Volume 11, Issue 49 December 10, 2019

CDC Science Clips: Volume 11, Issue 49, December 10, 2019

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

  1. Top Articles of the Week
    Selected weekly by a senior CDC scientist from the standard sections listed below.
    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions
      • Who are the undiagnosed? Disparities in hypertension diagnoses in vulnerable populationsexternal icon
        Meador M, Lewis JH, Bay RC, Wall HK, Jackson C.
        Fam Community Health. 2020 Jan/Mar;43(1):35-45.
        This study builds upon a project that developed clinical criteria to identify undiagnosed hypertension patients "hiding in plain sight" (HIPS) by examining patient characteristics to understand whether there are disparities in hypertension diagnosis. We examined electronic health record demographic data for patients identified by the HIPS criteria and subgroups at 3 Missouri health centers. Identified patients who returned for a follow-up visit and were subsequently diagnosed with hypertension tended to be older, black/African American, uninsured, and classified as having obesity. Younger, white, healthy weight females were less likely to be diagnosed. These findings point to exploring possible biases/other nonclinical factors in hypertension diagnosis.

    • Communicable Diseases
      • Entertainment-education can affect positive behavior change. Taking Care of Me is an effective, video-based intervention designed to improve patients' continuum of HIV care outcomes. The study's aim was to refine the pre-final video at points where patients stopped watching and missed embedded health messages. We evaluated the video using systematic unobtrusive observations triangulated with electronic medical record (EMR) data. We conducted observations in three HIV treatment facilities' waiting rooms in the southern US in 2016. Using a web-based data collection instrument, one observer spent 8 h at each facility observing patients' engagement with the video. We mapped the embedded messages in each scene and identified the messages that patients missed when they stopped watching. We compared missed messages to treatment initiation, medication adherence, and retention in care data abstracted from each clinic's EMR system. We were able to identify specific scenes where low levels of engagement corresponded to lower than expected retention in care outcomes and edit these scenes to improve engagement. Identifying and editing video scenes to increase viewership potentially could enhance intervention efficacy. Our methods could be used to assess and refine other video-based interventions being developed in resource limited settings.

      • Availability of injectable antimicrobial drugs for gonorrhea and syphilis, United States, 2016external icon
        Pearson WS, Cherry DK, Leichliter JS, Bachmann LH, Cummings NA, Hogben M.
        Emerg Infect Dis. 2019 Nov;25(11):2154-2156.
        We estimated the availability of the injectable antimicrobial drugs recommended for point-of-care treatment of gonorrhea and syphilis among US physicians who evaluated patients with sexually transmitted infections in 2016. Most physicians did not have these drugs available on-site. Further research is needed to determine the reasons for the unavailability of these drugs.

    • Disaster Control and Emergency Services
      • OBJECTIVES: The aim of this study was to identify the needs of state, tribal, local, and territorial (STLT) public health officials in communicating, implementing, and monitoring nonpharmaceutical interventions (NPIs) during an influenza pandemic. METHODS: A Web-based survey collected data from a nonrandom sample of STLT health departments. RESULTS: A total of 267 of 346 public health officials responded (77.2% response rate). STLTs identified the general public, families, childcare programs, K-12 schools, and workplaces as their priority audiences for NPI communication. Training needs included NPI decision-making strategies, triggers for implementing NPIs, and communicating NPI recommendations to families and communities, as well as a more practical orientation and real-world examples of how to incorporate NPI guidance into preparedness and response activities. Information is needed on health messaging for various populations and settings and on the legal authority for implementing specific NPIs. CONCLUSIONS: Future NPI recommendations by CDC should continue to be based on feedback solicited from STLT health departments. To fill identified gaps, CDC used these findings to create NPI guidance and materials to assist in prepandemic planning and preparedness for STLTs and various community settings.

    • Epidemiology and Surveillance
      • Prion disease incidence in the United States, 2003-2015external icon
        Maddox RA, Person MK, Blevins JE, Abrams JY, Appleby BS, Schonberger LB, Belay ED.
        Neurology. 2019 Nov 22.
        OBJECTIVE: To report the incidence of prion disease in the United States. METHODS: Prion disease decedents were retrospectively identified from the US national multiple cause-of-death data for 2003-2015 and matched with decedents in the National Prion Disease Pathology Surveillance Center (NPDPSC) database through comparison of demographic variables. NPDPSC decedents with neuropathologic or genetic test results positive for prion disease for whom no match was found in the multiple cause-of-death data were added as cases for incidence calculations; those with cause-of-death data indicating prion disease but with negative neuropathology results were removed. Age-specific and age-adjusted average annual incidence rates were then calculated. RESULTS: A total of 5,212 decedents were identified as having prion disease, for an age-adjusted average annual incidence of 1.2 cases per million population (range 1.0 per million [2004 and 2006] to 1.4 per million [2013]). The median age at death was 67 years. Ten decedents were <30 years of age (average annual incidence of 6.2 per billion); only 2 of these very young cases were sporadic forms of prion disease. Average annual incidence among those >/=65 years of age was 5.9 per million. CONCLUSIONS: Prion disease incidence can be estimated by augmenting mortality data with the results of neuropathologic and genetic testing. Cases <30 years of age were extremely rare, and most could be attributed to exogenous factors or the presence of a genetic mutation. Continued vigilance for prion diseases in all age groups remains prudent.

    • Health Disparities
      • The relationship between census tract-level poverty and domestically-acquired Salmonella incidence, analysis of FoodNet Data, 2010-2016external icon
        Hadler JL, Clogher P, Libby T, Wilson E, Oosmanally N, Ryan P, Magnuson L, Lathrop S, McGuire S, Cieslak P, Fankhauser M, Ray L, Geissler A, Hurd S.
        J Infect Dis. 2019 Nov 23.
        BACKGROUND: The relationships between socioeconomic status (SES) and domestically-acquired salmonellosis and leading Salmonella serotypes are poorly understood. METHODS: We analyzed surveillance data from laboratory-confirmed cases of salmonellosis from 2010-2016 for all 10 Foodborne Disease Active Surveillance Network (FoodNet) sites, having a catchment population of 47.9 million. Case-residential data were geocoded, linked to census tract poverty (CTP) level, then categorized into four CTP-level groups. After excluding those reporting international travel before illness onset, age-specific and age-adjusted salmonellosis incidence rates were calculated for each CTP level, overall and for each of the 10 leading serotypes. RESULTS: Of 52,821 (>96%) geocodable Salmonella infections, 48,111 (91.1%) were domestically-acquired. Higher age-adjusted incidence occurred with higher CTP level (p<0.001, relative risk (RR) for highest (>20%) compared to lowest (<5%) CTP group = 1.37). Children <5 years had the highest RR (2.07). While this relationship was consistent by race/ethnicity and by serotype, it was not present in five FoodNet sites or among those 18-49 years. CONCLUSION: Children and older adults living in higher CTP have had a higher incidence of domestically-acquired salmonellosis. There is a need to understand SES differences for risk factors for domestically-acquired salmonellosis by age group and FoodNet site to help focus prevention efforts.

    • Health Economics
      • Cost-effectiveness of pre-exposure prophylaxis among adolescent sexual minority malesexternal icon
        Wang LY, Hamilton DT, Rosenberg ES, Aslam MV, Sullivan PS, Katz DA, Dunville RL, Barrios LC, Goodreau SM.
        J Adolesc Health. 2019 Oct 29.
        PURPOSE: Pre-exposure prophylaxis (PrEP) has been proven safe and effective in preventing HIV among adolescent sexual minority males (ASMM), but the cost-effectiveness of PrEP in ASMM remains unknown. Building on a recent epidemiological network modeling study of PrEP among ASMM, we estimated the cost-effectiveness of PrEP use in a high prevalence U.S. setting with significant disparities in HIV between black and white ASMM. METHODS: Based on the estimated number of infections averted and the number of ASMM on PrEP from the previous model and published estimates of PrEP costs, HIV treatment costs, and quality-adjusted life years (QALYs) gained per infection prevented, we estimated the cost-effectiveness of PrEP use in black and white ASMM over 10 years using a societal perspective and lifetime horizon. Effectiveness was measured as lifetime QALYs gained. Cost estimates included 10-year PrEP costs and lifetime HIV treatment costs saved. Cost-effectiveness was measured as cost/QALY gained. Multiple sensitivity analyses were performed on key model input parameters and assumptions used. RESULTS: Under base-case assumptions, PrEP use yielded an incremental cost-effectiveness ratio of $33,064 per QALY in black ASMM and $427,788 per QALY in white ASMM. In all sensitivity analyses, the cost-effectiveness ratio of PrEP use remained <$100,000 per QALY in black ASMM and >$100,000 per QALY in white ASMM. CONCLUSIONS: We found favorable cost-effectiveness ratios for PrEP use among black ASMM or other ASMM in communities with high HIV burden at current PrEP costs. Clinicians providing services in high-prevalence communities, and particularly those serving high-prevalence communities of color, should consider including PrEP services.

    • Healthcare Associated Infections
      • Antimicrobial-resistant pathogens associated with pediatric healthcare-associated infections: Summary of data reported to the National Healthcare Safety Network, 2015-2017external icon
        Weiner-Lastinger LM, Abner S, Benin AL, Edwards JR, Kallen AJ, Karlsson M, Magill SS, Pollock D, See I, Soe MM, Walters MS, Dudeck MA.
        Infect Control Hosp Epidemiol. 2019 Nov 25:1-12.
        OBJECTIVE: To describe common pathogens and antimicrobial resistance patterns for healthcare-associated infections (HAIs) among pediatric patients that occurred in 2015-2017 and were reported to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN). METHODS: Antimicrobial resistance data were analyzed for pathogens implicated in central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonias (VAPs), and surgical site infections (SSIs). This analysis was restricted to device-associated HAIs reported from pediatric patient care locations and SSIs among patients <18 years old. Percentages of pathogens with nonsusceptibility (%NS) to selected antimicrobials were calculated by HAI type, location type, and surgical category. RESULTS: Overall, 2,545 facilities performed surveillance of pediatric HAIs in the NHSN during this period. Staphylococcus aureus (15%), Escherichia coli (12%), and coagulase-negative staphylococci (12%) were the 3 most commonly reported pathogens associated with pediatric HAIs. Pathogens and the %NS varied by HAI type, location type, and/or surgical category. Among CLABSIs, the %NS was generally lowest in neonatal intensive care units and highest in pediatric oncology units. Staphylococcus spp were particularly common among orthopedic, neurosurgical, and cardiac SSIs; however, E. coli was more common in abdominal SSIs. Overall, antimicrobial nonsusceptibility was less prevalent in pediatric HAIs than in adult HAIs. CONCLUSION: This report provides an updated national summary of pathogen distributions and antimicrobial resistance patterns among pediatric HAIs. These data highlight the need for continued antimicrobial resistance tracking among pediatric patients and should encourage the pediatric healthcare community to use such data when establishing policies for infection prevention and antimicrobial stewardship.

    • Injury and Violence
      • The association between gender inequality and sexual violence in the U.Sexternal icon
        Kearns MC, D'Inverno AS, Reidy DE.
        Am J Prev Med. 2019 Nov 18.
        INTRODUCTION: Few societal-level factors are established as risk or protective factors for sexual violence. Traditional gender norms and gender inequality are linked to sexual violence, but much of this research was conducted internationally or is becoming outdated and may not reflect current norms in the U.S. This study expands on previously published research by examining gender inequality's association with state-level sexual violence. METHODS: Using state-level prevalence estimates published in the National Intimate Partner and Sexual Violence Survey 2010-2012 State Report and the Gender Inequality Index, Pearson correlations were examined to investigate the relationship between state-level gender inequality and lifetime victimization for various types of sexual violence among U.S. female and male adults. The analysis was conducted in 2019. RESULTS: Findings indicate that states with a high degree of gender inequality also report higher prevalence estimates among women for rape using physical force. Gender inequality was also negatively correlated with noncontact unwanted sexual experiences among women and men. In addition, an exploratory analysis of the relationship between individual indicators of gender inequality and violence outcomes suggest that the adolescent birth rate, female government representation, and labor force participation demonstrate an association with certain state-level violence outcomes, although the patterns were inconsistent. CONCLUSIONS: Although this study relied on cross-sectional data, collectively, these findings suggest that gender inequality may represent an important societal-level factor associated with sexual violence among women and men. However, this relationship appears complex and requires further research. These findings have potential to inform population-level violence prevention approaches.

    • Substance Use and Abuse
      • Analysis of toxic metals in liquid from electronic cigarettesexternal icon
        Gray N, Halstead M, Gonzalez-Jimenez N, Valentin-Blasini L, Watson C, Pappas RS.
        Int J Environ Res Public Health. 2019 Nov 13;16(22).
        As the technology of electronic nicotine delivery systems (ENDS), including e-cigarettes, evolves, assessing metal concentrations in liquids among brands over time becomes challenging. A method for quantification of chromium, nickel, copper, zinc, cadmium, tin, and lead in ENDS liquids using triple quadrupole inductively coupled plasma mass spectrometry was developed. The method's limits of detection (LODs) were 0.031, 0.032, 3.15, 1.27, 0.108, 0.099, 0.066 microg/g for Cr, Ni, Cu, Zn, Cd, Sn, and Pb respectively. Liquids analyzed were from different brands and flavors of refill bottles or single-use, rechargeable, and pod devices from different years. Scanning electron microscopy with energy dispersive spectroscopy further evaluated the device components' compositions. Refill liquids before contacting a device were below lowest reportable levels (LRL) for all metals. Copper and zinc were elevated in liquids from devices containing brass. Cadmium was <LRL in all liquids and was not observed in device components. Cr, Ni, Cu, Zn, Sn, and Pb, reported in microg/g, ranged from <LRL to 0.396, 4.04, 903, 454, 0.898, and 13.5 respectively. Elevated metal concentrations in the liquid were also elevated in aerosol from the corresponding device. The data demonstrates the impact of device design and materials on toxic metals in ENDS liquid.

