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Volume 11, Issue 47 November 26, 2019

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CDC Science Clips: Volume 11, Issue 47, November 26, 2019

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

The report consists of these components:

  1. Top Articles of the Week

    Selected weekly by a senior CDC scientist from the standard sections listed below.
    The names of CDC authors are indicated in bold text.
    • Communicable Diseases
      • Opioid use fueling HIV transmission in an urban setting: An outbreak of HIV infection among people who inject drugs – Massachusetts, 2015-2018external icon
        Alpren C, Dawson EL, John B, Cranston K, Panneer N, Fukuda HD, Roosevelt K, Klevens RM, Bryant J, Peters PJ, Lyss SB, Switzer W, Burrage A, Murray A, Agnew-Brune C, Stiles T, McClung P, Campbell EM, Breen C, Randall LM, Dasgupta S, Onofrey S, Bixler D, Hampton K, Jaeger JL, Hsu KK, Adih W, Callis B, Goldman LR, Danner SP, Jia H, Tumpney M, Board A, Brown C, DeMaria A, Buchacz K.
        Am J Public Health. 2019 Nov 14:e1-e8.
        Objectives. To describe and control an outbreak of HIV infection among people who inject drugs (PWID).Methods. The investigation included people diagnosed with HIV infection during 2015 to 2018 linked to 2 cities in northeastern Massachusetts epidemiologically or through molecular analysis. Field activities included qualitative interviews regarding service availability and HIV risk behaviors.Results. We identified 129 people meeting the case definition; 116 (90%) reported injection drug use. Molecular surveillance added 36 cases to the outbreak not otherwise linked. The 2 largest molecular groups contained 56 and 23 cases. Most interviewed PWID were homeless. Control measures, including enhanced field epidemiology, syringe services programming, and community outreach, resulted in a significant decline in new HIV diagnoses.Conclusions. We illustrate difficulties with identification and characterization of an outbreak of HIV infection among a population of PWID and the value of an intensive response.Public Health Implications. Responding to and preventing outbreaks requires ongoing surveillance, with timely detection of increases in HIV diagnoses, community partnerships, and coordinated services, all critical to achieving the goal of the national Ending the HIV Epidemic initiative. (Am J Public Health. Published online ahead of print November 14, 2019: e1-e8. doi:10.2105/AJPH.2019.305366).

    • Environmental Health
      • Exposures to chemical mixtures during pregnancy and neonatal outcomes: The HOME studyexternal icon
        Kalloo G, Wellenius GA, McCandless L, Calafat AM, Sjodin A, Romano ME, Karagas MR, Chen A, Yolton K, Lanphear BP, Braun JM.
        Environ Int. 2019 Nov 11;134:105219.
        INTRODUCTION: Exposure to mixtures of environmental chemicals are prevalent among pregnant women and may be associated with altered fetal growth and gestational age. To date, most research regarding environmental chemicals and neonatal outcomes has focused on the effect of individual agents. METHODS: In a prospective cohort of 380 pregnant women from Cincinnati, OH (enrolled 2003-2006), we used biomarkers to estimate exposure to 43 phenols, phthalates, metals, organophosphate/pyrethroid/organochlorine pesticides, polychlorinated biphenyls, polybrominated diphenyl ethers, perfluoroalkyl substances (PFAS), and environmental tobacco smoke. Using three approaches, we estimated covariate-adjusted associations of chemical mixtures or individual chemicals with gestational-age-specific birth weight z-scores, birth length, head circumference, and gestational age: k-means clustering, principal components (PC), and one-chemical-at-a-time regression. RESULTS: We identified three chemical mixture profiles using k-means clustering. Women in cluster 1 had higher concentrations of most phenols, three phthalate metabolites, several metals, organophosphate/organochlorine pesticides, polychlorinated biphenyls, and several PFAS than women in clusters 2 and 3. On average, infants born to women in clusters 1 (-1.2cm; 95% CI: -1.9, -0.5) and 2 (-0.5cm; 95% CI: -1.1, 0.1) had lower birth length than infants in cluster 3. Six PCs explained 50% of the variance in biomarker concentrations and biomarkers with similar chemical structures or from shared commercial/industrial settings loaded onto commons PCs. Each standard deviation increase in PC 1 (organochlorine pesticides, some phenols) and PC 6 (cadmium, bisphenol A) was associated with 0.2cm (95% CI: -0.4, 0.0) and 0.1cm (95% CI: -0.4, 0.1) lower birth length, respectively. Organochlorine compounds, parabens, and cadmium were inversely associated with birth length in the one-chemical-at-a-time analysis. Cluster membership, PC scores, and individual chemicals were not associated with other birth outcomes. CONCLUSION: All three methods of characterizing multiple chemical exposures in this cohort identified inverse associations of select organochlorine compounds, phenols, and cadmium with birth length, but not other neonatal outcomes.

    • Global Health
      • International mass gatherings and travel-associated illness: A GeoSentinel cross-sectional, observational studyexternal icon
        Gautret P, Angelo KM, Asgeirsson H, Duvignaud A, van Genderen PJ, Bottieau E, Chen LH, Parker S, Connor BA, Barnett ED, Libman M, Hamer DH.
        Travel Med Infect Dis. 2019 Nov 7:101504.
        BACKGROUND: Travelers to international mass gatherings may be exposed to conditions which increase their risk of acquiring infectious diseases. Most existing data come from single clinical sites seeing returning travelers, or relate to single events. METHODS: Investigators evaluated ill travelers returning from a mass gathering, and presenting to a GeoSentinel site between August 2015 and April 2019, and collected data on the nature of the event and the relation between final diagnoses and the mass gathering. RESULTS: Of 296 ill travelers, 51% were female and the median age was 54 years (range: 1-88). Over 82% returned from a religious mass gathering, most frequently Umrah or Hajj. Only 3% returned from the Olympics in Brazil or South Korea. Other mass gatherings included other sporting events, cultural or entertainment events, and conferences. Respiratory diseases accounted for almost 80% of all diagnoses, with vaccine preventable illnesses such as influenza and pneumonia accounting for 26% and 20% of all diagnoses respectively. This was followed by gastrointestinal illnesses, accounting for 4.5%. Sixty-three percent of travelers reported having a pre-travel encounter with a healthcare provider. CONCLUSIONS: Despite this surveillance being limited to patients presenting to GeoSentinel sites, our findings highlight the importance of respiratory diseases at mass gatherings, the need for pre-travel consultations before mass gatherings, and consideration of vaccination against influenza and pneumococcal disease..

    • Health Economics
      • Re-evaluating the potential impact and cost-effectiveness of rotavirus vaccination in 73 Gavi countries: a modelling studyexternal icon
        Debellut F, Clark A, Pecenka C, Tate J, Baral R, Sanderson C, Parashar U, Kallen L, Atherly D.
        Lancet Glob Health. 2019 Dec;7(12):e1664-e1674.
        BACKGROUND: Previous studies have found rotavirus vaccination to be highly cost-effective in low-income countries. However, updated evidence is now available for several inputs (ie, rotavirus disease mortality rates, rotavirus age distributions, vaccine timeliness, and vaccine efficacy by duration of follow-up), new rotavirus vaccines have entered the market, vaccine prices have decreased, and cost-effectiveness thresholds have been re-examined. We aimed to provide updated cost-effectiveness estimates to inform national decisions about the new introduction and current use of rotavirus vaccines in Gavi countries. METHODS: We calculated the potential costs and effects of rotavirus vaccination for ten successive birth cohorts in 73 countries previously and currently eligible for Gavi support, compared with no vaccination. We used a deterministic cohort model to calculate numbers of rotavirus gastroenteritis cases, outpatient visits, hospitalisations, and deaths between birth and 5 years, with and without rotavirus vaccination. We calculated treatment costs from the government and societal perspectives. The primary outcome measure was the incremental cost-effectiveness ratio (discounted US$ per disability-adjusted life-year averted). Country-specific model input parameters were based on the scientific literature, published meta-analyses, and international databases. We ran deterministic and probabilistic uncertainty analyses. FINDINGS: Over the period 2018-27, rotavirus vaccination has the potential to prevent nearly 600 000 deaths in Gavi countries. Averted outpatient visits and hospitalisations could lead to treatment savings of approximately $484.1 million from the government perspective and $878.0 million from the societal perspective. The discounted dollars per disability-adjusted life-year averted has a very high probability (>90%) of being less than 0.5 times the gross domestic product per capita in 54 countries, and less than 1.0 times gross domestic product per capita in 63 countries. INTERPRETATION: Rotavirus vaccination continues to represent good value for money across most Gavi countries despite lower rotavirus mortality estimates and more stringent willingness-to-pay thresholds. FUNDING: Bill & Melinda Gates Foundation.

    • Healthcare Associated Infections
      • International Society of Cardiovascular Infectious Diseases guidelines for the diagnosis, treatment and prevention of disseminated mycobacterium chimaera infection following cardiac surgery with cardiopulmonary bypassexternal icon
        Hasse B, Hannan M, Keller PM, Maurer FP, Sommerstein R, Mertz D, Wagner D, Fernandez-Hidalgo N, Nomura J, Manfrin V, Bettex D, Conte AH, Durante-Mangoni E, Hing-Cheung Tang T, Stuart RL, Lundgren J, Gordon S, Jarashow MC, Schreiber PW, Niemann S, Kohl TA, Daley C, Stewardson AJ, Whitener CJ, Perkins K, Plachouras D, Lamagni T, Chand M, Freiberger T, Zweifel S, Sander P, Schulthess B, Scriven J, Sax H, van Ingen J, Mestres CA, Diekema D, Brown-Elliott BA, Wallace RJ, Baddour LM, Miro JM, Hoen B.
        J Hosp Infect. 2019 Nov 9.
        Mycobacterial infection-related morbidity and mortality in patients following cardiopulmonary bypass surgery is high and and there is a growing need for a consensus-based expert opinion to provide international guidance for diagnosing, preventing and treating in these patients. In this document the International Society for Cardiovascular Infectious Diseases (ISCVID) covers aspects of prevention (field of hospital epidemiology), clinical management (infectious disease specialists, cardiac surgeons, ophthalmologists, others), laboratory diagnostics (microbiologists, molecular diagnostics), device management (perfusionists, cardiac surgeons) and public health aspects.

    • Immunity and Immunization
      • Heterogeneity in influenza seasonality and vaccine effectiveness in Australia, Chile, New Zealand and South Africa: early estimates of the 2019 influenza seasonexternal icon
        Sullivan SG, Arriola CS, Bocacao J, Burgos P, Bustos P, Carville KS, Cheng AC, Chilver MB, Cohen C, Deng YM, El Omeiri N, Fasce RA, Hellferscee O, Huang QS, Gonzalez C, Jelley L, Leung VK, Lopez L, McAnerney JM, McNeill A, Olivares MF, Peck H, Sotomayor V, Tempia S, Vergara N, von Gottberg A, Walaza S, Wood T.
        Euro Surveill. 2019 Nov;24(45).
        We compared 2019 influenza seasonality and vaccine effectiveness (VE) in four southern hemisphere countries: Australia, Chile, New Zealand and South Africa. Influenza seasons differed in timing, duration, intensity and predominant circulating viruses. VE estimates were also heterogeneous, with all-ages point estimates ranging from 7-70% (I2: 33%) for A(H1N1)pdm09, 4-57% (I2: 49%) for A(H3N2) and 29-66% (I2: 0%) for B. Caution should be applied when attempting to use southern hemisphere data to predict the northern hemisphere influenza season.

    • Laboratory Sciences
      • Development of a syphilis serum bank to support research, development, and evaluation of syphilis diagnostic tests in the United Statesexternal icon
        Shukla M, Sun Y, McCormick J, Hopkins A, Pereira L, Gaynor A, Kersh E, Fakile Y.
        Diagn Microbiol Infect Dis. 2019 Oct 24:114913.
        The Centers for Disease Control and Prevention’s (CDC) Division of STD Prevention, in collaboration with the Association of Public Health Laboratories (APHL), is developing a nationally available syphilis serum repository for research of Food and Drug Administration (FDA)-cleared or investigational syphilis diagnostic assays in the United States. State and local public health laboratories (PHL) submitted de-identified residual sera with information on collection date, volume, storage conditions, freeze-thaw cycles, PHL serology results, reported syphilis stage and demographic details if available. Previous test results were blinded and sera (N = 152 reported syphilis stage, N = 131 unknown status) were tested at CDC using five FDA-cleared and one investigational syphilis tests. Treponemal and nontreponemal test sensitivity ranged from 76.3-100% and 63.2-100%, respectively, among staged specimens. The conventional treponemal assays showed high concordance of 95.4%. By providing syphilis stage and comprehensive serological test data, developed repository may serve as a valuable resource for diagnostic test validation studies.

