disparities
      1. PURPOSE: Compare selected sociodemographic and sexual risk characteristics of black/African American (black) men who have sex with men only (MSMO) and men who have sex with men and women (MSMW) in the southeastern United States (the South). METHODS: We conducted bivariate and multivariable analyses to explore the sociodemographic characteristics and sexual risk behaviors of 584 MSMW and MSMO in the South. RESULTS: MSMW had lesser odds of having a college or graduate degree (aOR = 0.32; 95% CI = 0.19, 0.54) and having > 2 male oral sex partners (aOR = 0.20; 95% CI = 0.08, 0.48) compared to MSMO. MSMW had greater odds of being homeless (aOR = 3.11; 95% CI = 1.80, 5.38) and selecting “top” sexual position (aOR = 1.70; 95% CI = 1.07, 2.72) compared to MSMO. CONCLUSION: MSMW in the South experience social and structural factors that may affect their risk for HIV infection. Strategies to address these factors should be considered in prevention and care efforts for this population.

      2. Changing the conversation: Applying a health equity framework to maternal mortality reviewsexternal icon
        Kramer MR, Strahan AE, Preslar J, Zaharatos J, St Pierre A, Grant J, Davis NL, Goodman D, Callaghan W.
        Am J Obstet Gynecol. 2019 Sep 6.
        The risk of maternal death in the U.S. is higher than peer nations and rising, and varies dramatically by the race and place of residence of the woman. Critical efforts to reduce maternal mortality include patient risk stratification and system-level quality improvement efforts targeting specific aspects of clinical care. These efforts are important for addressing the causes of an individual’s risk, but research to date suggests that individual risk factors alone do not adequately explain between-group disparities in pregnancy-related death by race, ethnicity, or geography. The holistic review and multidisciplinary makeup of maternal mortality review committees (MMRC) make them well positioned to fill knowledge gaps about the drivers of racial and geographic inequity in maternal death. However, committees may lack the conceptual framework, contextual data, and evidence base needed to identify community-based contributing factors to death, and when appropriate to make recommendations for future action. By incorporating a multileveled, theory-grounded framework for causes of health inequity, along with indicators of the ‘community vital signs’ – the social and community context in which women live, work, and seek healthcare – MMRCs may identify novel underlying factors at the community level that enhance understanding of racial and geographic inequity in maternal mortality. By considering evidence-informed community and regional resources and policies for addressing these factors, novel prevention recommendations, including recommendations that extend outside the realm of the formal health care system, may emerge.

    • Health Economics
      1. Analysis of the profitability of adult vaccination in 13 private provider practices in the United Statesexternal icon
        Yarnoff B, Khavjou O, King G, Bates L, Zhou F, Leidner AJ, Shen AK.
        Vaccine. 2019 Sep 5.
        Vaccination coverage among adults remains low in the United States. Understanding the barriers to provision of adult vaccination is an important step to increasing vaccination coverage and improving public health. To better understand financial factors that may affect practice decisions about adult vaccination, this study sought to understand how costs compared with payments for adult vaccinations in a sample of U.S. physician practices. We recruited a convenience sample of 19 practices in nine states in 2017. We conducted a time-motion study to assess the time costs of vaccination activities and conducted a survey of practice managers to assess materials, management, and dose costs and payments for vaccination. We received complete cost and payment data from 13 of the 19 practices. We calculated annual income from vaccination services by comparing estimated costs with payments received for vaccine doses and vaccine administration. Median annual total income from vaccination services was $90,343 at family medicine practices (range: $3968-$249,628), $28,267 at internal medicine practices (-$32,659-$141,034) and $2886 at obstetrics and gynecology practices (-$73,451-$23,820). Adult vaccination was profitable at the median of our sample, but there is wide variation in profitability due to differences in costs and payment rates across practices. This study provides evidence on the financial viability of adult vaccination and supports actions for improving financial viability. These results can help inform practices’ decisions whether to provide adult vaccines and contribute to keeping adults up-to-date with the recommended vaccination schedule.

    • Immunity and Immunization
      1. Distribution of Neisseria meningitidis serogroup B (NmB) vaccine antigens in meningococcal disease causing isolates in the United States during 2009-2014, prior to NmB vaccine licensureexternal icon
        Chang HY, Vuong J, Hu F, Liberator P, Chen A, Kretz CB, Blain A, Hao L, Retchless AC, Whaley MJ, Anderson AS, Wang X.
        J Infect. 2019 Sep 7.
        OBJECTIVES: Two Neisseria meningitidis serogroup B (NmB) vaccines are licensed in the United States. To estimate their potential coverage, we examined the vaccine antigen diversity among meningococcal isolates prior to vaccine licensure. METHODS: NmB vaccine antigen genes of invasive isolates collected in the U.S. from 2009-2014 were characterized by Sanger or whole-genome sequencing. RESULTS: During 2009-2014, the predominant antigen types have remained similar to those reported in 2000-2008 for NmB and 2006-2008 for NmC, NmY, with the emergence of a few new types. FHbp of subfamily B or variant 1 (B/v1) remained prevalent among NmB whereas FHbp of subfamily A or variant 2 and 3 (A/v2-3) were more prevalent among non-NmB. FHbp peptide 1 (B24/1.1) remains the most prevalent type in NmB. Full-length NadA peptide was detected in 26% of isolates, primarily in NmB and NmW. The greatest diversity of NhbA peptides was detected among NmB, with p0005 as the most prevalent type. CONCLUSIONS: The prevalence and diversity of the NmB vaccine antigens have remained stable with common antigen types persisting over time. The data collected prior to NmB vaccine licensure provide the baseline to understand the potential impact of NmB vaccines on antigen diversity and strain coverage.

      2. Pneumococcal conjugate vaccine impact on meningitis and pneumonia among children aged <5 years – Zimbabwe, 2010-2016external icon
        Dondo V, Mujuru H, Nathoo K, Jacha V, Tapfumanei O, Chirisa P, Manangazira P, Macharaga J, de Gouveia L, Mwenda JM, Katsande R, Weldegebriel G, Pondo T, Matanock A, Lessa FC.
        Clin Infect Dis. 2019 Sep 5;69(Supplement_2):S72-s80.
        BACKGROUND: Streptococcus pneumoniae is a leading cause of pneumonia and meningitis in children aged <5 years. Zimbabwe introduced 13-valent pneumococcal conjugate vaccine (PCV13) in 2012 using a 3-dose infant schedule with no booster dose or catch-up campaign. We evaluated the impact of PCV13 on pediatric pneumonia and meningitis. METHODS: We examined annual changes in the proportion of hospitalizations due to pneumonia and meningitis among children aged <5 years at Harare Central Hospital (HCH) pre-PCV13 (January 2010-June 2012) and post-PCV13 (July 2013-December 2016) using a negative binomial regression model, adjusting for seasonality. We also evaluated post-PCV13 changes in serotype distribution among children with confirmed pneumococcal meningitis at HCH and acute respiratory infection (ARI) trends using Ministry of Health outpatient data. RESULTS: Pneumonia hospitalizations among children aged <5 years steadily declined pre-PCV13; no significant change in annual decline was observed post-PCV13. Post-PCV13 introduction, meningitis hospitalization decreased 30% annually (95% confidence interval [CI], -42, -14) among children aged 12-59 months, and no change was observed among children aged 0-11 months. Pneumococcal meningitis caused by PCV13 serotypes decreased from 100% in 2011 to 50% in 2016. Annual severe and moderate outpatient ARI decreased by 30% (95% CI, -33, -26) and 7% (95% CI, -11, -2), respectively, post-PCV13 introduction. CONCLUSIONS: We observed declines in pediatric meningitis hospitalizations, PCV13-type pneumococcal meningitis, and severe and moderate ARI outpatient visits post-PCV13 introduction. Low specificity of discharge codes, changes in referral patterns, and improvements in human immunodeficiency virus care may have contributed to the lack of additional declines in pneumonia hospitalizations post-PCV13 introduction.

