Volume 11, Issue 6, February 5, 2019

CDC Science Clips: Volume 11, Issue 6, February 5, 2019

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

This week Science Clips is pleased to feature articles on the association between Zika virus and Guillain-Barré syndrome (GBS)

Soon after reporting local transmission of Zika virus in December 2015, the Puerto Rico Department of Health (PRDH) and US Centers for Disease Control and Prevention (CDC) began identifying cases of GBS, an uncommon autoimmune condition characterized by progressive, bilateral weakness and diminished reflexes. At the time, several countries affected by Zika virus had reported a concurrent increase in patients with GBS; however, scientific data was extremely limited. PRDH, CDC, the University of Puerto Rico, and other local partners established a jurisdiction-wide emergency public health surveillance system to identify GBS patients during the 2016 Zika virus epidemic in Puerto Rico. Patient specimens were tested for evidence of Zika virus infection.

The articles featured below are the results of these efforts, making critical scientific contributions to describe the association between Zika virus and GBS, including: emergency public health surveillance and preparedness, GBS epidemiology and baseline incidence, Zika virus laboratory identification by specimen types, GBS short- and long-term clinical characteristics, and Zika-associated GBS pathophysiology.

  1. Key Scientific Articles in Featured Topic Areas
    Subject matter experts decide what topic to feature, and articles are selected from the last 3 to 6 months of published literature. Key topic coincides monthly with other CDC products (e.g. Vital Signs).
    • Zoonotic and Vectorborne Diseases – Zika Virus and Guillain-Barré Syndrome
      1. Implementation and Evaluation of Guillain-Barré Syndrome Surveillance in Puerto Rico during the 2016 Zika Virus EpidemicExternal
        Major CG, Dirlikov E, Medina NA, Lugo-Robles R, Matos D, Munoz-Jordan J, Colon-Sanchez C, Garcia-Negron M, Olivero-Segarra M, Malave-Gonzalez G, Thomas DL, Luciano CA, Waterman SH, Sejvar J, Sharp TM, Rivera-Garcia B.
        P R Health Sci J. 2018 Dec;37(Special Issue):S85-s92.
        OBJECTIVE: Guillain-Barré syndrome (GBS) is an uncommon autoimmune disorder that follows infection or vaccination, and increased incidence has been reported during Zika virus (ZIKV) transmission. During the 2016 ZIKV epidemic, the Puerto Rico Department of Health (PRDH) implemented the Enhanced GBS Surveillance System (EGBSSS). Here, we describe EGBSSS implementation and evaluate completeness, validity, and timeliness. METHODS: GBS cases were identified using passive surveillance and discharge diagnostic code for GBS. Completeness was evaluated by capture-recapture methods. Sensitivity and positive predictive value (PPV) for confirmed GBS cases were calculated for both case identification methods. Median time to completion of key time steps were compared by quarter (Q1-4) and hospital size. RESULTS: A total of 122 confirmed GBS cases with onset of neurologic illness in 2016 were identified. Capture-recapture methodology estimated that four confirmed GBS cases were missed by both identification methods. Identification of cases by diagnostic code had a higher sensitivity than passive surveillance (89% vs. 80%), but a lower PPV (60% vs. 72%). There was a significant decrease from Q1 to Q3 in median time from hospital admission to case reporting (11 days vs. 2 days, p = 0.032) and from Q2 to Q3 in median time from specimen receipt to arbovirus laboratory test reporting (35 days vs. 26 days, p = 0.004). CONCLUSION: EGBSSS provided complete, valid, and increasingly timely surveillance data, which guided public health action and supported healthcare providers during the ZIKV epidemic. This evaluation provides programmatic lessons for GBS surveillance and emergency response surveillance.