    • Medicine

    • Parasitic Diseases
      • Estimating malaria burden among pregnant women using data from antenatal care centres in Tanzania: a population-based studyexternal icon
        Kitojo C, Gutman JR, Chacky F, Kigadye E, Mkude S, Mandike R, Mohamed A, Reaves EJ, Walker P, Ishengoma DS.
        Lancet Glob Health. 2019 Dec;7(12):e1695-e1705.
        BACKGROUND: More timely estimates of malaria prevalence are needed to inform optimal control strategies and measure progress. Since 2014, Tanzania has implemented nationwide malaria screening for all pregnant women within the antenatal care system. We aimed to compare malaria test results during antenatal care to two population-based prevalence surveys in Tanzanian children aged 6-59 months to examine their potential in measuring malaria trends and progress towards elimination. METHODS: Malaria test results from pregnant women screened at their first antenatal care visits at health-care facilities (private and public) in all 184 districts of Tanzania between Jan 1, 2014, and Dec 31, 2017, were collected from the Health Management Information Systems and District Health Information System 2. We excluded facilities with no recorded antenatal care attendees during the time period. We standardised results to account for testing uptake and weighted them by the timing of two population-based surveys of childhood malaria prevalence done in 2015-16 (Demographic and Health Survey) and 2017 (Malaria Indicator Survey). We assessed regional-level correlation using Spearman’s coefficient and assessed the consistency of monthly district-level prevalence ranking using Kendall’s correlation coefficient. FINDINGS: Correlation between malaria prevalence at antenatal care and among children younger than 5 years was high (r>/=0.83 for both surveys), although declines in prevalence at antenatal care were generally smaller than among children. Consistent heterogeneity (p<0.05) in antenatal care prevalence at the district level was evident in all but one region (Kilimanjaro). Data from antenatal care showed declining prevalence in three regions (Arusha, Kilimanjaro, and Manyara) where surveys estimated zero prevalence. INTERPRETATION: Routine antenatal care-based screening can be used to assess heterogeneity in transmission at finer resolution than population-based surveys, and provides sample sizes powered to detect changes, notably in areas of low transmission where surveys lack power. Declines in prevalence at antenatal care might lag behind those among children, highlighting the value of monitoring burden and continuing prevention efforts among pregnant women as transmission declines. The pregnancy-specific benefits and cost-effectiveness of antenatal care-based screening remain to be assessed. FUNDING: None.

    • Substance Use and Abuse
      • BACKGROUND AND AIMS: Due to their small sample sizes, geographic specificity and limited examination of socio-demographic characteristics, recent studies of methamphetamine use among people using heroin in the United States are limited in their ability to identify national and regional trends and to characterize populations at risk for using heroin and methamphetamine. This study aimed to examine trends and correlates of methamphetamine use among heroin treatment admissions in the United States. DESIGN: Longitudinal analysis of data from the 2008 to 2017 Treatment Episode Data Set. Descriptive statistics, trend analyses and multivariable logistic regression were used to examine characteristics associated with methamphetamine use among heroin treatment admissions. SETTING: United States. PARTICIPANTS: Treatment admissions of people aged >/= 12 years whose primary substance of use is heroin. MEASUREMENTS: Primary measurement was heroin treatment admissions involving methamphetamine. Secondary measurements were demographics of sex, age, race/ethnicity, US census region, living arrangement and employment status. FINDINGS: The percentage of primary heroin treatment admissions reporting methamphetamine use increased each year from 2.1% in 2008 to 12.4% in 2017, a relative percentage increase of 490% and an annual percentage change (APC) of 23.4% (P < 0.001). During the study period, increases were seen among males and females and among all demographic and geographic groups examined. Among primary heroin treatment admissions reporting methamphetamine use in 2017, 47.1% reported injecting, 46.0% reported smoking, 5.1% reporting snorting and 1.8% reported oral/other as their usual route of methamphetamine use. CONCLUSIONS: Methamphetamine use among heroin treatment admissions in the United States increased from one in 50 primary heroin treatment admissions in 2008 to one in 8 admissions in 2017.

      • Tobacco and marijuana use among US college and noncollege young adults, 2002-2016external icon
        Odani S, Soura BD, Tynan MA, Lavinghouze R, King BA, Agaku I.
        Pediatrics. 2019 Nov 11.
        OBJECTIVES: To assess trends and behavioral patterns of marijuana and cigarette and/or cigar (ie, smoked tobacco) use among 18- to 22-year-old US young adults who were in or not in college. METHODS: Data were from the 2002-2016 National Survey on Drug Use and Health. Past-30-day and past-12-month use of marijuana and smoked tobacco were assessed by college enrollment status. chi(2) tests were used to examine within- and between-group differences. Trends were assessed by using logistic regression and relative percentage change (RPC). RESULTS: Among both college and noncollege individuals during 2002 to 2016, exclusive marijuana use increased (faster increase among college students; RPC = 166.6 vs 133.7), whereas exclusive smoked tobacco use decreased (faster decrease among college students; RPC = -47.4 vs -43.2). In 2016, 51.6% of noncollege and 46.8% of college individuals reported past-12-month usage of marijuana and/or smoked tobacco products (P < .05). Exclusive marijuana use was higher among college than noncollege individuals, both for past-30-day (11.5% vs 8.6%) and past-12-month use (14.6% vs 10.8%). Exclusive smoked tobacco use was higher among noncollege than college individuals, both for past-30-day (17.7% vs 10.4%) and past-12-month (17.4% vs 12.2%) use (P < .05). CONCLUSIONS: Exclusive marijuana use is increasing among young adults overall, whereas exclusive smoked tobacco use is decreasing: faster rates are seen among college students. Exclusive marijuana use is higher among college students, whereas exclusive smoked tobacco use is higher among noncollege individuals. Surveillance of tobacco and marijuana use among young people is important as the policy landscape for these products evolves.

    • Zoonotic and Vectorborne Diseases
      • Genomic epidemiology as a public health tool to combat mosquito-borne virus outbreaksexternal icon
        Pollett S, Fauver JR, Maljkovic Berry I, Melendrez M, Morrison A, Gillis LD, Johansson MA, Jarman RG, Grubaugh ND.
        J Infect Dis. 2019 Nov 10.
        Next-generation sequencing technologies, exponential increases in the availability of virus genomic data, and ongoing advances in phylogenomic methods have made genomic epidemiology an increasingly powerful tool for public health response to a range of mosquito-borne virus outbreaks. In this review, we offer a brief primer on the scope and methods of phylogenomic analyses that can answer key epidemiological questions during mosquito-borne virus public health emergencies. We then focus on case examples of outbreaks, including those caused by dengue, Zika, yellow fever, West Nile, and chikungunya viruses, to demonstrate the utility of genomic epidemiology to support the prevention and control of mosquito-borne virus threats. We extend these case studies with operational perspectives on how to best incorporate genomic epidemiology into structured surveillance and response programs for mosquito-borne virus control. Many tools for genomic epidemiology already exist, but so do technical and nontechnical challenges to advancing their use. Frameworks to support the rapid sharing of multidimensional data and increased cross-sector partnerships, networks, and collaborations can support advancement on all scales, from research and development to implementation by public health agencies.

  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 association of nativity/length of residence and cardiovascular disease risk factors in the United Statesexternal icon
        Fryar CD, Fakhouri TH, Carroll MD, Frenk SM, Ogden CL.
        Prev Med. 2019 Nov 9:105893.
        Differences by nativity status for cardiovascular disease (CVD) risk factors have been previously reported. Recent research has focused on understanding how other acculturation factors, such as length of residence, affect health behaviors and outcomes. This study examines the association between CVD risk factors and nativity/length of US residence. Using cross-sectional data from 15,965 adults in the 2011-2016 National Health and Nutrition Examination Surveys (analyzed in 2018), prevalence ratios and predicted marginals from logistic regression models are used to estimate associations of CVD risk factors (i.e., hypertension, hypercholesterolemia, diabetes, overweight/obesity and smoking) with nativity/length of residence (<15years, >/=15years) in the US. In sex-, age-, education- and race and Hispanic origin- adjusted analyses, a higher percentage of US (50 states and District of Columbia) born adults (86.4%) had >/=1 CVD risk factor compared to non-US born residents in the US <15years (80.1%) but not >/=15years (85.1%). Compared to US born counterparts, regardless of length of residence, hypertension overall and smoking among non-Hispanic white and Hispanic adults were lower among non-US born residents. Overweight/obesity overall and diabetes among Hispanic adults were lower among non-US born residents in the US <15years. In contrast, non-US born non-Hispanic Asian residents in the US <15years had higher prevalence of diabetes. Non-US born adults were less likely to have most CVD risk factors compared to US born adults regardless of length of residence, although, for smoking and diabetes this pattern differed by race and Hispanic origin.

      2. Philadelphia Telemedicine Glaucoma Detection and Follow-Up Study: Cataract classifications following eye screeningexternal icon
        Hark LA, Adeghate J, Katz LJ, Ulas M, Waisbourd M, Maity A, Zhan T, Hegarty S, Leiby BE, Pasquale LR, Leite S, Saaddine JB, Haller JA, Myers JS.
        Telemed J E Health. 2019 Nov 13.
        Background: Cataracts are a major cause of visual impairment and blindness in the United States and worldwide. Introduction: Risk factors for cataracts include age over 40 years, smoking, diabetes, low socioeconomic status, female sex, steroid use, ocular trauma, genetic factors, and exposure to ultraviolet-B light. Community-based telemedicine vision screenings can be an efficient method for detecting cataracts in underserved populations. The Philadelphia Telemedicine Glaucoma Detection and Follow-Up Study reports the prevalence and risk factors for cataracts in individuals screened and examined for glaucoma and other eye diseases. Materials and Methods: A total of 906 high-risk individuals were screened for glaucoma using telemedicine in seven primary care practices and four Federally Qualified Health Centers in Philadelphia. Participants with suspicious nerves or other abnormalities on fundus photographs, unreadable images, and ocular hypertension returned for an eye examination with an ophthalmologist at the same community location. Results: Of the participants screened through telemedicine, 347 (38.3%) completed a follow-up eye examination by an ophthalmologist. Of these, 267 (76.9%) were diagnosed with cataracts, of which 38 (14.2%) had visually significant cataracts. Participants who were diagnosed with visually significant cataract were more likely to be older (p < 0.001), have diabetes (p = 0.003), and worse visual acuity (p < 0.001). Discussion: Our study successfully detected and confirmed cataracts in a targeted, underserved urban population at high risk for eye disease. Conclusions: Telemedicine programs offer an opportunity to identify and refer individuals who would benefit from continuous follow-up eye care and treatment to improve visual function and quality of life.

      3. Population-based prevalence and incidence estimates of primary discoid lupus erythematosus from the Manhattan Lupus Surveillance Programexternal icon
        Izmirly P, Buyon J, Belmont HM, Sahl S, Wan I, Salmon J, Askanase A, Bathon JM, Geraldino-Pardilla L, Ali Y, Ginzler E, Putterman C, Gordon C, Helmick C, Parton H.
        Lupus Sci Med. 2019 ;6(1).
        Objective Epidemiological data for primary discoid lupus erythematosus (pDLE) remain limited, particularly for racial/ethnic populations in the USA. The Manhattan Lupus Surveillance Program (MLSP) is a population-based retrospective registry of cases with SLE and related diseases including pDLE in Manhattan and was used to provide estimates of the prevalence and incidence of pDLE across major racial/ethnic populations. Methods MLSP cases were identified from rheumatologists, hospitals and population databases. Two case definitions were used for pDLE: the primary case definition which was any physician diagnosis found in the chart and a secondary case definition which was limited to cases diagnosed by a rheumatologist and/or dermatologist. Rates among Manhattan residents were age-adjusted, and capture-recapture analyses were conducted to assess case under-ascertainment. Results Based on the primary definition, age-adjusted overall prevalence and incidence rates of pDLE among Manhattan residents were 6.5 and 0.8 per 100 000 person-years, which increased to 9.0 and 1.3 after capture-recapture adjustment. Prevalence and incidence rates were approximately two and six times higher, respectively, among women compared with men (p<0.0001). Higher prevalence was also found among non-Latino blacks (23.5) and Latinos (8.2) compared with non-Latino whites (1.8) and non-Latino Asians (0.6) (p<0.0001). Incidence was highest among non-Latino blacks (2.4) compared with all other racial/ethnic groups. Similar relationships were observed for the secondary case definition. Conclusion Data from the MLSP provide epidemiological estimates for pDLE among the major racial/ethnic populations in the USA and reveal disparities in pDLE prevalence and incidence by sex and race/ethnicity among Manhattan residents.

      4. Bridging the divide between epilepsy and mental health to drive solutionsexternal icon
        Kobau R, Manderscheid R, Owens S, Curt LaFrance W, Sajatovic M.
        Epilepsy Behav. 2019 Nov 6:106576.
        Since its establishment in 2000, Epilepsy & Behavior has published more than 1000 papers on mental health issues among people with epilepsy, including about 200 reviews. These studies on prevalence, treatment, and guidance for future research are important contributions to the field, and they offer great promise. Yet these papers and the multitude published in other journals over the years have failed to result in systematic, scaled changes in how the epilepsy field in the United States addresses mental health issues. The mental health assessment and management gap is especially notable given decades-old, as well as more recent, recommendations from national initiatives on epilepsy, consensus statements, and other expert appeals to reduce psychiatric burden. Selected or comprehensive elements of emerging models and latest approaches from behavioral health (e.g., peer support) and public health (e.g., community-clinical linkages) highlight current opportunities to engage multiple community partners and sectors to bridge the epilepsy and behavioral health fields to implement solutions for improved mental healthcare for people with epilepsy. In honor of the 20th anniversary of Epilepsy & Behavior and its contribution to the literature and the field, we seek to build public health roadmaps to bridge the epilepsy and behavioral health divide-with new epilepsy partners who can expand community-based partnerships that may help facilitate systematic changes to close mental health treatment gaps. Special Issue: Epilepsy & Behavior’s 20th Anniversary.

