Volume 11, Issue 44 November 5, 2019

CDC Science Clips: Volume 11, Issue 44, November 5, 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 collaborate with CDC Vital Signs by featuring scientific articles from the latest issue on Preventing Adverse Childhood Experiences. The items marked with an asterisk may be of particular interest to clinicians and public health professionals seeking background information in this area.

  1. CDC Vital Signs
    • Injury and Violence – Preventing Adverse Childhood Experiences
      1. *Preventing adverse childhood experiences (ACES): leveraging the best available evidencepdf icon
        Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
        Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Injury Prevention and Control. 2019 .
        This is a resource to help states and communities leverage the best available evidence to prevent adverse childhood experiences (ACEs) from happening in the first place as well as lessen harms when ACEs do occur. It features six strategies drawn from the CDC Technical Packages to Prevent Violence.

      2. *Preventing Adverse Childhood Experiences: We all have a role in preventing ACEs [Training Modules]
        Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention.
        . 2018.
        Adverse childhood experiences – commonly known as ACEs – affect children and families across all communities. ACEs can impact kids’ health and well-being, and they can have long-term effects on adults’ health and wellness. They can even have consequences that affect entire families, communities, and our whole society. This training will help you understand, recognize, and prevent ACEs. You’ll learn about risk and protective factors, outcomes associated with ACEs, and evidence-based strategies you can use to reduce or eliminate the impact of ACEs and stop them from occurring in the first place. After completing the introductory Training Modules, select a module with information for professionals working directly with and on behalf of kids and familes. These modules will help you gain skills and knowledge about how you can prevent ACEs as mental health provider, medical provider, and others.

      3. BACKGROUND: An increasing number of studies are identifying associations between adverse childhood experiences (ACEs) and ill health throughout the life course. We aimed to calculate the proportions of major risk factors for and causes of ill health that are attributable to one or multiple types of ACE and the associated financial costs. METHODS: In this systematic review and meta-analysis, we searched for studies in which risk data in individuals with ACEs were compared with these data in those without ACEs. We searched six electronic databases (MEDLINE, CINAHL, PsycINFO, Applied Social Sciences Index and Abstracts, Criminal Justice Databases, and the Education Resources Information Center) for quantitative studies published between Jan 1, 1990, and July 11, 2018, that reported risks of health-related behaviours and causes of ill health in adults that were associated with cumulative measures of ACEs (ie, number of ACEs). We included studies in adults in populations that did not have a high risk of ACEs, that had sample sizes of at least 1000 people, and that provided ACE prevalence data. We calculated the pooled RR for risk factors (harmful alcohol use, illicit drug use, smoking, and obesity) and causes of ill health (cancer, diabetes, cardiovascular disease, respiratory disease, anxiety, and depression) associated with ACEs. RRs were used to estimate the population-attributable fractions (PAFs) of risk attributable to ACEs and the disability-adjusted life-years (DALYs) and financial costs associated with ACEs. This study was prospectively registered in PROSPERO (CRD42018090356). FINDINGS: Of 4387 unique articles found following our initial search, after review of the titles (and abstracts, when the title was relevant), we assessed 880 (20%) full-text articles. We considered 221 (25%) full-text articles for inclusion, of which 23 (10%) articles met all selection criteria for our meta-analysis. We found a pooled prevalence of 23.5% of individuals (95% CI 18.7-28.5) with one ACE and 18.7% (14.7-23.2) with two or more ACEs in Europe (from ten studies) and of 23.4% of individuals (22.0-24.8) with one ACE and 35.0% (31.6-38.4) with two or more ACEs in north America (from nine studies). Illicit drug use had the highest PAFs associated with ACEs of all the risk factors assessed in both regions (34.1% in Europe; 41.1% in north America). In both regions, PAFs of causes of ill health were highest for mental illness outcomes: ACEs were attributed to about 30% of cases of anxiety and 40% of cases of depression in north America and more than a quarter of both conditions in Europe. Costs of cardiovascular disease attributable to ACEs were substantially higher than for most other causes of ill health because of higher DALYs for this condition. Total annual costs attributable to ACEs were estimated to be US$581 billion in Europe and $748 billion in north America. More than 75% of these costs arose in individuals with two or more ACEs. INTERPRETATION: Millions of adults across Europe and north America live with a legacy of ACEs. Our findings suggest that a 10% reduction in ACE prevalence could equate to annual savings of 3 million DALYs or $105 billion. Programmes to prevent ACEs and moderate their effects are available. Rebalancing expenditure towards ensuring safe and nurturing childhoods would be economically beneficial and relieve pressures on health-care systems. FUNDING: World Health Organization Regional Office for Europe.

      4. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Studyexternal icon
        Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS.
        Am J Prev Med. 1998 May;14(4):245-58.
        BACKGROUND: The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described. METHODS: A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life. RESULTS: More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P < .001). Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life. CONCLUSIONS: We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

      5. Adverse childhood experiences (ACEs), including child abuse, have been linked with poor health outcomes in adulthood. The mechanisms that explain these relations are less understood. This study assesses whether associations of ACEs and health risks are mediated by adult socioeconomic conditions, and whether these pathways are different for maltreatment than for other types of adversities. Using the Behavioral Risk Factor Surveillance System 2012 survey (N=29,229), we employ structural equation modeling to (1) estimate associations of the number and type of ACEs with five health risks-depression, obesity, tobacco use, binge drinking, and self-reported sub-optimal health; and (2) assess whether adult socioeconomic conditions-marriage, divorce and separation, educational attainment, income and insurance status-mediate those associations. Findings suggest both direct and indirect associations between ACEs and health risks. At high numbers of ACEs, 15-20% of the association between number of ACEs and adult health risks was attributable to socioeconomic conditions. Associations of three ACEs (exposure to domestic violence, parental divorce, and residing with a person who was incarcerated) with health risks were nearly entirely explained by socioeconomic conditions in adulthood. However, child physical, emotional, and sexual abuse were significantly associated with several adult health risks, beyond the effects of other adversities, and socioeconomic conditions explained only a small portion of these associations. These findings suggest that the pathways to poor adult health differ by types of ACEs, and that childhood abuse is more likely than other adversities to have a direct impact.

      6. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysisexternal icon
        Hughes K, Bellis MA, Hardcastle KA, Sethi D, Butchart A, Mikton C, Jones L, Dunne MP.
        Lancet Public Health. 2017 Aug;2(8):e356-e366.
        BACKGROUND: A growing body of research identifies the harmful effects that adverse childhood experiences (ACEs; occurring during childhood or adolescence; eg, child maltreatment or exposure to domestic violence) have on health throughout life. Studies have quantified such effects for individual ACEs. However, ACEs frequently co-occur and no synthesis of findings from studies measuring the effect of multiple ACE types has been done. METHODS: In this systematic review and meta-analysis, we searched five electronic databases for cross-sectional, case-control, or cohort studies published up to May 6, 2016, reporting risks of health outcomes, consisting of substance use, sexual health, mental health, weight and physical exercise, violence, and physical health status and conditions, associated with multiple ACEs. We selected articles that presented risk estimates for individuals with at least four ACEs compared with those with none for outcomes with sufficient data for meta-analysis (at least four populations). Included studies also focused on adults aged at least 18 years with a sample size of at least 100. We excluded studies based on high-risk or clinical populations. We extracted data from published reports. We calculated pooled odds ratios (ORs) using a random-effects model. FINDINGS: Of 11 621 references identified by the search, 37 included studies provided risk estimates for 23 outcomes, with a total of 253 719 participants. Individuals with at least four ACEs were at increased risk of all health outcomes compared with individuals with no ACEs. Associations were weak or modest for physical inactivity, overweight or obesity, and diabetes (ORs of less than two); moderate for smoking, heavy alcohol use, poor self-rated health, cancer, heart disease, and respiratory disease (ORs of two to three), strong for sexual risk taking, mental ill health, and problematic alcohol use (ORs of more than three to six), and strongest for problematic drug use and interpersonal and self-directed violence (ORs of more than seven). We identified considerable heterogeneity (I(2) of >75%) between estimates for almost half of the outcomes. INTERPRETATION: To have multiple ACEs is a major risk factor for many health conditions. The outcomes most strongly associated with multiple ACEs represent ACE risks for the next generation (eg, violence, mental illness, and substance use). To sustain improvements in public health requires a shift in focus to include prevention of ACEs, resilience building, and ACE-informed service provision. The Sustainable Development Goals provide a global platform to reduce ACEs and their life-course effect on health. FUNDING: Public Health Wales.

      7. CONTEXT: The purpose of this systematic literature review was to summarize current evidence from RCTs for the efficacy of interventions involving pediatric health care to prevent poor outcomes associated with adverse childhood experiences measured in childhood (C-ACEs). EVIDENCE ACQUISITION: On January 18, 2018, investigators searched PubMed, PsycInfo, SocIndex, Web of Science, Cochrane, and reference lists for English language RCTs involving pediatric health care and published between January 1, 1990, and December 31, 2017. Studies were included if they were (1) an RCT, (2) on a pediatric population, and (3) recruited or screened based on exposure to C-ACEs. Investigators extracted data about the study sample and recruitment strategy, C-ACEs, intervention and control conditions, intermediate and child outcomes, and significant associations reported. EVIDENCE SYNTHESIS: A total of 22 articles describing results of 20 RCTs were included. Parent mental illness/depression was the most common C-ACE measured, followed by parent alcohol or drug abuse, and domestic violence. Most interventions combined parenting education, social service referrals, and social support for families of children aged 0-5years. Five of six studies that directly involved pediatric primary care practices improved outcomes, including three trials that involved screening for C-ACEs. Eight of 15 studies that measured child health outcomes, and 15 of 17 studies that assessed the parent-child relationship, demonstrated improvement. CONCLUSIONS: Multicomponent interventions that utilize professionals to provide parenting education, mental health counseling, social service referrals, or social support can reduce the impact of C-ACEs on child behavioral/mental health problems and improve the parent-child relationship for children aged 0-5years.

      8. Importance: Early adversity is associated with leading causes of adult morbidity and mortality and effects on life opportunities. Objective: To provide an updated prevalence estimate of adverse childhood experiences (ACEs) in the United States using a large, diverse, and representative sample of adults in 23 states. Design, Setting, and Participants: Data were collected through the Behavioral Risk Factor Surveillance System (BRFSS), an annual, nationally representative telephone survey on health-related behaviors, health conditions, and use of preventive services, from January 1, 2011, through December 31, 2014. Twenty-three states included the ACE assessment in their BRFSS. Respondents included 248934 noninstitutionalized adults older than 18 years. Data were analyzed from March 15 to April 25, 2017. Main Outcomes and Measures: The ACE module consists of 11 questions collapsed into the following 8 categories: physical abuse, emotional abuse, sexual abuse, household mental illness, household substance use, household domestic violence, incarcerated household member, and parental separation or divorce. Lifetime ACE prevalence estimates within each subdomain were calculated (range, 1.00-8.00, with higher scores indicating greater exposure) and stratified by sex, age group, race/ethnicity, annual household income, educational attainment, employment status, sexual orientation, and geographic region. Results: Of the 214157 respondents included in the sample (51.51% female), 61.55% had at least 1 and 24.64% reported 3 or more ACEs. Significantly higher ACE exposures were reported by participants who identified as black (mean score, 1.69; 95% CI, 1.62-1.76), Hispanic (mean score, 1.80; 95% CI, 1.70-1.91), or multiracial (mean score, 2.52; 95% CI, 2.36-2.67), those with less than a high school education (mean score, 1.97; 95% CI, 1.88-2.05), those with income of less than $15000 per year (mean score, 2.16; 95% CI, 2.09-2.23), those who were unemployed (mean score, 2.30; 95% CI, 2.21-2.38) or unable to work (mean score, 2.33; 95% CI, 2.25-2.42), and those identifying as gay/lesbian (mean score 2.19; 95% CI, 1.95-2.43) or bisexual (mean score, 3.14; 95% CI, 2.82-3.46) compared with those identifying as white, those completing high school or more education, those in all other income brackets, those who were employed, and those identifying as straight, respectively. Emotional abuse was the most prevalent ACE (34.42%; 95% CI, 33.81%-35.03%), followed by parental separation or divorce (27.63%; 95% CI, 27.02%-28.24%) and household substance abuse (27.56%; 95% CI, 27.00%-28.14%). Conclusions and Relevance: This report demonstrates the burden of ACEs among the US adult population using the largest and most diverse sample to date. These findings highlight that childhood adversity is common across sociodemographic characteristics, but some individuals are at higher risk of experiencing ACEs than others. Although identifying and treating ACE exposure is important, prioritizing primary prevention of ACEs is critical to improve health and life outcomes throughout the lifespan and across generations.