      2. Clinical Features of Guillain-Barré Syndrome With vs Without Zika Virus Infection, Puerto Rico, 2016External
        Dirlikov E, Major CG, Medina NA, Lugo-Robles R, Matos D, Munoz-Jordan JL, Colon-Sanchez C, Garcia M, Olivero-Segarra M, Malave G, Rodriguez-Vega GM, Thomas DL, Waterman SH, Sejvar JJ, Luciano CA, Sharp TM, Rivera-Garcia B.
        JAMA Neurol. 2018 Sep 1;75(9):1089-1097.
        Importance: The pathophysiologic mechanisms of Guillain-Barré syndrome (GBS) associated with Zika virus (ZIKV) infection may be indicated by differences in clinical features. Objective: To identify specific clinical features of GBS associated with ZIKV infection. Design, Setting, and Participants: During the ZIKV epidemic in Puerto Rico, prospective and retrospective strategies were used to identify patients with GBS who had neurologic illness onset in 2016 and were hospitalized at all 57 nonspecialized hospitals and 2 rehabilitation centers in Puerto Rico. Guillain-Barré syndrome diagnosis was confirmed via medical record review using the Brighton Collaboration criteria. Specimens (serum, urine, cerebrospinal fluid, and saliva) from patients with GBS were tested for evidence of ZIKV infection by real-time reverse transcriptase-polymerase chain reaction; serum and cerebrospinal fluid were also tested by IgM enzyme-linked immunosorbent assay. In this analysis of public health surveillance data, a total of 123 confirmed GBS cases were identified, of which 107 had specimens submitted for testing; there were 71 patients with and 36 patients without evidence of ZIKV infection. Follow-up telephone interviews with patients were conducted 6 months after neurologic illness onset; 60 patients with and 27 patients without evidence of ZIKV infection participated. Main Outcomes and Measures: Acute and long-term clinical characteristics of GBS associated with ZIKV infection. Results: Of 123 patients with confirmed GBS, the median age was 54 years (age range, 4-88 years), and 68 patients (55.3%) were male. The following clinical features were more frequent among patients with GBS and evidence of ZIKV infection compared with patients with GBS without evidence of ZIKV infection: facial weakness (44 [62.0%] vs 10 [27.8%]; P < .001), dysphagia (38 [53.5%] vs 9 [25.0%]; P = .005), shortness of breath (33 [46.5%] vs 9 [25.0%]; P = .03), facial paresthesia (13 [18.3%] vs 1 [2.8%]; P = .03), elevated levels of protein in cerebrospinal fluid (49 [94.2%] vs 23 [71.9%]; P = .008), admission to the intensive care unit (47 [66.2%] vs 16 [44.4%]; P = .03), and required mechanical ventilation (22 [31.0%] vs 4 [11.1%]; P = .02). Six months after neurologic illness onset, patients with GBS and evidence of ZIKV infection more frequently reported having excessive or inadequate tearing (30 [53.6%] vs 6 [26.1%]; P = .03), difficulty drinking from a cup (10 [17.9%] vs 0; P = .03), and self-reported substantial pain (15 [27.3%] vs 1 [4.3%]; P = .03). Conclusions and Relevance: In this study, GBS associated with ZIKV infection was found to have higher morbidity during the acute phase and more frequent cranial neuropathy during acute neuropathy and 6 months afterward. Results indicate GBS pathophysiologic mechanisms that may be more common after ZIKV infection.

      3. Postmortem Findings in Patient with Guillain-Barré Syndrome and Zika Virus InfectionExternal
        Dirlikov E, Torres JV, Martines RB, Reagan-Steiner S, Perez GV, Rivera A, Major C, Matos D, Munoz-Jordan J, Shieh WJ, Zaki SR, Sharp TM.
        Emerg Infect Dis. 2018 Jan;24(1):114-117.
        Postmortem examination results of a patient with Guillain-Barré syndrome and confirmed Zika virus infection revealed demyelination of the sciatic and cranial IV nerves, providing evidence of the acute demyelinating inflammatory polyneuropathy Guillain-Barré syndrome variant. Lack of evidence of Zika virus in nervous tissue suggests that pathophysiology was antibody mediated without neurotropism.

      4. Postmortem Findings in Person with Guillain-Barré Syndrome and Zika Virus [Podcast]
        Dirlikov E.
        Emerging Infectious Diseases Podcast. 2018 May 2.
        Dr. Emilio Dirlikov, an EIS officer in CDC’s Center for Global Health, discusses the connection between Guillain-Barré Syndrome and Zika Virus.