      3. Impact of 13-valent pneumococcal conjugate vaccine on meningitis and pneumonia hospitalizations in children aged <5 years in Senegal, 2010-2016external icon
        Faye PM, Sonko MA, Diop A, Thiongane A, Ba ID, Spiller M, Ndiaye O, Dieye B, Mwenda JM, Sow AI, Diop B, Diallo A, Farrar JL.
        Clin Infect Dis. 2019 Sep 5;69(Supplement_2):S66-s71.
        BACKGROUND: Senegal introduced a 13-valent pneumococcal conjugate vaccine (PCV13) in October 2013, given at 6, 10, and 14 weeks of age. We document trends of meningitis and pneumonia after the PCV13 introduction. METHODS: From October 2010-October 2016, hospitalization data for clinical meningitis and pneumonia in children aged <5 years were collected from logbooks at a large, tertiary, pediatric hospital in Dakar. We used a set of predetermined keywords to define hospitalizations for extraction from hospital registers. We conducted a time-series analysis and compared hospitalizations before and after the PCV13 introduction, accounting for seasonality. The initial PCV13 uptake period (October 2013-September 2014) was considered to be transitional and was excluded. RESULTS: Over the 7-year period, 1836 and 889 hospitalizations with a discharge diagnosis of pneumonia and meningitis, respectively, occurred in children aged <5 years. In children aged <12 months, a small, significant reduction in pneumonia was observed post-PCV13 (-3.8%, 95% confidence interval [CI] -1.5 to -5.9%). No decline was observed among children aged 12-59 months (-0.7%, 95% CI -0.8 to 2.2%). Meningitis hospitalizations remained stable for children aged <12 months (1.8%, 95% CI -0.9 to 4.4%) and 12-59 months (-0.5%, 95% CI -3.6 to 2.6%). CONCLUSIONS: We used data from 1 hospital to detect a small, significant reduction in all-cause pneumonia hospitalizations 2 years post-PCV13 introduction in infants; the same trend was not measurable in children aged 12-59 months or in meningitis cases. There is a need for continued surveillance to assess the long-term impact of sustained PCV13 use and to monitor how pneumococcus is causing disease in the meningitis belt.

      4. The clinical impact and cost-effectiveness of measles-mumps-rubella vaccination to prevent measles importations among international travelers from the United Statesexternal icon
        Hyle EP, Fields NF, Fiebelkorn AP, Walker AT, Gastanaduy P, Rao SR, Ryan ET, LaRocque RC, Walensky RP.
        Clin Infect Dis. 2019 Jul 2;69(2):306-315.
        BACKGROUND: Measles importations and the subsequent spread from US travelers returning from abroad are responsible for most measles cases in the United States. Increasing measles-mumps-rubella (MMR) vaccination among departing US travelers could reduce the clinical impact and costs of measles in the United States. METHODS: We designed a decision tree to evaluate MMR vaccination at a pretravel health encounter (PHE), compared with no encounter. We derived input parameters from Global TravEpiNet data and literature. We quantified Riskexposure to measles while traveling and the average number of US-acquired cases and contacts due to a measles importation. In sensitivity analyses, we examined the impact of destination-specific Riskexposure, including hot spots with active measles outbreaks; the percentage of previously-unvaccinated travelers; and the percentage of travelers returning to US communities with heterogeneous MMR coverage. RESULTS: The no-encounter strategy projected 22 imported and 66 US-acquired measles cases, costing $14.8M per 10M travelers. The PHE strategy projected 15 imported and 35 US-acquired cases at $190.3M per 10M travelers. PHE was not cost effective for all international travelers (incremental cost-effectiveness ratio [ICER] $4.6M/measles case averted), but offered better value (ICER <$100 000/measles case averted) or was even cost saving for travelers to hot spots, especially if travelers were previously unvaccinated or returning to US communities with heterogeneous MMR coverage. CONCLUSIONS: PHEs that improve MMR vaccination among US international travelers could reduce measles cases, but are costly. The best value is for travelers with a high likelihood of measles exposure, especially if the travelers are previously unvaccinated or will return to US communities with heterogeneous MMR coverage.

      5. WHO international standard for anti-rubella: learning from its applicationexternal icon
        Kempster SL, Almond N, Dimech W, Grangeot-Keros L, Huzly D, Icenogle J, El Mubarak HS, Mulders MN, Nubling CM.
        Lancet Infect Dis. 2019 Sep 6.
        The WHO international standard for anti-rubella was first established in the 1960s when clinical diagnostics were in their infancy. Since the endorsement of the first international standard for anti-rubella IgG (RUBI-1-94), new rubella vaccines have been developed and global coverage of rubella vaccination has increased. Methods used to measure concentrations of anti-rubella IgG have also evolved to rapid, high-throughput binding assays, which have replaced often cumbersome and highly technical functional assays. During this timeframe, the protective concentration of antibody was set at 10 IU/mL by extrapolation of functional assay correlates; however, the subpopulation of antibodies within a polyclonal serum that confer protection remained undefined. Anti-rubella assays have variable formats, including antigens used, such that the same clinical sample tested on different assays can report different values with potentially devastating consequences, such as recommending to terminate pregnancy. WHO convened a meeting of experts in the rubella field to discuss the use of RUBI-1-94 and the potential future role of this international standard. The main conclusions of this meeting questioned the appropriateness of 10 IU/mL as the cutoff for protection and acknowledged the continuing role of RUBI-1-94 as a reference preparation to address analytical sensitivity and assay variation.

      6. Vaccination capability inventory of community, migrant, and homeless health centers: A survey reportexternal icon
        Lewis JH, Whelihan K, Roy D, White EJ, Morgan C, Vora RS, Boyle KR, Luebbering C, Bay RC, Lindley MC.
        J Public Health Manag Pract. 2019 Sep 4.
        CONTEXT: Federally funded Community, Migrant, and Homeless Health Centers provide health services to the most vulnerable communities in the United States. However, little is known about their capabilities and processes for providing vaccinations to adults. PROGRAM: We conducted the first national survey of health centers assessing their inventory, workflow, capacity for, and barriers to provision of routinely recommended adult vaccines. In addition, we asked health center leaders’ perceptions regarding best practices and policy recommendations for adult vaccinations. IMPLEMENTATION: A survey was developed on the basis of domains elicited from advisory panels and focus groups and was sent electronically to leaders of 762 health centers throughout the United States and its territories; data were collected and analyzed in 2018. EVALUATION: A total of 319 survey responses (42%) were obtained. Health centers reported stocking most routinely recommended vaccines for adults; zoster vaccines were not stocked regularly due to supply and storage issues. Respondents most commonly reported adequate reimbursement for vaccination services from private insurance and Medicaid. Most vaccinations were provided during primary care encounters; less than half of health centers reported providing vaccines during specialist visits. Vaccines administered at the health center were most commonly documented in an open field of the electronic health record (96%) or in an immunization information system (72%). Recommendations for best practices related to better documentation of vaccinations and communication with immunization information systems were provided. DISCUSSION: Health centers provide most adult vaccines to their patients despite financial and technological barriers to optimal provisioning. Further studies at point of care could help identify mechanisms for system improvements.