      9. Adverse childhood experiences and life opportunities: Shifting the narrativeexternal icon
        Metzler M, Merrick M, Klevens J, Ports K, Ford D.
        Child Youth Serv Rev. 2017 ;72:141-149.
        Substantial research shows that early adversity, including child abuse and neglect, is associated with diminished health across the life course and across generations. Less well understood is the relationship between early adversity and adult socioeconomic status, including education, employment, and income. Collectively, these outcomes provide an indication of overall life opportunity. We analyzed data from 10 states and the District of Columbia that used the adverse childhood experiences (ACE) module in the 2010 Behavioral Risk Factor Surveillance System to examine the association between ACEs and adult education, employment, and income. Compared to participants with no ACEs, those with higher ACE scores were more likely to report high school non-completion, unemployment, and living in a household below the federal poverty level. This evidence suggests that preventing early adversity may impact health and life opportunities that reverberate across generations. Current efforts to prevent early adversity might be more successful if they broaden public and professional understanding (i.e., the narrative) of the links between early adversity and poverty. We discuss our findings within the context of structural policies and processes that may further contribute to the intergenerational continuity of child abuse and neglect and poverty.

      10. Advances in biology are providing deeper insights into how early experiences are built into the body with lasting effects on learning, behavior, and health. Numerous evaluations of interventions for young children facing adversity have demonstrated multiple, positive effects but they have been highly variable and difficult to sustain or scale. New research on plasticity and critical periods in development, increasing understanding of how gene-environment interaction affects variation in stress susceptibility and resilience, and the emerging availability of measures of toxic stress effects that are sensitive to intervention provide much-needed fuel for science-informed innovation in the early childhood arena. This growing knowledge base suggests 4 shifts in thinking about policy and practice: (1) early experiences affect lifelong health, not just learning; (2) healthy brain development requires protection from toxic stress, not just enrichment; (3) achieving breakthrough outcomes for young children facing adversity requires supporting the adults who care for them to transform their own lives; and (4) more effective interventions are needed in the prenatal period and first 3 years after birth for the most disadvantaged children and families. The time has come to leverage 21st-century science to catalyze the design, testing, and scaling of more powerful approaches for reducing lifelong disease by mitigating the effects of early adversity.

  2. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Chronic Diseases and Conditions
      1. The effect of comorbid medical and psychiatric diagnoses on chronic fatigue syndromeexternal icon
        Natelson BH, Lin JS, Lange G, Khan S, Stegner A, Unger ER.
        Ann Med. 2019 Oct 23:1-18.
        OBJECTIVE: To determine if presence of co-existing medically unexplained syndromes or psychiatric diagnoses affect symptom frequency, severity or activity impairment in Chronic Fatigue Syndrome. PATIENTS: Sequential Chronic Fatigue Syndrome patients presenting in one clinical practice. DESIGN: Participants underwent a psychiatric diagnostic interview and were evaluated for fibromyalgia, irritable bowel syndrome and/or multiple chemical sensitivity. RESULTS: Current and lifetime psychiatric diagnosis was common (68%) increasing mental fatigue/health but not other illness variables and not with diagnosis of other medically unexplained syndromes. 81% of patients had at least one of these conditions with about a third having all three co-existing syndromes. Psychiatric diagnosis was not associated with their diagnosis. Increasing the number of these unexplained conditions was associated with increasing impairment in physical function, pain and rates of being unable to work. CONCLUSIONS: Patients with Chronic Fatigue Syndrome should be evaluated for current psychiatric conditions because of their impact on patient quality of life, but they do not act as a symptom multiplier for the illness. Other co-existing medically unexplained syndromes are more common than psychiatric co-morbidities in patients presenting for evaluation of medically unexplained fatigue and are also more associated with increased disability and the number and severity of symptoms. Key Messages When physicians see patients with medically unexplained fatigue, they often infer that this illness is due to an underlying psychiatric problem. This paper shows that the presence of co-existing psychiatric diagnoses does not impact on any aspect of the phenomenology of medically unexplained fatigue also known as chronic fatigue syndrome. Therefore, psychiatric status is not an important causal contributor to CFS. In contrast, the presence of other medically unexplained syndromes [irritable bowel syndrome; fibromyalgia and/or multiple chemical sensitivity] do impact on the illness such that the more of these that co-exist the more health-related burdens the patient has.

      2. Trends in preventive visits among U.S. youth where weight and height were recorded: 2005-2016external icon
        Santo L, Rui P, Hales CM, Arem H, Ogden CL.
        Am J Prev Med. 2019 Nov;57(5):716-717.

        [No abstract]

    • Communicable Diseases
      1. Incidence and etiology of infectious diarrhea from a facility-based surveillance system in Guatemala, 2008-2012external icon
        Arvelo W, Hall AJ, Henao O, Lopez B, Bernart C, Moir JC, Reyes L, Montgomery SP, Morgan O, Estevez A, Parsons MB, Lopez MR, Gomez G, Vinje J, Gregoricus N, Parashar U, Mintz ED, McCracken J, Bryan JP, Lindblade KA.
        BMC Public Health. 2019 Oct 22;19(1):1340.
        BACKGROUND: Diarrhea is a major cause of morbidity and mortality, yet incidence and etiology data are limited. We conducted laboratory-based diarrhea surveillance in Guatemala. METHODS: A diarrhea case was defined as >/=3 loose stools in a 24-h period in a person presenting to the surveillance facilities. Epidemiologic data and stool specimens were collected. Specimens were tested for bacterial, parasitic, and viral pathogens. Yearly incidence was adjusted for healthcare seeking behaviors determined from a household survey conducted in the surveillance catchment area. RESULTS: From November 2008 to December 2012, the surveillance system captured 5331 diarrhea cases; among these 1381 (26%) had specimens tested for all enteric pathogens of interest. The adjusted incidence averaged 659 diarrhea cases per 10,000 persons per year, and was highest among children aged < 5 years, averaging 1584 cases per 10,000 children per year. Among 1381 (26%) specimens tested for all the pathogens of interest, 235 (17%) had a viral etiology, 275 (20%) had a bacterial, 50 (4%) had parasites, and 86 (6%) had co-infections. Among 827 (60%) specimens from children aged < 5 years, a virus was identified in 196 (23%) patients; 165 (20%) had norovirus and 99 (12%) rotavirus, including co-infections. Among 554 patients aged >/=5 years, 103 (19%) had a bacterial etiology, including diarrheagenic Escherichia coli in 94 (17%) cases, Shigella spp. in 31 (6%), Campylobacter spp. in 5 (1%), and Salmonella spp. in 4 (1%) cases. Detection of Giardia and Cryptosporidium was infrequent (73 cases; 5%). CONCLUSIONS: There was a substantial burden of viral and bacterial diarrheal diseases in Guatemala, highlighting the importance of strengthening laboratory capacity for rapid detection and control and for evaluation of public health interventions.

      2. Response and remediation actions following the detection of Naegleria fowleri in two treated drinking water distribution systems, Louisiana, 2013-2014external icon
        Cope JR, Kahler AM, Causey J, Williams JG, Kihlken J, Benjamin C, Ames AP, Forsman J, Zhu Y, Yoder JS, Seidel CJ, Hill VR.
        J Water Health. 2019 Oct;17(5):777-787.
        Naegleria fowleri causes the usually fatal disease primary amebic meningoencephalitis (PAM), typically in people who have been swimming in warm, untreated freshwater. Recently, some cases in the United States were associated with exposure to treated drinking water. In 2013, a case of PAM was reported for the first time in association with the exposure to water from a US treated drinking water system colonized with culturable N. fowleri. This system and another were found to have multiple areas with undetectable disinfectant residual levels. In response, the water distribution systems were temporarily converted from chloramine disinfection to chlorine to inactivate N. fowleri and reduced biofilm in the distribution systems. Once >1.0 mg/L free chlorine residual was attained in all systems for 60 days, water testing was performed; N. fowleri was not detected in water samples after the chlorine conversion. This investigation highlights the importance of maintaining adequate residual disinfectant levels in drinking water distribution systems. Water distribution system managers should be knowledgeable about the ecology of their systems, understand potential water quality changes when water temperatures increase, and work to eliminate areas in which biofilm growth may be problematic and affect water quality.

      3. HIV-1 genetic diversity to estimate time of infection and infer adherence to pre-exposure prophylaxisexternal icon
        Council OD, Ruone S, Mock PA, Khalil G, Martin A, Curlin ME, McNicholl JM, Heneine W, Leelawiwat W, Choopanya K, Vanichseni S, Cherdtrakulkiat T, Anekvorapong R, Martin M, Garcia-Lerma JG.
        Aids. 2019 Oct 10.
        OBJECTIVE: To estimate time of HIV infection in participants from the Bangkok Tenofovir Study (BTS) with daily oral tenofovir disoproxil fumarate (TDF) for pre-exposure prophylaxis (PrEP) and relate infection with adherence patterns. DESIGN: We used the diversity structure of the virus population at the first RNA-positive sample to estimate the date of infection, and mapped these estimates to medication diaries obtained under daily directly observed therapy (DOT). METHODS: HIV genetic diversity was investigated in all 17 PrEP breakthrough infections and in 16 placebo recipients. We generated 10 to 25 HIV env sequences from each participant by single genome amplification, and calculated time since infection (and 95% confidence interval) using Poisson models of early virus evolution. Study medication diaries obtained under daily DOT were then used to compute the number of missed TDF doses at the approximate date of infection. RESULTS: Fifteen of the 17 PrEP breakthrough infections were successfully amplified. Of these, 13 were initiated by a single genetic variant and generated reliable estimates of time since infection (median=47 [IQR=35] days). Eleven of these 13 were under daily DOT at the estimated time of infection. Analysis of medication diaries in these 11 participants showed 100% adherence in five, 90-95% adherence in two, 55% adherence in one, and non-adherence in three. CONCLUSIONS: We estimated time of infection in participants from BTS and found several infections when high levels of adherence to TDF were reported. Our results suggest that the biological efficacy of daily TDF against parenteral HIV exposure is not 100%.

      4. Comparative modelling of tuberculosis epidemiology and policy outcomes in Californiaexternal icon
        Menzies NA, Parriott A, Shrestha S, Dowdy DW, Cohen T, Salomon JA, Marks SM, Hill AN, Winston CA, Asay G, Barry P, Readhead A, Flood J, Kahn JG, Shete PB.
        Am J Respir Crit Care Med. 2019 Oct 18.
        Rationale Mathematical modelling is used to understand disease dynamics, forecast trends, and inform public health prioritization. We conducted a comparative analysis of tuberculosis (TB) epidemiology and potential intervention effects in California, using three previously developed epidemiologic models of TB. Measurements and Methods We compared model results between 2005 and 2050 under a base case scenario representing current TB services, and alternative scenarios including: (i) sustained interruption of Mycobacterium tuberculosis (Mtb) transmission, (ii) sustained resolution of latent TB infection (LTBI) and TB prior to entry of new residents, and (iii) one-time targeted testing and treatment of LTBI among 25% of non-US-born individuals residing in California. Results Model estimates of TB cases and deaths in California were in close agreement over the historical period but diverged for LTBI prevalence and new Mtb infections-outcomes for which definitive data are unavailable. Between 2018 and 2050, models projected average annual declines of 0.58-1.42% in TB cases, without additional interventions. A one-time LTBI testing and treatment intervention among non-US-born residents was projected to produce sustained reductions in TB incidence. Models found prevalent Mtb infection and migration to be more significant drivers of future TB incidence than local transmission. Conclusions All models projected a stagnation in the decline of TB incidence, highlighting the need for additional interventions including greater access to LTBI diagnosis and treatment for non-US-born individuals. Differences in model results reflect gaps in historical data and uncertainty in the trends of key parameters, demonstrating the need for high-quality, up-to-date TB determinant and outcome data.

      5. Validation of acute gastroenteritis-related International Classification of Diseases, Clinical Modification Codes in pediatric and adult US populationsexternal icon
        Pindyck T, Hall AJ, Tate JE, Cardemil CV, Kambhampati AK, Wikswo ME, Payne DC, Grytdal S, Boom JA, Englund JA, Klein EJ, Halasa N, Selvarangan R, Staat MA, Weinberg GA, Beenhouwer DO, Brown ST, Holodniy M, Lucero-Obusan C, Marconi VC, Rodriguez-Barradas MC, Parashar U.
        Clin Infect Dis. 2019 Oct 18.
        International Classification of Diseases diagnostic codes are used to estimate acute gastroenteritis (AGE) disease burden. We validated AGE-related codes in pediatric and adult populations using 2 multiregional active surveillance platforms. The sensitivity of AGE codes was similar (54% and 58%) in both populations and increased with addition of vomiting-specific codes.