      5. AIMS: Type 2 diabetes mellitus (T2DM) rates continue to increase across women of reproductive age in the United States. The Ohio Type 2 Diabetes Learning Collaborative aimed to improve education and screening for T2DM among women aged 18-44years at high risk for developing T2DM. METHODS: Fifteen primary care practices across Ohio participated in a 12-month quality improvement (QI) collaborative, which included monthly calls to share best practices, one-on-one QI coaching, and Plan-Do-Study-Act cycles. Monthly, practices submitted data on three outcome measures on preventive education and three measures on clinical screening for T2DM. RESULTS: Increases across each of the three preventive education rates (range of percent increase: 53.6% – 60.0%) and each of the three screening rates for T2DM (15.0% – 19.4%) were observed. Specifically, screening rates for high-risk women with two or more risk factors for T2DM (excluding gestational diabetes mellitus (GDM)) increased by 16.8% (60.5%-77.3%) while rates for T2DM among women with a history of GDM increased by 15.0% (75.0 – 90.0). CONCLUSIONS: A quality improvement collaborative increased preventive education and screening rates for women at high-risk for T2DM in primary care settings.

    • Communicable Diseases
      1. Reported variability in healthcare facility policies regarding healthcare personnel working while experiencing influenza-like illnesses: An emerging infections network surveyexternal icon
        Babcock HM, Beekmann SE, Pillai SK, Santibanez S, Lee L, Kuhar DT, Campbell AP, Patel A, Polgreen PM.
        Infect Control Hosp Epidemiol. 2019 Nov 14:1-6.
        BACKGROUND: Presenteeism, or working while ill, by healthcare personnel (HCP) experiencing influenza-like illness (ILI) puts patients and coworkers at risk. However, hospital policies and practices may not consistently facilitate HCP staying home when ill. OBJECTIVE AND METHODS: We conducted a mixed-methods survey in March 2018 of Emerging Infections Network infectious diseases physicians, describing institutional experiences with and policies for HCP working with ILI. RESULTS: Of 715 physicians, 367 (51%) responded. Of 367, 135 (37%) were unaware of institutional policies. Of the remaining 232 respondents, 206 (89%) reported institutional policies regarding work restrictions for HCP with influenza or ILI, but only 145 (63%) said these were communicated at least annually. More than half of respondents (124, 53%) reported that adherence to work restrictions was not monitored or enforced. Work restrictions were most often not perceived to be enforced for physicians-in-training and attending physicians. Nearly all (223, 96%) reported that their facility tracked laboratory-confirmed influenza (LCI) in patients; 85 (37%) reported tracking ILI. For employees, 109 (47%) reported tracking of LCI and 53 (23%) reported tracking ILI. For independent physicians, not employed by the facility, 30 (13%) reported tracking LCI and 11 (5%) ILI. CONCLUSION: More than one-third of respondents were unaware of whether their institutions had policies to prevent HCP with ILI from working; among those with knowledge of institutional policies, dissemination, monitoring, and enforcement of these policies was highly variable. Improving communication about work-restriction policies, as well as monitoring and enforcement, may help prevent the spread of infections from HCP to patients.

      2. Effectiveness of a behavior change intervention with hand sanitizer use and respiratory hygiene in reducing laboratory-confirmed influenza among schoolchildren in Bangladesh: A cluster randomized controlled trialexternal icon
        Biswas D, Ahmed M, Roguski K, Ghosh PK, Parveen S, Nizame FA, Rahman MZ, Chowdhury F, Rahman M, Luby SP, Sturm-Ramirez K, Iuliano AD.
        Am J Trop Med Hyg. 2019 Nov 4.
        Schoolchildren are commonly linked to influenza transmission. Handwashing with soap has been shown to decrease infections; however, improving handwashing practices using soap and water is difficult in low-resource settings. In these settings, alternative hygiene options, such as hand sanitizer, could improve handwashing promotion to reduce influenza virus infections. We conducted a cluster randomized control trial in 24 primary schools in Dhaka to assess the effectiveness of hand sanitizer and a respiratory hygiene education intervention in reducing influenza-like illness (ILI) and laboratory-confirmed influenza during June-September 2015. Twelve schools were randomly selected to receive hand sanitizer and respiratory hygiene education, and 12 schools received no intervention. Field staff actively followed children daily to monitor for new ILI episodes (cough with fever) through school visits and by phone if a child was absent. When an illness episode was identified, medical technologists collected nasal swabs to test for influenza viruses. During the 10-week follow-up period, the incidence of ILI per 1,000 student-weeks was 22 in the intervention group versus 27 in the control group (P-value = 0.4). The incidence of laboratory-confirmed influenza was 53% lower in the intervention schools (3/1,000 person-weeks) than in the control schools (6/1,000 person-weeks) (P-value = 0.01). Hand sanitizer and respiratory hygiene education can help to reduce the risk of influenza virus transmission in schools.

      3. Epidemic control is necessary to eliminate human immunodeficiency virus infections. We assessed epidemic control in the United States by applying 4 proposed UNAIDS metrics to national surveillance data collected between 2010 and 2015. Although epidemic control in the United States is possible, progress by UNAIDS metrics has been mixed.

      4. Haiti poliovirus environmental surveillanceexternal icon
        Coulliette-Salmond AD, Alleman MM, Wilnique P, Rey-Benito G, Wright HB, Hecker JW, Miles S, Penaranda S, Lafontant D, Corvil S, Francois J, Rossignol E, Stanislas M, Gue E, Faye PC, Castro CJ, Schmidt A, Ng TF, Burns CC, Vega E.
        Am J Trop Med Hyg. 2019 Nov 4.
        Poliovirus (PV) environmental surveillance was established in Haiti in three sites each in Port-au-Prince and Gonaives, where sewage and fecal-influenced environmental open water channel samples were collected monthly from March 2016 to February 2017. The primary objective was to monitor for the emergence of vaccine-derived polioviruses (VDPVs) and the importation and transmission of wild polioviruses (WPVs). A secondary objective was to compare two environmental sample processing methods, the gold standard two-phase separation method and a filter method (bag-mediated filtration system [BMFS]). In addition, non-polio enteroviruses (NPEVs) were characterized by next-generation sequencing using Illumina MiSeq to provide insight on surrogates for PVs. No WPVs or VDPVs were detected at any site with either concentration method. Sabin (vaccine) strain PV type 2 and Sabin strain PV type 1 were found in Port-au-Prince, in March and April samples, respectively. Non-polio enteroviruses were isolated in 75-100% and 0-58% of samples, by either processing method during the reporting period in Port-au-Prince and Gonaives, respectively. Further analysis of 24 paired Port-au-Prince samples confirmed the detection of a human NPEV, and echovirus types E-3, E-6, E-7, E-11, E-19, E-20, and E-29. The comparison of the BMFS filtration method to the two-phase separation method found no significant difference in sensitivity between the two methods (mid-P-value = 0.55). The experience of one calendar year of sampling has informed the appropriateness of the initially chosen sampling sites, importance of an adequate PV surrogate, and robustness of two processing methods.

      5. Progress toward poliomyelitis eradication – Pakistan, January 2018-September 2019external icon
        Hsu CH, Kader M, Mahamud A, Bullard K, Jorba J, Agbor J, Safi MM, Jafari HS, Ehrhardt D.
        MMWR Morb Mortal Wkly Rep. 2019 Nov 15;68(45):1029-1033.
        Afghanistan and Pakistan are the only countries that continue to confirm ongoing wild poliovirus type 1 (WPV1) transmission (1). During January 2018-September 2019 the number of WPV1 cases in Pakistan increased, compared with the number during the previous 4 years. This report updates previous reports on Pakistan’s polio eradication activities, progress, and challenges (2,3). In 2018, Pakistan reported 12 WPV1 cases, a 50% increase from eight cases in 2017, and a 31% increase in the proportion of WPV1-positive sites under environmental surveillance (i.e., sampling of sewage to detect poliovirus). As of November 7, 2019, 80 WPV1 cases had been reported, compared with eight cases by the same time in 2018. An intensive schedule of supplementary immunization activities (SIAs)* implemented by community health workers in the core reservoirs (i.e., Karachi, Peshawar, and Quetta) where WPV1 circulation has never been interrupted, and by mobile teams, has failed to interrupt WPV1 transmission in core reservoirs and prevent WPV1 resurgence in nonreservoir areas. Sewage samples have indicated wide WPV1 transmission in nonreservoir areas in other districts and provinces. Vaccine refusals, chronically missed children, community campaign fatigue, and poor vaccination management and implementation have exacerbated the situation. To overcome challenges to vaccinating children who are chronically missed in SIAs and to attain country and global polio eradication goals, substantial changes are needed in Pakistan’s polio eradication program, including continuing cross-border coordination with Afghanistan, gaining community trust, conducting high-quality vaccination campaigns, improving oversight of field activities, and improving managerial processes to unify eradication efforts.

      6. Knowledge, attitudes, and practices regarding coccidioidomycosis among healthcare providers in four counties in Washington State, 2017external icon
        Hubber J, Person A, Jecha L, Flodin-Hursh D, Stiffler J, Hill H, Bassham S, McCotter OZ, Oltean HN.
        Med Mycol. 2019 Nov 9.
        Coccidioidomycosis is an emerging infection in Washington State. The epidemiology of the disease in Washington is poorly understood at present; underrecognition and underreporting of coccidioidomycosis is suspected based on reports of only severe disease. We sought to characterize healthcare provider knowledge, attitudes, and practices regarding coccidioidomycosis awareness, diagnosis, and treatment in south-central Washington. We conducted a cross-sectional survey of actively practicing healthcare providers in four counties in south-central Washington, an area recently described as endemic for Coccidioides. Survey results were used to assess awareness of reporting requirements, confidence in ability to diagnose and treat, confidence that knowledge is current, calculated knowledge score, and consideration of risk in patient population. The majority of respondents were unaware of the reporting requirement for coccidioidomycosis in Washington and further unaware that the disease had been reported in the state. Less than a third of survey respondents reported confidence in their ability to diagnose coccidioidomycosis and confidence that their knowledge is current. The majority of respondents never or rarely consider a diagnosis of coccidioidomycosis, and <25% of respondents indicated a working knowledge of serologic tests for the infection. The average knowledge score for respondents was 65%. Previous education, training, or practice regarding coccidioidomycosis was the only identified predictor of confidence and consideration of risk. These data indicate the substantial need for education and training among healthcare providers in south-central Washington and support the concern that a small proportion of existing cases of coccidioidomycosis are reported to the health department.

      7. Prevalence and risk factors of tuberculosis disease in South African correctional facilities in 2015external icon
        Jordan AM, Podewils LJ, Castro KG, Zishiri V, Charalambous S.
        Int J Tuberc Lung Dis. 2019 Nov 1;23(11):1198-1204.
        SETTING: Sixteen South African correctional facilities.OBJECTIVE: To determine the prevalence of and risk factors for tuberculosis (TB) in South African correctional facilities using data collected during a TB screening program in South African correctional facilities in 2015.DESIGN: Inmates in 16 South African correctional facilities were screened for TB from January to December 2015. Inmates reporting >/=1 TB symptom or having an abnormal computer-assisted digital chest X-ray (CXR) provided sputum. Abnormal CXRs were interpreted by a radiologist. Sputum was tested for Mycobacterium tuberculosis using Xpert((R)) MTB/RIF. Data from 16 South African correctional facilities were used in regression analysis, and prevalence estimates calculated for 12 South African correctional facilities with >30% screening coverage.RESULTS: In 12 South African correctional facilities included in the prevalence estimates, 837 inmates had TB disease (2653/100 000) as indicated by current TB treatment or screening-identified TB by radiologist or Xpert. Previous TB was associated with increased odds of screening-identified TB in HIV-positive inmates (OR 4.3, 95%CI 2.5-7.3). For HIV-negative inmates, previous TB (adjusted OR [aOR] 4.9, 95%CI 1.7-14.1) and self-reported symptoms vs. none (1 symptom, aOR 8.8, 95%CI 1.2-67.7; >2 symptoms, aOR 21.7, 95%CI 3.0-158.8) were independently associated with increased odds of screening-identified TB.CONCLUSIONS: Routine TB screening, including CXR, is needed in South African correctional facilities to identify and refer inmates with active TB.