      • Characteristics of e-cigarette, or vaping, products used by patients with associated lung injury and products seized by law enforcement - Minnesota, 2018 and 2019external icon
        Taylor J, Wiens T, Peterson J, Saravia S, Lunda M, Hanson K, Wogen M, D'Heilly P, Margetta J, Bye M, Cole C, Mumm E, Schwerzler L, Makhtal R, Danila R, Lynfield R, Holzbauer S.
        MMWR Morb Mortal Wkly Rep. 2019 Nov 29;68(47):1096-1100.
        During August 9-October 31, 2019, 96 patients were classified as having e-cigarette, or vaping, product use-associated lung injury (EVALI) by the Minnesota Department of Health (MDH); other patients are being investigated for case classification and exposures. Among 58 patients interviewed, 53 (91%) reported obtaining tetrahydrocannabinol (THC)-containing products from informal sources such as friends, family members, or in-person or online dealers. Using gas chromatography-mass spectrometry (GCMS), the MDH Public Health Laboratory (PHL) analyzed 46 THC-containing e-cigarette, or vaping, products obtained from 12 EVALI patients for various potential toxicants, including vitamin E acetate, which has recently been detected in some THC-containing products and in samples of lung fluid from EVALI patients (1-4). To explore whether vitamin E acetate is a recently added component in THC-containing products, MDH tested ten products seized by law enforcement in 2018, before the EVALI outbreak, and 20 products seized in 2019, during the outbreak. Twenty-four products obtained from 11 EVALI patients from 2019 contained vitamin E acetate. Among the seized products tested by MDH, none seized in 2018 contained vitamin E acetate, although all tested THC-containing products seized in 2019 tested positive for vitamin E acetate. These chemical analyses of products obtained from EVALI patients and of products intended for the illicit market both before and during the outbreak support a potential role for vitamin E acetate in the EVALI outbreak; however, the number of products tested was small, and further research is needed to establish a causal link between exposure to inhaled vitamin E acetate and EVALI. Collaboration between public health jurisdictions and law enforcement to characterize THC-containing products circulating before the recognition of the EVALI outbreak and during the outbreak might provide valuable information about a dynamic market. These Minnesota findings highlight concerns about e-cigarette, or vaping, products that contain THC acquired from informal sources. Because local supply chains and policy environments vary, CDC continues to recommend not using e-cigarette, or vaping, products that contain THC or any e-cigarette, or vaping, products obtained from informal sources. E-cigarette, or vaping, products should never be used by youths, young adults, or pregnant women.* Until the relationship between inhaled vitamin E acetate and lung health is better characterized, vitamin E acetate should not be added to e-cigarette, or vaping, products.

    • Zoonotic and Vectorborne Diseases
      • Psittacosis outbreak among workers at chicken slaughter plants, Virginia and Georgia, USA, 2018external icon
        Shaw KA, Szablewski CM, Kellner S, Kornegay L, Bair P, Brennan S, Kunkes A, Davis M, McGovern OL, Winchell J, Kobayashi M, Burton N, de Perio MA, Gabel J, Drenzek C, Murphy J, Holsinger C, Forlano L.
        Emerg Infect Dis. 2019 Nov;25(11):2143-2145.
        During August-October, 2018, an outbreak of severe respiratory illness was reported among poultry slaughter plant workers in Virginia and Georgia, USA. A multiorganizational team investigated the cause and extent of illness, determined that the illness was psittacosis, and evaluated and recommended controls for health hazards in the workplace to prevent additional cases.

  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. BACKGROUND: Patients only benefit from clinical management of arthritis if they are under the care of a physician or other health professional. OBJECTIVES: We profiled adults who reported doctor-diagnosed arthritis who are not currently being treated for it to understand better who they are. METHODS: Individuals with no current treatment (NCT) were identified by "no" to "Are you currently being treated by a doctor or other health professional for arthritis or joint symptoms?" Demographics, current symptoms, physical functioning, arthritis limitations and interference in life activities, and level of agreement with treatment and attitude statements were assessed in this cross-sectional, descriptive study of noninstitutionalized US adults aged 45 years or older with self-reported, doctor-diagnosed arthritis (n = 1793). RESULTS: More than half of the study population, 52%, reported NCT (n = 920). Of those with NCT, 27% reported fair/poor health, 40% reported being limited by their arthritis, 51% had daily arthritis pain, 59% reported 2 or more symptomatic joints, and 19% reported the lowest third of physical functioning. Despite NCT, 83% with NCT agreed or strongly agreed with the importance of seeing a doctor for diagnosis and treatment. CONCLUSIONS: Greater than half of those aged 45 years or older with arthritis were not currently being treated for it, substantial proportions of whom experienced severe symptoms and poor physical function and may benefit from clinical management and guidance, complemented by community-delivered public health interventions (self-management education, physical activity). Further research to understand the reasons for NCT may identify promising intervention points to address missed treatment opportunities and improve quality of life and functioning.

    • Communicable Diseases
      1. Increasing knowledge of HIV status in a country with high HIV testing coverage: Results from the Botswana Combination Prevention Projectexternal icon
        Alwano MG, Bachanas P, Block L, Roland M, Sento B, Behel S, Lebelonyane R, Wirth K, Ussery F, Bapati W, Motswere-Chirwa C, Abrams W, Ussery G, Miller JA, Bile E, Fonjungo P, Kgwadu A, Holme MP, Del Castillo L, Gaolathe T, Leme K, Majingo N, Lockman S, Makhema J, Bock N, Moore J.
        PLoS One. 2019 ;14(11):e0225076.
        INTRODUCTION: Achieving widespread knowledge of HIV-positive status is a crucial step to reaching universal ART coverage, population level viral suppression, and ultimately epidemic control. We implemented a multi-modality HIV testing approach to identify 90% or greater of HIV-positive persons in the Botswana Combination Prevention Project (BCPP) intervention communities. METHODS: BCPP is a cluster-randomized trial designed to evaluate the impact of combination prevention interventions on HIV incidence in 30 communities in Botswana. Community case finding and HIV testing that included home and targeted mobile testing were implemented in the 15 intervention communities. We described processes for identifying HIV-positive persons, uptake of HIV testing by age, gender and venue, characteristics of persons newly diagnosed through BCPP, and coverage of knowledge of status reached at the end of study. RESULTS: Of the 61,655 eligible adults assessed in home or mobile settings, 13,328 HIV-positive individuals, or 93% of the estimated 14,270 positive people in the communities were identified through BCPP. Knowledge of status increased by 25% over the course of the study with the greatest increases seen among men (37%) as compared to women (19%) and among youth aged 16-24 (77%) as compared to older age groups (21%). Although more men were tested through mobile than through home-based testing, higher rates of newly diagnosed HIV-positive men were found through home than mobile testing. CONCLUSIONS: Even when HIV testing coverage is high, additional gains can be made using a multi-modality HIV testing strategy to reach different sub-populations who are being missed by non-targeted program activities. Men and youth can be reached and will engage in community testing when services are brought to places they access routinely.

      2. Gut carriage of antimicrobial resistance genes among young children in urban Maputo, Mozambique: Associations with enteric pathogen carriage and environmental risk factorsexternal icon
        Berendes D, Knee J, Sumner T, Capone D, Lai A, Wood A, Patel S, Nala R, Cumming O, Brown J.
        PLoS One. 2019 ;14(11):e0225464.
        Because poor sanitation is hypothesized as a major direct and indirect pathway of exposure to antimicrobial resistance genes (ARGs), we sought to determine a) the prevalence of and b) environmental risk factors for gut carriage of key ARGs in a pediatric cohort at high risk of enteric infections due to poor water, sanitation, and hygiene (WASH) conditions. We investigated ARGs in stool from young children in crowded, low-income settlements of Maputo, Mozambique, and explored potential associations with concurrent enteric pathogen carriage, diarrhea, and environmental risk factors, including WASH. We collected stool from 120 children <14 months old and tested specimens via quantal, multiplex molecular assays for common bacterial, viral, and protozoan enteric pathogens and 84 ARGs encoding potential resistance to 7 antibiotic classes. We estimated associations between ARG detection (number and diversity detected) and concurrently-measured enteric pathogen carriage, recently-reported diarrhea, and risk factors in the child's living environment. The most commonly-detected ARGs encoded resistance to macrolides, lincosamides, and streptogramins (100% of children); tetracyclines (98%); beta-lactams (94%), aminoglycosides (84%); fluoroquinolones (48%); and vancomycin (38%). Neither concurrent diarrhea nor measured environmental (including WASH) conditions were associated with ARG detection in adjusted models. Enteric pathogen carriage and ARG detection were associated: on average, 18% more ARGs were detected in stool from children carrying bacterial pathogens than those without (adjusted risk ratio (RR): 1.18, 95% confidence interval (CI): 1.02, 1.37), with 16% fewer ARGs detected in children carrying parasitic pathogens (protozoans, adjusted RR: 0.84, 95% CI: 0.71, 0.99). We observed gut ARGs conferring potential resistance to a range of antibiotics in this at-risk cohort that had high rates of enteric infection, even among children <14 months-old. Gut ARGs did not appear closely correlated with WASH, though environmental conditions were generally poor. ARG carriage may be associated with concurrent carriage of bacterial enteric pathogens, suggesting indirect linkages to WASH that merit further investigation.

      3. Determinants of linear growth faltering among children with moderate-to-severe diarrhea in the Global Enteric Multicenter Studyexternal icon
        Brander RL, Pavlinac PB, Walson JL, John-Stewart GC, Weaver MR, Faruque AS, Zaidi AK, Sur D, Sow SO, Hossain MJ, Alonso PL, Breiman RF, Nasrin D, Nataro JP, Levine MM, Kotloff KL.
        BMC Med. 2019 Nov 25;17(1):214.
        BACKGROUND: Moderate-to-severe diarrhea (MSD) in the first 2 years of life can impair linear growth. We sought to determine risk factors for linear growth faltering and to build a clinical prediction tool to identify children most likely to experience growth faltering following an episode of MSD. METHODS: Using data from the Global Enteric Multicenter Study of children 0-23 months old presenting with MSD in Africa and Asia, we performed log-binomial regression to determine clinical and sociodemographic factors associated with severe linear growth faltering (loss of >/= 0.5 length-for-age z-score [LAZ]). Linear regression was used to estimate associations with DeltaLAZ. A clinical prediction tool was developed using backward elimination of potential variables, and Akaike Information Criterion to select the best fit model. RESULTS: Of the 5902 included children, mean age was 10 months and 43.2% were female. Over the 50-90-day follow-up period, 24.2% of children had severe linear growth faltering and the mean DeltaLAZ over follow-up was - 0.17 (standard deviation [SD] 0.54). After adjustment for age, baseline LAZ, and site, several factors were associated with decline in LAZ: young age, acute malnutrition, hospitalization at presentation, non-dysenteric diarrhea, unimproved sanitation, lower wealth, fever, co-morbidity, or an IMCI danger sign. Compared to children 12-23 months old, those 0-6 months were more likely to experience severe linear growth faltering (adjusted prevalence ratio [aPR] 1.97 [95% CI 1.70, 2.28]), as were children 6-12 months of age (aPR 1.72 [95% CI 1.51, 1.95]). A prediction model that included age, wasting, stunting, presentation with fever, and presentation with an IMCI danger sign had an area under the ROC (AUC) of 0.67 (95% CI 0.64, 0.69). Risk scores ranged from 0 to 37, and a cut-off of 21 maximized sensitivity (60.7%) and specificity (63.5%). CONCLUSION: Younger age, acute malnutrition, MSD severity, and sociodemographic factors were associated with short-term linear growth deterioration following MSD. Data routinely obtained at MSD may be useful to predict children at risk for growth deterioration who would benefit from interventions.

      4. Infectious etiologies of intussusception among children <2 years old in 4 Asian countriesexternal icon
        Burnett E, Kabir F, Van Trang N, Rayamajhi A, Satter SM, Liu J, Yousafzai MT, Anh DD, Basnet AT, Flora MS, Houpt E, Qazi SH, Canh TM, Rayamajhi AK, Saha BK, Saddal NS, Muneer S, Hung PH, Islam T, Ali SA, Tate JE, Yen C, Parashar UD.
        J Infect Dis. 2019 Nov 22.
        BACKGROUND: The etiology of intussusception, the leading cause of bowel obstruction in infants, is unknown in most cases. Adenovirus has been associated with intussusception, and a slightly increased risk of intussusception with rotavirus vaccination has been found in several countries. We conducted a case-control study among children <2 years old in Bangladesh, Nepal, Pakistan, and Vietnam to evaluate infectious etiologies of intussusception before rotavirus vaccine introduction. METHODS: From 2015-2017, we enrolled one-to-one matched intussusception cases and hospital controls; 249 pairs are included. Stool specimens were tested for 37 infectious agents using TaqMan Array technology. We used conditional logistic regression to estimate the odds ratio and 95% confidence interval (CI) of each pathogen associated with intussusception in a pooled analysis and in quantitative sub-analyses. RESULTS: Adenovirus (OR: 2.67, 95%CI: 1.75, 4.36) and human herpes virus 6 (OR: 3.50, 95%CI: 1.15, 10.63) were detected more frequently in cases than controls. Adenovirus C detection <20 quantification cycles was associated with intussusception (OR: 18.59, 95%CI: 2.45, 140.89). Wild-type rotavirus was not associated with intussusception (OR: 1.07, 95%CI: 0.52, 2.22). CONCLUSIONS: In this comprehensive evaluation, adenovirus and HHV-6 were associated with intussusception. Future research is needed to better understand mechanisms leading to intussusception, particularly after rotavirus vaccination.