      6. Homelessness is a substantial barrier to consistent, recommended HIV care, access and adherence to antiretroviral therapy (ART), and sustained viral suppression, thus increasing the risk for morbidity and transmission. We used data from the Medical Monitoring Project for June 1, 2015-May 31, 2017 to estimate the weighted prevalence of homelessness among persons with diagnosed HIV (PWH) (N = 7665) overall and by selected sociodemographic, behavioral, and clinical characteristics. Prevalence of homelessness was 8.5%. PWH experiencing homelessness were > 3 times as likely to have needed and not received shelter or housing services (32% vs. 10%), > 4 times as likely to inject drugs (9% vs. 2%), and > 7 times as likely to engage in exchange sex (10% vs. 1%), respectively, compared with PWH who did not experience homelessness. Homelessness was associated with lower HIV care retention, ART dose adherence, and sustained viral suppression. This analysis demonstrates substantial need for enhanced treatment, care, and service delivery for PWH experiencing homelessness. Research has demonstrated that housing assistance programs improve HIV-related outcomes and diminish HIV risk behaviors; therefore, housing assistance for PWH should be prioritized in public health policies and practice.

      7. Epidemiological impact of expedited partner therapy for men who have sex with men: A modeling studyexternal icon
        Weiss KM, Jones JS, Katz DA, Gift TL, Bernstein K, Workowski K, Rosenberg ES, Jenness SM.
        Sex Transm Dis. 2019 Nov;46(11):697-705.
        BACKGROUND: Expedited partner therapy (EPT) is an intervention for patients with gonorrhea or chlamydia, providing index patients with prescriptions or medication to give to their partners. Expedited partner therapy is recommended for heterosexuals but not for men who have sex with men (MSM), partially due to concerns about overtreatment of uninfected partners and missed opportunities for human immunodeficiency virus (HIV) diagnosis. METHODS: We extended our stochastic network-based mathematical model of HIV, gonorrhea, and chlamydia among MSM to include EPT. The EPT implementation was simulated for 10 years. Counterfactual scenarios varied EPT coverage, provision, uptake, and partnership window duration. We estimated sexually transmitted infection (STI) incidence, proportion of infections averted, and process outcomes under each scenario. RESULTS: Delivery of EPT to 20% of eligible MSM index patients (coverage) reduced cumulative STI incidence by 27% (interquartile range, 13%-39%) over 10 years compared with current estimated STI screening levels. A 20% increase in providing medication to non-index partners (provision) averted 32% (interquartile range, 20%-41%) of STI infections compared with estimated STI screening levels. When targeted by partnership type, EPT solely to casual partners maximized the population-level infections averted. The proportion of partners given medication who had no current STI varied from 52% to 63%, depending on coverage level. The proportion of partners given medication with undiagnosed HIV infection was 4% across scenarios. CONCLUSIONS: Expedited partner therapy could reduce bacterial STI incidence for MSM. However, this intervention could result in missed opportunities for HIV/STI prevention and a substantial increase in use of antimicrobials by STI-uninfected MSM, raising concerns about cost and antimicrobial resistance.

    • Disease Reservoirs and Vectors
      1. Failure of the Asian longhorned tick, Haemaphysalis longicornis, to serve as an experimental vector of the Lyme disease spirochete, Borrelia burgdorferi sensu strictoexternal icon
        Breuner NE, Ford SL, Hojgaard A, Osikowicz LM, Parise CM, Rosales Rizzo MF, Bai Y, Levin ML, Eisen RJ, Eisen L.
        Ticks Tick Borne Dis. 2019 Oct 16:101311.
        The invasive, human-biting Asian longhorned tick, Haemaphysalis longicornis, was detected in New Jersey in the eastern United States in August of 2017 and by November of 2018 this tick had been recorded from 45 counties across 9 states, primarily along the Eastern Seaboard. The establishment of H. longicornis in the United States has raised the questions of how commonly it will bite humans and which native pathogens may naturally infect this tick. There also is a need for experimental vector competence studies with native pathogens to determine if H. longicornis can acquire a given pathogen while feeding, pass it transstadially, and then transmit the pathogen in the next life stage. In this experimental study, we evaluated the vector competence of a population of H. longicornis originating from the United States (New York) for a native isolate (B31) of the Lyme disease spirochete, Borrelia burgdorferi sensu stricto (s.s.). In agreement with a previous experimental study on the vector competence of H. longicornis for Borrelia garinii, we found that uninfected H. longicornis larvae could acquire B. burgdorferi s.s. while feeding on infected Mus musculus mice (infection prevalence >50% in freshly fed larvae) but that the infection was lost during the molt to the nymphal stage. None of 520 tested molted nymphs were found to be infected, indicating that transstadial passage of B. burgdorferi s.s. is absent or rare in H. longicornis; and based on the potential error associated with the number of nymphs testing negative in this study, we estimate that the upper 95% limit for infection prevalence was 0.73%. An Ixodes scapularis process control showed both effective acquisition of B. burgdorferi s.s. from infected mice by uninfected larvae and transstadial passage to the nymphal stage (infection prevalence of 80-82% for both freshly fed larvae and molted nymphs). We also observed that although H. longicornis larvae could be compelled to feed on mice by placing the ticks within feeding capsules, attachment and feeding success was minimal (<0.5%) when larvae were placed freely on the fur of the mice. We conclude that H. longicornis is unlikely to contribute more than minimally, if at all, to transmission of Lyme disease spirochetes in the United States.

      2. Susceptibility to insecticides and resistance mechanisms in three populations of Aedes aegypti from Peruexternal icon
        Pinto J, Palomino M, Mendoza-Uribe L, Sinti C, Liebman KA, Lenhart A.
        Parasit Vectors. 2019 Oct 22;12(1):494.
        BACKGROUND: Epidemics of dengue, chikungunya and Zika are a growing threat to areas where Aedes aegypti are present. The efficacy of chemical control of Ae. aegypti is threatened by the increasing frequency of insecticide resistance. The objective of this study was to determine the susceptibility status as well as the biochemical and molecular mechanisms underlying insecticide resistance in three populations of Ae. aegypti in high risk areas of dengue, chikungunya, and Zika in Peru. METHODS: Bioassays were conducted on adult Ae. aegypti to evaluate their susceptibility to insecticides used currently or historically for mosquito control in Peru, including six pyrethroids, three organophosphates and one organochlorine, in populations of Ae. aegypti from the districts of Chosica (Department of Lima), Punchana (Department of Loreto) and Piura (Department of Piura). Resistance mechanisms were determined by biochemical assays to assess activity levels of key detoxification enzyme groups (nonspecific esterases, multi-function oxidases, glutathione S-transferases and insensitive acetylcholinesterase). Real-time PCR assays were used to detect two kdr mutations (V1016I and F1534C) on the voltage-gated sodium channel gene. RESULTS: Resistance to DDT was detected in all three populations, and resistance to pyrethroids was detected in all populations except the population from Chosica, which still exhibited susceptibility to deltamethrin. Resistance to organophosphates was also detected, with the exception of populations from Punchana and Piura, which still demonstrated susceptibility to malathion. In general, no increase or alteration of activity of any enzyme group was detected. Both 1016I and 1534C alleles were detected in Punchana and Piura, while only the 1534C allele was detected in Chosica. CONCLUSIONS: The results suggest that resistance to multiple classes of insecticides exist in areas important to Ae. aegypti-borne disease transmission in Peru. The F1534C mutation was present in all 3 populations and the V1016I mutation was present in 2 populations. To our knowledge, this is the first report of the presence of 1016I and 1534C in Ae. aegypti in Peru. The absence of highly elevated enzymatic activity suggests that target site resistance is a key mechanism underlying insecticide resistance in these populations, although further research is needed to fully understand the role of metabolic resistance mechanisms in these populations.

      3. Knowledge, attitudes, and practices related to anthrax and animal care: A case-control study in Georgiaexternal icon
        Traxler RM, Napetvaridze T, Asanishvili Z, Geleishvili M, Rukhadze K, Maghlakelidze G, Broladze M, Kokhreidze M, Maes EF, Reynolds D, Salman M, Shadomy SV, Rao S.
        PLoS One. 2019 ;14(10):e0224176.
        INTRODUCTION: Anthrax is endemic in Georgia and recent outbreaks prompted a livestock-handler case-control study with a component to evaluate anthrax knowledge, attitudes, and practices (KAP) among livestock handlers or owners. METHODS: Cases were handlers of livestock with confirmed animal anthrax from June 2013-May 2015. Handlers of four matched unaffected animals were selected as controls, two from the same village as the case animal (“village control”) and two from 3-10 km away (“area control”). Descriptive statistics were reported and conditional logistic regression was performed to estimate the magnitude of the association of cases with specific study KAP factors. RESULTS: Cases were more likely male, had lower level college education, less animal care experience, and provided more animal care to their cattle. Cases had lower odds of burying a suddenly dead animal compared to all controls (Odds Ratio [OR]: 0.32, 95% Confidence interval [CI]:0.12, 0.88) and area controls (OR: 0.32, 95% CI: 0.11, 0.91). On an 8-point knowledge scale, cases having an animal with anthrax had a 1.31 times greater knowledge score compared to all controls (95% CI: 1.03, 1.67). Cases had higher odds of ever having human anthrax or knowing another person who had anthrax compared to all controls (OR: 4.56, 95% CI: 1.45, 14.30) and area controls (OR: 7.16, 95% CI: 1.52, 33.80). DISCUSSION: Cases were more knowledgeable of anthrax and had better anthrax prevention practices, but these are likely a result of the case investigation and ring vaccination following the death of their animal. CONCLUSIONS: The findings reveal a low level of knowledge and practices related to anthrax control and prevention, and will guide educational material development to fill these gaps.

    • Genetics and Genomics
      1. Tracking human genes along the translational continuumexternal icon
        Lee K, Clyne M, Yu W, Lu Z, Khoury MJ.
        NPJ Genom Med. 2019 ;4:25.
        Understanding the drivers of research on human genes is a critical component to success of translation efforts of genomics into medicine and public health. Using publicly available curated online databases we sought to identify specific genes that are featured in translational genetic research in comparison to all genomics research publications. Articles in the CDC’s Public Health Genomics and Precision Health Knowledge Base were stratified into studies that have moved beyond basic research to population and clinical epidemiologic studies (T1: clinical and population human genome epidemiology research), and studies that evaluate, implement, and assess impact of genes in clinical and public health areas (T2+: beyond bench to bedside). We examined gene counts and numbers of publications within these phases of translation in comparison to all genes from Medline. We are able to highlight those genes that are moving from basic research to clinical and public health translational research, namely in cancer and a few genetic diseases with high penetrance and clinical actionability. Identifying human genes of translational value is an important step towards determining an evidence-based trajectory of the human genome in clinical and public health practice over time.

    • Health Economics
      1. The financial and time burden associated with phenylketonuria treatment in the United Statesexternal icon
        Rose AM, Grosse SD, Garcia SP, Bach J, Kleyn M, Simon NJ, Prosser LA.
        Mol Genet Metab Rep. 2019 ;21.
        Background: Phenylketonuria (PKU) imposes a substantial burden on people living with the condition and their families. However, little is known about the time cost and financial burden of having PKU or caring for a child with the condition. Methods and findings: Primary data were collected with a detailed cost and utilization survey. Primary outcomes included utilization and out-of-pocket costs of medical services, medical formula, and prescribed low-protein food consumption, as well as the time and perceived effort involved in following the PKU diet. Respondents were people living with PKU or parents of children with PKU identified through a state newborn screening program database. Secondary administrative claims data were also used to calculate mean total, insurer, and out-of-pocket payments in inpatient, outpatient (office visits, emergency room, and laboratory tests), and pharmacy settings for privately insured persons with PKU. Payments were calculated for sapropterin and for PKU formula. In primary data analysis (children n = 32, adults n = 52), annual out-of-pocket costs were highest for low-protein foods (child = $1651; adult = $967) compared with other categories of care. The time burden of PKU care was high; families reported spending more than 300 h per year shopping for and preparing special diet foods. In secondary data analysis, children 12-17 years old had the highest average medical expenditures ($54,147; n = 140) compared to children 0-11 years old ($19,057; n = 396) and adults 18 years and older ($40,705; n = 454). Medication costs were the largest contributor to medical costs, accounting for 61-81% of total costs across age groups. Sapropterin was the largest driver of medication costs, accounting for 85% of child medication costs and 92% of adult medication costs. Conclusion: Treatment for PKU incurs a substantial time and cost burden on persons with PKU and their families. Estimated medical expenditures using claims data varied by age group, but sapropterin represented the largest cost for PKU treatment from a payer perspective across age groups.