      5. Acute Zika Virus Infection as a Risk Factor for Guillain-Barré Syndrome in Puerto RicoExternal
        Dirlikov E, Medina NA, Major CG, Munoz-Jordan JL, Luciano CA, Rivera-Garcia B, Sharp TM.
        Jama. 2017 Oct 17;318(15):1498-1500.

        [No abstract]

      6. [No abstract]

      7. Incidence and clinical characteristics of Guillain-Barré syndrome before the introduction of Zika virus in Puerto RicoExternal
        Salinas JL, Major CG, Pastula DM, Dirlikov E, Styczynski A, Luciano CA, Wojna V, Sharp TM, Sejvar JJ, Rivera-Garcia B.
        J Neurol Sci. 2017 Jun 15;377:102-106.
        BACKGROUND: Zika virus has been associated with increases in Guillain-Barré syndrome (GBS) incidence. A GBS incidence estimation and clinical description was performed to assess baseline GBS epidemiology before the introduction of Zika virus in Puerto Rico. METHODS: Hospitalization administrative data from an island-wide insurance claims database and U.S. Census Bureau population estimates provided a crude GBS incidence for 2013. This estimate was adjusted using the proportion of GBS cases meeting Brighton criteria for confirmed GBS from nine reference hospitals. Characteristics of confirmed GBS cases in the same nine hospitals during 2012-2015 are described. RESULTS: A total of 136 GBS hospitalization claims were filed in 2013 (crude GBS incidence was 3.8 per 100,000 population). The adjusted GBS incidence was 1.7 per 100,000 population. Of 67 confirmed GBS cases during 2012-2015, 66% had an antecedent illness. Median time from antecedent illness to GBS onset was 7days. Most cases (67%) occurred during July-September. CONCLUSIONS: Puerto Rico’s GBS incidence for 2013 was estimated using a combination of administrative data and medical records review; this method could be employed in other regions to monitor GBS incidence before and after the introduction of GBS infectious triggers.

      8. Guillain-Barré Syndrome and Healthcare Needs during Zika Virus Transmission, Puerto Rico, 2016External
        Dirlikov E, Kniss K, Major C, Thomas D, Virgen CA, Mayshack M, Asher J, Mier YT, Salinas JL, Pastula DM, Sharp TM, Sejvar J, Johansson MA, Rivera-Garcia B.
        Emerg Infect Dis. 2017 Jan;23(1):134-136.
        To assist with public health preparedness activities, we estimated the number of expected cases of Zika virus in Puerto Rico and associated healthcare needs. Estimated annual incidence is 3.2-5.1 times the baseline, and long-term care needs are predicted to be 3-5 times greater than in years with no Zika virus.

      9. Guillain-Barré Syndrome During Ongoing Zika Virus Transmission – Puerto Rico, January 1-July 31, 2016External
        Dirlikov E, Major CG, Mayshack M, Medina N, Matos D, Ryff KR, Torres-Aponte J, Alkis R, Munoz-Jordan J, Colon-Sanchez C, Salinas JL, Pastula DM, Garcia M, Segarra MO, Malave G, Thomas DL, Rodriguez-Vega GM, Luciano CA, Sejvar J, Sharp TM, Rivera-Garcia B.
        MMWR Morb Mortal Wkly Rep. 2016 Sep 2;65(34):910-4.
        Guillain-Barré syndrome (GBS) is a postinfectious autoimmune disorder characterized by bilateral flaccid limb weakness attributable to peripheral nerve damage (1). Increased GBS incidence has been reported in countries with local transmission of Zika virus, a flavivirus transmitted primarily by certain Aedes species mosquitoes (2). In Puerto Rico, three arthropod-borne viruses (arboviruses) are currently circulating: Zika, dengue, and chikungunya. The first locally acquired Zika virus infection in Puerto Rico was reported in December 2015 (3). In February 2016, the Puerto Rico Department of Health (PRDH), with assistance from CDC, implemented the GBS Passive Surveillance System (GBPSS) to identify new cases of suspected GBS (4). Fifty-six suspected cases of GBS with onset of neurologic signs during January 1-July 31, 2016, were identified. Thirty-four (61%) patients had evidence of Zika virus or flavivirus infection; the median age of these patients was 55 years (range = 21-88 years), and 20 (59%) patients were female. These 34 patients were residents of seven of eight PRDH public health regions. All 34 patients were hospitalized and treated with intravenous immunoglobulin G (IVIg), the standard treatment for GBS; 21 (62%) required intensive care unit admission, including 12 (35%) who required endotracheal intubation and mechanical ventilation. One patient died of septic shock after treatment for GBS. Additionally, 26 cases of neurologic conditions other than GBS were reported through GBPSS, including seven (27%) in patients with evidence of Zika virus or flavivirus infection. Residents of and travelers to Puerto Rico and countries with active Zika virus transmission should follow recommendations for prevention of Zika virus infections.* Persons with signs or symptoms consistent with GBS should promptly seek medical attention. Health care providers in areas with ongoing local transmission seeing patients with neurologic illnesses should consider GBS and report suspected cases to public health authorities.