      7. Declines in pneumonia and meningitis hospitalizations in children under 5 years of age after introduction of 10-valent pneumococcal conjugate vaccine in Zambia, 2010-2016external icon
        Mpabalwani EM, Lukwesa-Musyani C, Imamba A, Nakazwe R, Matapo B, Muzongwe CM, Mufune T, Soda E, Mwenda JM, Lutz CS, Pondo T, Lessa FC.
        Clin Infect Dis. 2019 Sep 5;69(Supplement_2):S58-s65.
        BACKGROUND: Pneumococcus is a leading cause of pneumonia and meningitis. Zambia introduced a 10-valent pneumococcal conjugate vaccine (PCV10) in July 2013 using a 3-dose primary series at ages 6, 10, and 14 weeks with no booster. We evaluated the impact of PCV10 on meningitis and pneumonia hospitalizations. METHODS: Using hospitalization data from first-level care hospitals, available at the Ministry of Health, and from the largest pediatric referral hospital in Lusaka, we identified children aged <5 years who were hospitalized with pneumonia or meningitis from January 2010-December 2016. We used time-series analyses to measure the effect of PCV10 on monthly case counts by outcome and age group (<1 year, 1-4 years), accounting for seasonality. We defined the pre- and post-PCV10 periods as January 2010-June 2013 and July 2014-December 2016, respectively. RESULTS: At first-level care hospitals, pneumonia and meningitis hospitalizations among children aged <5 years accounted for 108 884 and 1742 admissions in the 42 months pre-PCV10, respectively, and 44 715 and 646 admissions in the 30 months post-PCV10, respectively. Pneumonia hospitalizations declined by 37.8% (95% confidence interval [CI] 21.4-50.3%) and 28.8% (95% CI 17.7-38.7%) among children aged <1 year and 1-4 years, respectively, while meningitis hospitalizations declined by 72.1% (95% CI 63.2-79.0%) and 61.6% (95% CI 50.4-70.8%), respectively, in these age groups. In contrast, at the referral hospital, pneumonia hospitalizations remained stable and a smaller but significant decline in meningitis was observed among children aged 1-4 years (39.3%, 95% CI 16.2-57.5%). CONCLUSIONS: PCV10 introduction was associated with declines in meningitis and pneumonia hospitalizations in Zambia, especially in first-level care hospitals.

      8. Measles and rubella immunity in the population of Bhutan, 2017external icon
        Wangchuk S, Nogareda F, Tshering N, Khandu L, Pelden S, Wannemuehler K, Wangdi S, Wangchuk U, Mulders M, Tamang T, Patel MK.
        Vaccine. 2019 Sep 6.
        BACKGROUND: In 2017, measles elimination was verified in Bhutan, and the country appears to have sufficiently high vaccination coverage to achieve rubella elimination. However, a measles and rubella serosurvey was conducted to find if any hidden immunity gaps existed that could threaten Bhutan’s elimination status. METHODS: A nationwide, three-stage, cluster seroprevalence survey was conducted among individuals aged 1-4, 5-17, and >20 years in 2017. Demographic information and children’s vaccination history were collected, and a blood specimen was drawn. Serum was tested for measles and rubella immunoglobulin G (IgG). Frequencies, weighted proportions, and prevalence ratios for measles and rubella seropositivity were calculated by demographic and vaccination history, taking into account the study design. RESULTS: Of the 1325 individuals tested, 1045 (81%, 95% CI 78%-85%) were measles IgG seropositive, and 1290 (97%, 95% CI 95%-99%) were rubella IgG seropositive. Rubella IgG seropositivity was high in all three age strata, but only 47% of those aged 5-17 years were measles IgG seropositive. Additionally, only 41% of those aged 5-17 years who had documented receipt of two doses of measles- or measles-rubella-containing vaccine were seropositive for measles IgG, but almost all these children were rubella IgG seropositive. CONCLUSIONS: An unexpected measles immunity gap was identified among children 5-17 years of age. It is unclear why this immunity gap exists; however, it could have led to a large outbreak and threatened sustaining of measles elimination in Bhutan. Based on this finding, a mass vaccination campaign was conducted to close the immunity gap.

    • Informatics
      1. Defining the hepatitis C cure cascade in an urban health system using the electronic health recordexternal icon
        Miller LS, Millman AJ, Lom J, Osinubi A, Ahmed F, Dupont S, Rein D, Vellozzi C, Harris AM.
        J Viral Hepat. 2019 Sep 10.
        Hepatitis C virus (HCV) infection is a public health threat. The electronic health record (EHR) can be used to monitor patients along the HCV cure cascade and highlight opportunities for interventions to improve cascade outcomes. We developed an HCV patient registry using data from Grady Health System’s (GHS) EHR and performed a cross sectional analysis of 72,745 GHS patients who received anti-HCV testing from 2004-2016. We created a testing cascade: 1) anti-HCV reactive, 2) HCV RNA tested, and 3) HCV RNA detectable; and a cure cascade: 1) HCV RNA detectable, 2) engaged in care, 3) treatment prescribed, 4) sustained virologic response (SVR) tested, and 5) SVR documented. 9,893 (14%) had reactive anti-HCV tests of 72,745 patients tested, 5,109 (52%) of these had HCV RNA tested, and 4,224 (43%) were HCV RNA detectable. 2,738 (65%) of 4,224 with detectable RNA were engaged in care, 909 (22%) were prescribed antiviral therapy, and 354 (8%) achieved SVR. Factors associated with HCV treatment included cirrhosis, tobacco use, depression, diabetes, obesity, alcohol use, male gender, black race, and Medicare insurance. Uninsured patients were significantly less likely to be prescribed HCV treatment. In conclusion, Using EHR data, we identified high anti-HCV prevalence and noted gaps in HCV RNA testing, linkage to care, and treatment. The EHR can be used to evaluate the effectiveness of targeted interventions to overcome these gaps.

    • Laboratory Sciences
      1. The epidemiological signature of influenza B virus and its B/Victoria and B/Yamagata lineages in the 21st centuryexternal icon
        Caini S, Kusznierz G, Garate VV, Wangchuk S, Thapa B, de Paula Junior FJ, Ferreira de Almeida WA, Njouom R, Fasce RA, Bustos P, Feng L, Peng Z, Araya JL, Bruno A, de Mora D, Barahona de Gamez MJ, Pebody R, Zambon M, Higueros R, Rivera R, Kosasih H, Castrucci MR, Bella A, Kadjo HA, Daouda C, Makusheva A, Bessonova O, Chaves SS, Emukule GO, Heraud JM, Razanajatovo NH, Barakat A, El Falaki F, Meijer A, Donker GA, Huang QS, Wood T, Balmaseda A, Palekar R, Arevalo BM, Rodrigues AP, Guiomar R, Lee VJ, Ang LW, Cohen C, Treurnicht F, Mironenko A, Holubka O, Bresee J, Brammer L, Le MT, Hoang PV, El Guerche-Seblain C, Paget J.
        PLoS One. 2019 ;14(9):e0222381.
        We describe the epidemiological characteristics, pattern of circulation, and geographical distribution of influenza B viruses and its lineages using data from the Global Influenza B Study. We included over 1.8 million influenza cases occurred in thirty-one countries during 2000-2018. We calculated the proportion of cases caused by influenza B and its lineages; determined the timing of influenza A and B epidemics; compared the age distribution of B/Victoria and B/Yamagata cases; and evaluated the frequency of lineage-level mismatch for the trivalent vaccine. The median proportion of influenza cases caused by influenza B virus was 23.4%, with a tendency (borderline statistical significance, p = 0.060) to be higher in tropical vs. temperate countries. Influenza B was the dominant virus type in about one every seven seasons. In temperate countries, influenza B epidemics occurred on average three weeks later than influenza A epidemics; no consistent pattern emerged in the tropics. The two B lineages caused a comparable proportion of influenza B cases globally, however the B/Yamagata was more frequent in temperate countries, and the B/Victoria in the tropics (p = 0.048). B/Yamagata patients were significantly older than B/Victoria patients in almost all countries. A lineage-level vaccine mismatch was observed in over 40% of seasons in temperate countries and in 30% of seasons in the tropics. The type B virus caused a substantial proportion of influenza infections globally in the 21st century, and its two virus lineages differed in terms of age and geographical distribution of patients. These findings will help inform health policy decisions aiming to reduce disease burden associated with seasonal influenza.