    • Healthcare Associated Infections
      1. Multiple importations and transmission of colistin-resistant Klebsiella pneumoniae in a hospital in northern Indiaexternal icon
        Mathur P, Khurana S, de Man TJ, Rastogi N, Katoch O, Veeraraghavan B, Neeravi AR, Venkatesan M, Kumar S, Sagar S, Gupta A, Aggarwal R, Soni KD, Malhotra R, Velayudhan A, Siromany V, Malpiedi P, Lutgring J, Laserson K, Gupta N, Srikantiah P, Sharma A.
        Infect Control Hosp Epidemiol. 2019 Oct 18:1-7.
        OBJECTIVE: Resistance to colistin, a last resort antibiotic, has emerged in India. We investigated colistin-resistant Klebsiella pneumoniae(ColR-KP) in a hospital in India to describe infections, characterize resistance of isolates, compare concordance of detection methods, and identify transmission events. DESIGN: Retrospective observational study. METHODS: Case-patients were defined as individuals from whom ColR-KP was isolated from a clinical specimen between January 2016 and October 2017. Isolates resistant to colistin by Vitek 2 were confirmed by broth microdilution (BMD). Isolates underwent colistin susceptibility testing by disk diffusion and whole-genome sequencing. Medical records were reviewed. RESULTS: Of 846 K. pneumoniae isolates, 34 (4%) were colistin resistant. In total, 22 case-patients were identified. Most (90%) were male; their median age was 33 years. Half were transferred from another hospital; 45% died. Case-patients were admitted for a median of 14 days before detection of ColR-KP. Also, 7 case-patients (32%) received colistin before detection of ColR-KP. All isolates were resistant to carbapenems and susceptible to tigecycline. Isolates resistant to colistin by Vitek 2 were also resistant by BMD; 2 ColR-KP isolates were resistant by disk diffusion. Moreover, 8 multilocus sequence types were identified. Isolates were negative for mobile colistin resistance (mcr) genes. Based on sequencing analysis, in-hospital transmission may have occurred with 8 case-patients (38%). CONCLUSIONS: Multiple infections caused by highly resistant, mcr-negative ColR-KP with substantial mortality were identified. Disk diffusion correlated poorly with Vitek 2 and BMD for detection of ColR-KP. Sequencing indicated multiple importation and in-hospital transmission events. Enhanced detection for ColR-KP may be warranted in India.

      2. Antibiotic prescribing variability in a large urgent care network: A new target for outpatient stewardshipexternal icon
        Stenehjem E, Wallin A, Fleming-Dutra KE, Buckel WR, Stanfield V, Brunisholz KD, Sorensen J, Samore MH, Srivastava R, Hicks LA, Hersh AL.
        Clin Infect Dis. 2019 Oct 23.
        Improving antibiotic prescribing in outpatient settings is a public health priority. In the United States, urgent care (UC) encounters are increasing and have high rates of inappropriate antibiotic prescribing. Our objective was to characterize antibiotic prescribing practices during UC encounters, with a focus on respiratory tract conditions. This was a retrospective cohort study of UC encounters in the Intermountain Healthcare network. Among 1.16 million UC encounters, antibiotics were prescribed during 34% of UC encounters and respiratory conditions accounted for 61% of all antibiotics prescribed. Of respiratory encounters, 50% resulted in antibiotic prescriptions, yet the variability at the level of the provider ranged from 3% to 94%. Similar variability between providers was observed for respiratory conditions where antibiotics were not indicated and in first-line antibiotic selection for sinusitis, otitis media, and pharyngitis. These findings support the importance of developing antibiotic stewardship interventions specifically targeting UC settings. We describe antibiotic prescribing in a large network of urgent care (UC) clinics. The high volume of infectious diseases encounters and extreme provider variability in antibiotic prescribing frequency and quality highlight the importance of antibiotic stewardship interventions specifically targeting UCs.

    • Laboratory Sciences
      1. BACKGROUND: Progressive disseminated histoplasmosis (PDH) is an important cause of mortality in persons living with HIV (PLHIV), especially in countries where patients have limited access to antiretroviral therapies and diagnostic testing. OBJECTIVE: A Lateral Flow Assay (LFA) to detect Histoplasma capsulatum antigen in serum developed by MiraVista((R)) was evaluated. METHODS: We tested 75 serum samples: 24 from PLHIV and culture-proven PDH and 51 from PLHIV with other fungal and bacterial infections as well as people without HIV. LFA devices were read manually (read by eye) and by an automated reader. RESULTS: When the LFA was read manually, sensitivity was 96% and specificity was 90%. When an automated reader was used, sensitivity was 92% and specificity was 94%. The Kappa index comparing manual and automated reader was 0.90. Cross-reactions were observed principally in samples from patients with proven diagnosis of paracoccidioidomycosis. CONCLUSIONS: The MiraVista((R)) Diagnostics Histoplasma antigen LFA had high analytical performance and good agreement between manual and automated reader. This LFA allows Histoplasma antigen testing with minimal laboratory equipment and infrastructure requirements.

      2. BACKGROUND: Assessing vitamin A status in populations remains a high public health priority for low- and middle-income countries. However, analytical difficulties with serum retinol measurements persist in international laboratories. Nearly all participants in a Centers for Disease Control and Prevention external quality assessment program use HPLC to measure serum retinol, but round-to-round results failing to meet acceptable criteria suggest the need to provide a straightforward stable HPLC ultraviolet (UV) method that can be adopted by these laboratories to improve performance. We present a protein precipitation HPLC-UV method that measures serum retinol below the deficiency cutoff value (<0.7 mumol/L or 20 mug/dL) that is suitable for low- and middle-income countries and uses commercially available materials. METHODS: Serum (25 muL) added to retinyl acetate was precipitated with acetonitrile (125 muL) to extract retinol. Solvent-based calibration solutions required no extraction. Calibration used either single-point (50 mug/dL) or multipoint solutions (0.52-100 mug/dL). C18 column (4.6 x 100 mm) and acetonitrile with 0.1% triethylamine/water (83/17, v/v) as isocratic mobile phase (1.1 mL/min), achieved baseline separation (7 minutes). RESULTS: With only 25 muL of serum, the limit of detection was 0.52 mug/dL. Single- and multipoint calibration generated equivalent results. Over several years, between-run imprecision was </=7.1% in multiple quality-control materials. Overall mean (CV) method bias for NIST-certified reference materials (e-series) was -0.2% (5.8%). Maximally, 180 samples were processed within 24 h. CONCLUSIONS: This method was robust and stable over years and accurately measured serum retinol with low-volume samples. Thus, it may be of interest to low- and middle-income countries and to pediatric and finger stick applications.

      3. Exposure to insoluble particles in the lung elicits inflammatory responses that eliminate deposited particulates and repair damaged tissue. Overzealous or prolonged responses lead to chronic conditions, such as fibrosis and malignancy, which are frequently progressive and refractory to drug therapy leading to high rates of disability and mortality. The molecular events underlying the progression of lung inflammation to chronic pathology, in particular, the conversion to fibrosis, remain poorly understood. Fibrogenic multi-walled carbon nanotubes (MWCNTs) have been shown to stimulate prominent acute inflammation that evolves into chronic lesions characterized by chronic inflammation, interstitial fibrosis, and granulomas in mouse lungs. In this communication, we examined the in vivo activation of nuclear factor-kappaB (NF-kappaB) signaling in fibroblastic cells during the inflammatory and fibrotic progression induced by MWCNTs. Wild-type C57BL/6J male mice were exposed to two fibrogenic MWCNTs (Mitsui XNRI MWNT-7 and long MWCNTs) by pharyngeal aspiration. Both MWCNTs strongly stimulated the nuclear translocation of NF-kappaB p65 in lung fibroblasts and myofibroblasts during the acute and chronic responses. Phosphorylated NF-kappaB p65 at serine 276, a marker of NF-kappaB activation, was markedly induced by MWCNTs in the nucleus of fibroblastic cells. Moreover, two NF-kappaB-regulated genes encoding pro-fibrotic mediators, tissue inhibitor of metalloproteinase 1 (TIMP1), and osteopontin (OPN), respectively, were significantly induced in lung fibroblasts and myofibroblasts. These results demonstrate that NF-kappaB is activated to mediate transactivation of pro-fibrotic genes in fibroblastic cells during pulmonary acute and chronic responses to CNTs, providing a mechanistic framework for analyzing gene regulation in pulmonary fibrotic progression through NF-kappaB signaling.

      4. Culture cell block controls as a tool to the biomolecular diagnosis of infectious diseasesexternal icon
        Jose Tadeu de Araujo L, Salas-Gomez D, Midori Kimura L, Fernandes Possatto Takahashi J, de Souza Barrel J, Rollin DC, Mariotti Guerra J.
        Appl Immunohistochem Mol Morphol. 2019 Oct 17.
        The cell block (CB) technique has allowed easy obtainment of samples such as cellular and culture suspensions, to perform specific molecular tests such as immunohistochemistry and in situ hybridization. It has been improved along time, accuracy, and quality of the diagnoses, however, the cost of a commercial gel matrix for the preparation of CB is high and not suitable depending on the situation. The objective of this study is to test agarose as an alternative to the commercial gel matrix in the preparation of Aspergillus fumigatus’ CB.

      5. Evaluation of a bead-based Salmonella molecular serotyping method for Salmonella isolated from food and environmental samplesexternal icon
        Moore MM, Nucci MJ, Madson SM, Wagley GS, Keys CE, Brown EW, McQuiston JR, Fields PI.
        J Food Prot. 2019 Nov;82(11):1973-1987.
        Salmonella is a leading cause of foodborne illness worldwide, and foods containing Salmonella (except raw meat and poultry products) are considered adulterated. Serotyping of Salmonella is an essential part of surveillance and investigation of outbreaks. This study evaluated a bead-based Salmonella molecular serotyping (SMS) method, which included the O-group 1, H-antigen, alternate target, and O-group 2 assays, compared with traditional serotyping. Salmonella was isolated from food, pet food, and environmental samples or were reference strains. A total of 572 isolates were analyzed by using two formats of the SMS method in comparison with traditional methods: 485 were analyzed by using Radix SMS (a custom user-mixed format), 218 were analyzed by using Luminex SMS (a commercial kit format), and 131 of the total isolates were analyzed by both formats for comparison. The SMS method was evaluated on the basis of the successful identification of antigens by the probes included in the method. The method identified 550 (96.2%) isolates as expected, 6 (1.0%) isolates were not identified as initially expected but were shown to be correctly identified by SMS after reanalysis by traditional serotyping, and 16 (2.8%) isolates not identified as expected possessed an antigen that should have been detected by the method but was not. Among the isolates considered correctly identified, 255 (44.6%) were identified to a single serovar, 44 (7.7%) required additional biochemical testing to differentiate variants or subspecies, and 251 (43.9%) were partially serotyped because probes for some antigens were not in the assay or had allelic variation for known serovars. Whole genome sequencing, SeqSero, and the Salmonella In Silico Typing Resource gave added confirmation for three isolates. Addition of the O-group 2 assay enabled the identification of 55 (9.6%) of 572 isolates. The SMS method could fully or partially serotype most isolates within a day. The SMS method should be a valuable tool when faster screening methods are needed, such as outbreaks and screening large numbers of environmental isolates.

      6. Serum folate forms are stable during repeated analysis in the presence of ascorbic acid and during frozen sample storageexternal icon
        Paladugula N, Fazili Z, Sternberg MR, Gabey G, Pfeiffer CM.
        J Appl Lab Med. 2019 May;3(6):993-1002.
        BACKGROUND: Serum folate forms, and particularly tetrahydrofolate, are sensitive to oxidation. METHODS: Using a repeated measures design, we investigated the stability of folate forms in convenience samples with added ascorbic acid (AA; 5 g/L) analyzed initially and after variable (approximately 1-33 weeks) storage time at -70 degrees C. We examined the recovery of tetrahydrofolate added at different spiking levels to serum with and without AA (5 g/L). We also assessed the long-term frozen storage stability of folate forms. RESULTS: Repeat analysis produced consistent results with the initial analysis; the mean relative change (95% CI; Lin’s concordance correlation between initial and repeat result; sample size) was 0.08% (-0.24% to 0.39%; r c = 0.999; n = 301) for 5-methyltetrahydrofolate, 4.23% (2.44%-6.05%; r c = 0.984; n = 211) for pyrazino-s-triazine derivative of 4alpha-hydroxy-5-methyltetrahydrofolate (MeFox), -0.22% (-1.90% to 1.49%; r c = 0.986; n = 214) for folic acid, and 1.49% (-2.71% to 5.88%; r c = 0.889; n = 81) for tetrahydrofolate. Linear regression testing for a time trend indicated an estimated average percent change of less than +/-5% for samples retested after 4 months: 5-methyltetrahydrofolate P trend = 0.0007, folic acid P trend < 0.0001, MeFox P trend = 0.38, and tetrahydrofolate P trend = 0.0256. The mean +/- SD tetrahydrofolate spiking recovery was 96.7% +/- 9.4% for serum with added AA, but <50% for serum without added AA. We observed </=10% loss for most serum folate forms during 4 years of storage at -70 degrees C. CONCLUSIONS: Serum containing added AA showed acceptable stability of folate forms during repeat analysis from the same vial within 4 months, complete spiking recovery of tetrahydrofolate during sample processing, and long-term frozen storage stability of folate forms.