  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. COPD and rural health: A dialogue on the national action planExternal
        Moore P, Atkins GT, Cramb S, Croft JB, Davis L, Dolor RJ, Doyle D, Elehwany M, James C, Knudson A, Linnell J, Mannino D, Rommes JM, Sood A, Stockton E, Weissman DN, Witte M, Wyatt E, Yarbrough WC, Yawn BP, Johnson L, Morris T, Kiley JP, Ammary-Risch NJ, Punturieri A.
        J Rural Health. 2019 Jan 24.

        [No abstract]

      2. Blood pressure assessment in adults in clinical practice and clinic-based research: JACC Scientific Expert PanelCdc-pdfExternal
        Muntner P, Einhorn PT, Cushman WC, Whelton PK, Bello NA, Drawz PE, Green BB, Jones DW, Juraschek SP, Margolis KL, Miller ER, Navar AM, Ostchega Y, Rakotz MK, Rosner B, Schwartz JE, Shimbo D, Stergiou GS, Townsend RR, Williamson JD, Wright JT, Appel LJ, National Heart L, Blood Institute Working G.
        J Am Coll Cardiol. 2019 ;73(3):317-335.
        The accurate measurement of blood pressure (BP) is essential for the diagnosis and management of hypertension. Restricted use of mercury devices, increased use of oscillometric devices, discrepancies between clinic and out-of-clinic BP, and concerns about measurement error with manual BP measurement techniques have resulted in uncertainty for clinicians and researchers. The National Heart, Lung, and Blood Institute of the U.S. National Institutes of Health convened a working group of clinicians and researchers in October 2017 to review data on BP assessment among adults in clinical practice and clinic-based research. In this report, the authors review the topics discussed during a 2-day meeting including the current state of knowledge on BP assessment in clinical practice and clinic-based research, knowledge gaps pertaining to current BP assessment methods, research and clinical needs to improve BP assessment, and the strengths and limitations of using BP obtained in clinical practice for research and quality improvement activities.