      2. Mycoplasma hyopneumoniae is the etiological agent of enzootic pneumonia (EP), a widespread disease that causes major economic losses to the pig industry. The swine host response plays an important role in the outcome of M. hyopneumoniae infections. The whole proteome of newborn pig trachea (NPTr) epithelial cells infected with the M. hyopneumoniae pathogenic strain 7448 was analyzed using an LC-MS/MS approach to shed light on intracellular processes triggered in response to the pathogen. Overall, 853 swine protein species were identified, 156 of which were differentially represented in response to M. hyopneumoniae 7448 infection in comparison with non-infected control cells. These differentially represented proteins were categorized by function. Fifty-seven of them were assigned to the immune system and/or response to stimulus functional subcategories. Comparative expression analysis of these immune-related proteins in NPTr cells infected with attenuated or non-pathogenic mycoplasmas (M. hyopneumoniae J strain and M. flocculare, respectively) revealed proteins whose abundance was altered only in response to the pathogenic M. hyopneumoniae 7448 strain. Among these proteins, calcium homeostasis and endoplasmic reticulum stress-related biomarkers were detected, providing evidence of molecular mechanisms that might lead to swine cell apoptosis.

      3. Genetic similarity of gonococcal homologs to meningococcal outer membrane proteins of serogroup B vaccineexternal icon
        Marjuki H, Topaz N, Joseph SJ, Gernert KM, Kersh EN, Wang X.
        MBio. 2019 Sep 10;10(5).
        The human pathogens Neisseria gonorrhoeae and Neisseria meningitidis share high genome identity. Retrospective analysis of surveillance data from New Zealand indicates the potential cross-protective effect of outer membrane vesicle (OMV) meningococcal serogroup B vaccine (MeNZB) against N. gonorrhoeae A licensed OMV-based MenB vaccine, MenB-4C, consists of a recombinant FHbp, NhbA, NadA, and the MeNZB OMV. Previous work has identified several abundantly expressed outer membrane proteins (OMPs) as major components of the MenB-4C OMV with high sequence similarity between N. gonorrhoeae and N. meningitidis, suggesting a mechanism for cross-protection. To build off these findings, we performed comparative genomic analysis on 970 recent N. gonorrhoeae isolates collected through a U.S surveillance system against N. meningitidis serogroup B (NmB) reference sequences. We identified 1,525 proteins that were common to both Neisseria species, of which 57 proteins were predicted to be OMPs using in silico methods. Among the MenB-4C antigens, NhbA showed moderate sequence identity (73%) to the respective gonococcal homolog, was highly conserved within N. gonorrhoeae, and was predicted to be surface expressed. In contrast, the gonococcal FHbp was predicted not to be surface expressed, while NadA was absent in all N. gonorrhoeae isolates. Our work confirmed recent observations (E. A. Semchenko, A. Tan, R. Borrow, and K. L. Seib, Clin Infect Dis, 2018, and describes homologous OMPs from a large panel of epidemiologically relevant N. gonorrhoeae strains in the United States against NmB reference strains. Based on our results, we report a set of OMPs that may contribute to the previously observed cross-protection and provide potential antigen targets to guide the next steps in gonorrhea vaccine development.IMPORTANCE Gonorrhea, a sexually transmitted disease, causes substantial global morbidity and economic burden. New prevention and control measures for this disease are urgently needed, as strains resistant to almost all classes of antibiotics available for treatment have emerged. Previous reports demonstrate that cross-protection from gonococcal infections may be conferred by meningococcal serogroup B (MenB) outer membrane vesicle (OMV)-based vaccines. Among 1,525 common proteins shared across the genomes of both N. gonorrhoeae and N. meningitidis, 57 proteins were predicted to be surface expressed (outer membrane proteins [OMPs]) and thus preferred targets for vaccine development. The majority of these OMPs showed high sequence identity between the 2 bacterial species. Our results provide valuable insight into the meningococcal antigens present in the current OMV-containing MenB-4C vaccine that may contribute to cross-protection against gonorrhea and may inform next steps in gonorrhea vaccine development.

      4. Patterns of inter- and intrasubspecific homologous recombination inform eco-evolutionary dynamics of Xylella fastidiosaexternal icon
        Potnis N, Kandel PP, Merfa MV, Retchless AC, Parker JK, Stenger DC, Almeida RP, Bergsma-Vlami M, Westenberg M, Cobine PA, De La Fuente L.
        Isme j. 2019 Sep;13(9):2319-2333.
        High rates of homologous recombination (HR) in the bacterial plant pathogen Xylella fastidiosa have been previously detected. This study aimed to determine the extent and explore the ecological significance of HR in the genomes of recombinants experimentally generated by natural transformation and wild-type isolates. Both sets of strains displayed widespread HR and similar average size of recombined fragments consisting of random events (2-10 kb) of inter- and intrasubspecific recombination. A significantly higher proportion and greater lengths (>10 kb, maximum 31.5 kb) of recombined fragments were observed in subsp. morus and in strains isolated in Europe from intercepted coffee plants shipped from the Americas. Such highly recombinant strains pose a serious risk of emergence of novel variants, as genetically distinct and formerly geographically isolated genotypes are brought in close proximity by global trade. Recently recombined regions in wild-type strains included genes involved in regulation and signaling, host colonization, nutrient acquisition, and host evasion, all fundamental traits for X. fastidiosa ecology. Identification of four recombinant loci shared between wild-type and experimentally generated recombinants suggests potential hotspots of recombination in this naturally competent pathogen. These findings provide insights into evolutionary forces possibly affecting the adaptive potential to colonize the host environments of X. fastidiosa.