      7. Simian foamy viruses in Central and South America: A new world of discoveryexternal icon
        Santos AF, Cavalcante LT, Muniz CP, Switzer WM, Soares MA.
        Viruses. 2019 Oct 20;11(10).
        Foamy viruses (FVs) are the only exogenous retrovirus to date known to infect neotropical primates (NPs). In the last decade, an increasing number of strains have been completely or partially sequenced, and molecular evolution analyses have identified an ancient co-speciation with their hosts. In this review, the improvement of diagnostic techniques that allowed the determination of a more accurate prevalence of simian FVs (SFVs) in captive and free-living NPs is discussed. Determination of DNA viral load in American primates indicates that oral tissues are the viral replicative site and that buccal swab collection can be an alternative to diagnose SFV infection in NPs. Finally, the transmission potential of NP SFVs to primate workers in zoos and primate centers of the Americas is examined.

      8. Pan-viral serology implicates enteroviruses in acute flaccid myelitisexternal icon
        Schubert RD, Hawes IA, Ramachandran PS, Ramesh A, Crawford ED, Pak JE, Wu W, Cheung CK, O’Donovan BD, Tato CM, Lyden A, Tan M, Sit R, Sowa GA, Sample HA, Zorn KC, Banerji D, Khan LM, Bove R, Hauser SL, Gelfand AA, Johnson-Kerner BL, Nash K, Krishnamoorthy KS, Chitnis T, Ding JZ, McMillan HJ, Chiu CY, Briggs B, Glaser CA, Yen C, Chu V, Wadford DA, Dominguez SR, Ng TF, Marine RL, Lopez AS, Nix WA, Soldatos A, Gorman MP, Benson L, Messacar K, Konopka-Anstadt JL, Oberste MS, DeRisi JL, Wilson MR.
        Nat Med. 2019 Oct 21.
        Since 2012, the United States of America has experienced a biennial spike in pediatric acute flaccid myelitis (AFM)(1-6). Epidemiologic evidence suggests non-polio enteroviruses (EVs) are a potential etiology, yet EV RNA is rarely detected in cerebrospinal fluid (CSF)(2). CSF from children with AFM (n = 42) and other pediatric neurologic disease controls (n = 58) were investigated for intrathecal antiviral antibodies, using a phage display library expressing 481,966 overlapping peptides derived from all known vertebrate and arboviruses (VirScan). Metagenomic next-generation sequencing (mNGS) of AFM CSF RNA (n = 20 cases) was also performed, both unbiased sequencing and with targeted enrichment for EVs. Using VirScan, the viral family significantly enriched by the CSF of AFM cases relative to controls was Picornaviridae, with the most enriched Picornaviridae peptides belonging to the genus Enterovirus (n = 29/42 cases versus 4/58 controls). EV VP1 ELISA confirmed this finding (n = 22/26 cases versus 7/50 controls). mNGS did not detect additional EV RNA. Despite rare detection of EV RNA, pan-viral serology frequently identified high levels of CSF EV-specific antibodies in AFM compared with controls, providing further evidence for a causal role of non-polio EVs in AFM.

      9. Streptococcus pyogenes pbp2x mutation confers reduced susceptibility to beta-lactam antibioticsexternal icon
        Vannice K, Ricaldi J, Nanduri S, Fang FC, Lynch J, Bryson-Cahn C, Wright T, Duchin J, Kay M, Chochua S, Van Beneden C, Beall B.
        Clin Infect Dis. 2019 Oct 20.
        Two near-identical clinical Streptococcus pyogenes isolates of emm subtype emm43.4 with a pbp2x missense mutation (T553K) were detected. Minimum inhibitory concentrations (MICs) for ampicillin and amoxicillin were 8-fold higher, and the MIC for cefotaxime was 3-fold higher than for near-isogenic control isolates, consistent with a first-step in developing beta-lactam resistance.

      10. The effect of laboratory test-based clinical decision support tools on medication errors and adverse drug events: A laboratory medicine best practices systematic reviewexternal icon
        Whitehead NS, Williams L, Meleth S, Kennedy S, Ubaka-Blackmoore N, Kanter M, O’Leary KJ, Classen D, Jackson B, Murphy DR, Nichols J, Stockwell D, Lorey T, Epner P, Taylor J, Graber ML.
        J Appl Lab Med. 2019 May;3(6):1035-1048.
        BACKGROUND: Laboratory and medication data in electronic health records create opportunities for clinical decision support (CDS) tools to improve medication dosing, laboratory monitoring, and detection of side effects. This systematic review evaluates the effectiveness of such tools in preventing medication-related harm. METHODS: We followed the Laboratory Medicine Best Practice (LMBP) initiative’s A-6 methodology. Searches of 6 bibliographic databases retrieved 8508 abstracts. Fifteen articles examined the effect of CDS tools on (a) appropriate dose or medication (n = 5), (b) laboratory monitoring (n = 4), (c) compliance with guidelines (n = 2), and (d) adverse drug events (n = 5). We conducted meta-analyses by using random-effects modeling. RESULTS: We found moderate and consistent evidence that CDS tools applied at medication ordering or dispensing can increase prescriptions of appropriate medications or dosages [6 results, pooled risk ratio (RR), 1.48; 95% CI, 1.27-1.74]. CDS tools also improve receipt of recommended laboratory monitoring and appropriate treatment in response to abnormal test results (6 results, pooled RR, 1.40; 95% CI, 1.05-1.87). The evidence that CDS tools reduced adverse drug events was inconsistent (5 results, pooled RR, 0.69; 95% CI, 0.46-1.03). CONCLUSIONS: The findings support the practice of healthcare systems with the technological capability incorporating test-based CDS tools into their computerized physician ordering systems to (a) identify and flag prescription orders of inappropriate dose or medications at the time of ordering or dispensing and (b) alert providers to missing laboratory tests for medication monitoring or results that warrant a change in treatment. More research is needed to determine the ability of these tools to prevent adverse drug events.

      11. Development and characterization of a reverse-genetics system for influenza D virusexternal icon
        Yu J, Liu R, Zhou B, Chou TW, Ghedin E, Sheng Z, Gao R, Zhai SL, Wang D, Li F.
        J Virol. 2019 Nov 1;93(21).
        Influenza D virus (IDV) of the Orthomyxoviridae family has a wide host range and a broad geographical distribution. Recent IDV outbreaks in swine along with serological and genetic evidence of IDV infection in humans have raised concerns regarding the zoonotic potential of this virus. To better study IDV at the molecular level, a reverse-genetics system (RGS) is urgently needed, but to date, no RGS had been described for IDV. In this study, we rescued the recombinant influenza D/swine/Oklahoma/1314/2011 (D/OK) virus by using a bidirectional seven-plasmid-based system and further characterized rescued viruses in terms of growth kinetics, replication stability, and receptor-binding capacity. Our results collectively demonstrated that RGS-derived viruses resembled the parental viruses for these properties, thereby supporting the utility of this RGS to study IDV infection biology. In addition, we developed an IDV minigenome replication assay and identified the E697K mutation in PB1 and the L462F mutation in PB2 that directly affected the activity of the IDV ribonucleoprotein (RNP) complex, resulting in either attenuated or replication-incompetent viruses. Finally, by using the minigenome replication assay, we demonstrated that a single nucleotide polymorphism at position 5 of the 3′ conserved noncoding region in IDV and influenza C virus (ICV) resulted in the inefficient cross-recognition of the heterotypic promoter by the viral RNP complex. In conclusion, we successfully developed a minigenome replication assay and a robust reverse-genetics system that can be used to further study replication, tropism, and pathogenesis of IDV.IMPORTANCE Influenza D virus (IDV) is a new type of influenza virus that uses cattle as the primary reservoir and infects multiple agricultural animals. Increased outbreaks in pigs and serological and genetic evidence of human infection have raised concerns about potential IDV adaptation in humans. Here, we have developed a plasmid-based IDV reverse-genetics system that can generate infectious viruses with replication kinetics similar to those of wild-type viruses following transfection of cultured cells. Further characterization demonstrated that viruses rescued from the described RGS resembled the parental viruses in biological and receptor-binding properties. We also developed and validated an IDV minireplicon reporter system that specifically measures viral RNA polymerase activity. In summary, the reverse-genetics system and minireplicon reporter assay described in this study should be of value in identifying viral determinants of cross-species transmission and pathogenicity of novel influenza D viruses.

      12. Real-time measurement of airborne carbon nanotubes in workplace atmospheresexternal icon
        Zheng L, Kulkarni P.
        Anal Chem. 2019 Oct 15;91(20):12713-12723.
        With growing applications of carbon nanomaterials, there is a concern over health risks presented by inhalation of carbon nanotube (CNT) aerosol in workplace atmospheres. Current methods used for CNT aerosol measurement lack selectivity to specific form of carbonaceous component or allotrope of interest. Moreover, the detection limits of these methods are also inadequate for short-term monitoring. Here, we describe, for the first time, a near real-time, field-portable instrument for selective quantification of airborne CNT concentration. The approach uses an automated cyclical scheme involving collect-analyze-ablate steps to obtain continuous near real-time measurement using Raman spectroscopy. The method achieves significantly lower detection limits by employing corona-assisted particle microconcentration for efficient coupling with laser Raman spectroscopy. A combination of techniques involving (i) use of characteristic Raman peaks, (ii) distinct ratio of disordered and graphitic peaks, and (iii) principal component classification and regression is employed to identify and quantify the specific form of the aerosolized carbonaceous nanomaterial. We show that the approach is capable of selectively quantifying trace single-walled CNT in the presence of interfering agents such as diesel particulate matter. The detection limit of the method for the single-walled CNT studied in this work was 60 ng m(-3), corresponding to a 10 min aerosol collection period, which is significantly lower than that for the NIOSH Method 5040 ( approximately 0.15 mug m(-3) for an 8-h collection on a 25 mm filter at 4 L min(-1)), a commonly used method for elemental carbon. We demonstrate the automated real-time capability of this field-portable method by continuously measuring a transient single-walled CNT aerosol.

    • Maternal and Child Health
      1. Analysis of mortality among neonates and children with spina bifida: An International Registry-Based Study, 2001-2012external icon
        Bakker MK, Kancherla V, Canfield MA, Bermejo-Sanchez E, Cragan JD, Dastgiri S, De Walle HE, Feldkamp ML, Groisman B, Gatt M, Hurtado-Villa P, Kallen K, Landau D, Lelong N, Lopez Camelo JS, Martinez L, Morgan M, Mutchinick OM, Nembhard WN, Pierini A, Sipek A, Rissmann A, Szabova E, Tagliabue G, Wertelecki W, Zarante I, Mastroiacovo P.
        Paediatr Perinat Epidemiol. 2019 Oct 21.
        BACKGROUND: Medical advancements have resulted in better survival and life expectancy among those with spina bifida, but a significantly increased risk of perinatal and postnatal mortality for individuals with spina bifida remains. OBJECTIVES: To examine stillbirth and infant and child mortality among those affected by spina bifida using data from multiple countries. METHODS: We conducted an observational study, using data from 24 population- and hospital-based surveillance registries in 18 countries contributing as members of the International Clearinghouse for Birth Defects Surveillance and Research (ICBDSR). Cases of spina bifida that resulted in livebirths or stillbirths from 20 weeks’ gestation or elective termination of pregnancy for fetal anomaly (ETOPFA) were included. Among liveborn spina bifida cases, we calculated mortality at different ages as number of deaths among liveborn cases divided by total number of liveborn cases with spina bifida. As a secondary outcome measure, we estimated the prevalence of spina bifida per 10 000 total births. The 95% confidence interval for the prevalence estimate was estimated using the Poisson approximation of binomial distribution. RESULTS: Between years 2001 and 2012, the overall first-week mortality proportion was 6.9% (95% CI 6.3, 7.7) and was lower in programmes operating in countries with policies that allowed ETOPFA compared with their counterparts (5.9% vs. 8.4%). The majority of first-week mortality occurred on the first day of life. In programmes where information on long-term mortality was available through linkage to administrative databases, survival at 5 years of age was 90%-96% in Europe, and 86%-96% in North America. CONCLUSIONS: Our multi-country study showed a high proportion of stillbirth and infant and child deaths among those with spina bifida. Effective folic acid interventions could prevent many cases of spina bifida, thereby preventing associated childhood morbidity and mortality.