      8. High risk of subacute sclerosing panencephalitis following measles outbreaks in Georgiaexternal icon
        Khetsuriani N, Sanadze K, Abuladze M, Tatishvili N.
        Clin Microbiol Infect. 2019 Nov 7.
        OBJECTIVE: To describe cases and estimate subacute sclerosing panencephalitis (SSPE) risk following large-sale measles outbreaks in Georgia. SSPE, a rare, fatal late complication of measles, is often overlooked in assessments focused on the acute illness. Georgia had 8,377 and 11,495 reported measles cases during the 2004-2005 and 2013-2015 outbreaks, respectively, but SSPE burden has not been assessed. METHODS: SSPE cases diagnosed during 2008-2017 were identified from hospitalization registries in major neurologic departments likely to admit SSPE patients. Information on reported measles cases and deaths was obtained from the national measles surveillance system and published reports. The risk of SSPE (number of measles cases per one SSPE case) was calculated for cases associated with the 2004-2005 outbreak. Crude estimates were adjusted to account for potential underreporting of measles, using 50%, 25% and 10% estimates of completeness of reporting. RESULTS: Sixteen SSPE cases diagnosed during 2008-2017 were identified. Eleven (92%) of 12 SSPE cases with known history of measles had infection at <2 years and one (8%) at 3 years of age. Crude estimate of SSPE risk for the 2004-2005 outbreak was 1:1,396. Adjusted estimates were 1:2,792, 1:1:5,584, and 1:13,960, assuming 50%, 25% and 10% completeness of reporting measles cases, respectively. CONCLUSIONS: The review demonstrated substantial risk of SSPE in Georgia, supporting recent data suggesting that risk of SSPE following measles infection is higher than previously thought. To prevent SSPE in Georgia, very high timely immunization coverage for measles should be achieved among children and immunity gap among adults should be closed.

      9. E. coli recovery from antimicrobial hand towels used in rural households in Kenyaexternal icon
        Kim S, Quick R, Stauber C, Oremo J, Murphy J.
        J Microbiol Methods. 2019 Nov 9:105776.
        An antimicrobial towel designed for repeated use was developed to prevent recontamination of washed hands after drying. This field trial in Kenya found that nearly all antimicrobial hand towels and untreated control towels were contaminated with E. coli after household use. The antimicrobial towel did not inactivate E. coli.

      10. Temporal and genotypic associations of sporadic norovirus gastroenteritis and reported norovirus outbreaks in middle Tennessee, 2012-2016external icon
        Parikh MP, Vandekar S, Moore C, Thomas L, Britt N, Piya B, Stewart LS, Batarseh E, Hamdan L, Cavallo SJ, Swing AM, Garman KN, Constantine-Renna L, Chappell J, Payne DC, Vinje J, Hall AJ, Dunn JR, Halasa N.
        Clin Infect Dis. 2019 Nov 13.
        BACKGROUND: In the United States, surveillance of norovirus gastroenteritis is largely restricted to outbreaks, limiting our knowledge of the contribution of sporadic illness to the overall impact on reported outbreaks. Understanding norovirus transmission dynamics is vital for improving preventive measures, including norovirus vaccine development. METHODS: We analyzed seasonal patterns and genotypic distribution between sporadic pediatric norovirus cases and reported norovirus outbreaks in middle Tennessee. Sporadic cases were ascertained via the New Vaccine Surveillance Network in a single county, while reported norovirus outbreaks from seven middle Tennessee counties were included in the study. We investigated the predictive value of sporadic cases on outbreaks using a two-state discrete Markov model. RESULTS: Between December 2012 and June 2016, there were 755 pediatric sporadic norovirus cases and 45 reported outbreaks. Almost half (42.2%) of outbreaks occurred in long-term care facilities. Most sporadic cases (74.9%) and reported outbreaks (86.8%) occurred between November and April. Peak sporadic norovirus activity was often contemporaneous with outbreak occurrence. Among both sporadic cases and outbreaks, GII genogroup noroviruses were most prevalent (90.1% and 83.3%) with GII.4 being the dominant genotype (39.0% and 52.8%). The predictive model suggested that the 3-day moving average of sporadic cases was positively associated with the probability of an outbreak occurring. CONCLUSIONS: Despite the demographic differences between the surveillance populations, the seasonal and genotypic associations between sporadic cases and outbreaks are suggestive of contemporaneous community transmission. Public health agencies may use this knowledge to expand surveillance and identify target populations for interventions, including future vaccines.

      11. Noncountable tuberculosis case reporting, National Tuberculosis Surveillance System, United States, 2010-2014external icon
        Pratt RH, Manangan LP, Cummings CN, Langer AJ.
        Public Health Rep. 2019 Nov 13:33354919884302.
        OBJECTIVES: Supplemental federal funding is allocated to state and local tuberculosis (TB) programs using a formula that considers only countable cases reported to the National Tuberculosis Surveillance System (NTSS). Health departments submit reports of cases, which are countable unless another (US or international) jurisdiction has already counted the case or the case represents a recurrence of TB diagnosed </=12 months after completion of treatment for a previous TB episode. Noncountable cases are a resource burden, so in 2009, NTSS began accepting noncountable case reports as an indicator of program burden. We sought to describe the volume and completeness of noncountable case reports. METHODS: We analyzed 2010-2014 NTSS data to determine the number and distribution of noncountable cases reported. We also surveyed jurisdictions to determine the completeness of noncountable case reporting and obtain information on jurisdictions’ experience in reporting noncountable cases. In addition, we prepared a hypothetical recalculation of the funding formula to evaluate the effect of including noncountable cases on funding allocations. RESULTS: Of 54 067 TB case reports analyzed, 1720 (3.2%) were noncountable; 47 of 60 (78.3%) jurisdictions reported >/=1 noncountable case. Of 60 programs surveyed, 34 (56.7%) responded. Of the 34 programs that responded, 24 (70.6%) had not reported all their noncountable cases to NTSS, and 11 (32.4%) stated that reporting noncountable cases was overly burdensome, considering the cases were not funded. CONCLUSIONS: Complete data on noncountable TB cases help support estimates of programmatic burden. Ongoing training and a streamlined reporting system to NTSS can facilitate noncountable case reporting.

      12. Assessment of readiness to transition from antenatal HIV surveillance surveys to PMTCT program data based HIV surveillance, in South Africa, the 2017 Antenatal Sentinel HIV Surveyexternal icon
        Selamawit AW, Kufa T, Barron P, Ayalew K, Cheyip M, Chirombo BC, Lombard C, Manda S, Pillay Y, Puren AJ.
        Int J Infect Dis. 2019 Nov 8.
        OBJECTIVE: South Africa has used antenatal HIV surveys for HIV surveillance in pregnant women since 1990. We assessed South Africa’s readiness to transition to programme data based antenatal HIV surveillance with respect to PMTCT uptake, accuracy of point-of-care rapid testing (RT) and selection bias with using programme data in the context of the 2017 antenatal HIV survey. METHODS: Between 1 October and 15 November 2017, the national survey was conducted in 1,595 public antenatal facilities selected using stratified multistage cluster sampling method. Results of point-of-care RT were obtained from medical records. Blood samples were taken from eligible pregnant women and tested for HIV using immunoassays (IA) in the laboratory. Descriptive statistics were used to report on: PMTCT uptake; agreement between HIV point-of-care RT and laboratory-based HIV-1 IA; and selection bias associated with using programme data for surveillance. RESULTS: PMTCT HIV testing uptake was high (99.8%). The positive percent agreement (PPA) between RT and IA was lower than the World Health Organization (WHO) benchmark (97.6%) at 96.3% (95% confidence interval (CI):95.9%-96.6%). The negative percent agreement was above the WHO benchmark (99.5%), at 99.7%(95%CI:99.6%-99.7%) nationally. PPA markedly varied by province (92.9%-98.3%). Selection bias due to exclusion of participants with no RT results was within the recommended threshold at 0.3%. CONCLUSION: For the three components assessed, South Africa was close to meeting the WHO standard for transitioning to routine RT data for antenatal HIV surveillance. The wide variations in PPA across provinces should be addressed.

    • Environmental Health
      1. An exploratory analysis of urinary organophosphate ester metabolites and oxidative stress among pregnant women in Puerto Ricoexternal icon
        Ingle ME, Watkins D, Rosario Z, VelezVega CM, Calafat AM, Ospina M, Ferguson KK, Cordero JF, Alshawabkeh A, Meeker JD.
        Sci Total Environ. 2019 Nov 4;703:134798.
        BACKGROUND: Organophosphate esters (OPEs) are used as flame retardants and plasticizers. Oxidative stress, the imbalance of reactive oxygen species and antioxidants, measured prenatally has been associated with adverse birth outcomes including preeclampsia and preterm birth. We are the first study to investigate the relationship between OPEs and oxidative stress among pregnant women. METHODS: Pregnant women 18-40 yrs. were recruited in Northern Puerto Rico (n=47) between 2011 and 2015. OPE concentrations of: bis(2-chloroethyl) phosphate (BCEtP), bis(1-chloro-2-propyl) phosphate (BCPP), bis(1,3-dichloro-2-propyl) phosphate (BDCPP), dibutyl phosphate (DNBP), and diphenyl phosphate (DPHP) and biomarkers for oxidative stress, 8-hydroxy-2′-deoxyguanosine (8-OHdG) and 8-isoprostane were measured in urine up to three times during pregnancy. Associations between oxidative stress biomarkers and OPEs were assessed using linear mixed models adjusted for specific gravity, age, BMI, and income. RESULTS: Metabolites BCEtP, BDCPP, and DPHP were frequently detected (>97%). OPE metabolite concentrations remained stable over time (Intraclass correlation coefficients (ICCs): 0.51-0.60). Metabolites BCEtP, BCPP, and DPHP were associated with an increase in 8-isoprostane and OHdG. An interquartile range (IQR) increase in BDCPP was associated with a 21% increase in 8-isoprostane (p<0.01), while and IQR increase in DPHP and BCPP was associated with a 12% increase (p=0.04, p=0.08, respectively). IQR increases in BDCPP and DPHP were also associated with an 18 and 19% increase in OHdG, respectively (p<0.01). CONCLUSION: OPE metabolites were frequently detected and our results suggest that exposure to OPEs is associated with higher levels of oxidative stress. Further investigation into these relationships and birth outcomes is warranted.

      2. Follow-up of the Libby, Montana screening cohort: A 17-year mortality studyexternal icon
        Larson TC, Williamson L, Antao VC.
        J Occup Environ Med. 2019 Nov 8.
        OBJECTIVE: To evaluate mortality patterns among participants in a community-based screening program for asbestos-related disease. METHODS: We calculated standardized mortality ratios (SMRs) and stratified results by exposure group (three occupational exposure groups, household contacts and residents without occupational asbestos exposure) and by radiographic abnormality presence. RESULTS: All-cause mortality (15.8%; 1,429/8,043) was statistically lower than expected. Asbestosis was statistically elevated in all exposure groups. Lung cancer was moderately associated with vermiculite miner/miller employment. Mesothelioma was elevated in that same exposure group and among residents. Systemic autoimmune disease mortality was also elevated. Radiographic parenchymal abnormalities were associated with lung cancer mortality. CONCLUSION: In addition to asbestos-related mortality in occupational exposure groups, this initial mortality follow-up of this cohort also shows elevated mortality for some asbestos-related causes in non-occupational exposure groups.

    • Health Disparities
      1. Purpose: In 2017, among all women in the United States, Hispanic women and Latinas (Hispanics/Latinas) accounted for 16% of women with HIV. Populations with high HIV disparities, including Hispanics/Latinas, experience treatment and care outcomes that are well below the national goals. The objective of this qualitative review was to identify social and structural barriers to HIV care from the perspective of Hispanics/Latinas. Methods: Our qualitative review was conducted in six stages: (1) searched and reviewed studies with a focus on Hispanics/Latinas with diagnosed HIV in the United States, published between January 2008 and August 2018; (2) removed unpublished reports and dissertations; (3) limited the search to keywords linked to social and structural HIV outcomes; (4) limited our search to studies that included samples of >/=30% Hispanics/Latinos and >/=30% female; (5) extracted and summarized the data; and (6) conducted a contextual review to identify common themes. Results: We identified 1796 articles; 84 titles and abstracts were screened for full-text review; 16 were selected for full review; and 6 articles met our inclusion criteria for final analysis. Barrier themes to HIV care for Hispanics/Latinas included HIV-related stigma from health professionals, legal consequences of seeking HIV services (including fear of deportation), and language barriers while utilizing HIV services and medications. Conclusion: Although the evidence addressing facilitators and barriers to care among HIV-positive women is sparse, interventions, resources, and enhanced training for health professionals to decrease social and structural barriers to HIV services for Hispanics/Latinas are warranted.