      5. Changes in micronutrient and inflammation serum biomarker concentrations after a norovirus human challengeexternal icon
        Williams AM, Ladva CN, Leon JS, Lopman BA, Tangpricha V, Whitehead RD, Armitage AE, Wray K, Morovat A, Pasricha SR, Thurnham D, Tanumihardjo SA, Shahab-Ferdows S, Allen L, Flores-Ayala RC, Suchdev PS.
        Am J Clin Nutr. 2019 Aug 30.
        BACKGROUND: To accurately assess micronutrient status, it is necessary to characterize the effects of inflammation and the acute-phase response on nutrient biomarkers. OBJECTIVE: Within a norovirus human challenge study, we aimed to model the inflammatory response of C-reactive protein (CRP) and alpha-1-acid glycoprotein (AGP) by infection status, model kinetics of micronutrient biomarkers by inflammation status, and evaluate associations between inflammation and micronutrient biomarkers from 0 to 35 d post-norovirus exposure. METHODS: Fifty-two healthy adults were enrolled into challenge studies in a hospital setting and followed longitudinally; all were exposed to norovirus, half were infected. Post hoc analysis of inflammatory and nutritional biomarkers was performed. Subjects were stratified by inflammation resulting from norovirus exposure. Smoothed regression models analyzed the kinetics of CRP and AGP by infection status, and nutritional biomarkers by inflammation. Linear mixed-effects models were used to analyze the independent relations between CRP, AGP, and biomarkers for iron, vitamin A, vitamin D, vitamin B-12, and folate from 0 to 35 d post-norovirus exposure. RESULTS: Norovirus-infected subjects had median (IQR) peak concentrations for CRP [16.0 (7.9-29.5) mg/L] and AGP [0.9 (0.8-1.2) g/L] on day 3 and day 4 postexposure, respectively. Nutritional biomarkers that differed (P < 0.05) from baseline within the inflamed group were ferritin (elevated day 3), hepcidin (elevated days 2, 3), serum iron (depressed days 2-4), transferrin saturation (depressed days 2-4), and retinol (depressed days 3, 4, and 7). Nutritional biomarker concentrations did not differ over time within the uninflamed group. In mixed models, CRP was associated with ferritin (positive) and serum iron and retinol (negative, P < 0.05). CONCLUSION: Using an experimental infectious challenge model in healthy adults, norovirus infection elicited a time-limited inflammatory response associated with altered serum concentrations of certain iron and vitamin A biomarkers, confirming the need to consider adjustments of these biomarkers to account for inflammation when assessing nutritional status. These trials were registered at as NCT00313404 and NCT00674336.

    • Maternal and Child Health
      1. Receipt of American Heart Association-recommended preconception health care among privately insured women with congenital heart defects, 2007-2013external icon
        Farr SL, Downing KF, Ailes EC, Gurvitz M, Koontz G, Tran EL, Alverson CJ, Oster ME.
        J Am Heart Assoc. 2019 Sep 17;8(18):e013608.
        Background Our objective was to estimate receipt of preconception health care among women with congenital heart defects (CHD), according to 2017 American Heart Association recommendations, as a baseline for evaluating recommendation implementation. Methods and Results Using 2007 to 2013 IBM MarketScan Commercial Databases, we identified women with CHD diagnosis codes ages 15 to 44 years who became pregnant and were enrolled in health insurance for >/=11 months in the year before estimated conception. We assessed documentation of complete blood count, electrolytes, thyroid-stimulating hormone, liver function, ECG, comprehensive echocardiogram, and exercise stress test, using procedural codes, and outpatient prescription claims for US Food and Drug Administration category D and X cardiac-related medications. Differences were examined according to CHD severity, age, region of residence, year of conception, and documented encounters at obstetric and cardiology practices. We found 2524 pregnancies among 2003 women with CHD (14.4% severe CHD). In the 98.3% of women with a healthcare encounter in the year before conception, <1% received all and 22.6% received no American Heart Association-recommended tests or assessments (range: 54.4% for complete blood count to 3.1% for exercise stress test). Women with the highest prevalence of receipt of recommended care were 35 to 44 years old, pregnant in 2012 to 2013, or had a documented obstetric or cardiology encounter in the year before conception (P<0.05 for all). In 9.0% of pregnancies, >/=1 prescriptions for US Food and Drug Administration category D or X cardiac-related medications were filled in the year before conception. Conclusions A low percentage of women with CHD received American Heart Association-recommended preconception health care in the year before conception.

      2. This report details the proceedings and conclusions from the 3rd International Congress on Unexplained Deaths in Infants and Children, held November 26-27, 2018 at the Radcliffe Institute at Harvard University. The Congress was motivated by the increasing rejection of the diagnosis Sudden Infant Death Syndrome (SIDS) in the medical examiner community, leading to falsely depressed reported SIDS rates and undermining the validity and reliability of the diagnosis, which remains a leading cause of infant and child mortality. We describe the diagnostic shift away from SIDS and the practical issues contributing to it. The Congress was attended by major figures and opinion leaders in this area from countries significantly engaged in this problem. Four categories (International Classification of Diseases (ICD)-11 categories of MH11, MH12, MH14, PB00-PB0Z) were recommended for classification, and explicit definitions and guidance were provided for death certifiers. SIDS was reframed as unexplained sudden death in infancy or SIDS/MH11 to emphasize that either term signifies the lack of explanation following a rigorous investigation. A distinct category for children over the age of 1 was recommended (MH12). Definitions and exclusions were provided for the alternative categories of accidental asphyxia and undetermined. As recommended, unexplained sudden death in infancy or SIDS on a death certificate will code a unique, trackable entity, accurately reflecting the inability to determine a definitive explanation, while satisfying surveillance needs and reliable identification for research efforts. The conclusions will be submitted to the World Health Organization for inclusion in the upcoming ICD-11.

      3. Potential of the Community Counts registry to characterize rare bleeding disordersexternal icon
        Gupta S, Acharya S, Roberson C, Lail A, Soucie JM, Shapiro A.
        Haemophilia. 2019 Sep 11.
        INTRODUCTION: Rare bleeding disorders (RBDs) comprise of heterogeneous coagulation factor deficiencies and platelet disorders that are underreported worldwide. AIM: First report on RBD data from United States haemophilia treatment center network (USHTCN). METHODS: A national surveillance system for the federally recognized USHTCN developed in collaboration with the Centers for Disease Control and Prevention (CDC) and American Thrombosis and Haemostasis Network (ATHN) was queried for patients with RBDs. Patient counts were extracted from the HTC Population Profile (HTC PP) component including limited data on patients followed through the USHTCN, and from the Registry component, including patient authorized, detailed clinical data. The prevalence of RBDs in the United States was estimated based on the HTC PP data and compared to the expected national prevalence based on data extrapolated from Orphanet, an international registry. RESULTS: Based on the estimated prevalence of RBD in the overall 2017 US population, the cases in the HTC network were lower than expected for FI, FII, FX, and FV + FVIII deficiencies by 36%, 61%, 75% and 94%, respectively, and higher than expected for FXIII, FV, FVII, and FXI deficiencies by 7%, 14%, 33% and 185%, respectively. The proportion of RBD patients reported in the HTC PP, enrolled in the Registry, was 10.8%. CONCLUSIONS: There is a clear need to identify individuals with RBDs who could benefit from the comprehensive care provided in the USHTCN. In addition, increased enrolment of people with all RBDs in the Registry is needed to improve knowledge of treatment outcomes of patients with RBDs in the United States.