      5. Robustness of NHANES estimates of the U.S. prevalence of a positive tuberculin skin testexternal icon
        Haddad MB, Lash TL, Hill AN, Navin TR, Castro KG, Gandhi NR, Winston CA.
        Epidemiology. 2019 Nov 14.
        BACKGROUND: A single 2-year National Health and Nutrition Examination Survey (NHANES) cycle is designed to provide accurate and stable estimates of conditions with prevalence of at least 10%. Recent NHANES-based estimates of a tuberculin skin test >/=10 mm in the noninstitutionalized U.S. civilian population are at most 6.3%. METHODS: NHANES included a tuberculin skin test in 1971-1972, 1999-2000, and 2011-2012. We examined the robustness of NHANES-based estimates of the U.S. population prevalence of a skin test >/=10 mm with a bias analysis that considered the influence of non-U.S. birth distributions and within-household skin test results, reclassified borderline-positive results, and adjusted for tuberculin skin test item nonresponse. RESULTS: The weighted non-U.S. birth distribution among NHANES participants was similar to that in the overall U.S. population; further adjustment was unnecessary. We found no evidence of bias due to sampling multiple participants per household. Prevalence estimates changed 0.3% with reclassification of borderline-positive tuberculin skin test results and 0.2%-0.3% with adjustment for item nonresponse. CONCLUSIONS: For estimating the national prevalence of a tuberculin skin test >/=10 mm during these three survey cycles, a conventional NHANES analysis using the standard participant weights and masked design parameters that are provided in the public-use datasets appears robust.

      6. Status of HIV case-based surveillance implementation - 39 U.S. PEPFAR-supported countries, May-July 2019external icon
        Holmes JR, Dinh TH, Farach N, Manders EJ, Kariuki J, Rosen DH, Kim AA.
        MMWR Morb Mortal Wkly Rep. 2019 Nov 29;68(47):1089-1095.
        Human immunodeficiency virus (HIV) case-based surveillance (CBS) systematically and continuously collects available demographic and health event data (sentinel events*) about persons with HIV infection from diagnosis and, if available, throughout routine clinical care until death, to characterize HIV epidemics and guide program improvement (1,2). Surveillance signals such as high viral load, mortality, or recent HIV infection can be used for rapid public health action. To date, few standardized assessments have been conducted to describe HIV CBS systems globally (3,4). For this assessment, a survey was disseminated during May-July 2019 to all U.S. President's Emergency Plan for AIDS Relief (PEPFAR)-supported countries with CDC presence(dagger) (46) to describe CBS implementation and identify facilitators and barriers. Among the 39 (85%) countries that responded,( section sign) 20 (51%) have implemented CBS, 15 (38%) were planning implementation, and four (10%)( paragraph sign) had no plans for implementation. All countries with CBS reported capturing information at the point of diagnosis, and 85% captured sentinel event data. The most common characteristic (75% of implementation countries) that facilitated implementation was using a health information system for CBS. Barriers to CBS implementation included lack of country policies/guidance on mandated reporting of HIV and on CBS, lack of unique identifiers to match and deduplicate patient-level data, and lack of data security standards. Although most surveyed countries reported implementing or planning for implementation of CBS, these barriers need to be addressed to implement effective HIV CBS that can inform the national response to the HIV epidemic.

      7. Orolabial lymphogranuloma venereum, Michigan, USAexternal icon
        Ilyas S, Richmond D, Burns G, Bowden KE, Workowski K, Kersh EN, Chandrasekar PH.
        Emerg Infect Dis. 2019 Nov;25(11):2112-2114.
        Orolabial lymphogranuloma venereum was diagnosed for a man in Michigan, USA, who had sex with men, some infected with HIV. High index of suspicion for lymphogranuloma venereum led to accurate diagnosis, successful therapy, and description of an L2b variant with a unique genetic mutation.

      8. Background and Aims: In Niger, acute respiratory infections (ARIs) are the second most common cause of death in children aged younger than 5 years. However, the etiology of ARI is poorly understood in the country. This study aims to describe viral and bacterial infections among children aged younger than 5 years hospitalized with febrile ARI at two hospitals in Niamey, Niger's capital city, and the reported clinical procedures. Methods: We conducted a prospective study among children aged younger than 5 years hospitalized with febrile ARI at two national hospitals in Niamey between January and December 2015. Clinical presentation and procedures during admission were documented using a standardized case investigation form. Nasopharyngeal specimens collected from each patient were tested for a panel of respiratory viruses and bacteria using the Fast Track Diagnostic 21 Plus kit. Results: We enrolled and tested 638 children aged younger than 5 years, of whom 411 (64.4%) were aged younger than 1 year, and 15 (2.4%) died during the study period. Overall, 496/638 (77.7%) specimens tested positive for at least one respiratory virus or bacterium; of these, 195 (39.3%) tested positive for respiratory viruses, 126 (25.4%) tested positive for respiratory bacteria, and 175 (35.3%) tested positive for both respiratory viruses and bacteria. The predominant viruses detected were respiratory syncytial virus (RSV) (149/638; 23.3%), human parainfluenza virus (HPIV) types 1 to 4 (78/638; 12.2%), human rhinovirus (HRV) (62/638; 9.4%), human adenovirus (HAV) (60/638; 9.4%), and influenza virus (INF) (52/638; 8.1%). Streptococcus pneumoniae (249/638; 39.0%) was the most frequently detected bacterium, followed by Staphylococcus aureus (112/638; 12.2%) and Haemophilus influenzae type B (16/638; 2.5%). Chest X-rays were performed at the discretion of the attending physician on 301 (47.2%) case patients. Of these patients, 231 (76.7%) had abnormal radiological findings. A total of 135/638 (21.2%) and 572/638 (89.7%) children received antibiotic treatment prior to admission and during admission, respectively. Conclusion: A high proportion of respiratory viruses was detected among children aged younger than 5 years with febrile ARI, raising concerns about excessive use of antibiotics in Niger.

      9. Provision of STD services in community settings after the loss and return of state funding to support service provision: Observations from select providers in Massachusetts, 2010 and 2013external icon
        Loosier PS, Carter MW, Hsu KK, Doshi S, Peterson Maddox BL, Kroeger K, Cranston K.
        J Public Health Manag Pract. 2020 Jan/Feb;26(1):E18-e27.
        CONTEXT: In 2008, the $1.2 M sexually transmitted disease (STD) services line item supporting STD clinical services by the Massachusetts Department of Public Health was eliminated, forcing the cessation of all state-supported STD service delivery. OBJECTIVE: To determine the impact on community provision of STD services after the elimination of state funds supporting STD service provision. DESIGN AND SETTING: Rapid ethnographic assessments were conducted in May 2010 and September 2013 to better understand the impact of budget cuts on STD services in Massachusetts. The rapid ethnographic assessment teams identified key informants through Massachusetts's STD and human immunodeficiency virus programs. PARTICIPANTS: Fifty providers/clinic administrators in 19 sites (15 unique) participated in a semistructured interview (community health centers [n = 10; 53%], hospitals [n = 4; 21%], and other clinical settings [n = 5; 26%]). RESULTS: Results clustered under 3 themes: financial stability of agencies/clinics, the role insurance played in the provision of STD care, and perceived clinic capacity to offer appropriate STD services. Clinics faced hard choices about whether to provide care to patients or refer elsewhere patients who were unable or unwilling to use insurance. Clinics that decided to see patients regardless of ability to pay often found themselves absorbing costs that were then passed along to their parent agency; the difficulty and financial strain incurred by a clinic's parent agency by providing STD services without support by state grant dollars emerged as a primary concern. Meeting patient demand with staff with appropriate training and expertise remained a concern. CONCLUSIONS: Provision of public health by private health care providers may increase concern among some community provision sites about the sustainability of service provision absent external funds, either from the state or from the third-party billing. Resource constraints may be felt across clinic operations. Provision of public health in the for-profit health system involves close consideration of resources, including those: leveraged, used to provide uncompensated care, or available for collection through third-party billing.

      10. Treatment of Clostridioides difficile infection and non-compliance with treatment guidelines in adults in 10 US geographical locations, 2013-2015external icon
        Novosad SA, Mu Y, Winston LG, Johnston H, Basiliere E, Olson DM, Farley MM, Revis A, Wilson L, Perlmutter R, Holzbauer SM, Whitten T, Phipps EC, Dumyati GK, Beldavs ZG, Ocampo VL, Davis CM, Kainer M, Gerding DN, Guh AY.
        J Gen Intern Med. 2019 Nov 25.
        BACKGROUND: Infectious Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) guidelines describe recommended therapy for Clostridioides difficile infection (CDI). OBJECTIVE: To describe CDI treatment and, among those with severe CDI, determine predictors of adherence to the 2010 IDSA/SHEA treatment guidelines. DESIGN: We analyzed 2013-2015 CDI treatment data collected through the Centers for Disease Control and Prevention's Emerging Infections Program. Generalized linear mixed models were used to identify predictors of guideline-adherent therapy. PATIENTS: A CDI case was defined as a positive stool specimen in a person aged >/= 18 years without a positive test in the prior 8 weeks; severe CDI cases were defined as having a white blood cell count >/= 15,000 cells/mul. MAIN MEASURES: Prescribing and predictors of guideline-adherent CDI therapy for severe disease. KEY RESULTS: Of 18,243 cases, 14,257 (78%) were treated with metronidazole, 7683 (42%) with vancomycin, and 313 (2%) with fidaxomicin. The median duration of therapy was 14 (interquartile range, 11-15) days. Severe CDI was identified in 3250 (18%) cases; of 3121 with treatment data available, 1480 (47%) were prescribed guideline-adherent therapy. Among severe CDI cases, hospital admission (adjusted odds ratio [aOR] 2.48; 95% confidence interval [CI] 1.90, 3.24), age >/= 65 years (aOR 1.37; 95% CI 1.10, 1.71), Charlson comorbidity index >/= 3 (aOR 1.27; 95% CI 1.04, 1.55), immunosuppressive therapy (aOR 1.21; 95% CI 1.02, 1.42), and inflammatory bowel disease (aOR 1.56; 95% CI 1.13, 2.17) were associated with being prescribed guideline-adherent therapy. CONCLUSIONS: Provider adherence to the 2010 treatment guidelines for severe CDI was low. Although the updated 2017 CDI guidelines, which expand the use of oral vancomycin for all CDI, might improve adherence by removing the need to apply severity criteria, other efforts to improve adherence are likely needed, including educating providers and addressing barriers to prescribing guideline-adherent therapy, particularly in outpatient settings.

      11. Accuracy of real-time multi-model ensemble forecasts for seasonal influenza in the U.Sexternal icon
        Reich NG, McGowan CJ, Yamana TK, Tushar A, Ray EL, Osthus D, Kandula S, Brooks LC, Crawford-Crudell W, Gibson GC, Moore E, Silva R, Biggerstaff M, Johansson MA, Rosenfeld R, Shaman J.
        PLoS Comput Biol. 2019 Nov 22;15(11):e1007486.
        Seasonal influenza results in substantial annual morbidity and mortality in the United States and worldwide. Accurate forecasts of key features of influenza epidemics, such as the timing and severity of the peak incidence in a given season, can inform public health response to outbreaks. As part of ongoing efforts to incorporate data and advanced analytical methods into public health decision-making, the United States Centers for Disease Control and Prevention (CDC) has organized seasonal influenza forecasting challenges since the 2013/2014 season. In the 2017/2018 season, 22 teams participated. A subset of four teams created a research consortium called the FluSight Network in early 2017. During the 2017/2018 season they worked together to produce a collaborative multi-model ensemble that combined 21 separate component models into a single model using a machine learning technique called stacking. This approach creates a weighted average of predictive densities where the weight for each component is determined by maximizing overall ensemble accuracy over past seasons. In the 2017/2018 influenza season, one of the largest seasonal outbreaks in the last 15 years, this multi-model ensemble performed better on average than all individual component models and placed second overall in the CDC challenge. It also outperformed the baseline multi-model ensemble created by the CDC that took a simple average of all models submitted to the forecasting challenge. This project shows that collaborative efforts between research teams to develop ensemble forecasting approaches can bring measurable improvements in forecast accuracy and important reductions in the variability of performance from year to year. Efforts such as this, that emphasize real-time testing and evaluation of forecasting models and facilitate the close collaboration between public health officials and modeling researchers, are essential to improving our understanding of how best to use forecasts to improve public health response to seasonal and emerging epidemic threats.

      12. Progress toward HIV epidemic control in Lesothoexternal icon
        Thin K, Frederix K, McCracken S, Letsie M, Low A, Patel H, Parekh B, Motsoane T, Ahmed N, Justman J, Callaghan L, Tembo S, Schwitters A.
        Aids. 2019 Dec 1;33(15):2393-2401.
        OBJECTIVE: The Lesotho Population-based HIV Impact Assessment survey was conducted nationally and designed to measure HIV prevalence, incidence, and viral load suppression (VLS). DESIGN: A nationally representative sample of 9403 eligible households was surveyed between November 2016 and May 2017; analyses account for study design. Consenting participants provided blood samples, socio-demographic, and behavioral information. METHODS: Blood samples were tested using the national rapid HIV testing algorithm. HIV-seropositive results were confirmed with Geenius supplemental assay. Screening for detectable concentrations of antiretroviral analytes was conducted on dried blood specimens from all HIV-positive adults using high-resolution liquid chromatography coupled with tandem mass spectrometry. Self-reported and/or antiretroviral biomarker data were used to classify individuals as HIV-positive and on treatment. Viral load testing was performed on all HIV-positive samples at central labs. VLS was defined as HIV RNA below 1000 copies/ml. RESULTS: Overall, 25.6% of adults aged 15-59 years were HIV-positive. Among seropositive adults, 81.0% (male 76.6%, female 84.0%) reported knowing their HIV status, 91.8% of people living with HIV (male 91.6%, female 92.0%) who reported knowing their status reporting taking antiretrovirals, and 87.7% (male and female 87.7%) of these had VLS. Younger age was significantly associated with being less likely to be aware of HIV status for both sexes. CONCLUSIONS: Findings from this population-based survey provide encouraging data in terms of HIV testing and treatment uptake and coverage. Specific attention to reaching youth to engage them in HIV-related interventions are critical to achieving epidemic control.

      13. Modelling treatment of latent TB: Shortening the leap of faith?external icon
        Vernon A, Bishai W.
        Am J Respir Crit Care Med. 2019 Nov 25.