      2. BACKGROUND: Discrimination is a major driver of health disparities among minority groups and can impede the reach of public health programs. In the Dominican Republic, residents of bateyes, or agricultural ‘company towns,’ often face barriers to health care. This study examined the extent of perceived discrimination among batey populations and places the findings within the context of disease elimination efforts. METHODS: In March-April 2016, a stratified, multi-stage cluster survey that included the 9-item Everyday Discrimination Scale (EDS) was conducted among residents (n = 768) of bateyes across the Dominican Republic. Exploratory factor analysis, differential item functioning, and linear and logistic regression were used to assess associations between EDS scores, ethnic group status, reasons for discrimination, and healthcare-seeking behavior. RESULTS: Three ethnic groups were identified in the population: Haitian-born persons (42.5%), Dominican-born persons with Haitian descent (25.5%), and Dominican-born persons without Haitian descent (32.0%). Mean EDS scores (range 0-45) were highest among persons born in Haiti (18.2, 95% confidence interval [CI] = 16.4-20.1), followed by persons with Haitian descent (16.5, 95% CI = 14.9-18.0), and those without Haitian descent (13.3, 95% CI = 12.1-14.5). Higher EDS scores were significantly associated with Haitian birth (beta = 6.8, 95% CI = 4.2-9.4; p < 0.001) and Haitian descent (beta = 6.1, 95% CI = 3.2-9.0; p < 0.001). Most respondents (71.5%) had scores high enough to elicit reasons for their discrimination. Regardless of ethnic group, poverty was a common reason for discrimination, but Haitian-born and Haitian-descended people also attributed discrimination to their origin, documentation status, or skin color. EDS scores were not significantly associated with differences in reported care-seeking for recent fever (beta = 1.7, 95% CI = – 1.4-4.9; p = 0.278). CONCLUSION: Perceived discrimination is common among batey residents of all backgrounds but highest among Haitian-born people. Discrimination did not appear to be a primary barrier to care-seeking, suggesting other explanations for reduced care-seeking among Haitian populations. Public health community engagement strategies should avoid exacerbating stigma, build active participation in programs, and work towards community ownership of disease control and elimination goals.

      3. Disparities in receipt of eye exams among Medicare part B fee-for-service beneficiaries with diabetes – United States, 2017external icon
        Lundeen EA, Wittenborn J, Benoit SR, Saaddine J.
        MMWR Morb Mortal Wkly Rep. 2019 Nov 15;68(45):1020-1023.
        Approximately 30 million persons in the United States have diabetes. Persons with diabetes are at risk for vision loss from diabetic retinopathy and other eye diseases (1). Diabetic retinopathy, the most common diabetes-related eye disease, affects 29% of U.S. adults aged >/=40 years with diabetes (2) and is the leading cause of incident blindness among working-age adults (1). It is caused by chronically high blood glucose damaging blood vessels in the retina. Annual dilated eye exams are recommended for persons with diabetes because early detection and timely treatment of diabetic eye diseases can prevent irreversible vision loss. Studies have documented prevalence of annual eye exams among U.S. adults with diabetes; however, a lack of recent state-level data limits identification of geographic disparities in adherence to this recommendation. Medicare claims from the 50 states, the District of Columbia (DC), Puerto Rico, and U.S. Virgin Islands (USVI) were examined to assess the prevalence of eye exams in 2017 among beneficiaries with diabetes who were continuously enrolled in Part B fee-for-service insurance, which covers annual eye exams for beneficiaries with diabetes. This report also examines disparities, by state and race/ethnicity, in receipt of eye exams. Nationally, 54.1% of beneficiaries with diabetes had an eye exam in 2017. Prevalence ranged from 43.9% in Puerto Rico to 64.8% in Rhode Island. Fewer than 50% of beneficiaries received an eye exam in seven states (Alabama, Alaska, Kentucky, Louisiana, Nevada, West Virginia, and Wyoming) and Puerto Rico. Non-Hispanic white (white) beneficiaries had a higher prevalence of receiving an eye exam (55.6%) than did non-Hispanic blacks (blacks) (48.9%) and Hispanics (48.2%). Barriers to receiving eye care (e.g., suboptimal clinical care coordination and referral, low health literacy, and lack of perceived need for care) might limit Medicare beneficiaries’ ability to follow this preventive care recommendation. Understanding and addressing these barriers might prevent irreversible vision loss among persons with diabetes.

    • Health Economics
      1. The economic burden of malaria on households and the health system in a high transmission district of Mozambiqueexternal icon
        Alonso S, Chaccour CJ, Elobolobo E, Nacima A, Candrinho B, Saifodine A, Saute F, Robertson M, Zulliger R.
        Malar J. 2019 Nov 11;18(1):360.
        BACKGROUND: Malaria remains a leading cause of morbidity and mortality in Mozambique. Increased investments in malaria control have reduced the burden, but few studies have estimated the costs of malaria in the country. This paper estimates the economic costs associated with malaria care to households and to the health system in the high burden district of Mopeia in central Mozambique. METHODS: Malaria care-seeking and morbidity costs were routinely collected among 1373 households with at least one child enrolled in an active case detection (ACD) cohort in Mopeia, and through cross-sectional surveys with 824 families in 2017 and 805 families in 2018. Household costs included direct medical expenses, transportation and opportunity costs of the time lost due to illness. Structured questionnaires were used to estimate the health system costs associated with malaria care in all 13 district health facilities. Cost estimations followed an ingredient-based approach with a top-down allocation approach for health system expenses. RESULTS: Among participants in cross-sectional studies, households sought care for nine severe malaria cases requiring hospital admission and for 679 uncomplicated malaria cases. Median household costs associated with uncomplicated malaria among individuals of all ages were US$ 3.46 (IQR US$ 0.07-22.41) and US$ 81.08 (IQR US$ 39.34-88.38) per severe case. Median household costs were lower among children under five (ACD cohort): US$ 1.63 (IQR US$ 0.00-7.79) per uncomplicated case and US$ 64.90 (IQR US$ 49.76-80.96) per severe case. Opportunity costs were the main source of household costs. Median health system costs associated with malaria among patients of all ages were US$ 4.34 (IQR US$ 4.32-4.35) per uncomplicated case and US$ 26.56 (IQR US$ 18.03-44.09) per severe case. Considering household and health system costs, the overall cost of malaria care to society was US$ 7.80 per uncomplicated case and US$ 107.64 per severe case, representing an economic malaria burden of US$ 332,286.24 (IQR US$ 186,355.84-1,091,212.90) per year only in Mopeia. CONCLUSIONS: Despite the provision of free malaria services, households in Mopeia incur significant direct and indirect costs associated with the disease. Furthermore, the high malaria cost on the Mozambican health system underscores the need to strengthen malaria prevention to reduce the high burden and improve productivity in the region.

      2. Cost savings associated with video directly observed therapy for treatment of tuberculosisexternal icon
        Lam CK, Fluegge K, Macaraig M, Burzynski J.
        Int J Tuberc Lung Dis. 2019 Nov 1;23(11):1149-1154.
        OBJECTIVE: To calculate the per-session and annual direct program costs to implement directly observed therapy (DOT) for tuberculosis treatment and to conduct a cost attribution analysis under varying proportions of DOT utilization for four DOT types.DESIGN: Program data covering the study period from September 2014 to August 2015 in New York City (NYC) were used to conduct a retrospective bottom-up micro-costing economic evaluation. For each DOT type, potential per-session and annual program savings were estimated as the cost averted by adopting a uniform distribution of DOT alternatives. Sensitivity analyses explored aggregate cost impacts of unequal distributions.RESULTS: There was a total of 38 035 unique DOT visits, of which 12 002 (32%) were clinic-based (CDOT); 15 483 (41%) were field-based (FDOT); 7185 (19%) were live-video (LVDOT); and 3365 (9%) were recorded-video (RVDOT). The per-session direct costs (in 2016 $US) for DOT services delivered during the study period were $8.46 for CDOT; $19.83 for FDOT; $6.54 for LVDOT; and $5.35 for RVDOT. Sensitivity analyses supported the main findings.CONCLUSIONS: Significant cost savings were estimated with increased utilization of VDOT. Assuming equivalent treatment adherence, duration, completion, and adverse events across DOT types, RVDOT was the modality that most minimized cost.

    • Healthcare Associated Infections
      1. Hepatitis B virus mutant infections in hemodialysis patients: A case seriesexternal icon
        Apata IW, Nguyen DB, Khudyakov Y, Mixson-Hayden T, Rosenberg J, Zahn M, Greenko J, Clement E, Portney AE, Kulkarni PA, Comer M, Adams E, Kamili S, Patel PR, Moorman AC.
        Kidney Medicine. 2019 .
        Rationale & Objective: Hepatitis B virus (HBV) transmission in hemodialysis units has become a rare event since implementation of hemodialysis-specific infection control guidelines: performing hemodialysis for hepatitis B surface antigen (HBsAg)-positive patients in an HBV isolation room, vaccinating HBV-susceptible (HBV surface antibody and HBsAg negative) patients, and monthly HBsAg testing in HBV-susceptible patients. Mutations in HBsAg can result in false-negative HBsAg results, leading to failure to identify HBsAg seroconversion from negative to positive. We describe 4 unique cases of HBsAg seroconversion caused by mutant HBV infection or reactivation in hemodialysis patients. Study Design: Following identification of a possible HBsAg seroconversion and mutant HBV infection, public health investigations were launched to conduct further HBV testing of case patients and potentially exposed patients. A case patient was defined as a hemodialysis patient with suspected mutant HBV infection because of false-negative HBsAg testing results. Confirmed case patients had HBV DNA sequences demonstrating S-gene mutations. Setting & Participants: Case patients and patients potentially exposed to the case patient in the respective hemodialysis units in multiple US states. Results: 4 cases of mutant HBV infection in hemodialysis patients were identified; 3 cases were confirmed using molecular sequencing. Failure of some HBsAg testing platforms to detect HBV mutations led to delays in applying HBV isolation procedures. Testing of potentially exposed patients did not identify secondary transmissions. Limitations: Lack of access to information on past HBsAg testing platforms and results led to challenges in ascertaining when HBsAg seroconversion occurred and identifying and testing all potentially exposed patients. Conclusions: Mutant HBV infections should be suspected in patients who test HBsAg negative and concurrently test positive for HBV DNA at high levels. Dialysis providers should consider using HBsAg assays that can also detect mutant HBV strains for routine HBV testing.

      2. Diagnosis and antibiotic management of otitis media and otitis externa in United States veteransexternal icon
        Pontefract B, Nevers M, Fleming-Dutra KE, Hersh A, Samore M, Madaras-Kelly K.
        Open Forum Infect Dis. 2019 Nov;6(11):ofz432.
        Background: Acute otitis media (AOM) and otitis media with effusion (OME) occur primarily in children, whereas acute otitis externa (AOE) occurs with similar frequency in children and adults. Data on the incidence and management of otitis in adults are limited. This study characterizes the incidence, antibiotic management, and outcomes for adults with otitis diagnoses. Methods: A retrospective cohort of ambulatory adult veterans who presented with acute respiratory tract infection (ARI) diagnoses at 6 VA Medical Centers during 2014-2018 was created. Then, a subcohort of patients with acute otitis diagnoses was developed. Patient visits were categorized with administrative diagnostic codes for ARI (eg, sinusitis, pharyngitis) and otitis (OME, AOM, and AOE). Incidence rates for each diagnosis were calculated. Proportions of otitis visits with antibiotic prescribing, complications, and specialty referral were summarized. Results: Of 46 634 ARI visits, 3898 (8%) included an otitis diagnosis: OME (22%), AOM (44%), AOE (31%), and multiple otitis diagnoses (3%). Incidence rates were otitis media 4.0 (95% confidence interval [CI], 3.9-4.2) and AOE 2.0 (95% CI, 1.9-2.1) diagnoses per 1000 patient-years. By comparison, the incidence rates for pharyngitis (8.4; 95% CI, 8.2-8.6) and sinusitis (15.2; 95% CI, 14.9-15.5) were higher. Systemic antibiotics were prescribed in 75%, 63%, and 21% of AOM, OME, and AOE visits, respectively. Complications for otitis visits were low irrespective of antibiotic treatment. Conclusions: Administrative data indicated that otitis media diagnoses in adults were half as common as acute pharyngitis, and the majority received antibiotic treatment, which may be inappropriate. Prospective studies verifying diagnostic accuracy and antibiotic appropriateness are warranted.

    • Immunity and Immunization
      1. On the “take” as a biomarkerexternal icon
        Baden LR, Damon IK.
        N Engl J Med. 2019 Nov 14;381(20):1962-1963.

        [No abstract]

      2. Update on vaccine-derived poliovirus outbreaks – worldwide, January 2018-June 2019external icon
        Jorba J, Diop OM, Iber J, Henderson E, Zhao K, Quddus A, Sutter R, Vertefeuille JF, Wenger J, Wassilak SG, Pallansch MA, Burns CC.
        MMWR Morb Mortal Wkly Rep. 2019 Nov 15;68(45):1024-1028.
        Certification of global eradication of indigenous wild poliovirus type 2 occurred in 2015 and of type 3 in 2019. Since the launch of the Global Polio Eradication Initiative (GPEI) in 1988 and broad use of live, attenuated oral poliovirus vaccine (OPV), the number of wild poliovirus cases has declined >99.99% (1). Genetically divergent vaccine-derived poliovirus* (VDPV) strains can emerge during vaccine use and spread in underimmunized populations, becoming circulating VDPV (cVDPV) strains, and resulting in outbreaks of paralytic poliomyelitis.(dagger) In April 2016, all oral polio vaccination switched from trivalent OPV (tOPV; containing vaccine virus types 1, 2, and 3) to bivalent OPV (bOPV; containing types 1 and 3) (2). Monovalent type 2 OPV (mOPV2) is used in response campaigns to control type 2 cVDPV (cVDPV2) outbreaks. This report presents data on cVDPV outbreaks detected during January 2018-June 2019 (as of September 30, 2019). Compared with January 2017-June 2018 (3), the number of reported cVDPV outbreaks more than tripled, from nine to 29; 25 (86%) of the outbreaks were caused by cVDPV2. The increase in the number of outbreaks in 2019 resulted from VDPV2 both inside and outside of mOPV2 response areas. GPEI is planning future use of a novel type 2 OPV, stabilized to decrease the likelihood of reversion to neurovirulence. However, all countries must maintain high population immunity to decrease the risk for cVDPV emergence. Cessation of all OPV use after certification of polio eradication will eliminate the risk for VDPV emergence.