      4. Beyond birth outcomes: Interpregnancy interval and injury-related infant mortalityexternal icon
        Thoma ME, Rossen LM, De Silva DA, Warner M, Simon AE, Moskosky S, Ahrens KA.
        Paediatr Perinat Epidemiol. 2019 Sep 12.
        BACKGROUND: Several studies have examined the association between IPI and birth outcomes, but few have explored the association between interpregnancy interval (IPI) and postnatal outcomes. OBJECTIVE: We examined the association between IPI and injury-related infant mortality, a leading cause of postneonatal mortality. METHODS: We used 2011-2015 US period-linked birth-infant death vital statistics data to generate a multiyear birth cohort of non-first-born singleton births (N = 9 782 029). IPI was defined as the number of months between a live birth and the start of the pregnancy leading to the next live birth. Causes of death in the first year of life were identified using ICD-10 codes. Hazard ratios (HR) for IPI categories were estimated using Cox proportional hazards models adjusted for birth order, county poverty level, and maternal characteristics (marital status, race/ethnicity, education, age at previous birth). RESULTS: After adjustment, overall infant mortality (48.1 per 10 000 births) was higher for short and long IPIs compared with IPI 18-23 months (reference): <6, aHR 1.61, 95% CI 1.54, 1.68; 6-11, aHR 1.22, 95% CI 1.17, 1.26; and 60+ months, aHR 1.12, 95% CI 1.08, 1.16. In comparison, the risk of injury-related infant mortality (4.4 per 10 000 births) decreased with longer IPIs: <6, aHR 1.77, 95% CI 1.55, 2.01; 6-11, aHR 1.41, 95% CI 1.25, 1.59; 12-17, aHR 1.25, 95% CI 1.10, 1.41; 24-59, aHR 0.78, 95% CI 0.69, 0.87; and 60+ months, aHR 0.55, 95% CI 0.48, 0.62. CONCLUSION: Unlike overall infant mortality, injury-related infant mortality decreased with IPI length. While injury-related deaths are rare, these patterns suggest that the timing between births may be a marker of risk for fatal infant injuries. The first year postpartum may be an ideal time for the delivery of evidence-based injury prevention programmes as well as family planning services.

    • Nutritional Sciences
      1. Formulas to estimate dietary sodium intake from spot urine alter sodium-mortality relationshipexternal icon
        He FJ, Ma Y, Campbell NR, MacGregor GA, Cogswell ME, Cook NR.
        Hypertension. 2019 Sep;74(3):572-580.
        To study the effect of formulas on the estimation of dietary sodium intake (sodium intake) and its association with mortality, we analyzed the TOHP (Trials of Hypertension Prevention) follow-up data. Sodium intake was assessed by measured 24-hour urinary sodium excretion and estimations from sodium concentration using the Kawasaki, Tanaka, and INTERSALT (International Cooperative Study on Salt, Other Factors, and Blood Pressure) formulas. We used both the average of 3 to 7 urinary measurements during the trial period and the first measurement at the beginning of each trial. Additionally, we kept sodium concentration constant to test whether the formulas were independently associated with mortality. We included 2974 individuals aged 30 to 54 years with prehypertension, not assigned to sodium intervention. During a median 24-year follow-up, 272 deaths occurred. The average measured sodium intake was 3766+/-1290 mg/d. All estimated values, including those with constant sodium concentration, were systematically biased with overestimation at lower levels and underestimation at higher levels. There was a significant linear association between the average measured sodium intake (ie, gold standard method) and mortality. This relationship was altered by using the estimated sodium intakes. There appeared to be a J- or U-shaped relationship for the average estimated sodium by all formulas. Despite variations in the sodium-mortality relationship among various formulas, a common pattern was that all estimated values including those with constant sodium appeared to be inversely related to mortality at lower levels of sodium intake. These results demonstrate that inaccurate estimates of sodium cannot be used in association studies, particularly as the formulas per se seem to be related to mortality independent of sodium.

      2. Folate status in the US population 20 y after the introduction of folic acid fortificationexternal icon
        Pfeiffer CM, Sternberg MR, Zhang M, Fazili Z, Storandt RJ, Crider KS, Yamini S, Gahche JJ, Juan W, Wang CY, Potischman N, Williams J, LaVoie DJ.
        Am J Clin Nutr. 2019 Aug 27.
        BACKGROUND: Enriched cereal-grain products have been fortified in the United States for >20 y to improve folate status in women of reproductive age and reduce the risk of folic acid-responsive neural tube birth defects (NTDs). OBJECTIVES: Our objectives were to assess postfortification changes in folate status in the overall US population and in women aged 12-49 y and to characterize recent folate status by demographic group and use of folic acid-containing supplements. METHODS: We examined cross-sectional serum and RBC folate data from the NHANES 1999-2016. RESULTS: Serum folate geometric means increased from 2007-2010 to 2011-2016 in persons aged >/=1 y (38.7 compared with 40.6 nmol/L) and in women (35.3 compared with 37.0 nmol/L), whereas RBC folate showed no significant change. Younger age groups, men, and Hispanic persons showed increased serum and RBC folate concentrations, whereas non-Hispanic black persons and supplement nonusers showed increased serum folate concentrations. The folate insufficiency prevalence (RBC folate <748 nmol/L; NTD risk) in women decreased from 2007-2010 (23.2%) to 2011-2016 (18.6%) overall and in some subgroups (e.g., women aged 20-39 y, Hispanic and non-Hispanic black women, and supplement nonusers). After covariate adjustment, RBC folate was significantly lower in all age groups (by approximately 10-20%) compared with persons aged >/=60 y and in Hispanic (by 8.2%), non-Hispanic Asian (by 12.1%), and non-Hispanic black (by 20.5%) compared with non-Hispanic white women (2011-2016). The 90th percentile for serum ( approximately 70 nmol/L) and RBC ( approximately 1800 nmol/L) folate in supplement nonusers aged >/=60 y was similar to the geometric mean in users (2011-2014). CONCLUSIONS: Blood folate concentrations in the US population overall and in women have not decreased recently, and folate insufficiency rates are approximately 20%. Continued monitoring of all age groups is advisable given the high folate status particularly in older supplement users.

    • Occupational Safety and Health
      1. [No abstract]

      2. An exploratory assessment of applying risk management practices to engineered nanomaterialsexternal icon
        Iavicoli I, Leso V, Piacci M, Cioffi DL, Guseva Canu I, Schulte PA.
        Int J Environ Res Public Health. 2019 Sep 7;16(18).
        The widespread industrial application of nanotechnology has increased the number of workers exposed to engineered nanomaterials (ENMs), but it is not clear to what extent prevention guidance is practiced. Our aim was to explore the extent that companies manufacturing and/or using ENMs apply risk assessment and management measures. Thirty-four companies were surveyed with an international 35-item questionnaire investigating company and workforce features, types of ENM handled, and risk evaluation and preventive measures adopted. Among participating companies, 62% had a maximum of 10 employees. Metal-based nanomaterials were most frequently identified (73%). Environmental monitoring was performed by 41% of the companies, while engineering exposure controls were approximately reported by 50%. Information and training programs were indicated by 85% of the sample, only 9% performed specific health surveillance for ENM workers. Personal protective equipment primarily included gloves (100%) and eye/face protection (94%). This small-scale assessment can contribute to the limited amount of published literature on the topic. Future investigations should include a greater number of companies to better represent ENM workplaces and a direct access to industrial settings to collect information on site. Finally, deeper attention should be paid to define standardized frameworks for ENM risk assessment that may guide nano-specific preventive actions.