      14. Group sex events among cisgender men who have sex with men: Cross-sectional and longitudinal survey study to explore participation and risk-taking behaviorsexternal icon
        Violette LR, Niemann LA, McMahan VM, Katz DA, Chavez PR, Clark HA, Cornelius-Hudson A, Ethridge SF, McDougal SJ, Ure Ii G, Stekler JD, Delaney KP.
        JMIR Res Protoc. 2019 Nov 27;8(11):e15426.
        BACKGROUND: Group sex events (GSEs) are common among cisgender men who have sex with men (MSM), pose a unique risk profile for HIV and sexually transmitted disease (STD) transmission, and may be on the rise, in part because of Web-based networking platforms. However, collecting data on GSEs can be challenging, and many gaps exist in our knowledge about GSE participation among MSM. OBJECTIVE: The objective of this study was to develop survey questions addressing aggregate and partner-specific group sex behaviors to measure prevalence of GSEs and associated risks in persons participating in Project Diagnostic Evaluation To Expand Critical Testing Technologies (DETECT), including MSM seeking HIV and STD testing at a public clinic in Seattle, Washington. METHODS: We developed a computer self-assisted survey that included questions about participant demographics, sexual history, and risk behaviors, including group sex, as a part of Project DETECT, a Centers for Disease Control and Prevention-funded study evaluating point-of-care HIV tests. Aggregate and partner-specific questions asked about participation in all GSEs, threesomes, and four-or-more-somes including questions about number and HIV status of sex partners and condom use during the events. To evaluate question performance, we assessed the discrepancies in reporting between the aggregate and partner-specific questions, quantified question refusal rates, and calculated the additional time required to answer the GSE questions. Information about network density (number of partnerships of overlapping duration) was estimated and compared for MSM who did and did not report GSEs. RESULTS: Among 841 visits by 690 MSM who were asked any group sex survey question, participation in a GSE of any type in the past 3 months was reported at 293 visits (293/841, 34.8%). We found that 9.0% (76/841) of MSM in the sample reported >/=1 four-or-more-some in the partner-specific questions but did not report in the aggregate. The proportion of refusals on any given aggregate GSE-related question ranged from 0% (0/273) to 10.6% (15/141) (median 2.6%) and partner-specific questions ranged from 0% (0/143) to 22% (5/23) (median 3.0%), with questions about four-or-more-somes having the highest proportions of refusals. Completing the aggregate group sex questions added 1 to 2 minutes and the partner-specific questions added an additional 2 to 4 minutes per partner to the total survey length. As expected, the partner-specific GSE questions documented higher density of sexual networks that was not captured by asking about total partner counts and overlap of specific partnerships. CONCLUSIONS: We found that the Project DETECT survey was able to obtain nuanced information about GSEs. The question skip patterns and consistency checks were effective, and survey fatigue was minimal. More research is needed on GSEs, and our survey represents a promising data collection tool to help fill gaps in knowledge about the subject.

    • Disease Reservoirs and Vectors
      1. A novel avian isolate of hepatitis E virus from Pakistanexternal icon
        Iqbal T, Rashid U, Idrees M, Afroz A, Kamili S, Purdy MA.
        Virol J. 2019 Nov 21;16(1):142.
        BACKGROUND: Avian hepatitis E virus (aHEV) has been associated with hepatitis-splenomegaly syndrome (HSS) in chickens along with asymptomatic subclinical infection in many cases. So far, four genotypes have been described, which cause infection in chickens, specifically in broiler breeders and layer chickens. In the present study, we isolated and identified two novel aHEV strains from the bile of layer chickens in Pakistan evincing clinical symptoms related to HSS. METHODOLOGY: Histology of liver and spleen tissues was carried out to observe histopathological changes in these tissues. Bile fluid and fecal suspensions were used for viral RNA isolation through MegNA pure and Trizol method which was further used for viral genome detection and characterization by cDNA synthesis and amplification of partial open reading frame (ORF) 1, ORF2 and complete ORF3. The bioinformatics tools; Molecular Evolutionary Genetics Analysis version 6.0 (MEGA 6), Mfold and ProtScale were used for phylogenic analysis, RNA secondary structure prediction and protein hydropathy analysis, respectively. RESULTS: Sequencing and phylogenetic analysis on the basis of partial methyltranferase (MeT), helicase (Hel) domain, ORF2 and complete ORF3 sequence suggests these Pakistani aHEV (Pak aHEV) isolates may belong to a Pakistani specific clade. The overall sequence similarity between the Pak aHEV sequences was 98-100%. The ORF1/ORF3 intergenic region contains a conserved cis-reactive element (CRE) and stem-loop structure (SLS). Analysis of the amino acid sequence of ORF3 indicated two hydrophobic domains (HD) and single conserved proline-rich domain (PRD) PREPSAPP (PXXPXXPP) with a single PSAP motif found in C-terminal. Amino acid changes S15 T, A31T, Q35H and G46D unique to the Pak aHEV sequences were found in the N-terminal region of ORF3. CONCLUSIONS: Our data suggests that Pak aHEV isolates may represent a novel Pakistani clade and high sequence homology to each other support the supposition they may belong to a monophyletic clade circulating in the region around Pakistan. The data presented in this study provide further information for aHEV genetic diversity, genotype mapping, global distribution and epidemiology.

    • Environmental Health

      1. Supporting local health departments and partners to prepare for and respond to water emergenciesexternal icon
        Galan D, Smith T, Yoder J.
        J Public Health Manag Pract. 2020 Jan/Feb;26(1):91-93.

      2. Longitudinal association of biomarkers of pesticide exposure with cardiovascular disease risk factors in youth with diabetesexternal icon
        Kaur N, Starling AP, Calafat AM, Sjodin A, Clouet-Foraison N, Dolan LM, Imperatore G, Jensen ET, Lawrence JM, Ospina M, Pihoker C, Taylor KW, Turley C, Dabelea D, Jaacks LM.
        Environ Res. 2019 Nov 14:108916.
        BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death among individuals with diabetes, but little is known about the role of exposures to environmental chemicals such as pesticides in the early development of CVD risk in this population. OBJECTIVES: To describe changes over time in concentrations of pesticide biomarkers among youth with diabetes in the United States and to estimate the longitudinal association between these concentrations and established risk factors for CVD. METHODS: Pesticide biomarkers were quantified in urine and serum samples from 87 youth with diabetes participating in the multi-center SEARCH cohort study. Samples were obtained around the time of diagnosis (baseline visit, between 2006 and 2010) and, on average, 5.4 years later (follow-up visit, between 2012 and 2015). We calculated geometric mean (95% CI) pesticide biomarker concentrations. Eight CVD risk factors were measured at these two time points: body mass index (BMI) z-score, HbA1c, insulin sensitivity, fasting C-peptide (FCP), LDL cholesterol, HDL cholesterol, total cholesterol, and triglycerides. Linear regression models were used to estimate the associations between each pesticide biomarker at baseline and each CVD risk factor at follow-up, adjusting for baseline health outcome, elapsed time between baseline and follow up, sex, age, race/ethnicity, and diabetes type. RESULTS: Participants were, on average, 14.2 years old at their baseline visit, and most were diagnosed with type 1 diabetes (57.5%). 4-nitrophenol, 3-phenoxybenzoic acid, 2,4-dichlorophenoxyacetic acid (2,4-D), 3,5,6-trichloro-2-pyridinol, 2,2-bis(4-chlorophenyl)-1,1-dichloroethene, and hexachlorobenzene were detected in a majority of participants at both time points. Participants in the highest quartile of 2,4-D and 4-nitrophenol at baseline had HbA1c levels at follow-up that were 1.05 percentage points (95% CI: -0.40, 2.51) and 1.27 percentage points (0.22, 2.75) higher, respectively, than participants in the lowest quartile of these pesticide biomarkers at baseline. These participants also had lower log FCP levels (indicating reduced beta-cell function) compared to participants in the lowest quartile at baseline: beta (95% CI) for log FCP of -0.64 (-1.17, -0.11) for 2,4-D and -0.39 (-0.96, 0.18) for 4-nitrophenol. In other words, participants in the highest quartile of 2,4-D had a 47.3% lower FCP level compared to participants in the lowest quartile, and those in the highest quartile of 4-nitrophenol had a 32.3% lower FCP level than those in the lowest quartile. Participants with trans-nonachlor concentrations in the highest quartile at baseline had HbA1c levels that were 1.45 percentage points (-0.11, 3.01) higher and log FCP levels that were -0.28 (-0.84, 0.28) lower than participants in the lowest quartile at baseline, that is to say, participants in the highest quartile of trans-nonachlor had a 24.4% lower FCP level than those in the lowest quartile. While not all of these results were statistically significant, potentially due to the small same size, clinically, there appears to be quantitative differences. No associations were observed between any pesticide biomarker at baseline with BMI z-score or insulin sensitivity at follow-up. CONCLUSIONS: Exposure to select pesticides may be associated with impaired beta-cell function and poorer glycemic control among youth with diabetes.

    • Health Disparities
      1. Hepatitis C-related mortality among American Indian/Alaska Native persons in the northwestern United States, 2006-2012external icon
        Hatcher SM, Joshi S, Robinson BF, Weiser T.
        Public Health Rep. 2019 Nov 25:33354919887748.
        OBJECTIVE: American Indian and Alaska Native (AI/AN) persons are commonly misclassified in epidemiologic and administrative data sets. The race-corrected hepatitis C virus (HCV)-related mortality rate among AI/AN persons in the Northwest United States (Idaho, Oregon, and Washington State) is unknown. We quantified the disparity in HCV-related mortality between AI/AN persons and non-Hispanic white (NHW) persons in the Northwest during 2006-2012 after correcting misclassified AI/AN race. METHODS: After conducting probabilistic record linkage between death records and the Northwest Tribal Registry, we calculated HCV-related mortality rates for AI/AN and NHW persons by using National Center for Health Statistics bridged-race estimates standardized to the US 2000 standard population. RESULTS: The 2006-2012 aggregate age-adjusted HCV-related mortality rate per 100 000 population in the Northwest was 19.6 (95% confidence interval [CI], 17.3-22.2) for AI/AN persons and 5.9 (95% CI, 5.7-6.1) for NHW persons (rate ratio [RR] = 3.3; 95% CI, 3.0-3.8). The disparity was larger among females (RR = 4.6; 95% CI, 3.8-5.5) than among males (RR = 2.9; 95% CI, 2.5-3.4). CONCLUSION: The disproportionate rate of HCV-related mortality among AI/AN persons in the Northwest highlights the need to expand HCV education, screening, and treatment among this population.

    • Health Economics
      1. Return on investment of self-management education and home visits for children with asthmaexternal icon
        Swann JL, Griffin PM, Keskinocak P, Bieder I, Yildirim FM, Nurmagambetov T, Hsu J, Seeff L, Singleton CM.
        J Asthma. 2019 Nov 22:1-10.
        Objective: Priorities of the Centers for Disease Control and Prevention's 6|18 Initiative include outpatient asthma self-management education (ASME) and home-based asthma visits (home visit) as interventions for children with poorly-controlled asthma. ASME and home visit intervention programs are currently not widely available. This project was to assess the economic sustainability of these programs for state asthma control programs reimbursed by Medicaid.Methods: We used a simulation model based on parameters from the literature and Medicaid claims, controlling for regression to the mean. We modeled scenarios under various selection criteria based on healthcare utilization and age to forecast the return on investment (ROI) using data from New York. The resulting tool is available in Excel or Python.Results: Our model projected health improvement and cost savings for all simulated interventions. Compared against home visits alone, the simulated ASME alone intervention had a higher ROI for all healthcare utilization and age scenarios. Savings were primarily highest in simulated program participants who had two or more asthma-related emergency department visits or one inpatient visit compared to those participants who had one or more asthma-related emergency department visits. Segmenting the selection criteria by age did not significantly change the results.Conclusions: This model forecasts reduced healthcare costs and improved health outcomes as a result of ASME and home visits for children with high urgent healthcare utilization (more than two emergency department visits or one inpatient hospitalization) for asthma. Utilizing specific selection criteria, state based asthma control programs can improve health and reduce healthcare costs.

      2. Financial cost analysis of a strategy to improve the quality of administrative vaccination data in Ugandaexternal icon
        Ward K, Mugenyi K, MacNeil A, Luzze H, Kyozira C, Kisakye A, Matseketse D, Newall AT, Heywood AE, Bloland P, Pallas SW.
        Vaccine. 2019 Nov 22.
        BACKGROUND: High-quality vaccination data are critical to planning, implementation and evaluation of immunization programs. However, sub-optimal administrative vaccination data quality in low- and middle-income countries persist for heterogeneous reasons, though most relate to organizational factors and human behavior. The nationwide Data Improvement Team (DIT) strategy in Uganda aimed to strengthen human resource capacity to generate quality administrative vaccination data at the health facility. METHODS: A financial cost analysis of the Uganda DIT strategy (2014-2016) was conducted from the program funder perspective. Activity-based micro-costing from funder financial and program monitoring records was used to estimate total and unit costs by program area (in 2016 US dollars). Hypothetical scenarios were developed to illustrate potential approaches to reducing costs. RESULTS: Over 25 months the DIT strategy was implemented in all 116 operational districts and 3443 (89%) health facilities in Uganda at a total financial cost of US $575 275. Training and deployment of DITs accounted for the highest proportion of expenditure across program areas (69%). Transport, per diems, lodging, and honoraria for DIT members and national supervisors were the main cost drivers of the strategy. Deployment of 557 DIT members cost US $839 per DIT member, US $4 030 per district, and US $136 per health facility. The estimated opportunity cost of government staff time wasn't a major cost driver (2.5%) of total cost. CONCLUSION: The results provide the first estimates of the magnitude and drivers of cost to implement a national workforce capacity building strategy to improve administrative vaccination data quality in a low- or middle-income country. Financial costs are a critical input to combine with future outcome data to describe the cost of strategies relative to performance outcomes. The operational costs of the strategy were modest (0.5-1.6%) relative to the estimated operational costs of Uganda's national immunization program.