      3. BACKGROUND: Vaccines for the control of seasonal influenza are recommended by the World Health Organization (WHO) for use in specific risk groups, but their use requires operational considerations that may challenge immunization programs. Several middle-income countries have recently implemented seasonal influenza vaccination. Early program evaluation following vaccine introduction can help ascertain positive lessons learned and areas for improvement. METHODS: An influenza vaccine post-introduction evaluation (IPIE) tool was developed jointly by WHO and the U.S. Centers for Disease Control and Prevention to provide a systematic approach to assess influenza vaccine implementation processes. The tool was used in 2017 in three middle-income countries: Belarus, Morocco and Thailand. RESULTS: Data from the three countries highlighted a number of critical factors: Health workers (HWs) are a key target group, given their roles as key influencers of acceptance by other groups, and for ensuring vaccine delivery and improved coverage. Despite WHO recommendations, pregnant women were not always prioritized and may present unique challenges for acceptance. Target group denominators need to be better defined, and vaccine coverage should be validated with vaccine distribution data, including from the private sector. There is a need for strengthening adverse events reporting and for addressing potential vaccine hesitancy through the establishment of risk communication plans. The assessments led to improvements in the countries’ influenza vaccination programs, including a revision of policies, changes in vaccine management and coverage estimation, enhanced strategies for educating HWs and intensified collaboration between departments involved in implementing seasonal influenza vaccination. CONCLUSION: The IPIE tool was found useful for delineating operational strengths and weaknesses of seasonal influenza vaccination programs. HWs emerged as a critical target group to be addressed in follow-up action. Findings from this study can help direct influenza vaccination programs in other countries, as well as contribute to pandemic preparedness efforts. The updated IPIE tool is available on the WHO website http://www.who.int/immunization/research/development/influenza/en/index1.html.

      4. Evaluation of meningococcal vaccination policies among colleges and universities – United States, 2017external icon
        Oliver SE, Patton ME, Hoban M, Leino V, Mbaeyi SA, Hariri S, MacNeil JR.
        J Am Coll Health. 2019 Nov 11:1-6.
        Objective: Quadrivalent meningococcal conjugate vaccines (MenACWY) have been recommended routinely for adolescents since 2005; in 2015, serogroup B meningococcal (MenB) vaccines were recommended for persons aged 16-23 years based on individual clinical decision making. We surveyed college health providers or administrators to understand current meningococcal vaccine policies. Methods/Participants: In January 2017, we distributed a survey to 985 institutions in partnership with the American College Health Association to assess vaccination policies and outbreak response plans. Results: Overall, 352 (36%) institutions completed the survey. Most either required (N = 186, 53%) or recommended (N = 148, 42%) a meningococcal vaccine; only half (N = 167) had a policy specifically addressing MenB vaccines. Few institutions with a MenB vaccine policy required vaccination (N = 7, 4%); most recommended vaccination (N = 160, 96%). Conclusion: Most institutions have a meningococcal vaccination policy; however, there is substantial diversity in policies. Fewer schools have policies specifically addressing MenB vaccines.

      5. Safety and immunogenicity of the RTS,S/AS01 malaria vaccine in infants and children identified as HIV-infected during a randomized trial in sub-Saharan Africaexternal icon
        Otieno L, Guerra Mendoza Y, Adjei S, Agbenyega T, Agnandji ST, Aide P, Akoo P, Ansong D, Asante KP, Berkley JA, Gesase S, Hamel MJ, Hoffman I, Kaali S, Kamthunzi P, Kariuki S, Kremsner P, Lanaspa M, Lell B, Lievens M, Lusingu J, Malabeja A, Masoud NS, Mtoro AT, Njuguna P, Ofori-Anyinam O, Otieno GA, Otieno W, Owusu-Agyei S, Schuerman L, Sorgho H, Tanner M, Tinto H, Valea I, Vandoolaeghe P, Sacarlal J, Oneko M.
        Vaccine. 2019 Nov 7.
        BACKGROUND: We assessed the safety and immunogenicity of the RTS,S/AS01 malaria vaccine in a subset of children identified as HIV-infected during a large phase III randomized controlled trial conducted in seven sub-Saharan African countries. METHODS: Infants 6-12 weeks and children 5-17 months old were randomized to receive 4 RTS,S/AS01 doses (R3R group), 3 RTS,S/AS01 doses plus 1 comparator vaccine dose (R3C group), or 4 comparator vaccine doses (C3C group) at study months 0, 1, 2 and 20. Infants and children with WHO stage III/IV HIV disease were excluded but HIV testing was not routinely performed on all participants; our analyses included children identified as HIV-infected based on medical history or clinical suspicion and confirmed by polymerase chain reaction or antibody testing. Serious adverse events (SAEs) and anti-circumsporozoite (CS) antibodies were assessed. RESULTS: Of 15459 children enrolled in the trial, at least 1953 were tested for HIV and 153 were confirmed as HIV-infected (R3R: 51; R3C: 54; C3C: 48). Among these children, SAEs were reported for 92.2% (95% CI: 81.1-97.8) in the R3R, 85.2% (72.9-93.4) in the R3C and 87.5% (74.8-95.3) in the C3C group over a median follow-up of 39.3, 39.4 and 38.3 months, respectively. Fifteen HIV-infected participants in each group (R3R: 29.4%, R3C: 27.8%, C3C: 31.3%) died during the study. No deaths were considered vaccination-related. In a matched case-control analysis, 1 month post dose 3 anti-CS geometric mean antibody concentrations were 193.3 EU/mL in RTS,S/AS01-vaccinated HIV-infected children and 491.5 EU/mL in RTS,S/AS01-vaccinated immunogenicity controls with unknown or negative HIV status (p=0.0001). CONCLUSIONS: The safety profile of RTS,S/AS01 in HIV-infected children was comparable to that of the comparator (meningococcal or rabies) vaccines. RTS,S/AS01 was immunogenic in HIV-infected children but antibody concentrations were lower than in children with an unknown or negative HIV status. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov: NCT00866619.

    • Informatics
      1. Obesity-related clinical decision support tools in electronic health records (EHRs) can improve pediatric care, but the degree of adoption of these tools is unknown. DocStyles 2015 survey data from US pediatric healthcare providers (n = 1,156) were analyzed. Multivariable logistic regression identified provider characteristics associated with three EHR functionalities: automatically calculating body mass index (BMI) percentile (AUTO), displaying BMI trajectory (DISPLAY), and flagging abnormal BMIs (FLAG). Most providers had EHRs (88%). Of those with EHRs, 90% reporting having AUTO, 62% DISPLAY, and 54% FLAG functionalities. Only provider age was associated with all three functionalities. Compared to providers aged > 54 years, providers < 40 years had greater odds for: AUTO (adjusted odds ratio [aOR], 3.0; 95% confidence interval [CI], 1.58-5.70), DISPLAY (aOR, 2.07; 95% CI, 1.38-3.12), and FLAG (aOR, 1.67; 95% CI, 1.14-2.44). Future investigations can elucidate causes of lower adoption of EHR functions that display growth trajectories and flag abnormal BMIs.

      2. Flying, phones and flu: Anonymized call records suggest that Keflavik International Airport introduced pandemic H1N1 into Iceland in 2009external icon
        Kishore N, Mitchell R, Lash TL, Reed C, Danon L, Sigmundsdottir G, Vigfusson Y.
        Influenza Other Respir Viruses. 2019 Nov 9.
        BACKGROUND: Data collected by mobile devices can augment surveillance of epidemics in real time. However, methods and evidence for the integration of these data into modern surveillance systems are sparse. We linked call detail records (CDR) with an influenza-like illness (ILI) registry and evaluated the role that Icelandic international travellers played in the introduction and propagation of influenza A/H1N1pdm09 virus in Iceland through the course of the 2009 pandemic. METHODS: This nested case-control study compared odds of exposure to Keflavik International Airport among cases and matched controls producing longitudinal two-week matched odds ratios (mORs) from August to December 2009. We further evaluated rates of ILI among 1st- and 2nd-degree phone connections of cases compared to their matched controls. RESULTS: The mOR was elevated in the initial stages of the epidemic from 7 August until 21 August (mOR = 2.53; 95% confidence interval (CI) = 1.35, 4.78). During the two-week period from 17 August through 31 August, we calculated the two-week incidence density ratio of ILI among 1st-degree connections to be 2.96 (95% CI: 1.43, 5.84). CONCLUSIONS: Exposure to Keflavik International Airport increased the risk of incident ILI diagnoses during the initial stages of the epidemic. Using these methods for other regions of Iceland, we evaluated the geographic spread of ILI over the course of the epidemic. Our methods were validated through similar evaluation of a domestic airport. The techniques described in this study can be used for hypothesis-driven evaluations of locations and behaviours during an epidemic and their associations with health outcomes.

    • Injury and Violence
      1. Each year, more than 1 in 4 older adults in the United States report a fall and 1 in 10 a fall injury. Using nationally representative data from the 2016 US Behavioral Risk Factor Surveillance System, we evaluated demographic, geographic, functional, and health characteristics associated with falls and fall injuries among adults aged 65 years and older. Analyses included descriptive statistics and multivariable logistic regression to produce crude and adjusted percentages by characteristic. Characteristics most strongly associated with increased fall risk in order of adjusted percentage were depression, difficulty doing errands alone, and difficulty dressing or bathing. Characteristics most strongly associated with fall injury risk in order of adjusted percentage were depression, difficulty dressing or bathing, and being a member of an unmarried couple. The diverse health and functional characteristics associated with increased falls and fall injuries confirm the importance of screening and assessing older adult patients to determine their individual unique risk factors. Health care providers can use tools and resources from the Centers for Disease Control and Prevention’s STEADI (Stopping Elderly Accidents, Deaths, and Injuries) initiative to screen their older adult patients for fall risk, assess at-risk patients’ modifiable risk factors, and intervene to reduce risk by prescribing evidence-based interventions.

      2. Do violence acceptance and bystander actions explain the effects of green dot on reducing violence perpetration in high schools?external icon
        Bush HM, Coker AL, DeGue S, Clear ER, Brancato CJ, Fisher BS.
        J Interpers Violence. 2019 Nov 13.
        This study extends prior analyses from a 5-year multisite cluster-randomized controlled trial to examine how the previously reported effects of the Green Dot bystander-based prevention program worked to reduce violence perpetration. Bystander-based interventions are hypothesized to prevent violence by reducing violence acceptance and increasing trained participants’ willingness and ability to actively engage others in violence prevention using safe and effective bystander actions to diffuse or avoid potentially violent situations. We tested this hypothesis by examining whether Green Dot worked to reduce violence through two mediators measured over time: reducing violence acceptance and increasing bystander actions. When accounting for changes in these mediators over time, the effect of this intervention on violence perpetration was hypothesized to be attenuated or explained. At baseline (spring 2010) and annually (2011-2014), all students in recruited high schools (13 intervention, 13 control) completed an anonymous survey (response rate = 83.9%). Student responses were aggregated as school-level counts for the analysis. Path analyses estimated direct and indirect effects at specific points in the implementation of the intervention. Longitudinal models were used to determine if changes in violence acceptance and bystander actions could explain or attenuate the effect of the intervention. Time-framed path model analyses indicated that the intervention worked as expected to increase bystander behaviors and reduce violence acceptance; both potential mediators were significantly associated with sexual violence perpetration. In addition, after adjusting intent-to-treat models for the hypothesized mediators, the intervention was no longer associated with violence perpetration. In conclusion, these findings indicate that this bystander intervention worked as hypothesized to reduce sexual violence perpetration by creating theory-based changes in students’ violence acceptance and bystander actions.