      3. Associations of metrics of peak inhalation exposure and skin exposure indices with beryllium sensitization at a beryllium manufacturing facilityexternal icon
        Virji MA, Schuler CR, Cox-Ganser J, Stanton ML, Kent MS, Kreiss K, Stefaniak AB.
        Ann Work Expo Health. 2019 Sep 4.
        OBJECTIVES: Peak beryllium inhalation exposures and exposure to the skin may be relevant for developing beryllium sensitization (BeS). The objective of this study was to identify risk factors associated with BeS to inform the prevention of sensitization, and the development of chronic beryllium disease (CBD). METHODS: In a survey of short-term workers employed at a primary beryllium manufacturing facility between the years 1994-1999, 264 participants completed a questionnaire and were tested for BeS. A range of qualitative and quantitative peak inhalation metrics and skin exposure indices were created using: personal full-shift beryllium exposure measurements, 15 min to 24 h process-specific task and area exposure measurements, glove measurements as indicator of skin exposure, process-upset information gleaned from historical reports, and self-reported information on exposure events. Hierarchical clustering was conducted to systematically group participants based on similarity of patterns of 16 exposure variables. The associations of the exposure metrics with BeS and self-reported skin symptoms (in work areas processing beryllium salts as well as in other work areas) were evaluated using correlation analysis, log-binomial and logistic regression models with splines. RESULTS: Metrics of peak inhalation exposure, indices of skin exposure, and using material containing beryllium salts were significantly associated with skin symptoms and BeS; skin symptoms were a strong predictor of BeS. However, in this cohort, we could not tease apart the independent effects of skin exposure from inhalation exposure, as these exposures occurred simultaneously and were highly correlated. Hierarchical clustering identified groups of participants with unique patterns of exposure characteristics resulting in different prevalence of BeS and skin symptoms. A cluster with high skin exposure index and use of material containing beryllium salts had the highest prevalence of BeS and self-reported skin symptoms, followed by a cluster with high inhalation and skin exposure index and a very small fraction of jobs in which beryllium salts were used. A cluster with low inhalation and skin exposure and no workers using beryllium salts had no cases of BeS. CONCLUSION: Multiple pathways and types of exposure were associated with BeS and may be important for informing BeS prevention. Prevention efforts should focus on controlling airborne beryllium exposures with attention to peaks, use of process characteristics (e.g. the likelihood of upset conditions to design interventions) minimize skin exposure to beryllium particles, and in particular, eliminate skin contact with beryllium salts to interrupt potential exposure pathways for BeS risk.

    • Occupational Safety and Health – Mining
      1. Current review of pneumoconiosis among US coal minersexternal icon
        Hall NB, Blackley DJ, Halldin CN, Laney AS.
        Curr Environ Health Rep. 2019 Sep 6.
        PURPOSE OF REVIEW: This review summarizes recent research on pneumoconiosis in coal workers following the identification of the resurgence of this disease among US coal miners in the early 2000s. We describe the impact of this research and how this has led to increased public attention, benefitting affected miners. RECENT FINDINGS: The latest research shows that the prevalence of pneumoconiosis, including progressive massive fibrosis, continues to increase, especially in central Appalachia. Contributing factors may include mining of thin coal seams or cutting rock to access coal, which may expose miners to coal mine dust with a higher content of silica and silicates than in the past. The impact of recently implemented changes, such as the reduced occupational exposure limit for respirable coal mine dust and the introduction of continuous personal dust monitors, will likely take years to appropriately evaluate.

    • Parasitic Diseases
      1. Blood cytokine, chemokine and growth factor profiling in a cohort of pregnant women from tropical countriesexternal icon
        Dobano C, Bardaji A, Kochar S, Kochar SK, Padilla N, Lopez M, Unger HW, Ome-Kaius M, Castellanos ME, Arevalo-Herrera M, Hans D, Martinez-Espinosa FE, Botto-Menezes C, Malheiros A, Desai M, Casellas A, Chitnis CE, Rogerson S, Mueller I, Menendez C, Requena P.
        Cytokine. 2019 Sep 9;125:154818.
        The immune status of women changes during and after pregnancy, differs between blood compartments at delivery and is affected by environmental factors particularly in tropical areas endemic for multiple infections. We quantified the plasma concentration of a set of thirty-one TH1, TH2, TH17 and regulatory cytokines, pro-inflammatory and anti-inflammatory cytokines and chemokines, and growth factors (altogether biomarkers), in a cohort of 540 pregnant women from five malaria-endemic tropical countries. Samples were collected at recruitment (first antenatal visit), delivery (periphery, cord and placenta) and postpartum, allowing a longitudinal analysis. We found the lowest concentration of biomarkers at recruitment and the highest at postpartum, with few exceptions. Among them, IL-6, HGF and TGF-beta had the highest levels at delivery, and even higher concentrations in the placenta compared to peripheral blood. Placental concentrations were generally higher than peripheral, except for eotaxin that was lower. We also compared plasma biomarker concentrations between the tropical cohort and a control group from Spain at delivery, presenting overall higher biomarker levels the tropical cohort, particularly pro-inflammatory cytokines and growth factors. Only IL-6 presented lower levels in the tropical group. Moreover, a principal component analysis of biomarker concentrations at delivery showed that women from Spain grouped more homogenously, and that IL-6 and IL-8 clustered together in the tropical cohort but not in the Spanish one. Plasma cytokine concentrations correlated with Plasmodium antibody levels at postpartum but not during pregnancy. This basal profiling of immune mediators over gestation and in different compartments at delivery is important to subsequently understand response to infections and clinical outcomes in mothers and infants in tropical areas.

    • Substance Use and Abuse
      1. BACKGROUND AND AIMS: Due to their small sample sizes, geographic specificity, and limited examination of sociodemographic characteristics, recent studies of methamphetamine use among people using heroin in the U.S. are limited in their ability to identify national and regional trends and to characterize populations at risk for using heroin and methamphetamine. This study aimed to examine trends and correlates of methamphetamine use among heroin treatment admissions in the U.S. DESIGN: Longitudinal analysis of data from the 2008 through 2017 Treatment Episode Data Set. Descriptive statistics, trend analyses, and multivariable logistic regression were used to examine characteristics associated with methamphetamine use among heroin treatment admissions. SETTING: United States PARTICIPANTS: Treatment admissions of people >/=12 years whose primary substance of use is heroin. MEASUREMENTS: Primary measurement was heroin treatment admissions involving methamphetamine. Secondary measurements were demographics of sex, age, race/ethnicity, U.S. census region, living arrangement, and employment status. FINDINGS: The percentage of primary heroin treatment admissions reporting methamphetamine use increased each year from 2.1% in 2008 to 12.4% in 2017, a relative percentage increase of 490% and an annual percent change (APC) of 23.4% (p<0.001). During the study period, increases were seen among males and females, and across all demographic and geographic groups examined. Among primary heroin treatment admissions reporting methamphetamine use in 2017, 47.1% reported injecting, 46.0% reported smoking, 5.1% reporting snorting, and 1.8% reported oral/other as their usual route of methamphetamine use. CONCLUSIONS: Methamphetamine use among heroin treatment admissions in the United States increased from 1 in 50 primary heroin treatment admissions in 2008 to 1 in 12 admissions in 2017.