    • Healthcare Associated Infections
      1. Antimicrobial-resistant pathogens associated with adult healthcare-associated infections: Summary of data reported to the National Healthcare Safety Network, 2015-2017external icon
        Weiner-Lastinger LM, Abner S, Edwards JR, Kallen AJ, Karlsson M, Magill SS, Pollock D, See I, Soe MM, Walters MS, Dudeck MA.
        Infect Control Hosp Epidemiol. 2019 Nov 25:1-18.
        OBJECTIVE: Describe common pathogens and antimicrobial resistance patterns for healthcare-associated infections (HAIs) that occurred during 2015-2017 and were reported to the Centers for Disease Control and Prevention's (CDC's) National Healthcare Safety Network (NHSN). METHODS: Data from central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), and surgical site infections (SSIs) were reported from acute-care hospitals, long-term acute-care hospitals, and inpatient rehabilitation facilities. This analysis included device-associated HAIs reported from adult location types, and SSIs among patients >/=18 years old. Percentages of pathogens with nonsusceptibility (%NS) to selected antimicrobials were calculated for each HAI type, location type, surgical category, and surgical wound closure technique. RESULTS: Overall, 5,626 facilities performed adult HAI surveillance during this period, most of which were general acute-care hospitals with <200 beds. Escherichia coli (18%), Staphylococcus aureus (12%), and Klebsiella spp (9%) were the 3 most frequently reported pathogens. Pathogens varied by HAI and location type, with oncology units having a distinct pathogen distribution compared to other settings. The %NS for most pathogens was significantly higher among device-associated HAIs than SSIs. In addition, pathogens from long-term acute-care hospitals had a significantly higher %NS than those from general hospital wards. CONCLUSIONS: This report provides an updated national summary of pathogen distributions and antimicrobial resistance among select HAIs and pathogens, stratified by several factors. These data underscore the importance of tracking antimicrobial resistance, particularly in vulnerable populations such as long-term acute-care hospitals and intensive care units.

    • Immunity and Immunization
      1. BACKGROUND: Seasonal influenza vaccines aim to induce strain-specific neutralizing antibodies. Non-neutralizing antibodies may be more broadly cross-reactive and still protect through mechanisms including antibody-dependent cell-mediated cytotoxicity (ADCC). Influenza vaccines may stimulate ADCC antibodies in adults, but whether they do so in children is unknown. Here we examined how vaccination affects cross-reactive ADCC antibody responses in children after receipt of inactivated trivalent vaccine (IIV3) or quadrivalent live-attenuated vaccine (LAIV4). METHODS: Children aged 5-17 were recruited in fall 2014 to provide pre- and post-vaccination serum samples. Children aged 5-9 received LAIV4 based on then-current recommendation, and older children were randomly assigned to IIV3 or LAIV4. We used microtiter-plate-based flow cytometry with an NK cell line to examine ADCC antibody responses to the 2014-15 H3N2 vaccine component (A/Texas/50/2012 [TX12]) and a drifted strain, A/Switzerland/9715293/2013 (SW13). Responses were stratified by two-season (2013-14 and 2014-15) vaccine sequence. RESULTS: Eighty-five children received LAIV4 and 45 received IIV3. Prevaccination ADCC activity was highest in children who had received any vaccine in the prior season. Increase in ADCC antibody responses against the vaccine strain TX12 following vaccination was greatest for participants who received IIV3 in 2014-15 and LAIV4 in the prior season (geometric mean fold rise [MFR]=1.6, 95% CI. 1.23-2.11). This group also had a detectable ADCC response to the drifted SW13 strain. There was a modest ADCC response against SW13 in LAIV4 recipients who were unvaccinated in the previous season (MFR=1.18, 95% CI 1.10-1.25). There were no significant changes in 2014-15 ADCC response to vaccination among children who had received IIV3 in 2013-14. CONCLUSIONS: Vaccinating children with IIV3 after prior receipt of LAIV4 generated a modest increase in ADCC antibodies, including some cross-reactivity with an emerging drift variant. Other vaccine-induced ADCC responses were minimal and not affected by vaccine type or sequence.

      2. Shoulder injury related to vaccine administration (SIRVA): Petitioner claims to the National Vaccine Injury Compensation Program, 2010-2016external icon
        Hesse EM, Atanasoff S, Hibbs BF, Adegoke OJ, Ng C, Marquez P, Osborn M, Su JR, Moro PL, Shimabukuro T, Nair N.
        Vaccine. 2019 Nov 23.
        BACKGROUND: Since 2010, petitioner claims of shoulder injury related to vaccine administration (SIRVA) to the National Vaccine Injury Compensation Program (VICP) have been increasing. OBJECTIVE: To conduct a scientific review of clinical characteristics of SIRVA petitions to the VICP. METHODS: We queried the VICP's Injury Compensation System database for medical reports of alleged SIRVA and SIRVA-like injuries. Medical reports are summaries of petitioner claims and supporting documentation along with a VICP clinician reviewer diagnosis and assessment of criteria for concession. We conducted a descriptive analysis of SIRVA petitioner claims recommended by the VICP for concession as SIRVA injuries. RESULTS: We identified 476 petitioner claims recommended for concession. Claims per year increased from two in 2011, the first full year in the analytic period, to 227 in 2016. Median age was 51 years, 82.8% were women, and median body mass index was 25.1 (range 17.0-48.9). Four hundred cases (84.0%) involved influenza vaccine. Pharmacy or store (n = 168; 35.3%) was the most common place of vaccination followed by doctor's office (n = 147; 30.9%). Fewer than half of cases reported a suspected administration error; 172 (36.1%) reported 'injection too high' on the arm. Shoulder pain, rotator cuff problems, and bursitis were common initial diagnoses. Most (80.0%) cases received physical or occupational therapy, 60.1% had at least one steroid injection, and 32.6% had surgery. Most (71.9%) healthcare providers who gave opinions on causality considered the injury was caused by vaccination. A minority (24.3%) of cases indicated that symptoms had resolved by the last visit available in medical records. CONCLUSIONS: Most conceded claims for SIRVA were in women and involved influenza vaccines. Injection too high on the arm could be a factor due to the risk of injecting into underlying non-muscular tissues. Healthcare providers should be aware of proper injection technique and anatomical landmarks when administering vaccines.

      3. One objective of the 2013-2018 Global Polio Eradication Initiative (GPEI) Strategic Plan was the transition of GPEI polio essential functions to other public health programs [1]. For many developing countries, in addition to polio essential functions, GPEI funding has been supporting integrated communicable disease surveillance and routine immunization programs. As GPEI progresses toward polio eradication, GPEI funding for some polio-free countries is being scaled back. The Somalia Polio Eradication Program, led by international organizations in collaboration with local authorities, is a critical source of immunizations for >2.5 million children. In addition, the polio program has been supporting a range of communicable disease surveillance, basic health services (e.g. routine immunizations) as well as emergency response activities (e.g. outbreak response). To assess current capacities in Somalia, interviews were conducted with representatives of relief organizations and ministries of health (MoHs) from Somaliland, Puntland, and South-Central political zones to elicit their opinions on their agency's capacity to assume public health activities currently supported by GPEI funds. Seventy percent of international and 62% of representatives of domestic relief agencies reported low capacity to conduct communicable disease surveillance without GPEI funds. Responses from MoH representatives for the three zones in Somalia ranged from "very weak" to "strong" regarding capacity to conduct both polio and non-polio related communicable disease surveillance and outbreak response activities. Zones programs are unprepared to provide communicable diseases services if GPEI funding were substantially reduced abruptly. Polio transition planning must strategically plan for shifting of GPEI staffing, operational assets and funding to support identified gaps in Somalia's public health infrastructure.

    • Laboratory Sciences
      1. What is going on with the genus Dermacentor? Hybridizations, introgressions, oh my!external icon
        Goddard J, Allerdice M, Portugal JS, Moraru GM, Paddock CD, King J.
        J Med Entomol. 2019 Nov 26.
        In the 1930s, R. A. Cooley noted that Dermacentor occidentalis (Acarina: Ixodidae) and Dermacentor andersoni were closely related and could hybridize. Decades later, James Oliver discovered that crosses of Dermacentor variabilis, D. andersoni, and D. occidentalis could, on occasion, produce hybrids. A recent molecular analysis (both mtDNA and nDNA) in our laboratory revealed that certain specimens of Dermacentor andersoni nested with Dermacentor parumapertus. Does this close relationship, along with the mito-nuclear discordance we have observed, mean D. andersoni and D. parumapertus are a single species? By contemporary taxonomic criteria, this seems improbable based on their distinctly different morphologies, host associations, and ecologies. This paper explores ideas related to mito-nuclear discordance, hybridization, and introgression (primarily) not only in these two species but also other members of the genus Dermacentor. Both D. andersoni and D. parumapertus can be found on the same hosts and have sympatric distributions, so introgression of genetic material by occasional cross-mating between these two species is possible. Further, the difficulty in applying specific species concepts in ticks has been recently pointed out and a unified agreement on an integrative species concepts could clearly be useful in this situation. With the discovery of D. parumapertus as a potential vector of Rickettsia parkeri and the historically recognized role of D. andersoni in transmission of Rickettsia rickettsii, understanding the specific status of each lineage of these species (and others in the genus) is extremely important from a public health perspective.

      2. Iron oxide nanoparticle-induced neoplastic-like cell transformation in vitro is reduced with a protective amorphous silica coatingexternal icon
        Kornberg TG, Stueckle TA, Coyle J, Derk R, Demokritou P, Rojanasakul Y, Rojanasakul LW.
        Chem Res Toxicol. 2019 Nov 11.
        Iron oxide nanoparticles (IONP) have recently surged in production and use in a wide variety of biomedical and environmental applications. However, their potential long-term health effects, including carcinogenesis, are unknown. Limited research suggests IONP can induce genotoxicity and neoplastic transformation associated with particle dissolution and release of free iron ions. "Safe by design" strategies involve the modification of particle physicochemical properties to affect subsequent adverse outcomes, such as an amorphous silica coating to reduce IONP dissolution and direct interaction with cells. We hypothesized that long-term exposure to a specific IONP (nFe2O3) would induce neoplastic-like cell transformation, which could be prevented with an amorphous silica coating (SiO2-nFe2O3). To test this hypothesis, human bronchial epithelial cells (Beas-2B) were continuously exposed to a 0.6 mug/cm(2) administered a dose of nFe2O3 ( approximately 0.58 mug/cm(2) delivered dose), SiO2-nFe2O3 ( approximately 0.55 mug/cm(2) delivered dose), or gas metal arc mild steel welding fumes (GMA-MS, approximately 0.58 mug/cm(2) delivered dose) for 6.5 months. GMA-MS are composed of roughly 80% iron/iron oxide and were recently classified as a total human carcinogen. Our results showed that low-dose/long-term in vitro exposure to nFe2O3 induced a time-dependent neoplastic-like cell transformation, as indicated by increased cell proliferation and attachment-independent colony formation, which closely matched that induced by GMA-MS. This transformation was associated with decreases in intracellular iron, minimal changes in reactive oxygen species (ROS) production, and the induction of double-stranded DNA damage. An amorphous silica-coated but otherwise identical particle (SiO2-nFe2O3) did not induce this neoplastic-like phenotype or changes in the parameters mentioned above. Overall, the presented data suggest the carcinogenic potential of long-term nFe2O3 exposure and the utility of an amorphous silica coating in a "safe by design" hazard reduction strategy, within the context of a physiologically relevant exposure scenario (low-dose/long-term), with model validation using GMA-MS.

      3. Inhibition of calcium-calmodulin-dependent phosphodiesterase (PDE1) suppresses inflammatory responsesexternal icon
        O'Brien JJ, O'Callaghan JP, Miller DB, Chalgeri S, Wennogle LP, Davis RE, Snyder GL, Hendrick JP.
        Mol Cell Neurosci. 2019 Nov 23:103449.
        A novel, potent, and highly specific inhibitor of calcium-calmodulin-dependent phosphodiesterases (PDE) of the PDE1 family, ITI-214, was used to investigate the role of PDE1 in inflammatory responses. ITI-214 dose-dependently suppressed lipopolysaccharide (LPS)-induced gene expression of pro-inflammatory cytokines in an immortalized murine microglial cell line, BV2 cells. RNA profiling (RNA-Seq) was used to analyze the impact of ITI-214 on the BV2 cell transcriptome in the absence and the presence of LPS. ITI-214 was found to regulate classes of genes that are involved in inflammation and cell migration responses to LPS exposure. The gene expression changes seen with ITI-214 treatment were distinct from those elicited by inhibitors of other PDEs with anti-inflammatory activity (e.g., a PDE4 inhibitor), indicating a distinct mechanism of action for PDE1. Functionally, ITI-214 inhibited ADP-induced migration of BV2 cells through a P2Y12-receptor-dependent pathway, possibly due to increases in the extent of cAMP and VASP phosphorylation downstream of receptor activation. Importantly, this effect was recapitulated in P2 rat microglial cells in vitro, indicating that these pathways are active in native microglial cells. These studies are the first to demonstrate that inhibition of PDE1 exerts anti-inflammatory effects through effects on microglia signaling pathways. The ability of PDE1 inhibitors to prevent or dampen excessive inflammatory responses of BV2 cells and microglia provides a basis for exploring their therapeutic utility in the treatment of neurodegenerative diseases associated with increased inflammation and microglia proliferation such as Parkinson's disease and Alzheimer's disease.

      4. Population structure and genetic diversity among isolates of Coccidioides posadasii in Venezuela and surrounding regionsexternal icon
        Teixeira MM, Alvarado P, Roe CC, Thompson GR, Patane JS, Sahl JW, Keim P, Galgiani JN, Litvintseva AP, Matute DR, Barker BM.
        MBio. 2019 Nov 26;10(6).
        Coccidioides posadasii is a pathogenic fungus that causes coccidioidomycosis in many arid regions of the Americas. One of these regions is bordered by the Caribbean Sea, and the surrounding landscape may play an important role in the dispersion of C. posadasii across South America through southeastern Mexico, Honduras, Guatemala, and Venezuela. Comparative phylogenomic analyses of C. posadasii reveal that clinical strains from Venezuela are genetically distinct from the North American populations found in (i) Arizona and (ii) Texas, Mexico, and the rest of South America (TX/MX/SA). We find evidence for admixture between the Venezuela and the North American populations of C. posadasii in Central America. Additionally, the proportion of Venezuelan alleles in the admixed population decreases as latitude (and distance from Venezuela) increases. Our results indicate that the population in Venezuela may have been subjected to a recent bottleneck and shows a strong population structure. This analysis provides insight into potential for Coccidioides spp. to invade new regions.IMPORTANCE Valley Fever is a fungal disease caused by two species of fungi: Coccidioides immitis and C. posadasii These fungi are found throughout the arid regions of North and South America; however, our understanding of genetic diversity and disease in South America is limited. In this report, we analyze 10 new genomes of Coccidioides posadasii from regions bordering the Caribbean Sea. We show that these populations are distinct and that isolates from Venezuela are likely a result of a recent bottleneck. These data point to patterns that might be observed when investigating recently established populations.