      2. Prevalence and factors associated with safe infant sleep practicesexternal icon
        Hirai AH, Kortsmit K, Kaplan L, Reiney E, Warner L, Parks SE, Perkins M, Koso-Thomas M, D’Angelo DV, Shapiro-Mendoza CK.
        Pediatrics. 2019 Oct 21.
        OBJECTIVES: To examine prevalence of safe infant sleep practices and variation by sociodemographic, behavioral, and health care characteristics, including provider advice. METHODS: Using 2016 Pregnancy Risk Assessment Monitoring System data from 29 states, we examined maternal report of 4 safe sleep practices indicating how their infant usually slept: (1) back sleep position, (2) separate approved sleep surface, (3) room-sharing without bed-sharing, and (4) no soft objects or loose bedding as well as receipt of health care provider advice corresponding to each sleep practice. RESULTS: Most mothers reported usually placing their infants to sleep on their backs (78.0%), followed by room-sharing without bed-sharing (57.1%). Fewer reported avoiding soft bedding (42.4%) and using a separate approved sleep surface (31.8%). Reported receipt of provider advice ranged from 48.8% (room-sharing without bed-sharing) to 92.6% (back sleep position). Differences by sociodemographic, behavioral, and health care characteristics were larger for safe sleep practices ( approximately 10-20 percentage points) than receipt of advice ( approximately 5-10 percentage points). Receipt of provider advice was associated with increased use of safe sleep practices, ranging from 12% for room-sharing without bed-sharing (adjusted prevalence ratio: 1.12; 95% confidence interval: 1.09-1.16) to 28% for back sleep position (adjusted prevalence ratio: 1.28; 95% confidence interval: 1.21-1.35). State-level differences in safe sleep practices spanned 20 to 25 percentage points and did not change substantially after adjustment for available characteristics. CONCLUSIONS: Safe infant sleep practices, especially those other than back sleep position, are suboptimal, with demographic and state-level differences indicating improvement opportunities. Receipt of provider advice is an important modifiable factor to improve infant sleep practices.

      3. A hospital-based birth defects surveillance system in Kampala, Ugandaexternal icon
        Mumpe-Mwanja D, Barlow-Mosha L, Williamson D, Valencia D, Serunjogi R, Kakande A, Namale-Matovu J, Nankunda J, Birabwa-Male D, Okwero MA, Nsungwa-Sabiiti J, Musoke P.
        BMC Pregnancy Childbirth. 2019 Oct 22;19(1):372.
        BACKGROUND: In 2010, the World Health Assembly passed a resolution calling upon countries to prevent birth defects where possible. Though birth defects surveillance programs are an important source of information to guide implementation and evaluation of preventive interventions, many countries that shoulder the largest burden of birth defects do not have surveillance programs. This paper shares the results of a hospital-based birth defects surveillance program in Uganda which, can be adopted by similar resource-limited countries. METHODS: All informative births, including live births, stillbirths and spontaneous abortions; regardless of gestational age, delivered at four selected hospitals in Kampala from August 2015 to December 2017 were examined for birth defects. Demographic data were obtained by midwives through maternal interviews and review of hospital patient notes and entered in an electronic data collection tool. Identified birth defects were confirmed through bedside examination by a physician and review of photographs and a narrative description by a birth defects expert. Informative births (live, still and spontaneous abortions) with a confirmed birth defect were included in the numerator, while the total informative births (live, still and spontaneous abortions) were included in the denominator to estimate the prevalence of birth defects per 10,000 births. RESULTS: The overall prevalence of birth defects was 66.2/10,000 births (95% CI 60.5-72.5). The most prevalent birth defects (per 10,000 births) were: Hypospadias, 23.4/10,000 (95% CI 18.9-28.9); Talipes equinovarus, 14.0/10,000 (95% CI 11.5-17.1) and Neural tube defects, 10.3/10,000 (95% CI 8.2-13.0). The least prevalent were: Microcephaly, 1.6/10,000 (95% CI 0.9-2.8); Microtia and Anotia, 1.6/10,000 (95% CI 0.9-2.8) and Imperforate anus, 2.0/10,000 (95% CI 1.2-3.4). CONCLUSION: A hospital-based surveillance project with active case ascertainment can generate reliable epidemiologic data about birth defects prevalence and can inform prevention policies and service provision needs in low and middle-income countries.

      4. Population-based birth defects data in the United States, 2012-2016: A focus on abdominal wall defectsexternal icon
        Stallings EB, Isenburg JL, Short TD, Heinke D, Kirby RS, Romitti PA, Canfield MA, O’Leary LA, Liberman RF, Forestieri NE, Nembhard WN, Sandidge T, Nestoridi E, Salemi JL, Nance AE, Duckett K, Ramirez GM, Shan X, Shi J, Lupo PJ.
        Birth Defects Res. 2019 Oct 23.
        BACKGROUND/OBJECTIVES: In this report, the National Birth Defects Prevention Network (NBDPN) examines and compares gastroschisis and omphalocele for a recent 5-year birth cohort using data from 30 population-based birth defect surveillance programs in the United States. METHODS: As a special call for data for the 2019 NBDPN Annual Report, state programs reported expanded data on gastroschisis and omphalocele for birth years 2012-2016. We estimated the overall prevalence (per 10,000 live births) and 95% confidence intervals (CI) for each defect as well as by maternal race/ethnicity, maternal age, infant sex, and case ascertainment methodology utilized by the program (active vs. passive). We also compared distribution of cases by maternal and infant factors and presence/absence of other birth defects. RESULTS: The overall prevalence estimates (per 10,000 live births) were 4.3 (95% CI: 4.1-4.4) for gastroschisis and 2.1 (95% CI: 2.0-2.2) for omphalocele. Gastroschisis was more frequent among young mothers (<25 years) and omphalocele more common among older mothers (>40 years). Mothers of infants with gastroschisis were more likely to be underweight/normal weight prior to pregnancy and mothers of infants with omphalocele more likely to be overweight/obese. Omphalocele was twice as likely as gastroschisis to co-occur with other birth defects. CONCLUSIONS: This report highlights important differences between gastroschisis and omphalocele. These differences indicate the importance of distinguishing between these defects in epidemiologic assessments. The report also provides additional data on co-occurrence of gastroschisis and omphalocele with other birth defects. This information can provide a basis for future research to better understand these defects.

      5. The American Academy of Pediatrics published a clinical report on late-preterm (LPT) infants in 2007 that was largely based on a summary of a 2005 workshop convened by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, at which a change in terminology from “near term” to “late preterm” was proposed. This paradigm-shifting recommendation had a remarkable impact: federal agencies (the Centers for Disease Control and Prevention), professional societies (the American Academy of Pediatrics and American College of Obstetricians and Gynecologists), and organizations (March of Dimes) initiated nationwide monitoring and educational plans that had a significant effect on decreasing the rates of iatrogenic LPT deliveries. However, there is now an evolving concern. After nearly a decade of steady decreases in the LPT birth rate that largely contributed to the decline in total US preterm birth rates, the birth rate in LPT infants has been inching upward since 2015. In addition, evidence revealed by strong population health research demonstrates that being born as an early-term infant poses a significant risk to an infant’s survival, growth, and development. In this report, we summarize the initial progress and discuss the potential reasons for the current trends in LPT and early-term birth rates and propose research recommendations.

    • Nutritional Sciences
      1. Predictors of micronutrient powder sachet coverage and recent intake among children 12-23 months in Eastern Ugandaexternal icon
        Ford ND, Ruth LJ, Ngalombi S, Lubowa A, Halati S, Ahimbisibwe M, Mapango C, Whitehead RD, Jefferds ME.
        Matern Child Nutr. 2019 Oct;15(S5):e12792.
        We evaluated predictors of micronutrient powder (MNP) sachet coverage and recent intake using data from a cross-sectional survey representative of children aged 12-23 months in Amuria district, Uganda. In June/July 2016, caregivers were interviewed 12 months after implementation of an integrated MNP and infant and young child feeding pilot (N = 761). Logistic regression described predictors of (a) high-MNP sachet coverage (received at least 60 sachets/6 months) and (b) recent intake (consumed MNP during the 2 weeks preceding the survey) among children who had ever received MNP and had complete data (N = 683). Fifty-nine percent (95% Confidence Interval [CI] [53.8, 64.2]) of children had high-MNP sachet coverage, and 65.4% (95% CI [61.0, 69.9]) had recent intake. MNP ration cards (Adjusted Odds Ratio [AOR] 2.67, 95% CI [1.15, 6.23]), organoleptic changes to foods cooked with soda ash (AOR 1.52, 95% CI [1.08, 2.14]), having heard of anaemia (AOR 1.59, 95% CI [1.11, 2.26]), knowledge of correct MNP preparation (AOR 1.89, 95% CI [1.11, 3.19]), and current breastfeeding (AOR 2.04, 95% CI [1.36, 3.08]) were positively associated with MNP coverage whereas older child age (18-23 vs. 12-17 months) was inversely associated with coverage (AOR 0.32, 95% CI [0.23, 0.50]). MNP ration cards (AOR 2.86, 95% CI [1.34, 6.09]), having heard an MNP radio jingle (AOR 1.40, 95% CI [1.01, 1.94]), knowledge of correct MNP preparation (AOR 1.88, 95% CI [1.04, 3.39]), and the child not disliking MNP (AOR 1.90, 95% CI [1.13, 3.22]) were positively associated with recent intake. Interventions that increase caregiver knowledge and skills and focus on older children could improve MNP coverage and recent intake.

      2. Predictors of micronutrient powder (MNP) knowledge, coverage, and consumption during the scale-up of an integrated infant and young child feeding (IYCF-MNP) programme in Nepalexternal icon
        Locks LM, Dahal P, Pokharel R, Joshi N, Paudyal N, Whitehead RD, Chitekwe S, Mei Z, Lamichhane B, Garg A, Jefferds ME.
        Matern Child Nutr. 2019 Oct;15(S5):e12712.
        Large-scale programmes using micronutrient powders (MNPs) may not achieve maximum impact due to limited/inappropriate MNP coverage, consumption, and use. We identify predictors of MNP coverage, maternal knowledge of appropriate use, and child MNP consumption in Nepal. A cross-sectional survey was conducted in 2,578 mother-child pairs representative of children 6-23 months in two districts that were part of the post-pilot, scale-up of an integrated infant and young child feeding-MNP (IYCF-MNP) programme. Children aged 6-23 months were expected to receive 60 MNP sachets every 6 months from a female community health volunteer (FCHV) or health centre. Outcomes of interest were MNP coverage (ever received), maternal knowledge of appropriate use (correct response to seven questions), repeat coverage (receipt >/= twice; among children 12-23 months who had received MNP at least once, n = 1342), and high intake (child consumed >/=75% of last distribution, excluding those with recent receipt/insufficient time to use 75% at recommended one-sachet-per-day dose, n = 1422). Multivariable log-binomial regression models were used to identify predictors of the four outcomes. Coverage, knowledge of appropriate use, and repeat coverage were 61.3%, 33.5%, and 45.9%, respectively. Among MNP receivers, 97.9% consumed MNP at least once and 38.9% of eligible children consumed >/=75% of last distribution. FCHV IYCF-MNP counselling was positively associated with knowledge, coverage, repeat coverage, and high intake; health worker counselling with knowledge and coverage indicators; and radio messages with coverage indicators only. FCHV counselling had the strongest association with knowledge, coverage, and high intake. Community-based counselling may play a vital role in improving coverage and intake in MNP programmes.