    • Laboratory Sciences
      1. Identification of novel influenza A virus exposures by an improved high-throughput multiplex MAGPIX platform and serum adsorptionexternal icon
        Li ZN, Cheng E, Poirot E, Weber KM, Carney P, Chang J, Liu F, Gross FL, Holiday C, Fry A, Stevens J, Tumpey T, Levine MZ.
        Influenza Other Respir Viruses. 2019 Nov 8.
        BACKGROUND: The development of serologic assays that can rapidly assess human exposure to novel influenza viruses remains a public health need. Previously, we developed an 11-plex magnetic fluorescence microsphere immunoassay (MAGPIX) by using globular head domain recombinant hemagglutinins (rHAs) with serum adsorption using two ectodomain rHAs. METHODS: We compared sera collected from two cohorts with novel influenza exposures: animal shelter staff during an A(H7N2) outbreak in New York City in 2016-2017 (n = 119 single sera) and poultry workers from a live bird market in Bangladesh in 2012-2014 (n = 29 pairs). Sera were analyzed by microneutralization (MN) assay and a 20-plex MAGPIX assay with rHAs from 19 influenza strains (11 subtypes) combined with serum adsorption using 8 rHAs from A(H1N1) and A(H3N2) viruses. Antibody responses were analyzed to determine the novel influenza virus exposure. RESULTS: Among persons with novel influenza virus exposures, the median fluorescence intensity (MFI) against the novel rHA from exposed influenza virus had the highest correlation with MN titers to the same viruses and could be confirmed by removal of cross-reactivity from seasonal H1/H3 rHAs following serum adsorption. Interestingly, in persons with exposures to novel influenza viruses, age and MFIs against exposed novel HA were negatively correlated, whereas in persons without exposure to novel influenza viruses, age and MFI against novel HAs were positively correlated. CONCLUSIONS: This 20-plex high-throughput assay with serum adsorption will be a useful tool to detect novel influenza virus infections during influenza outbreak investigations and surveillance, especially when well-paired serum samples are not available.

      2. Background: The correlation of physico-chemical properties with mechanisms of toxicity has been proposed as an approach to predict the toxic potential of the vast number of emerging nanomaterials. Although relationships have been established between properties and the acute pulmonary inflammation induced by nanomaterials, properties’ effects on other responses, such as exacerbation of respiratory allergy, have been less frequently explored.Methods: In this study, the role of nickel oxide (NiO) physico-chemical properties in the modulation of ovalbumin (OVA) allergy was examined in a murine model. Results: 181 nm fine (NiO-F) and 42 nm ultrafine (NiO-UF) particles were characterized and incorporated into a time course study where measured markers of pulmonary injury and inflammation were associated with NiO particle surface area. In the OVA model, exposure to NiO, irrespective of any metric was associated with elevated circulating total IgE levels. Serum and lung cytokine levels were similar with respect to NiO surface area. The lower surface area was associated with an enhanced Th2 profile, whereas the higher surface area was associated with a Th1-dominant profile. Surface area-normalized groups also exhibited similar alterations in OVA-specific IgE levels and lung neutrophil number. However, lung eosinophil number and allergen challenge-induced alterations in lung function related more to particle size, wherein NiO-F was associated with an increased enhanced pause response and NiO-UF was associated with increased lung eosinophil burden.Conclusions: Collectively, these findings suggest that although NiO surface area correlates best with acute pulmonary injury and inflammation following respiratory exposure, other physico-chemical properties may contribute to the modulation of immune responses in the lung.

      3. The Centers for Disease Control and Prevention, Arbovirus Reference Collection (ARC) contains viral isolates from both environmental and human sources that are maintained in the laboratory through passage in suckling mouse brain and/or vertebrate and invertebrate cell culture. There has been increased concern regarding the effect of mycoplasma contamination on virus growth and its impact on research and phenotypic analysis. Therefore, quality control testing of virus preparations has become a routine part of the ARC quality assurance program. We compared the performance of three kits – the PCR Mycoplasma Detection Kit (ABM), the VenorGem Mycoplasma Detection Kit (Sigma), and the MycoAlert Mycoplasma Detection Kit (Lonza) – against a reference mycoplasma detection assay from the American Tissue Culture Collection (ATCC) using 744 virus preparations in the ARC, representing 721 unique viruses comprising twelve families and unclassified viruses. We found the ABM kit had the highest sensitivity and specificity, followed by the Sigma kit and Lonza kit, when compared to the ATCC kit. An increase in false positives was observed for the Lonza kit for preparations recently passaged in suckling mouse. Our data supports previously reported observations; that once introduced a specific species of mycoplasma is maintained within a lab.

      4. A possible relationship between telomere length and markers of neurodegeneration in rat brain after welding fume inhalation exposureexternal icon
        Shoeb M, Mustafa GM, Kodali VK, Smith K, Roach KA, Boyce G, Meighan T, Roberts JR, Erdely A, Antonini JM.
        Environ Res. 2019 Nov 5:108900.
        Inhalation of welding fume (WF) can result in the deposition of toxic metals, such as manganese (Mn), in the brain and may cause neurological changes in exposed workers. Alterations in telomere length are indicative of cellular aging and, possibly, neurodegeneration. Here, we investigated the effect of WF inhalation on telomere length and markers of neurodegeneration in whole brain tissue in rats. Male Fischer-344 (F-344) rats were exposed by inhalation to stainless steel WF (20mg/m(3) x 3h/d x 4d/wk x 5wk) or filtered air (control). Telomere length, DNA-methylation, gene expression of Trf1, Trf2, ATM, and APP, protein expression of p-Tau, alpha-synuclein, and presenilin 1 and 2 were assessed in whole brain tissue at 12wk after WF exposure ended. Results suggest that WF inhalation increased telomere length without affecting telomerase in whole brain. Moreover, we observed that components of the shelterin complex, Trf1 and Trf2, play an important role in telomere end protection, and their regulation may be responsible for the increase in telomere length. In addition, expression of different neurodegeneration markers, such as p-Tau, presenilin 1-2 and alpha-synuclein proteins, were increased in brain tissue from the WF-exposed rats as compared to control. These findings suggest a possible correlation between epigenetic modifications, telomere length alteration, and neurodegeneration because of the presence of factors in serum after WF exposure that may cause extra-pulmonary effects as well as the translocation of potentially neurotoxic metals associated with WF to the central nervous system (CNS). Further studies are needed to investigate the brain region specificity and temporal response of these effects.

    • Maternal and Child Health
      1. Using an online modified-delphi approach to engage patients and caregivers in determining the patient-centeredness of Duchenne muscular dystrophy care considerationsexternal icon
        Khodyakov D, Grant S, Denger B, Kinnett K, Martin A, Booth M, Armstrong C, Dao E, Chen C, Coulter I, Peay H, Hazlewood G, Street N.
        Med Decis Making. 2019 Nov 13.
        Purpose. To determine the patient-centeredness of endocrine and bone health Duchenne muscular dystrophy (DMD) care considerations using the RAND/PPMD Patient-Centeredness Method (RPM), which is a novel, online, modified-Delphi approach to engaging patients and caregivers in clinical guideline development. Methods. We solicited input on the patient-centeredness of care considerations from 28 individuals with DMD and 94 caregivers, randomly assigned to 1 of 2 mixed panels. During a 3-round online modified-Delphi process, participants rated the importance and acceptability of 19 DMD care considerations (round 1), reviewed and discussed the initial results (round 2), and revised their original ratings (round 3). Patient-centeredness was operationalized as importance and acceptability of recommendations. We considered a care consideration to be patient-centered if both panels deemed it important and acceptable. Results. Ninety-five panelists (78%) participated in this study. Of these, 88 (93%) participated in round 1, 74 (78%) in round 2, and 56 (59%) in round 3. Panelists deemed 12 care considerations to be patient-centered: 3 weight management, 3 bone health, 4 vertical growth, and 2 puberty recommendations. Seven care considerations did not meet patient-centeredness criteria. Common reasons were lack of evidence specific to DMD and concerns about insurance coverage, access to treatment, and patient safety. Conclusions. Using the RPM, Duchenne families considered most care considerations to be patient-centered. Besides being clinically appropriate, these considerations are likely to be consistent with the preferences, needs, and values of Duchenne families. While all relevant care considerations should be discussed during patient-provider encounters, those that did not meet patient-centeredness criteria in particular should be carefully considered as part of joint decision making between Duchenne families and their providers. Study Registration: HSRProj 20163126.

      2. Positive screening rates for bipolar disorder in pregnant and postpartum women and associated risk factorsexternal icon
        Masters GA, Brenckle L, Sankaran P, Person SD, Allison J, Moore Simas TA, Ko JY, Robbins CL, Marsh W, Byatt N.
        Gen Hosp Psychiatry. 2019 Oct 22;61:53-59.
        OBJECTIVE: Bipolar disorder affects 2-8% of pregnant and postpartum women; untreated illness is associated with poor outcomes. This study aimed to describe bipolar disorder screening rates in obstetric settings and associated characteristics. METHOD: Women were recruited during pregnancy through three months postpartum from 14 obstetric clinics in Massachusetts. The Mood Disorder Questionnaire (MDQ) was used to screen for bipolar disorder; a subset previously diagnosed with bipolar was also examined. Differences in characteristics by screening outcome were tested using chi-square and t-tests. RESULTS: Of 574 participating women, 18.8% screened positive for bipolar disorder. Compared to those with negative, those with positive bipolar screens had 18.5-times the prevalence of positive substance use screens (11.1% vs. 0.6%, p<0.001) and 3.4-times reported feeling they were not receiving adequate psychiatric help (24.0 vs. 7.0%, p<0.001). Less than half of those with positive bipolar screens (42.0%) and 61.3% with pre-existing bipolar reported receiving current psychiatric care. CONCLUSIONS: Almost one in five perinatal women screened positive for bipolar disorder. Positive screenings were associated with comorbid substance use and low treatment rates. This study highlights the importance of screening for bipolar disorder during the perinatal period and the need for systematic approaches to ensure adequate assessment and follow-up. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov identifier: NCT02760004.

    • Occupational Safety and Health
      1. BACKGROUND: We analyzed the Bureau of Labor Statistics (BLS) fatal and nonfatal injuries and illness data on U.S. workers in the wholesale and retail trade (WRT) sector from 2006 to 2016. The purpose was to identify elevated fatal and nonfatal injury and illness rates in WRT subsectors. METHODS: To assess the WRT health and economic burden, we retrieved multiple BLS data sets for fatal and nonfatal injury and illness data, affecting more than 20 million employees. We examined yearly changes in incidence rates for lost work-time across event and exposure categories. RESULTS: In 2016, 553 100 injuries and illnesses and 461 fatalities occurred among WRT workers. WRT has a disproportionately 5% larger burden of nonfatal injuries for its size. From 2006 through 2016, wholesale sector fatality rates (4.9/100 000 FTE) exceeded private industry rates (3.8/100 000 FTE). The largest causal fatal factors were transportation in wholesale and violence in retail. Private industry and WRT experienced a decline in nonfatal injuries and illnesses. Wholesale subsectors with elevated nonfatal rates included durable and nondurable goods, recycling, motor parts, lumber, metal and mineral, grocery, and alcohol merchants. Retail subsectors with elevated rates included motor parts dealers, gasoline stations, nonstores, tire dealers, home and garden centers, supermarkets, meat markets, warehouse clubs, pet stores, and fuel dealers. DISCUSSION: Through the identification of safety and health risks, researchers and safety practitioners will be able to develop interventions and focus future efforts in advancing the safety and health of WRT employees.

    • Occupational Safety and Health – Mining
      1. Comparison of several DPM field monitors for use in underground mining applicationsexternal icon
        Barrett C, Sarver E, Cauda E, Noll J, Vanderslice S, Volkwein J.
        Aerosol Air Qual Res. 2019 ;19(11):2367-2380.
        To improve worker health protection and support engineering applications in underground mines, such as ventilation-on-demand, capabilities are increasingly sought for continuous monitoring of diesel particulate matter (DPM). For near real-time monitoring over periods up to a full workshift, the FLIR Airtec handheld monitor was developed and calibrated to the NIOSH Standard Method 5040 measure of elemental carbon (EC), which is commonly used as an analytical surrogate for DPM. However, needs still exist for autonomous monitoring over longer periods (e.g., weeks to months). To meet those needs, two commercially available instruments are considered here, the Magee Scientific AE33 Aethalometer and the Sunset Laboratory Semi-continuous OC-EC Field Analyzer. Along with a prototyped monitor called the Airwatch, these were tested head-to-head against the Method 5040 EC and the Airtec in a controlled laboratory setting; and against one another in a field study at an underground mine. Key findings include: the OC-EC field analyzer performed well across a wide range of EC concentrations; the AE33 performed well at relatively low concentrations, but modifications or additional data corrections are likely needed at higher concentrations; and the Airwatch showed good potential, though significant improvements will be required if this instrument is to be further developed, including resolution of several mechanical issues and selection of an appropriate filter material and development of robust data corrections. Moreover, the relative advantages and disadvantages associated with each instrument (e.g., in terms of data quality, complexity and maintenance) must be considered in the context of the intended application and sampling environment.

      2. A laboratory apparatus (shield dust simulator) was designed and constructed to simulate the dust generated during the advance of longwall hydraulic roof supports, or shields. The objective of the study was to develop a tool that could be used to test the hypothesis that foam applied to a mine roof prior to a shield advance could be used to reduce the respirable dust generated during shield advances. This paper will outline the design parameters for the development of the system, as well as describe baseline testing of coal and limestone dust. Results show that the average instantaneous respirable dust concentrated during simulated shield advance. Confidence intervals were calculated from the instantaneous respirable dust data to determine the repeatability of the data produced by the device.