    • Maternal and Child Health
      1. Atypical antipsychotic use during pregnancy and birth defect risk: National Birth Defects Prevention Study, 1997-2011external icon
        Anderson KN, Ailes EC, Lind JN, Broussard CS, Bitsko RH, Friedman JM, Bobo WV, Reefhuis J, Tinker SC.
        Schizophr Res. 2019 Nov 21.
        PURPOSE: To examine the prevalence of, and factors associated with, atypical antipsychotic use among U.S. pregnant women, and potential associations between early pregnancy atypical antipsychotic use and risk for 14 birth defects. METHODS: We analyzed data from the National Birth Defects Prevention Study (1997-2011), a U.S. population-based case-control study examining risk factors for major structural birth defects. RESULTS: Atypical antipsychotic use during pregnancy was more common among women with pre-pregnancy obesity, and women who reported illicit drug use before and during pregnancy, smoking during pregnancy, alcohol use during pregnancy, or use of other psychiatric medications during pregnancy. We observed elevated associations (defined as a crude odds ratio [cOR] >/=2.0) between early pregnancy atypical antipsychotic use and conotruncal heart defects (6 exposed cases; cOR: 2.3, 95% confidence interval [CI]: 0.9-6.1), and more specifically Tetralogy of Fallot (3 exposed cases; cOR: 2.5, 95% CI: 0.7-8.8), cleft palate (4 exposed cases, cOR: 2.5, 95% CI: 0.8-7.6), anorectal atresia/stenosis (3 exposed cases, cOR: 2.8, 95% CI: 0.8-9.9), and gastroschisis (3 exposed cases, cOR: 2.1, 95% CI: 0.6-7.3). CONCLUSIONS: Our findings support the close clinical monitoring of pregnant women using atypical antipsychotics. Women treated with atypical antipsychotics generally access healthcare services before pregnancy; efforts to reduce correlates of atypical antipsychotic use might improve maternal and infant health in this population.

    • Medicine
      1. Overcoming a collective failure of imagination - how to diagnose it and what to do about itexternal icon
        Braun PA, Baker EL.
        J Public Health Manag Pract. 2020 Jan/Feb;26(1):83-85.

      2. U.S. physician recommendations to their patients about the use of complementary health approachesexternal icon
        Stussman BJ, Nahin RR, Barnes PM, Ward BW.
        J Altern Complement Med. 2019 Nov 25.
        Objective: There are no nationally representative studies using a probability sample that have been published examining whether physicians recommend complementary health approaches (CHAs) to their patients, as previous research has focused only on selected medical specialties or a particular U.S. region. This article fills a void in the current literature for robust data on recommendations for CHAs by office-based physicians in the United States. Design: Descriptive statistics and multivariable regression analyses of physician-level data were from the 2012 Physician Induction Interview of the National Ambulatory Medical Care Survey (NAMCS PII), a nationally representative survey of office-based physicians. Weighted response rate among eligible physicians sampled for the 2012 NAMCS PII was 59.7%. Setting/Location: United States. Outcome measures: Recommendations by physicians to their patients for any CHA, and individual CHAs: massage therapy, herbs/nonvitamin supplements, chiropractic/osteopathic manipulation, yoga, acupuncture, and mind-body therapies. Differences in recommendations by physician demographic characteristics were identified. Results: Massage therapy was the most commonly recommended CHA (30.4%), followed by chiropractic/osteopathic manipulation (27.1%), herbs/nonvitamin supplements (26.5%), yoga (25.6%), and acupuncture (22.4%). The most commonly recommended CHAs by general/family practice physicians were chiropractic/osteopathic manipulation (54.0%) and massage therapy (52.6%). Of all U.S. physicians, 53.1% recommended at least one CHA to patients during the previous 12 months. Multivariable analyses found physician's sex, race, specialty, and U.S. region to be significant predictors of CHA recommendations. Female physicians were more likely than male physicians to recommend massage therapy (adjusted odds ratio [aOR] = 1.76, 95% confidence interval [CI] = 1.40-2.20), herbs/nonvitamin supplements (aOR = 1.85, 95% CI = 1.46-2.35), yoga (aOR = 2.16, 95% CI = 1.70-2.75), acupuncture (aOR = 1.65, 95% CI = 1.27-2.13), and mind-body therapies (aOR = 2.63, 95% CI = 2.02-3.41) to patients. Psychiatrists (aOR = 0.13, 95% CI = 0.07-0.23), OB/GYNs (aOR = 0.38, 95% CI = 0.24-0.60), and pediatricians (aOR = 0.26, 95% CI = 0.18-0.38) were all less likely to recommend chiropractic/osteopathic manipulation than general and family practitioners. Conclusions: Overall, more than half of office-based physicians recommended at least one CHA to their patients. Female physicians recommended every individual CHA at a higher rate than male physicians except for chiropractic and osteopathic manipulation. These findings may enable consumers, physicians, and medical schools to better understand potential differences in use of CHAs with patients.

    • Nutritional Sciences
      1. US pediatrician practices on early nutrition, feeding, and growthexternal icon
        Boundy EO, Fisher Boyd A, Hamner HC, Belay B, Liebhart JL, Lindros J, Hassink S, Frintner MP.
        J Nutr Educ Behav. 2019 Nov 21.
        OBJECTIVE: Assess pediatrician practices around growth and nutrition for children under 2 years. DESIGN: 2017 cross-sectional survey of a national random sample of the American Academy of Pediatrics members. SETTING: US. PARTICIPANTS: Practicing primary care pediatricians and residents (n=698). MAIN OUTCOME MEASURES: World Health Organization growth chart use, solid food introduction recommendations, healthy behaviors discussion. ANALYSIS: Descriptive statistics were calculated for nutrition-related questions. McNemar tests compared recommendations on the introduction of different solid foods at <6 months; chi-square tests of independence examined outcomes by pediatrician and practice characteristics. RESULTS: Most respondents (82.2%) reported using the World Health Organization growth charts at all well visits. Nearly half (45.3%) recommended solid food introduction at 6 months; 48.2% recommended <6 months. Cereals were more frequently recommended at <6 months than fruits/vegetables or meats (P <.001). Topics most frequently discussed were limiting juice (92.3%), and sugar-sweetened beverages (92.0%), avoiding restrictive and permissive food practices (30.7%), and avoiding food as a reward (29.1%) were least discussed. Pediatricians in hospital/clinic settings discussed healthy behaviors less than group or solo/2-physician practices. CONCLUSIONS AND IMPLICATIONS: For children under 2 years, most pediatricians reported using recommended growth charts and discussing healthy behaviors. Fewer discussed responsive feeding topics. Results for guiding solid food introduction were mixed. Continued efforts to support pediatricians' work could improve the implementation of recommended practices.

    • Parasitic Diseases
      1. VAR2CSA serology to detect Plasmodium falciparum transmission patterns in pregnancyexternal icon
        Fonseca AM, Gonzalez R, Bardaji A, Jairoce C, Ruperez M, Jimenez A, Quinto L, Cistero P, Vala A, Sacoor C, Gupta H, Hegewisch-Taylor J, Brew J, Ndam NT, Kariuki S, Lopez M, Dobano C, Chitnis CE, Ouma P, Ramharter M, Abdulla S, Aponte JJ, Massougbodji A, Briand V, Mombo-Ngoma G, Desai M, Cot M, Nhacolo A, Sevene E, Macete E, Menendez C, Mayor A.
        Emerg Infect Dis. 2019 Oct;25(10):1851-1860.
        Pregnant women constitute a promising sentinel group for continuous monitoring of malaria transmission. To identify antibody signatures of recent Plasmodium falciparum exposure during pregnancy, we dissected IgG responses against VAR2CSA, the parasite antigen that mediates placental sequestration. We used a multiplex peptide-based suspension array in 2,354 samples from pregnant women from Mozambique, Benin, Kenya, Gabon, Tanzania, and Spain. Two VAR2CSA peptides of limited polymorphism were immunogenic and targeted by IgG responses readily boosted during infection and with estimated half-lives of <2 years. Seroprevalence against these peptides reflected declines and rebounds of transmission in southern Mozambique during 2004-2012, reduced exposure associated with use of preventive measures during pregnancy, and local clusters of transmission that were missed by detection of P. falciparum infections. These data suggest that VAR2CSA serology can provide a useful adjunct for the fine-scale estimation of the malaria burden among pregnant women over time and space.

      2. Integrated cross-sectional multiplex serosurveillance of IgG antibody responses to parasitic diseases and vaccines in Coastal Kenyaexternal icon
        Njenga SM, Kanyi HM, Arnold BF, Matendechero SH, Onsongo JK, Won KY, Priest JW.
        Am J Trop Med Hyg. 2019 Nov 25.
        Accurate and cost-effective identification of areas where co-endemic infections occur would enable public health managers to identify opportunities for implementation of integrated control programs. Dried blood spots collected during cross-sectional lymphatic filariasis surveys in coastal Kenya were used for exploratory integrated detection of IgG antibodies against antigens from several parasitic infections (Wuchereria bancrofti, Schistosoma mansoni, Plasmodium spp., Ascaris lumbricoides, and Strongyloides stercoralis) as well as for detection of responses to immunizing agents used against vaccine-preventable diseases (VPDs) (measles, diphtheria, and tetanus) using a multiplex bead assay (MBA) platform. High heterogeneity was observed in antibody responses by pathogen and antigen across the sentinel sites. Antibody seroprevalence against filarial antigens were generally higher in Ndau Island (P < 0.0001), which also had the highest prevalence of filarial antigenemia compared with other communities. Antibody responses to the Plasmodium species antigens CSP and MSP-119 were higher in Kilifi and Kwale counties, with Jaribuni community showing higher overall mean seroprevalence (P < 0.0001). Kimorigo community in Taita-Taveta County was the only area where antibody responses against S. mansoni Sm25 recombinant antigen were detected. Seroprevalence rates to Strongyloides antigen NIE ranged between 3% and 26%, and there was high heterogeneity in immune responses against an Ascaris antigen among the study communities. Differences were observed between communities in terms of seroprevalence to VPDs. Seroprotection to tetanus was generally lower in Kwale County than in other counties. This study has demonstrated that MBA holds promise for rapid integrated monitoring of trends of infections of public health importance in endemic areas.

      3. Determinants of uptake of intermittent preventive treatment during pregnancy: a reviewexternal icon
        Roman E, Andrejko K, Wolf K, Henry M, Youll S, Florey L, Ferenchick E, Gutman JR.
        Malar J. 2019 Nov 21;18(1):372.
        Malaria in pregnancy (MiP) contributes to devastating maternal and neonatal outcomes. Coverage of intermittent preventive treatment during pregnancy (IPTp) remains alarmingly low. Data was compiled from MiP programme reviews and performed a literature search on access to and determinants of IPTp. National malaria control and reproductive health (RH) policies may be discordant. Integration may improve coverage. Medication stock-outs are a persistent problem. Quality improvement programmes are often not standardized. Capacity building varies across countries. Community engagement efforts primarily focus on promotion of services. The majority of challenges can be addressed at country level to improve IPTp coverage.

    • Reproductive Health
      1. Stability of the vaginal, oral, and gut microbiota across pregnancy among African American women: the effect of socioeconomic status and antibiotic exposureexternal icon
        Dunlop AL, Knight AK, Satten GA, Cutler AJ, Wright ML, Mitchell RM, Read TD, Mulle J, Hertzberg VS, Hill CC, Smith AK, Corwin EJ.
        PeerJ. 2019 ;7:e8004.
        Objective: A growing body of research has investigated the human microbiota and pregnancy outcomes, especially preterm birth. Most studies of the prenatal microbiota have focused on the vagina, with fewer investigating other body sites during pregnancy. Although pregnancy involves profound hormonal, immunological and metabolic changes, few studies have investigated either shifts in microbiota composition across pregnancy at different body sites or variation in composition at any site that may be explained by maternal characteristics. The purpose of this study was to investigate: (1) the stability of the vaginal, oral, and gut microbiota from early (8-14 weeks) through later (24-30 weeks) pregnancy among African American women according to measures of socioeconomic status, accounting for prenatal antibiotic use; (2) whether measures of socioeconomic status are associated with changes in microbiota composition over pregnancy; and (3) whether exposure to prenatal antibiotics mediate any observed associations between measures of socioeconomic status and stability of the vaginal, oral, and gut microbiota across pregnancy. Methods: We used paired vaginal, oral, or gut samples available for 16S rRNA gene sequencing from two time points in pregnancy (8-14 and 24-30 weeks) to compare within-woman changes in measures of alpha diversity (Shannon and Chao1) and beta-diversity (Bray-Curtis dissimilarity) among pregnant African American women (n = 110). Multivariable linear regression was used to examine the effect of level of education and prenatal health insurance as explanatory variables for changes in diversity, considering antibiotic exposure as a mediator, adjusting for age, obstetrical history, and weeks between sampling. Results: For the oral and gut microbiota, there were no significant associations between measures of socioeconomic status or prenatal antibiotic use and change in Shannon or Chao1 diversity. For the vaginal microbiota, low level of education (high school or less) was associated with an increase in Shannon and Chao1 diversity over pregnancy, with minimal attenuation when controlling for prenatal antibiotic use. Conversely, for within-woman Bray-Curtis dissimilarity for early compared to later pregnancy, low level of education and prenatal antibiotics were associated with greater dissimilarity for the oral and gut sites, with minimal attenuation when controlling for prenatal antibiotics, and no difference in dissimilarity for the vaginal site. Conclusions: Measures of maternal socioeconomic status are variably associated with changes in diversity across pregnancy for the vaginal, oral, and gut microbiota, with minimal attenuation by prenatal antibiotic exposure. Studies that evaluate stability of the microbiota across pregnancy in association with health outcomes themselves associated with socioeconomic status (such as preterm birth) should incorporate measures of socioeconomic status to avoid finding spurious relationships.