    • Occupational Safety and Health
      1. Association of occupational exposure to disinfectants with incidence of chronic obstructive pulmonary disease among US female nursesexternal icon
        Dumas O, Varraso R, Boggs KM, Quinot C, Zock JP, Henneberger PK, Speizer FE, Le Moual N, Camargo CA.
        JAMA Netw Open. 2019 Oct 2;2(10):e1913563.
        Importance: Exposure to disinfectants in health care workers has been associated with respiratory health outcomes, including asthma. Despite the biological plausibility of an association between disinfectants (irritant chemicals) and risk of chronic obstructive pulmonary disease (COPD), available data are sparse. Objective: To investigate the association between exposure to disinfectants and COPD incidence in a large cohort of US female nurses. Design, Setting, and Participants: The Nurses’ Health Study II is a US prospective cohort study of 116429 female registered nurses from 14 US states who were enrolled in 1989 and followed up through questionnaires every 2 years since. The present study included women who were still in a nursing job and had no history of COPD in 2009, and used data from the 2009 through 2015 questionnaires. Clean and complete data used for this analysis were available in July 2018, and analyses were conducted from September 2018 through August 2019. Exposures: Occupational exposure to disinfectants, evaluated by questionnaire and a job-task-exposure matrix (JTEM). Main Outcomes and Measures: Incident physician-diagnosed COPD evaluated by questionnaire. Results: Among the 73 262 women included in the analyses, mean (SD) age at baseline was 54.7 (4.6) years and 70 311 (96.0%) were white, 1235 (1.7%) black, and 1716 (2.3%) other; and 1345 (1.8%) Hispanic, and 71 917 (98.2%) non-Hispanic. Based on 368145 person-years of follow-up, 582 nurses reported incident physician-diagnosed COPD. Weekly use of disinfectants to clean surfaces only (16 786 [22.9%] of participants exposed) and to clean medical instruments (13 899 [19.0%] exposed) was associated with COPD incidence, with adjusted hazard ratios of 1.38 (95% CI, 1.13-1.68) for cleaning surfaces only and 1.31 (95% CI, 1.07-1.61) for cleaning medical instruments after adjustment for age, smoking (pack-years), race, ethnicity, and body mass index. High-level exposure, evaluated by the JTEM, to several specific disinfectants (ie, glutaraldehyde, bleach, hydrogen peroxide, alcohol, and quaternary ammonium compounds) was significantly associated with COPD incidence, with adjusted hazard ratios ranging from 1.25 (95% CI, 1.04-1.51) to 1.36 (95% CI, 1.13-1.64). Associations were not modified by smoking or asthma status (P for interaction > .15). Conclusions and Relevance: These longitudinal results suggest that regular use of chemical disinfectants among nurses may be a risk factor for developing COPD. If future studies confirm these results, exposure-reduction strategies that are compatible with infection control in health care settings should be developed.

      2. The NIOSH B Reader Certification Program-An Update Report (1987-2018) and Future Directionsexternal icon
        Halldin CN, Hale J, Weissman D, Attfield M, Parker JE, Petsonk E, Cohen R, Markle T, Blackley D, Wolfe A, Tallaksen R, Laney AS.
        J Occup Environ Med. 2019 Oct 15.
        OBJECTIVE: The NIOSH B Reader Program provides the opportunity for physicians to demonstrate proficiency in the International Labour Office (ILO) system for classifying radiographs of pneumoconioses. We summarize trends in participation and examinee attributes and performance during 1987-2018. METHODS: Since 1987, NIOSH has maintained details of examinees and examinations. Attributes of examinees and their examination performance were summarized. Simple linear regression was used in trend analysis of passing rates over time. RESULTS: The mean passing rate for certification and recertification for the study period was 40.4%, and 82.6%, respectively. Since the mid-1990 s, the number of B Readers has declined and the mean age and years certified has increased. CONCLUSIONS: To address the declining B Reader population, NIOSH is currently taking steps to modernize the program and offer more opportunities for training and testing.

      3. Efficacy of an ambulance ventilation system in reducing EMS worker exposure to airborne particles from a patient cough aerosol simulatorexternal icon
        Lindsley WG, Blachere FM, McClelland TL, Neu DT, Mnatsakanova A, Martin SB, Mead KR, Noti JD.
        J Occup Environ Hyg. 2019 Oct 22:1-13.
        The protection of emergency medical service (EMS) workers from airborne disease transmission is important during routine transport of patients with infectious respiratory illnesses and would be critical during a pandemic of a disease such as influenza. However, few studies have examined the effectiveness of ambulance ventilation systems at reducing EMS worker exposure to airborne particles (aerosols). In our study, a cough aerosol simulator mimicking a coughing patient with an infectious respiratory illness was placed on a patient cot in an ambulance. The concentration and dispersion of cough aerosol particles were measured for 15 min at locations corresponding to likely positions of an EMS worker treating the patient. Experiments were performed with the patient cot at an angle of 0 degrees (horizontal), 30 degrees , and 60 degrees , and with the ambulance ventilation system set to 0, 5, and 12 air changes/hour (ACH). Our results showed that increasing the air change rate significantly reduced the airborne particle concentration (p < 0.001). Increasing the air change rate from 0 to 5 ACH reduced the mean aerosol concentration by 34% (SD = 19%) overall, while increasing it from 0 to 12 ACH reduced the concentration by 68% (SD = 9%). Changing the cot angle also affected the concentration (p < 0.001), but the effect was more modest, especially at 5 and 12 ACH. Contrary to our expectations, the aerosol concentrations at the different worker positions were not significantly different (p < 0.556). Flow visualization experiments showed that the ventilation system created a recirculation pattern which helped disperse the aerosol particles throughout the compartment, reducing the effectiveness of the system. Our findings indicate that the ambulance ventilation system reduced but did not eliminate worker exposure to infectious aerosol particles. Aerosol exposures were not significantly different at different locations within the compartment, including locations behind and beside the patient. Improved ventilation system designs with smoother and more unidirectional airflows could provide better worker protection.

      4. OBJECTIVES: Patient care aides, who provide basic care to patients in a variety of healthcare settings, have been observed to have higher prevalences of adverse health metrics than the general US workforce. However, few studies have examined how healthcare access and health behaviors and outcomes among patient care aides differ by work setting (home health, nursing home, and hospital). METHODS: Data from the 2013 to 2016 Behavioral Risk Factor Surveillance System were used to assess the prevalences of healthcare access, health-related behaviors, and health outcomes among patient care aides in different work settings, and among nurses (licensed vocational/practical and registered). Adjusted prevalence ratios were used to compare prevalences for healthcare workers to those for nonhealthcare clerical workers. RESULTS: Overall, patient care aides are a low-wage workforce with high prevalences of multiple adverse health metrics and low prevalences of positive health behaviors compared to clerical workers. Results differed by work setting. Home health aides had the lowest income levels and most adverse results for multiple metrics; nursing home aides had better healthcare access and somewhat better health outcomes. Most metrics were best (though still quite poor) for hospital aides, who showed few significant differences from clerical workers. CONCLUSIONS: These results show the need to focus resources on the patient care aide workforce, particularly those in home health. While some needs of nursing home aides, such as improving influenza vaccination coverage and reducing the prevalence of arthritis-related conditions, would benefit from standardized workplace interventions, alternate, workplace-specific approaches are needed for home health aides.

    • Parasitic Diseases
      1. A second case of human conjunctival infestation with Thelazia gulosa and a review of T. gulosa in North Americaexternal icon
        Bradbury RS, Gustafson DT, Sapp SG, Fox M, de Almeida M, Boyce M, Iwen P, Herrera V, Ndubuisi M, Bishop HS.
        Clin Infect Dis. 2019 Oct 22.
        We describe a second case of human infection caused by Thelazia gulosa (the cattle eye worm), likely acquired in California. For epidemiologic purposes, it is important to identify all Thelazia recovered from humans in North America to the species level.

      2. Conventional and high-sensitivity malaria rapid diagnostic test performance in two transmission settings: Haiti 2017external icon
        Rogier E, Hamre KE, Joseph V, Plucinski MM, Presume J, Romilus I, Mondelus G, Elisme T, van den Hoogen L, Lemoine JF, Drakeley C, Ashton RA, Chang MA, Existe A, Boncy J, Stresman G, Druetz T, Eisele TP.
        J Infect Dis. 2019 Oct 21.
        Accurate malaria diagnosis is foundational for control and elimination, and Haiti relies on HRP2-based rapid diagnostic tests (RDTs) identifying Plasmodium falciparum in clinical and community settings. In 2017, one household and two easy-access group (EAG) surveys tested all participants (N=32,506) by conventional and high-sensitivity RDTs (cRDT/hsRDT). A subset of blood samples (n=1,154) were laboratory tested for HRP2 by bead-based immunoassay and for P. falciparum 18S rDNA by PET-PCR. Both RDT types detected low concentrations of HRP2 with sensitivity estimates between 2.6 and 14.6 ng/mL. Compared to the predicate HRP2 laboratory assay,, RDT sensitivity ranged from 86.3% to 96.0% between tests and settings, and specificity from 90.0% to 99.6%. In the household survey, the hsRDT provided a significantly higher number of positive tests, but this represented a very small proportion (<0.2%) of all participants. These data show an hsRDT may have limited utility in a malaria elimination setting like Haiti.

    • Physical Activity
      1. American College of Sports Medicine Roundtable Report on Physical activity, sedentary behavior, and cancer prevention and controlexternal icon
        Patel AV, Friedenreich CM, Moore SC, Hayes SC, Silver JK, Campbell KL, Winters-Stone K, Gerber LH, George SM, Fulton JE, Denlinger C, Morris GS, Hue T, Schmitz KH, Matthews CE.
        Med Sci Sports Exerc. 2019 Nov;51(11):2391-2402.
        INTRODUCTION: The American College of Sports Medicine convened an International Multidisciplinary Roundtable on Exercise and Cancer in March 2018 to evaluate and translate the evidence linking physical activity and cancer prevention, treatment, and control. This article discusses findings from the Roundtable in relation to the biologic and epidemiologic evidence for the role of physical activity in cancer prevention and survival. RESULTS: The evidence supports that there are a number of biologically plausible mechanisms, whereby physical activity can influence cancer risk, and that physical activity is beneficial for the prevention of several types of cancer including breast, colon, endometrial, kidney, bladder, esophageal, and stomach. Minimizing time spent in sedentary behavior may also lower risk of endometrial, colon and lung cancers. Conversely, physical activity is associated with higher risk of melanoma, a serious form of skin cancer. Further, physical activity before and after a cancer diagnosis is also likely to be relevant for improved survival for those diagnosed with breast and colon cancer; with data suggesting that postdiagnosis physical activity provides greater mortality benefits than prediagnosis physical activity. CONCLUSIONS: Collectively, there is consistent, compelling evidence that physical activity plays a role in preventing many types of cancer and for improving longevity among cancer survivors, although the evidence related to higher risk of melanoma demonstrates the importance of sun safe practices while being physically active. Together, these findings underscore the importance of physical activity in cancer prevention and control. Fitness and public health professionals and health care providers worldwide are encouraged to spread the message to the general population and cancer survivors to be physically active as their age, abilities, and cancer status will allow.

    • Reproductive Health
      1. Menstrual cups and cash transfer to reduce sexual and reproductive harm and school dropout in adolescent schoolgirls: study protocol of a cluster-randomised controlled trial in western Kenyaexternal icon
        Zulaika G, Kwaro D, Nyothach E, Wang D, Zielinski-Gutierrez E, Mason L, Eleveld A, Chen T, Kerubo E, van Eijk A, Pace C, Obor D, Juma J, Oyaro B, Niessen L, Bigogo G, Ngere I, Henry C, Majiwa M, Onyango CO, Ter Kuile FO, Phillips-Howard PA.
        BMC Public Health. 2019 Oct 21;19(1):1317.
        BACKGROUND: Adolescent girls in sub-Saharan Africa are disproportionally vulnerable to sexual and reproductive health (SRH) harms. In western Kenya, where unprotected transactional sex is common, young females face higher rates of school dropout, often due to pregnancy, and sexually transmitted infections (STIs), including HIV. Staying in school has shown to protect girls against early marriage, teen pregnancy, and HIV infection. This study evaluates the impact of menstrual cups and cash transfer interventions on a composite of deleterious outcomes (HIV, HSV-2, and school dropout) when given to secondary schoolgirls in western Kenya, with the aim to inform evidence-based policy to improve girls’ health, school equity, and life-chances. METHODS: Single site, 4-arm, cluster randomised controlled superiority trial. Secondary schools are the unit of randomisation, with schoolgirls as the unit of measurement. Schools will be randomised into one of four intervention arms using a 1:1:1:1 ratio and block randomisation: (1) menstrual cup arm; (2) cash transfer arm, (3) cups and cash combined intervention arm, or (4) control arm. National and county agreement, and school level consent will be obtained prior to recruitment of schools, with parent consent and girls’ assent obtained for participant enrolment. Participants will be trained on safe use of interventions, with all arms receiving puberty and hygiene education. Annually, the state of latrines, water availability, water treatment, handwashing units and soap in schools will be measured. The primary endpoint is a composite of incident HIV, HSV-2, and all-cause school dropout, after 3 years follow-up. School dropout will be monitored each term via school registers and confirmed through home visits. HIV and HSV-2 incident infections and risk factors will be measured at baseline, mid-line and end-line. Intention to treat analysis will be conducted among all enrolled participants. Focus group discussions will provide contextual information on uptake of interventions. Monitoring for safety will occur throughout. DISCUSSION: If proved safe and effective, the interventions offer a potential contribution toward girls’ schooling, health, and equity in low- and middle-income countries. TRIAL REGISTRATION: NCT03051789 , 15th February 2017.