      3. Background: Collisions involving workers and mobile machines continue to be a major concern in underground coal mines. Over the last 30 years, these collisions have resulted in numerous injuries and fatalities. Recently, the Mine Safety and Health Administration (MSHA) proposed a rule that would require mines to equip mobile machines with proximity detection systems (PDSs) (systems designed for automated collision avoidance). Even though this regulation has not been enacted, some mines have installed PDSs on their scoops and hauling machines. However, early implementation of PDSs has introduced a variety of safety concerns. Past findings show that workers’ trust can affect technology integration and influence unsafe use of automated technologies. Methods: Using a mixed-methods approach, the present study explores the effect that factors such as mine of employment, age, experience, and system type have on workers’ trust in PDSs for mobile machines. The study also explores how workers are trained on PDSs and how this training influences trust. Results: The study resulted in three major findings. First, the mine of employment had a significant influence on workers’ trust in mobile PDSs. Second, hands-on and classroom training was the most common types of training. Finally, over 70% of workers are trained on the system by the mine compared with 36% trained by the system manufacturer. Conclusion: The influence of workers’ mine of employment on trust in PDSs may indicate that practitioners and researchers may need to give the organizational and physical characteristics of each mine careful consideration to ensure safe integration of automated systems.

    • Parasitic Diseases
      1. Estimation of malaria-attributable fever in malaria test-positive febrile outpatients in three provinces of Mozambique, 2018external icon
        Plucinski MM, Candrinho B, Dimene M, Smith T, Thwing J, Colborn J, Rogier E, Zulliger R.
        Am J Trop Med Hyg. 2019 Nov 4.
        Like most malaria-endemic countries, Mozambique relies on tabulation of confirmed malaria test-positive febrile patients to track incidence of malaria. However, this approach is potentially biased by incidental malaria parasitemia in patients with fever of another etiology. We compared pan-Plasmodium aldolase and lactate dehydrogenase and Plasmodium falciparum HRP2 antigen concentrations measured using a laboratory bead-based assay of samples collected from 1,712 febrile and afebrile patients of all ages in Maputo, Zambezia, and Cabo Delgado provinces. We used a Bayesian latent class model to estimate the proportion of malaria-attributable fevers in malaria test-positive febrile patients. Depending on the antigen, estimated rates of malaria-attributable fever in malaria test-positive febrile patients were 100% in Maputo, 33-58% in Zambezia, and 63-74% in Cabo Delgado. Our findings indicate that most malaria test-positive febrile patients in the three provinces of Mozambique had a fever that was likely caused by the concurrent malaria infection. Counting malaria test-positive febrile patients for estimation of malaria incidence appears to be appropriate in this setting.

    • Social and Behavioral Sciences
      1. As evidence-based interventions (EBIs) to prevent mental, emotional, and behavioral health problems continue to become available, approaches for implementation in systems and settings, at scale, are needed. The article, Scaling-up Evidence-based Interventions in U.S. Public Systems to Prevent Behavioral Health Problems: Challenges and Opportunities (Fagan et al. 2019) examines five large, complex public systems (behavioral health, child welfare, education, juvenile justice, and public health) that have adopted and implemented EBIs in various ways and presents common factors that support scale-up in these systems. This commentary builds on the authors’ strategic approach to offer a few additional considerations-issues of sustainability, ways of thinking about knowledge creation, and use of systems science/modeling approaches-to address scale-up in public systems. Moreover, the focus on public systems provides an opportunity to consider how the implementation and sustainment of EBIs might more directly address social determinants of health that are relevant across policy areas and public systems.

    • Substance Use and Abuse
      1. Evaluation of bronchoalveolar lavage fluid from patients in an outbreak of e-cigarette, or vaping, product use-associated lung injury – 10 states, August-October 2019external icon
        Blount BC, Karwowski MP, Morel-Espinosa M, Rees J, Sosnoff C, Cowan E, Gardner M, Wang L, Valentin-Blasini L, Silva L, De Jesus VR, Kuklenyik Z, Watson C, Seyler T, Xia B, Chambers D, Briss P, King BA, Delaney L, Jones CM, Baldwin GT, Barr JR, Thomas J, Pirkle JL.
        MMWR Morb Mortal Wkly Rep. 2019 Nov 15;68(45):1040-1041.
        CDC, the Food and Drug Administration (FDA), state and local health departments, and multiple public health and clinical partners are investigating a national outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI). Based on data collected as of October 15, 2019, 86% of 867 EVALI patients reported using tetrahydrocannabinol (THC)-containing products in the 3 months preceding symptom onset (1). Analyses of THC-containing product samples by FDA and state public health laboratories have identified potentially harmful constituents in these products, such as vitamin E acetate, medium chain triglyceride oil (MCT oil), and other lipids (2,3) (personal communication, D.T. Heitkemper, FDA Forensic Chemistry Center, November 2019). Vitamin E acetate, in particular, might be used as an additive in the production of e-cigarette, or vaping, products; it also can be used as a thickening agent in THC products (4). Inhalation of vitamin E acetate might impair lung function (5-7).

      2. Tobacco product use and cessation indicators among adults – United States, 2018external icon
        Creamer MR, Wang TW, Babb S, Cullen KA, Day H, Willis G, Jamal A, Neff L.
        MMWR Morb Mortal Wkly Rep. 2019 Nov 15;68(45):1013-1019.
        Cigarette smoking is the leading cause of preventable disease and death in the United States (1). The prevalence of adult cigarette smoking has declined in recent years to 14.0% in 2017 (2). However, an array of new tobacco products, including e-cigarettes, has entered the U.S. market (3). To assess recent national estimates of tobacco product use among U.S. adults aged >/=18 years, CDC, the Food and Drug Administration (FDA), and the National Cancer Institute analyzed data from the 2018 National Health Interview Survey (NHIS). In 2018, an estimated 49.1 million U.S. adults (19.7%) reported currently using any tobacco product, including cigarettes (13.7%), cigars (3.9%), e-cigarettes (3.2%), smokeless tobacco (2.4%), and pipes* (1.0%). Most tobacco product users (83.8%) reported using combustible products (cigarettes, cigars, or pipes), and 18.8% reported using two or more tobacco products. The prevalence of any current tobacco product use was higher in males; adults aged </=65 years; non-Hispanic American Indian/Alaska Natives; those with a General Educational Development certificate (GED); those with an annual household income <$35,000; lesbian, gay, or bisexual adults; uninsured adults; those with a disability or limitation; and those with serious psychological distress. The prevalence of e-cigarette and smokeless tobacco use increased during 2017-2018. During 2009-2018, there were significant increases in all three cigarette cessation indicators (quit attempts, recent cessation, and quit ratio). Implementing comprehensive population-based interventions in coordination with regulation of the manufacturing, marketing, and distribution of all tobacco products can reduce tobacco-related disease and death in the United States (1,4).

      3. Risk factors for e-cigarette, or vaping, product use-associated lung injury (EVALI) among adults who use e-cigarette, or vaping, products – Illinois, July-October 2019external icon
        Navon L, Jones CM, Ghinai I, King BA, Briss PA, Hacker KA, Layden JE.
        MMWR Morb Mortal Wkly Rep. 2019 Nov 15;68(45):1034-1039.
        The United States is experiencing an unprecedented outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) (1). All EVALI patients have used e-cigarette, or vaping, products, and most (>/=85%) have reported using products containing tetrahydrocannabinol (THC) (2,3), the principal psychoactive component of cannabis. To examine whether e-cigarette, or vaping, product use behaviors differed between adult EVALI patients and adults who use these products but have not developed lung injury, the Illinois Department of Public Health (IDPH) conducted an online public survey during September-October 2019 targeting e-cigarette, or vaping, product users in Illinois. Among 4,631 survey respondents, 94% reported using any nicotine-containing e-cigarette, or vaping, products in the past 3 months; 21% used any THC-containing products; and 11% used both THC-containing products and nicotine-containing products. Prevalence of THC-containing product use was highest among survey respondents aged 18-24 years (36%) and decreased with increasing age. E-cigarette, or vaping, product use behaviors of 66 EVALI patients aged 18-44 years who were interviewed as part of the ongoing outbreak investigation were compared with a subset of 519 survey respondents aged 18-44 years who reported use of THC-containing e-cigarette, or vaping, products. Compared with these survey respondents, EVALI patients had higher odds of reporting exclusive use of THC-containing products (adjusted odds ratio [aOR] = 2.0, 95% confidence interval [CI] = 1.1-3.6); frequent use (more than five times per day) of these products (aOR = 3.1, 95% CI = 1.6-6.0), and obtaining these products from informal sources, such as a dealer, off the street, or from a friend (aOR = 9.2, 95% CI = 2.2-39.4). The odds of using Dank Vapes, a class of largely counterfeit THC-containing products, was also higher among EVALI patients (aOR = 8.5, 95% CI = 3.8-19.0). These findings reinforce current recommendations not to use e-cigarette, or vaping, products that contain THC and not to use any e-cigarette, or vaping, products obtained from informal sources. In addition, because the specific compound or ingredient causing lung injury is not yet known, CDC continues to recommend that persons consider refraining from use of all e-cigarette, or vaping, products while the outbreak investigation continues (1).

    • Zoonotic and Vectorborne Diseases
      1. An open challenge to advance probabilistic forecasting for dengue epidemicsexternal icon
        Johansson MA, Apfeldorf KM, Dobson S, Devita J, Buczak AL, Baugher B, Moniz LJ, Bagley T, Babin SM, Guven E, Yamana TK, Shaman J, Moschou T, Lothian N, Lane A, Osborne G, Jiang G, Brooks LC, Farrow DC, Hyun S, Tibshirani RJ, Rosenfeld R, Lessler J, Reich NG, Cummings DA, Lauer SA, Moore SM, Clapham HE, Lowe R, Bailey TC, Garcia-Diez M, Carvalho MS, Rodo X, Sardar T, Paul R, Ray EL, Sakrejda K, Brown AC, Meng X, Osoba O, Vardavas R, Manheim D, Moore M, Rao DM, Porco TC, Ackley S, Liu F, Worden L, Convertino M, Liu Y, Reddy A, Ortiz E, Rivero J, Brito H, Juarrero A, Johnson LR, Gramacy RB, Cohen JM, Mordecai EA, Murdock CC, Rohr JR, Ryan SJ, Stewart-Ibarra AM, Weikel DP, Jutla A, Khan R, Poultney M, Colwell RR, Rivera-Garcia B, Barker CM, Bell JE, Biggerstaff M, Swerdlow D, Mier YT, Forshey BM, Trtanj J, Asher J, Clay M, Margolis HS, Hebbeler AM, George D, Chretien JP.
        Proc Natl Acad Sci U S A. 2019 Nov 11.
        A wide range of research has promised new tools for forecasting infectious disease dynamics, but little of that research is currently being applied in practice, because tools do not address key public health needs, do not produce probabilistic forecasts, have not been evaluated on external data, or do not provide sufficient forecast skill to be useful. We developed an open collaborative forecasting challenge to assess probabilistic forecasts for seasonal epidemics of dengue, a major global public health problem. Sixteen teams used a variety of methods and data to generate forecasts for 3 epidemiological targets (peak incidence, the week of the peak, and total incidence) over 8 dengue seasons in Iquitos, Peru and San Juan, Puerto Rico. Forecast skill was highly variable across teams and targets. While numerous forecasts showed high skill for midseason situational awareness, early season skill was low, and skill was generally lowest for high incidence seasons, those for which forecasts would be most valuable. A comparison of modeling approaches revealed that average forecast skill was lower for models including biologically meaningful data and mechanisms and that both multimodel and multiteam ensemble forecasts consistently outperformed individual model forecasts. Leveraging these insights, data, and the forecasting framework will be critical to improve forecast skill and the application of forecasts in real time for epidemic preparedness and response. Moreover, key components of this project-integration with public health needs, a common forecasting framework, shared and standardized data, and open participation-can help advance infectious disease forecasting beyond dengue.

      2. Prevalence of serum antibodies to Coxiella burnetii in Alaska Native persons from the Pribilof Islandsexternal icon
        Kersh GJ, Fitzpatrick K, Pletnikoff K, Brubaker M, Bruce M, Parkinson A.
        Zoonoses Public Health. 2019 Nov 8.
        BACKGROUND: Q fever is a febrile illness caused by infection with the bacterium Coxiella burnetii. It is most often transmitted by inhalation of the bacteria after it is shed by infected livestock. Recent studies have found very high C. burnetii infection rates among marine mammals, but it is not known if shedding by marine mammals creates a risk of Q fever among humans. To better understand infection of humans with exposure to marine mammals, the prevalence of antibodies against C. burnetii in serum samples taken from Alaskan Native persons residing on the Pribilof Islands was evaluated. The Pribilof Islands support large populations of northern fur seals infected with C. burnetii that may increase the risk of exposure for island residents. METHODS: Serum testing for IgG antibodies against C. burnetii (phase I and phase II) was performed, and demographic data were analysed utilizing banked serum specimens drawn from island residents from 1980 to 2000. RESULTS: The overall seroprevalence rate was 11.6% (95% CI = 9.3%-14.4%; 72/621). This is higher than the previously reported 3.1% (95% CI = 2.1%-4.3%) seroprevalence for the U.S. POPULATION: CONCLUSIONS: These results suggest that Alaskan Native persons may be at higher risk for exposure to C. burnetii than the general US. population, possibly due to proximity to large populations of infected marine mammals.

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

Page last reviewed: December 2, 2019, 12:00 AM
Content source: Centers for Disease Control and Prevention