      2. Abortion surveillance - United States, 2016external icon
        Jatlaoui TC, Eckhaus L, Mandel MG, Nguyen A, Oduyebo T, Petersen E, Whiteman MK.
        MMWR Surveill Summ. 2019 Nov 29;68(11):1-41.
        PROBLEM/CONDITION: Since 1969, CDC has conducted abortion surveillance to document the number and characteristics of women obtaining legal induced abortions in the United States. PERIOD COVERED: 2016. DESCRIPTION OF SYSTEM: Each year, CDC requests abortion data from the central health agencies of 52 reporting areas (the 50 states, the District of Columbia, and New York City). The reporting areas provide this information voluntarily. For 2016, data were received from 48 reporting areas. Abortion data provided by these 48 reporting areas for each year during 2007-2016 were used in trend analyses. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. RESULTS: A total of 623,471 abortions for 2016 were reported to CDC from 48 reporting areas. Among these 48 reporting areas, the abortion rate for 2016 was 11.6 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 186 abortions per 1,000 live births. From 2015 to 2016, the total number of reported abortions decreased 2% (from 636,902), the abortion rate decreased 2% (from 11.8 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 1% (from 188 abortions per 1,000 live births). From 2007 to 2016, the total number of reported abortions decreased 24% (from 825,240), the abortion rate decreased 26% (from 15.6 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 18% (from 226 abortions per 1,000 live births). In 2016, all three measures reached their lowest level for the entire period of analysis (2007-2016). In 2016 and throughout the period of analysis, women in their 20s accounted for the majority of abortions and had the highest abortion rates. In 2016, women aged 20-24 and 25-29 years accounted for 30.0% and 28.5% of all reported abortions, respectively, and had abortion rates of 19.1 and 17.8 abortions per 1,000 women aged 20-24 and 25-29 years, respectively. By contrast, women aged 30-34, 35-39, and >/=40 years accounted for 18.0%, 10.3%, and 3.5% of all reported abortions, respectively, and had abortion rates of 11.6, 6.9, and 2.5 abortions per 1,000 women aged 30-34, 35-39, and >/=40 years, respectively. From 2007 to 2016, the abortion rate decreased among women in all age groups. In 2016, adolescents aged <15 and 15-19 years accounted for 0.3% and 9.4% of all reported abortions, respectively, and had abortion rates of 0.4 and 6.2 abortions per 1,000 adolescents aged <15 and 15-19 years, respectively. From 2007 to 2016, the percentage of abortions accounted for by adolescents aged 15-19 years decreased 43%, and the abortion rate decreased 56%. This decrease in abortion rate was greater than the decreases for women in any older age group. In contrast to the percentage distribution of abortions and abortion rates by age, abortion ratios in 2016 and throughout the entire period of analysis were highest among adolescents and lowest among women aged 25-39 years. Abortion ratios decreased from 2007 to 2016 for women in all age groups. In 2016, almost two-thirds (65.5%) of abortions were performed at </=8 weeks' gestation, and nearly all (91.0%) were performed at </=13 weeks' gestation. Fewer abortions were performed between 14 and 20 weeks' gestation (7.7%) or at >/=21 weeks' gestation (1.2%). During 2007-2016, the percentage of abortions performed at >13 weeks' gestation remained consistently low (8.2%-9.0%). Among abortions performed at </=13 weeks' gestation, the percentage distributions of abortions by gestational age were highest among those performed at </=6 weeks' gestation (35.0%-38.4%). In 2016, 27.9% of all abortions were performed by early medical abortion (a nonsurgical abortion at </=8 weeks' gestation), 59.9% were performed by surgical abortion at </=13 weeks' gestation, 8.8% were performed by surgical abortion at >13 weeks' gestation, and 3.4% were performed by medical abortion at >8 weeks' gestation; all other methods were uncommon (0.1%). Among those that were eligible for early medical abortion on the basis of gestational age (i.e., performed at </=8 weeks' gestation), 41.9% were completed by this method. In 2016, women with one or more previous live births accounted for 59.0% of abortions, and women with no previous live births accounted for 41.0%. Women with one or more previous induced abortions accounted for 43.1% of abortions, and women with no previous abortions accounted for 56.9%. Deaths of women associated with complications from abortion are assessed as part of CDC's Pregnancy Mortality Surveillance System. In 2015, the most recent year for which data were reviewed for abortion-related deaths, two women were identified to have died as a result of complications from legal induced abortion and for one additional death, it was unknown whether the abortion was induced or spontaneous. INTERPRETATION: Among the 48 areas that reported data every year during 2007-2016, decreases in the total number, rate, and ratio of reported abortions resulted in historic lows for the period of analysis for all three measures of abortion. PUBLIC HEALTH ACTION: The data in this report can help program planners and policymakers identify groups of women with the highest rates of abortion. Unintended pregnancy is the major contributor to induced abortion. Increasing access to and use of effective contraception can reduce unintended pregnancies and further reduce the number of abortions performed in the United States.

    • Substance Use and Abuse
      1. Prevalence and determinants of cigarette smoking relapse among US adult smokers: a longitudinal studyexternal icon
        Alboksmaty A, Agaku IT, Odani S, Filippidis FT.
        BMJ Open. 2019 Nov 25;9(11):e031676.
        OBJECTIVES: This research project aims at estimating the prevalence of cigarette smoking relapse and determining its predictors among adult former smokers in the USA. SETTING: This research analysed secondary data retrieved from the Tobacco Use Supplement-Current Population Survey 2010-2011 cohort in the USA. PARTICIPANTS: Out of 18 499 participants who responded to the survey in 2010 and 2011, the analysis included a total sample size of 3258 ever smokers, who were living in the USA and reported quitting smoking in 2010. The survey's respondents who never smoked or reported current smoking in 2010 were excluded from the study sample. PRIMARY AND SECONDARY OUTCOME MEASURES: Smoking relapse was defined as picking up smoking in 2011 after reporting smoking abstinence in 2010. The prevalence of relapse over the 12-month follow-up period was estimated among different subgroups. Multivariable logistic regression models were applied to determine factors associated with relapse. RESULTS: A total of 184 former smokers reported smoking relapse by 2011 (weighted prevalence 6.8%; 95% CI 5.7% to 8.1%). Prevalence and odds of relapse were higher among young people compared with elders. Former smokers living in smoke-free homes (SFHs) had 60% lower odds of relapse compared with those living in homes that allowed smoking inside (adjusted OR 0.40; 95% CI 0.25 to 0.64). Regarding race/ethnicity, only Hispanics showed significantly higher odds of relapse compared with Whites (non-Hispanics). Odds of relapse were higher among never married, widowed, divorced and separated individuals, compared with the married group. Continuous smoking cessation for 6 months or more significantly decreased odds of relapse. CONCLUSIONS: Wider health determinants, such as race and age, but also living in SFHs showed significant associations with smoking relapse, which could inform the development of more targeted programmes to support those smokers who successfully quit, although further longitudinal studies are required to confirm our findings.

      2. Tobacco-free pharmacies and U.S. adult smoking behavior: Evidence from CVS Health's removal of tobacco salesexternal icon
        Ali FR, Neff L, Wang X, Hu SS, Schecter A, Mahoney M, Melstrom PC.
        Am J Prev Med. 2019 Nov 20.
        INTRODUCTION: Beginning September 3, 2014, CVS Health stopped selling tobacco products in all of its retail stores nationwide. This study assessed the impact of removing tobacco sales from CVS Health on cigarette smoking behaviors among U.S. adult smokers. METHODS: CVS Health retail location data (2012-2016) were linked with data from the Behavioral Risk Factor Surveillance System, a phone-based survey of the non-institutionalized civilian population aged >/=18 years. Using a difference-in-differences regression model, quit attempts and daily versus nondaily smoking were compared between smokers living in counties with CVS stores and counties without CVS stores, before and after CVS's removal of tobacco sales. Control variables included individuals' sociodemographic and health-related variables, state tobacco control variables, and urban status of counties. Analyses were conducted in 2018. RESULTS: During the 2-year period following the removal of tobacco sales from CVS Health, smokers living in counties with high CVS density (>/=3.5 CVS stores per 100,000 people) had a 2.21% (95% CI=0.08, 4.33) increase in their quit attempt rates compared with smokers living in counties without CVS stores. This effect was greater in urban areas (marginal effect: 3.03%, 95% CI=0.81, 5.25); however, there was no statistically significant impact in rural areas. Additionally, there was no impact on daily versus nondaily smoking in either urban or rural areas. CONCLUSIONS: Removing tobacco sales in retail pharmacies could help support cessation among U.S. adults who are attempting to quit smoking, particularly in urban areas.

      3. Update: Interim guidance for health care providers for managing patients with suspected e-cigarette, or vaping, product use-associated lung injury - United States, November 2019external icon
        Jatlaoui TC, Wiltz JL, Kabbani S, Siegel DA, Koppaka R, Montandon M, Adkins SH, Weissman DN, Koumans EH, O'Hegarty M, O'Sullivan MC, Ritchey MD, Chatham-Stephens K, Kiernan EA, Layer M, Reagan-Steiner S, Legha JK, Shealy K, King BA, Jones CM, Baldwin GT, Rose DA, Delaney LJ, Briss P, Evans ME.
        MMWR Morb Mortal Wkly Rep. 2019 Nov 22;68(46):1081-1086.
        CDC, the Food and Drug Administration (FDA), state and local health departments, and public health and clinical stakeholders are investigating a nationwide outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) (1). CDC has published recommendations for health care providers regarding EVALI (2-4). Recently, researchers from Utah and New York published proposed diagnosis and treatment algorithms for EVALI (5,6). EVALI remains a diagnosis of exclusion because, at present, no specific test or marker exists for its diagnosis, and evaluation should be guided by clinical judgment. Because patients with EVALI can experience symptoms similar to those associated with influenza or other respiratory infections (e.g., fever, cough, headache, myalgias, or fatigue), it might be difficult to differentiate EVALI from influenza or community-acquired pneumonia on initial assessment; EVALI might also co-occur with respiratory infections. This report summarizes recommendations for health care providers managing patients with suspected or known EVALI when respiratory infections such as influenza are more prevalent in the community than they have been in recent months (7). Recommendations include 1) asking patients with respiratory, gastrointestinal, or constitutional symptoms about the use of e-cigarette, or vaping, products; 2) evaluating those suspected to have EVALI with pulse oximetry and obtaining chest imaging, as clinically indicated; 3) considering outpatient management for clinically stable EVALI patients who meet certain criteria; 4) testing patients for influenza, particularly during influenza season, and administering antimicrobials, including antivirals, in accordance with established guidelines; 5) using caution when considering prescribing corticosteroids for outpatients, because this treatment modality has not been well studied among outpatients, and corticosteroids could worsen respiratory infections; 6) recommending evidence-based treatment strategies, including behavioral counseling, to help patients discontinue using e-cigarette, or vaping, products; and 7) emphasizing the importance of annual influenza vaccination for all persons aged >/=6 months, including patients who use e-cigarette, or vaping products.

      4. Associations of parental marijuana use with offspring marijuana, tobacco, and alcohol use and opioid misuseexternal icon
        Madras BK, Han B, Compton WM, Jones CM, Lopez EI, McCance-Katz EF.
        JAMA Netw Open. 2019 Nov 1;2(11):e1916015.
        Importance: Marijuana use is increasing among adults and often co-occurs with other substance use; therefore, it is important to examine whether parental marijuana use is associated with elevated risk of substance use among offspring living in the same household. Objective: To examine associations of parental marijuana use with offspring marijuana, tobacco, and alcohol use and opioid misuse. Design, Setting, and Participants: This cross-sectional study used survey data from the 2015 through 2018 National Surveys on Drug Use and Health (NSDUH), which provide nationally representative data on adolescents or young adults living with a parent (the mother or the father). Annual average percentages were based on survey sampling weights. Final analyses were conducted September 21 through 23, 2019. Exposures: Parental marijuana use status. Main Outcomes and Measures: Offspring self-reported use of marijuana, tobacco, or alcohol or misuse of opioids. Results: Survey respondents included 24900 father-offspring or mother-offspring dyads sampled from the same household. Among mothers living with adolescent offspring, 8.2% (95% CI, 7.3%-9.2%) had past-year marijuana use, while 7.6% (95% CI, 6.2%-9.2%) of mothers living with young adult offspring had past-year marijuana use. Among fathers living with adolescent offspring, 9.6% (95% CI, 8.5%-10.8%) had past-year marijuana use, and 9.0% (95% CI, 7.4%-10.9%) of fathers living with young adult offspring had past-year marijuana use. Compared with adolescents whose mothers never used marijuana, adjusted relative risk (ARR) of past-year marijuana use was higher among those whose mothers had lifetime (without past-year) marijuana use (ARR, 1.3; 95% CI, 1.1-1.6; P = .007), less than 52 days of past-year marijuana use (ARR, 1.7; 95% CI, 1.1-2.7; P = .02), or 52 days or more of past-year marijuana use (ARR, 1.5; 95% CI, 1.1-2.2; P = .02). Compared with young adults whose mothers never used marijuana, adjusted risk of past-year marijuana use was higher among those whose mothers had lifetime (without past-year) marijuana use (ARR, 1.4; 95% CI, 1.1-1.7; P = .001), less than 52 days of past-year marijuana use (ARR, 1.5; 95% CI, 1.0-2.3; P = .049), or 52 days or more of past-year marijuana use (ARR, 1.8; 95% CI, 1.3-2.5; P = .002). Compared with adolescents whose fathers never used marijuana, adolescents whose fathers had less than 52 days of past-year marijuana use were more likely to use marijuana (ARR, 1.8; 95% CI, 1.2-2.7; P = .006). Compared with young adults whose fathers never used marijuana, young adults whose fathers had 52 days or more of past-year marijuana use were more likely to use marijuana (ARR, 2.1; 95% CI, 1.6-2.9; P < .001). Compared with their peers whose parents never used marijuana and after adjusting for covariates, the adjusted risk of past-year tobacco use was higher among adolescents whose mothers had lifetime marijuana use (ARR, 1.3; 95% CI, 1.0-1.6; P = .03), less than 52 days of past-year marijuana use (ARR, 1.5; 95% CI, 1.0-2.1; P = .04), or 52 days or more of past-year marijuana use (ARR, 1.6; 95% CI, 1.1-2.3; P = .03); adolescents whose fathers had lifetime marijuana use (ARR, 1.5; 95% CI, 1.1-1.9; P = .004) or 52 days or more of past-year marijuana use (ARR, 1.8; 95% CI, 1.2-2.7; P = .006); young adults whose mothers had lifetime marijuana use (ARR, 1.2; 95% CI, 1.0-1.4; P = .04); and young adults whose fathers had 52 days or more of past-year marijuana use (ARR, 1.4; 95% CI, 1.0-1.9; P = .046). Compared with their peers whose parents had no past marijuana use and after adjusting for covariates, risk of past-year alcohol use was higher among adolescents whose mothers had lifetime marijuana use (ARR, 1.2; 95% CI, 1.1-1.4; P = .004), less than 52 days of past-year marijuana use (ARR, 1.5; 95% CI, 1.2-1.9; P = .002), or 52 days or more of past-year marijuana use (ARR, 1.3; 95% CI, 1.0-1.7; P = .04). After adjusting for covariates, parental marijuana use was not associated with opioid misuse by offspring. Conclusions and Relevance: In this cross-sectional study, parental marijuana use was associated with increased risk of substance use among adolescent and young adult offspring living in the same household. Screening household members for substance use and counseling parents on risks posed by current and past marijuana use are warranted.