    • Substance Use and Abuse
      1. A media campaign to increase health care provider assistance for patients who smoke cigarettesexternal icon
        Juster HR, Ortega-Peluso CA, Brown EM, Hayes KA, Sneegas K, Gopez G, Lavinghouze SR.
        Prev Chronic Dis. 2019 Oct 17;16:E143.
        Although most smokers visit a health care provider annually, only half report being provided evidence-based assistance with quitting, defined as brief counseling and an offer of medication. The New York State Department of Health designed a provider-targeted media campaign to increase provider-assisted quitting, which was implemented in 2016. Messaging focused on the addictive nature of tobacco products and evidence-based interventions. Online surveys of 400 New York State health care providers measured advertising awareness, associations between awareness and assistance with quit attempts, and perceptions that patients expect providers to assist with quitting. Forty-three percent of providers were aware of at least 1 advertisement, and providers who had seen an advertisement were more likely to provide evidence-based assistance (AOR = 2.55, P = .01), which includes recommending or prescribing cessation medications. Provider-targeted media is a promising approach to reach health care providers and encourage evidence-based smoking cessation treatment.

      2. INTRODUCTION: Polysubstance use and misuse can increase risks for nonfatal and fatal drug overdose. To categorize drugs used in combination in nonfatal overdoses, we analyzed data from emergency department (ED) overdose-related visits in 18 states funded by CDC’s Enhanced State Opioid Overdose Surveillance (ESOOS) program. METHODS: From 2017 to 2018, 120,706 ED visits included at least one hospital discharge code indicating acute drug poisoning for opioids, stimulants, hallucinogens, cannabis, anti-depressants, sedatives, alcohol, benzodiazepines, or other psychotropic drugs. Latent class analyses were conducted to determine the groupings of drug combinations in overdose visits. RESULTS: Latent class analyses indicated a model of 5 classes – mostly heroin overdose (42.5% of visits); mostly non-heroin opioid overdose/use (27.3%); opioid, polysubstance (11.0%); female, younger (<25years), other non-opioid drugs (10.5%); female, older (>55years), benzodiazepine (8.0%). Findings indicated that heroin continues to be a large burden to EDs, yet EDs are also seeing overdose survivors with polydrug toxicity. CONCLUSIONS: Medication-assisted treatment could be initiated in the emergency department following overdose for patients with opioid use disorder, and post-overdose protocols, such as naloxone provision and linkage to treatment and harm reduction services, have the potential to prevent future overdose for those at risk.

      3. BACKGROUND: Despite exponential growth in pharmacy-dispensed naloxone, little information is available regarding variation in naloxone prescribing pattern across specialty groups, regions, and patient populations. OBJECTIVE: Explore variation in pharmacy-dispensed naloxone by prescriber specialty and patient characteristics. DESIGN: Cross-sectional analysis of the 2016 national retail pharmacy naloxone prescription claims from the IQVIA Real Longitudinal Prescriptions database. PARTICIPANTS: Naloxone prescribers and individuals filling naloxone prescriptions. MAIN MEASURES: Descriptive statistics assess differences across prescriber specialty groups in number of naloxone prescribers, patient and prescription characteristics, and geographic variation in naloxone dispensation and naloxone market share across prescriber specialty groups or formulation. KEY RESULTS: In 2016, 100,958 naloxone prescriptions written by 14,026 prescribers were filled by 88,735 patients. Primary care physicians accounted for the largest share of naloxone prescribers (45.9%); pain and anesthesia physicians and non-physicians prescribed to significantly greater numbers of patients (means of 10 and 8, respectively). While responsible for a relatively small share of naloxone dispensed (6.1%), psychiatrists and addiction specialists disproportionately served younger individuals, accounting for 49.5% of all prescriptions for individuals aged 35 and younger. Naloxone fill rates differed greatly across geographic regions, with the highest per capita rates in New England and the most concentrated prescribing in the West South Central and South Atlantic regions, where naloxone prescribers had the highest average numbers of patients (9.7 and 7.9, respectively). The South Atlantic and West South Central also had naloxone markets dominated by the Evzio(R) auto-injector, responsible for 50.3% and 43.8% of all naloxone dispensed in the regions; in contrast, New England’s naloxone market was predominantly comprised of generic formulations (48.8%) and Narcan(R) nasal spray (45.4%). CONCLUSIONS: Our findings reflect a need to better understand barriers to uptake of naloxone prescribing behavior among physicians and other prescribers to ensure individuals have adequate opportunity to receive naloxone from their treating clinicians.

    • Vital Statistics
      1. Pregnant? Validity of the pregnancy checkbox on death certificates in four states, and characteristics associated with pregnancy checkbox errorsexternal icon
        Catalano A, Davis NL, Petersen EE, Harrison C, Kieltyka L, You M, Conrey EJ, Ewing AC, Callaghan WM, Goodman D.
        Am J Obstet Gynecol. 2019 Oct 19.
        BACKGROUND: Maternal mortality rates in the United States appear to be increasing. One potential reason may be increased identification of maternal deaths after the addition of a pregnancy checkbox to the death certificate. In 2016, four state health departments (Georgia, Louisiana, Michigan, Ohio) implemented a pregnancy checkbox quality assurance pilot, with technical assistance provided by the Centers for Disease Control and Prevention. The pilot aimed to improve accuracy of the pregnancy checkbox on death certificates and resultant state maternal mortality estimates. OBJECTIVE(S): To estimate the validity of the pregnancy checkbox on the death certificate and describe characteristics associated with errors using 2016 data from a four state quality assurance pilot. STUDY DESIGN: Potential pregnancy-associated deaths were identified by linking death certificates with birth or fetal death certificates from within a year preceding death or by pregnancy checkbox status. Death certificates which indicated the decedent was pregnant within a year of death via the pregnancy checkbox, but that did not link to a birth or fetal death certificate, were referred for active follow-up to confirm pregnancy status by either death certifier confirmation or medical record review. Descriptive statistics and 95% confidence intervals were used to examine the distributions of demographic characteristics by pregnancy confirmation category (i.e., confirmed pregnant, confirmed not pregnant, and unable to confirm). We compared the proportion confirmed pregnant and confirmed not pregnant within age, race/ethnicity, pregnancy checkbox category, and certifier type categories using a Wald test of proportions. Binomial and Poisson regression models were used to estimate prevalence ratios for having an incorrect pregnancy checkbox (false positive, false negative) by age group, race/ethnicity, pregnancy checkbox category, and certifier type. RESULTS: Among 467 potential pregnancy-associated deaths, 335 (72%) were confirmed pregnant either via linkage to a birth or fetal death certificate, certifier confirmation, or review of medical records. Ninety-seven (21%) women were confirmed not pregnant (false positives) and 35 (7%) were unable to be confirmed. Women confirmed pregnant were significantly younger than women confirmed not pregnant (p<.001). Deaths certified by coroners and medical examiners were more likely to be confirmed pregnant than confirmed not pregnant (p=0.04). The association between decedent age category and false positive status followed a dose-response relationship (p<0.001), with increasing prevalence ratios for each increase in age category. Death certificates of non-Hispanic black women were more likely to be false positives, compared with non-Hispanic white women [prevalence ratio (PR) 1.41, 95% confidence interval (CI) 1.01, 1.96]. The sensitivity of the pregnancy checkbox among these four states in 2016 was 62% and the positive predictive value was 68%. CONCLUSION(S): We provide a multi-state analysis of the validity of the pregnancy checkbox and highlight a need for more accurate reporting of pregnancy status on death certificates. States and other jurisdictions may increase the accuracy of their data used to calculate maternal mortality rates by implementing quality assurance processes.

    • Zoonotic and Vectorborne Diseases
      1. BACKGROUND: Exposure to blacklegged ticks Ixodes scapularis that transmit pathogens is thought to occur peri-domestically. However, the locations where people most frequently encounter infected ticks are not well characterized, leading to mixed messages from public health officials about where risk is highest. METHODS: We conducted a systematic review and meta-analysis on spatial risk factors for tick-borne disease and tick bites in eastern North America. We examined three scales: the residential yard, the neighborhood surrounding (but not including) the yard, and outside the neighborhood. Nineteen eligible studies represented 2741 cases of tick-borne illness and 1447 tick bites. Using random effects models, we derived pooled odds ratio (OR) estimates. RESULTS: The meta-analysis revealed significant disease risk factors at the scale of the yard (OR 2.60 95% CI 1.96 – 3.46), the neighborhood (OR 4.08 95% CI 2.49 – 6.68), and outside the neighborhood (OR 2.03 95% CI 1.59 – 2.59). Although significant risk exists at each scale, neighborhood scale risk factors best explained disease exposure. Analysis of variance revealed risk at the neighborhood scale was 57% greater than risk at the yard scale and 101% greater than risk outside the neighborhood. CONCLUSIONS: This analysis emphasizes the importance of understanding and reducing tick-borne disease risk at the neighborhood scale. Risk-reducing interventions applied at each scale could be effective, but interventions applied at the neighborhood scale are most likely to protect human health. TRIAL REGISTRATION: The study was registered with PROSPERO: CRD42017079169 .

      2. Fatal Lyme carditis in New England: Two case reportsexternal icon
        Marx GE, Leikauskas J, Lindstrom K, Mann E, Reagan-Steiner S, Matkovic E, Read JS, Kelso P, Kwit NA, Hinckley AF, Levine MA, Brown C.
        Ann Intern Med. 2019 Oct 22.

        [No abstract]

      3. Preventing sexual transmission of Zika virus infection during pregnancy, Puerto Rico, USA, 2016external icon
        Salvesen von Essen B, Kortsmit K, Warner L, D’Angelo DV, Shulman HB, Virella WH, Taraporewalla A, Harrison L, Ellington S, Shapiro-Mendoza C, Barfield W, Smith RA, Jamieson DJ, Cox S, Pazol K, Diaz PG, Herrera BR, Bernal MV.
        Emerg Infect Dis. 2019 Nov;25(11):2115-2119.
        We examined condom use throughout pregnancy during the Zika outbreak in Puerto Rico during 2016. Overall, <25% of women reported consistent condom use during pregnancy. However, healthcare provider counseling was associated with a 3-fold increase in consistent use, reinforcing the value of provider counseling in Zika prevention efforts.

      4. Expanding recognition of Rickettsia parkeri rickettsiosis in southern Arizona, 2016-2017external icon
        Yaglom HD, Casal M, Carson S, O’Grady CL, Dominguez V, Singleton J, Chung I, Lodge H, Paddock CD.
        Vector Borne Zoonotic Dis. 2019 Oct 22.
        Rickettsia parkeri rickettsiosis is an emerging, tick-borne disease in the United States (US), transmitted by the bite of Amblyomma maculatum group ticks. Clinical manifestations include fever, headache, myalgia, maculopapular rash, and a characteristic eschar that forms at the site of the tick bite. Arizona’s index case of R. parkeri rickettsiosis was reported in 2014. Seven additional confirmed and probable cases were identified during 2016-2017 through routine investigation of electronic laboratory reports and by self-reporting to public health authorities. Serum samples were evaluated for immunoglobulin G antibodies reactive with antigens of Rickettsia rickettsii (the agent of Rocky Mountain spotted fever [RMSF]) and R. parkeri using indirect immunofluorescence antibody tests. Eschar swab specimens were evaluated using Rickettsia genus-specific and R. parkeri-specific real-time PCR assays. Patients (six male, one female) ranged in age from 29 to 69 years (median of 41 years), and became ill between July 2016 and September 2017. Fever (6/7), myalgia (5/7), and arthralgia (5/7) were most commonly reported and 5/7 patients had a documented eschar. All patients reported a tick bite acquired in southern Arizona within 2-8 days before illness onset. Four patients worked as U.S. Border Patrol agents. Antibodies reactive to R. rickettsii, R. parkeri, or to both antigens were detected in all patients. Seroconversions between acute and convalescent-phase samples were identified for two patients and DNA of R. parkeri was identified in eschar swab samples from two patients. R. parkeri rickettsiosis is endemic to a region of the southwestern United States and presents an occupational risk that could be lessened by prevention messaging to Border Patrol agents. RMSF, a closely related and more severe spotted fever rickettsiosis, is also endemic to Arizona. Public health agencies can assist clinicians in distinguishing these two infections clinically through education and accessing species-specific diagnostic assays that can improve surveillance efforts for both diseases.

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

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