      3. Trends in eye care use and eyeglasses affordability: The US National Health Interview Survey, 2008-2016External
        Varadaraj V, Frick KD, Saaddine JB, Friedman DS, Swenor BK.
        JAMA Ophthalmol. 2019 Jan 24.
        Importance: Understanding eye care use over time is essential to estimate continued unmet health care needs and help guide future public health priorities. Objective: To update trends in using eye care and affording eyeglasses in the United States. Design, Setting, and Participants: This analysis of data from the US National Health Interview Survey included adults 18 years and older from 9 annual cross-sectional population-based samples ranging in size from 21781 to 36697 participants from 2008 to 2016. Data were analyzed from August 2017 to February 2018. Exposures: Visual impairment, defined as self-reported difficulty seeing despite wearing eyeglasses. Main Outcomes and Measures: Outcome measures included visits to an eye care professional and inability to afford eyeglasses when needed in the past year. Survey logistic regression, adjusted for age, sex, race/ethnicity, visual impairment status, education, employment, general health, poverty-income ratio, and vision insurance, was used to examine associations between survey year and eye care outcomes. Results: Analyses included 9 annual cross-sectional population-based samples pooled from 2008 to 2016, ranging in size from 21781 to 36697 participants aged 18 years or older. Compared with 2008, greater proportions of the US population were 65 years or older, Hispanic, or Asian in 2016. There was a significant trend for eye care use and difficulty affording eyeglasses from 2008 to 2016. In fully adjusted models, Americans were less likely to use eye care in 2014 compared with 2008 (odds ratio [OR], 0.90; 99.9% CI, 0.82-0.98; P < .001). Compared with 2008, Americans were also less likely to report difficulty affording eyeglasses from 2014 onwards (2014: OR, 0.82; 99.9% CI, 0.69-0.97; P < .001; 2015: OR, 0.81; 99.9% CI, 0.69-0.96; P < .001; 2016: OR, 0.70; 99.9% CI, 0.59-0.82; P < .001). After adjusting for all covariates, including survey year, those with visual impairment compared with those without were more likely to use eye care (OR, 1.54; 99.9% CI, 1.45-1.65; P < .001) but had greater difficulty affording eyeglasses (OR, 3.86; 99.9% CI, 0.58-0.72; P < .001). Women were also more likely to use eye care (OR, 1.42; 99.9% CI, 1.37-1.48; P < .001) and report difficulty affording eyeglasses (OR, 1.68; 99.9% CI, 1.56-1.81; P < .001) compared with men. Compared with non-Hispanic white individuals, black, Asian, and Hispanic individuals were less likely to use eye care, and Asian and black individuals were less likely to have difficulty affording eyeglasses. Conclusions and Relevance: These data indicate decreased difficulty affording eyeglasses among Americans from 2014 to 2016, possibly related to economic recovery and health care reform. However, the findings suggest women and racial/ethnic minorities are more likely to have lower use of eye care or inability to afford eyeglasses.

      4. PURPOSE: The American Heart Association has identified seven modifiable cardiovascular health (CVH) metrics, including four health behaviors (body mass index, smoking, physical activity, and dietary intake) and three health factors (total cholesterol, blood pressure, and fasting glucose). We sought to examine the association between CVH metrics and depression. METHODS: We analyzed data on 14,561 adults aged 20 years or older from the National Health and Nutrition Examination Survey 2007-2014. Depressive symptoms were assessed using the Patient Health Questionnaire; a score of 0-4, 5-9, and 10 or higher represented no or minimal, mild, moderate or severe depressive symptoms, respectively. CVH was categorized as inadequate, average, or optimum. We used multinomial logistic regression to assess the association between CVH and depression, adjusted for age, gender, race or ethnicity, education, and alcohol use. RESULTS: Prevalence of inadequate, average, and optimum CVH were 6.1%, 59.7%, and 34.2%; 14.9% and 7.8% of adults had mild and moderate/severe depression, respectively. Compared with participants with optimum CVH, prevalence ratios for moderate or severe depression were 4.39 (95% confidence interval, 3.32-5.80) and 2.64 (2.15-3.24) for those with inadequate and average CVH, respectively. The corresponding prevalence ratios for mild depression were 2.11 (1.77-2.52) and 1.36 (1.19-1.55). The association appeared to be stronger for CVH behaviors. CONCLUSIONS: There was a graded association between CVH metrics, particularly for health behaviors, and mild and moderate/severe depression among U.S. adults.