      2. State strategies to address opioid use disorder among pregnant and postpartum women and infants prenatally exposed to substances, including infants with neonatal abstinence syndromeexternal icon
        Kroelinger CD, Rice ME, Cox S, Hickner HR, Weber MK, Romero L, Ko JY, Addison D, Mueller T, Shapiro-Mendoza C, Fehrenbach SN, Honein MA, Barfield WD.
        MMWR Morb Mortal Wkly Rep. 2019 Sep 13;68(36):777-783.
        Since 1999, the rate of opioid use disorder (OUD) has more than quadrupled, from 1.5 per 1,000 delivery hospitalizations to 6.5 (1), with similar increases in incidence of neonatal abstinence syndrome (NAS) observed for infants (from 2.8 per 1,000 live births to 14.4) among Medicaid-insured deliveries (2). CDC’s response to the opioid crisis involves strategies to prevent opioid overdoses and related harms by building state capacity and supporting providers, health systems, and payers.* Recognizing systems gaps in provision of perinatal care and services, CDC partnered with the Association of State and Territorial Health Officials (ASTHO) to launch the Opioid Use Disorder, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative Learning Community (OMNI LC). OMNI LC supports systems change and capacity building in 12 states.(dagger) Qualitative data from participating states were analyzed to identify strategies, barriers, and facilitators for capacity building in state-defined focus areas. Most states focused on strategies to expand access to and coordination of quality services (10 of 12) or increase provider awareness and training (nine of 12). Fewer states focused on data, monitoring, and evaluation (four of 12); financing and coverage (three of 12); or ethical, legal, and social considerations (two of 12). By building capacity to strengthen health systems, state-identified strategies across all focus areas might improve the health trajectory of mothers, infants, and families affected by the U.S. opioid crisis.

      3. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin – preliminary reportexternal icon
        Layden JE, Ghinai I, Pray I, Kimball A, Layer M, Tenforde M, Navon L, Hoots B, Salvatore PP, Elderbrook M, Haupt T, Kanne J, Patel MT, Saathoff-Huber L, King BA, Schier JG, Mikosz CA, Meiman J.
        N Engl J Med. 2019 Sep 6.
        BACKGROUND: E-cigarettes are battery-operated devices that heat a liquid and deliver an aerosolized product to the user. Pulmonary illnesses related to e-cigarette use have been reported, but no large series has been described. In July 2019, the Wisconsin Department of Health Services and the Illinois Department of Public Health received reports of pulmonary disease associated with the use of e-cigarettes (also called vaping) and launched a coordinated public health investigation. METHODS: We defined case patients as persons who reported use of e-cigarette devices and related products in the 90 days before symptom onset and had pulmonary infiltrates on imaging and whose illnesses were not attributed to other causes. Medical record abstraction and case patient interviews were conducted with the use of standardized tools. RESULTS: There were 53 case patients, 83% of whom were male; the median age of the patients was 19 years. The majority of patients presented with respiratory symptoms (98%), gastrointestinal symptoms (81%), and constitutional symptoms (100%). All case patients had bilateral infiltrates on chest imaging (which was part of the case definition). A total of 94% of the patients were hospitalized, 32% underwent intubation and mechanical ventilation, and one death was reported. A total of 84% of the patients reported having used tetrahydrocannabinol products in e-cigarette devices, although a wide variety of products and devices was reported. Syndromic surveillance data from Illinois showed that the mean monthly rate of visits related to severe respiratory illness in June through August of 2019 was twice the rate that was observed in the same months in 2018. CONCLUSIONS: Case patients presented with similar clinical characteristics. Although the features of e-cigarette use that were responsible for injury have not been identified, this cluster of illnesses represents an emerging clinical syndrome or syndromes. Additional work is needed to characterize the pathophysiology and to identify the definitive causes.

      4. Severe pulmonary disease associated with electronic-cigarette-product use – interim guidanceexternal icon
        Schier JG, Meiman JG, Layden J, Mikosz CA, VanFrank B, King BA, Salvatore PP, Weissman DN, Thomas J, Melstrom PC, Baldwin GT, Parker EM, Courtney-Long EA, Krishnasamy VP, Pickens CM, Evans ME, Tsay SV, Powell KM, Kiernan EA, Marynak KL, Adjemian J, Holton K, Armour BS, England LJ, Briss PA, Houry D, Hacker KA, Reagan-Steiner S, Zaki S, Meaney-Delman D.
        MMWR Morb Mortal Wkly Rep. 2019 Sep 13;68(36):787-790.
        On September 6, 2019, this report was posted as an MMWR Early Release on the MMWR website ( As of August 27, 2019, 215 possible cases of severe pulmonary disease associated with the use of electronic cigarette (e-cigarette) products (e.g., devices, liquids, refill pods, and cartridges) had been reported to CDC by 25 state health departments. E-cigarettes are devices that produce an aerosol by heating a liquid containing various chemicals, including nicotine, flavorings, and other additives (e.g., propellants, solvents, and oils). Users inhale the aerosol, including any additives, into their lungs. Aerosols produced by e-cigarettes can contain harmful or potentially harmful substances, including heavy metals such as lead, volatile organic compounds, ultrafine particles, cancer-causing chemicals, or other agents such as chemicals used for cleaning the device (1). E-cigarettes also can be used to deliver tetrahydrocannabinol (THC), the principal psychoactive component of cannabis, or other drugs; for example, “dabbing” involves superheating substances that contain high concentrations of THC and other plant compounds (e.g., cannabidiol) with the intent of inhaling the aerosol. E-cigarette users could potentially add other substances to the devices. This report summarizes available information and provides interim case definitions and guidance for reporting possible cases of severe pulmonary disease. The guidance in this report reflects data available as of September 6, 2019; guidance will be updated as additional information becomes available.

    • Zoonotic and Vectorborne Diseases
      1. An investigation of Salmonella Fluntern illnesses linked to leopard geckos – United States, 2018external icon
        Koski L, DeBess E, Rosen HE, Reporter R, Waltz T, Leeper M, Concepcion Acevedo J, Karpiskova R, McCormick J, Gelbicova T, Morningstar-Shaw B, Nichols M, Leman RF.
        Zoonoses Public Health. 2019 Sep 11.
        Reptile contact can result in zoonotic non-typhoidal salmonellosis. In April 2018, Oregon Public Health Division contacted CDC about a cluster of four Salmonella serovar Fluntern (SF) illnesses in four states (OR, CA, IA, NY); patients reported contact with geckos, a popular reptile pet. PulseNet, the national molecular subtyping network of food-borne disease surveillance, subsequently identified additional SF clinical isolates. Twelve cases in 11 states were identified; median age was 5 years (range: <1-58 years). Three patients were hospitalized; no deaths were reported. Of those with exposure information (n = 10), all reported reptile exposure; 9 (90%) specified contact with leopard geckos. No common source of geckos was identified from reported purchase locations. Los Angeles County (LAC) health officials isolated SF from one patient’s leopard gecko. Five reptile/gecko isolates were identified from the USDA National Veterinary Services Laboratories (NVSL) from 2015 to 2018. Five countries responded to an Epidemic Intelligence Information System post by PulseNet; reptile isolate sequence data were received from Czech Republic. A clinical case from England was identified through the National Center for Biotechnology Information pathogen detection pipeline; the patient did not report contact with leopard geckos. Whole genome sequencing analysis revealed substantial genetic diversity between clinical and animal isolates; however, gecko and clinical isolates from LAC were highly related (1 allele difference). This investigation linking SF illnesses to leopard geckos highlights an important public health risk from pets. A better understanding of how geckos are distributed by the pet industry in the United States could improve traceability to points of origin and mitigate Salmonella transmission at gecko breeders. Earlier NVSL reports of SF isolates from geckos suggest the risk of human SF infection from geckos is not new. This investigation demonstrates a need to educate gecko breeders, retailers and gecko owners about the continued Salmonella infection risk from pet geckos.

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CDC Science Clips Production Staff

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

Page last reviewed: October 1, 2019, 12:00 AM