      5. Assessing the burden of neonatal abstinence syndrome: Validation of ICD-9-CM data, Florida, 2010-2011external icon
        Phillips-Bell GS, Holicky A, Lind JN, Sappenfield WM, Hudak ML, Petersen E, Anjorhin S, Watkins SM, Creanga AA, Correia JA.
        J Public Health Manag Pract. 2020 Jan/Feb;26(1):E1-e8.
        CONTEXT: On October 1, 2015, the United States transitioned from using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to ICD-10-CM. Continuing to monitor the burden of neonatal abstinence syndrome (NAS) after the transition presently requires use of data dependent on ICD-9-CM coding to enable trend analyses. Little has been published on the validation of using ICD-9-CM codes to identify NAS cases. OBJECTIVE: To assess the validity of hospital discharge data (HDD) from selected Florida hospitals for passive NAS surveillance, based on ICD-9-CM codes, which are used to quantify baseline prevalence of NAS. DESIGN: We reviewed infant and maternal data for all births at 3 Florida hospitals from 2010 to 2011. Potential NAS cases included infants with ICD-9-CM discharge codes 779.5 and/or 760.72 in linked administrative data (ie, HDD linked to vital records) or in unlinked HDD and infants identified through review of neonatal intensive care unit admission logs or inpatient pharmacy records. Confirmed infant cases met 3 clinician-proposed criteria. Sensitivity and positive predictive value were calculated to assess validity for the 2 ICD-9-CM codes, individually and combined. RESULTS: Of 157 confirmed cases, 134 with 779.5 and/or 760.72 codes were captured in linked HDD (sensitivity = 85.4%) and 151 in unlinked HDD (sensitivity = 96.2%). Positive predictive value was 74.9% for linked HDD and 75.5% for unlinked HDD. For either HDD types, the single 779.5 code had the highest positive predictive value (86%), lowest number of false positives, and good to excellent sensitivity. CONCLUSIONS: Passive surveillance using ICD-9-CM code 779.5 in either linked or unlinked HDD identified NAS cases with reasonable validity. Our work supports the use of ICD-9-CM code 779.5 to assess the baseline prevalence of NAS through 2015.

      6. Geospatial mapping and resource utilization tool in support of a national smoke-free public housing ruleexternal icon
        Tetlow S, Gurbaxani B, Graffunder C, Owen C, Tran D, Zhao J, Rodriguez JA, Ahn A, Choe K, Mummigatti V, Vedula D, Hayes K, Kelly M, McNabb S, Swann J.
        BMC Res Notes. 2019 Nov 25;12(1):767.
        OBJECTIVE: To advance public health support for the U.S. Department of Housing and Urban Development's smoke-free rule, the Centers for Disease Control and Prevention collaborated with the Georgia Institute of Technology to develop a geospatial mapping tool. The objective was to create a tool state and local public health agencies could use to tailor smoke-free educational materials and cessation interventions for specific public housing development resident populations. RESULTS: The resulting "Extinguish Tool" includes an interactive map of U.S. public housing developments (PHDs) and healthcare facilities that provides detailed information on individual PHDs, their proximity to existing healthcare facilities, and the demographic characteristics of residents. The tool also estimates the number of PHD residents who smoke cigarettes and calculates crude estimates of the potential economic benefits of providing cessation interventions to these residents. The geospatial mapping tool project serves as an example of a collaborative and innovative public health approach to protecting the health and well-being of the nation's two million public housing residents, including 760,000 children, from the harms of tobacco smoking and secondhand smoke exposure in the places where they live, play, and gather.

    • Veterinary Medicine
      1. Cryptosporidium parvum as a risk factor of diarrhea occurrence in neonatal alpacas in Peruexternal icon
        Gomez-Puerta LA, Gonzalez AE, Vargas-Calla A, Lopez-Urbina MT, Cama V, Xiao L.
        Parasitol Res. 2019 Nov 22.
        Cryptosporidiosis has been reported as an important cause of neonatal diarrhea and mortality in cattle, sheep, and other ruminants, but its impact on alpaca health has not been studied thoroughly. In this study, we have determined the prevalence and evaluated the role of cryptosporidiosis as a risk factor for diarrhea occurrence in newborn alpacas. During the calving season (January-March) of 2006, stool specimens (N = 1312) were collected from 24 herds of newborn alpacas in Puno and Cuzco, departments that account for the largest populations of alpacas in Peru. All the specimens were microscopically screened for Cryptosporidium spp. using the acid-fast technique. The association between Cryptosporidium detection and diarrhea was analyzed using chi(2) test and generalized lineal model. Cryptosporidium species were determined by PCR-RFLP analysis of the small subunit rRNA gene. Cryptosporidium oocysts were detected in 159 of 1312 (12.4%) newborn alpacas. Results of the analyses demonstrated that crypstosporidiosis was significantly associated with diarrhea (PR = 3.84; CI95% 2.54-5.81; p < 0.0001). Only Cryptosporidium parvum was detected in the 153 Cryptosporidium-infected animals. Thus, there is an association of C. parvum infection with diarrhea in neonatal alpacas.

    • Zoonotic and Vectorborne Diseases
      1. The first report of human infection with avian influenza A(H9N2) virus in Oman: the need for a One Health approachexternal icon
        Al-Mayahi Z, Al Kindi H, Davis CT, Al-Rawahi B, Al-Yaqoubi F, Jang Y, Jones J, Barnes JR, Davis W, Shu B, Lynch B, Wentworth DE, Al-Maskari Z, Al Maani A, Al Abri S.
        Int J Infect Dis. 2019 Nov 22.
        After detection of the first human case of avian influenza A subtype H9N2 in 1998, more than 40 cases were diagnosed worldwide. The spread of the virus, on the other hand, is more remarkable and significant in global poultry populations causing notable economic losses despite its low pathogenicity. Many surveillance studies and activities conducted in several countries proved the predominance of this virus subtype. We present a case report of A(H9N2) virus infection in a 14-month-old female from Oman. It is the first A(H9N2) human case reported from Oman and the Gulf Cooperation Countries and the second country outside of southern and eastern Asia, cases were also detected in Egypt. The patient had bronchial asthma and presented with high-grade temperature and symptoms of lower respiratory tract infection that necessitated admission to a high dependency unit in a tertiary care hospital. It is of urgency that a multisectoral One Health approach be established to combat the threat of avian influenza at the animal-human interface. In addition to enhancements of surveillance and control in poultry, there is a need to develop screening and preventive programs for high-risk occupations.

      2. Background: The Zika virus (ZIKV) caused a large outbreak in the Americas leading to the declaration of a Public Health Emergency of International Concern in February 2016. A causal relation between infection and adverse congenital outcomes such as microcephaly was declared by the World Health Organization (WHO) informed by a systematic review structured according to a framework of ten dimensions of causality, based on the work of Bradford Hill. Subsequently, the evidence has continued to accumulate, which we incorporate in regular updates of the original work, rendering it a living systematic review. Methods: We present an update of our living systematic review on the causal relation between ZIKV infection and adverse congenital outcomes and between ZIKV and GBS for four dimensions of causality: strength of association, dose-response, specificity, and consistency. We assess the evidence published between January 18, 2017 and July 1, 2019. Results: We found that the strength of association between ZIKV infection and adverse outcomes from case-control studies differs according to whether exposure to ZIKV is assessed in the mother (OR 3.8, 95% CI: 1.7-8.7, I (2)=19.8%) or the foetus/infant (OR 37.4, 95% CI: 11.0-127.1, I (2)=0%). In cohort studies, the risk of congenital abnormalities was 3.5 times higher after ZIKV infection (95% CI: 0.9-13.5, I (2)=0%). The strength of association between ZIKV infection and GBS was higher in studies that enrolled controls from hospital (OR: 55.8, 95% CI: 17.2-181.7, I (2)=0%) than in studies that enrolled controls at random from the same community or household (OR: 2.0, 95% CI: 0.8-5.4, I (2)=74.6%). In case-control studies, selection of controls from hospitals could have biased results. Conclusions: The conclusions that ZIKV infection causes adverse congenital outcomes and GBS are reinforced with the evidence published between January 18, 2017 and July 1, 2019.

      3. Do monkeypox exposures vary by ethnicity? Comparison of Aka- and Bantu-suspected monkeypox casesexternal icon
        Guagliardo SA, Doshi RH, Reynolds MG, Dzabatou-Babeaux A, Ndakala N, Moses C, McCollum AM, Petersen BW.
        Am J Trop Med Hyg. 2019 Nov 25.
        In 2017, a monkeypox outbreak occurred in Likouala Department, Republic of the Congo. Many of the affected individuals were of Aka ethnicity, hunter-gatherers indigenous to Central Africa who have worse health outcomes in comparison with other forest-dwelling peoples. To test the hypothesis that Aka people have different risk factors for monkeypox, we analyzed questionnaire data for 39 suspected cases, comparing Aka and Bantu groups. Aka people were more likely to touch animal urine/feces, find dead animals in/around the home, eat an animal that was found dead, or to have been scratched or bitten by an animal (P < 0.05, all variables). They were also more likely to visit the forest >/= once/week, sleep outside, or sleep on the ground (P < 0.001, all variables), providing opportunities for contact with monkeypox reservoirs during the night. The Aka and possibly other vulnerable groups may warrant special attention during educational and health promotion programs.

      4. Asymptomatic orthopoxvirus circulation in humans in the wake of a monkeypox outbreak among chimpanzees in Cameroonexternal icon
        Guagliardo SA, Monroe B, Moundjoa C, Athanase A, Okpu G, Burgado J, Townsend MB, Satheshkumar PS, Epperson S, Doty JB, Reynolds MG, Dibongue EE, Etoundi GA, Mathieu E, McCollum AM.
        Am J Trop Med Hyg. 2019 Nov 25.
        Monkeypox virus is a zoonotic Orthopoxvirus (OPXV) that causes smallpox-like illness in humans. In Cameroon, human monkeypox cases were confirmed in 2018, and outbreaks in captive chimpanzees occurred in 2014 and 2016. We investigated the OPXV serological status among staff at a primate sanctuary (where the 2016 chimpanzee outbreak occurred) and residents from nearby villages, and describe contact with possible monkeypox reservoirs. We focused specifically on Gambian rats (Cricetomys spp.) because it is a recognized possible reservoir and because contact with this species was common enough to render sufficient statistical power. We collected one 5-mL whole blood specimen from each participant to perform a generic anti-OPXV ELISA test for IgG and IgM antibodies and administered a questionnaire about prior symptoms of monkeypox-like illness and contact with possible reservoirs. Our results showed evidence of OPXV exposures (IgG positive, 6.3%; IgM positive, 1.6%) among some of those too young to have received smallpox vaccination (born after 1980, n = 63). No participants reported prior symptoms consistent with monkeypox. After adjusting for the education level, participants who frequently visited the forest were more likely to have recently eaten Gambian rats (OR: 3.36, 95% CI: 1.91-5.92, P < 0.001) and primate sanctuary staff were less likely to have touched or sold Gambian rats (OR: 0.23, 95% CI: 0.19-0.28, P < 0.001). The asymptomatic or undetected circulation of OPXVs in humans in Cameroon is likely, and contact with monkeypox reservoirs is common, raising the need for continued surveillance for human and animal disease.

      5. Seasonal influenza and avian influenza A(H5N1) virus surveillance among inpatients and outpatients, East Jakarta, Indonesia, 2011-2014external icon
        Lafond KE, Praptiningsih CY, Mangiri A, Syarif M, Triada R, Mulyadi E, Septiawati C, Setiawaty V, Samaan G, Storms AD, Uyeki TM, Iuliano AD.
        Emerg Infect Dis. 2019 Nov;25(11):2031-2039.
        During October 2011-September 2014, we screened respiratory specimens for seasonal and avian influenza A(H5N1) virus infections among outpatients with influenza-like illness and inpatients with severe acute respiratory infection (SARI) in East Jakarta, an Indonesia district with high incidence of H5N1 virus infection among poultry. In total, 31% (1,875/6,008) of influenza-like illness case-patients and 15% (571/3,811) of SARI case-patients tested positive for influenza virus. Influenza A(H1N1)pdm09, influenza A(H3N2), and influenza B virus infections were detected in all 3 years, and the epidemic season extended from November through May. Although 28% (2,810/10,135) of case-patients reported exposure to poultry, only 1 SARI case-patient with an H5N1 virus infection was detected. Therefore, targeted screening among case-patients with high-risk poultry exposures (e.g., a recent visit to a live bird market or close proximity to sick or dead poultry) may be a more efficient routine surveillance strategy for H5N1 virus in these types of settings.

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