      5. Medical financial hardship among cancer survivors in the United StatesExternal
        Zheng Z, Jemal A, Han X, Guy GP, Li C, Davidoff AJ, Banegas MP, Ekwueme DU, Yabroff KR.
        Cancer. 2019 Jan 21.
        BACKGROUND: The current study examined medical financial hardship in cancer survivors and those without a cancer history in the United States. METHODS: The 2013 to 2016 National Health Interview Survey was used to identify cancer survivors (stratified by ages 18-49 years [1424 survivors], ages 50-64 years [2916 survivors], and ages >/=65 years [6014 survivors]) and individuals without a cancer history (ages 18-64 years [66,951 individuals], ages 50-64 years [31,741 individuals], and ages >/=65 years [25,744 individuals]). Medical financial hardship was categorized into 3 domains: 1) material (eg, problems paying medical bills); 2) psychological (eg, worrying about paying medical bills); and 3) behavioral (eg, delaying/forgoing care due to cost). Generalized ordinal logistic regressions were used to examine the associations between cancer history, hardship, and health insurance deductibles/health savings accounts (among privately insured cancer survivors aged 18-64 years only). RESULTS: Compared with those without a cancer history, cancer survivors were more likely to report any material (ages 18-49 years: 43.4% vs 30.1%; ages 50-64 years: 32.8% vs 27.8%; and ages >/=65 years: 17.3% vs 14.7%), psychological (ages 18-49 years: 53.5% vs 47.1%), and behavioral (ages 18-49 years: 30.6% vs 21.8%; and ages 50-64 years: 27.2% vs 23.4%) measure of financial hardship, and multiple domains of hardship (age groups 18-49 years and 50-64 years; all P < .01). Among privately insured survivors, having a high-deductible health plan without a health savings account was found to be associated with greater hardship compared with having low-deductible insurance. CONCLUSIONS: Younger cancer survivors are particularly vulnerable to material, psychological, and behavioral medical financial hardship. Interventions designed to reduce financial hardship should consider multiple domains of hardship as well as insurance benefit design.

    • Communicable Diseases
      1. Treatment outcomes, diagnostic and therapeutic impact: Xpert vs. smear. A systematic review and meta-analysisExternal
        Agizew T, Boyd R, Auld AF, Payton L, Pals SL, Lekone P, Chihota V, Finlay A.
        Int J Tuberc Lung Dis. 2019 Jan 1;23(1):82-92.
        BACKGROUND: Compared with smear microscopy, Xpert((R)) MTB/RIF has the potential to reduce delays in tuberculosis (TB) diagnosis and treatment initiation, and improve treatment outcomes. We reviewed publications comparing treatment outcomes of drug-susceptible TB patients diagnosed using Xpert vs. smear. METHODS: Citations (2000-2016) reporting treatment outcomes of patients diagnosed using Xpert compared with smear were selected from PubMed, Scopus and conference abstracts. We conducted a systematic review and meta-analysis. Favorable (cured, completed) and unfavorable (failure, death, loss to follow-up) outcomes were pooled for meta-analysis; we also reviewed the number of TB cases diagnosed, time to treatment and empiric treatment. The Mantel-Haenszel method with a fixed-effect model was used; I(2) was calculated to measure heterogeneity. RESULTS: From 13 citations, 43 594 TB patients were included and 4825 were with known TB treatment outcome. From the pooled analysis, an unfavorable outcomes among those diagnosed using Xpert compared with smear was 20.2%, 541/2675 vs. 21.9%, 470/2150 (risk ratio 0.92, 95%CI 0.82-1.02). Statistical heterogeneity was low (I(2) = 0.0%, P = 0.910). Compared with smear, Xpert was reported to be superior in increasing the number of TB patients diagnosed (2/9 citations), increasing bacteriologically confirmed TB (7/9 citations), reducing empiric treatment (3/5 citations), reducing time to diagnosis (2/3 citations), and reducing time to treatment initiation (1/5 citations). CONCLUSIONS: Xpert implementation showed no discernible impact on treatment outcomes compared with conventional smear despite reduced time to diagnosis, time to treatment or reduced level of empiric treatment. Further research is required to learn more about gaps in the existing health system.

      2. Multidrug-resistant (MDR) tuberculosis (TB) emerged shortly after introduction of rifamycins in the 1960s; isoniazid resistance had already emerged by the mid-1950s. Without these two drugs, tuberculosis is very difficult and costly to treat, with unacceptably high rates of treatment failure, death, loss to follow-up, and no known preventive treatment. Global attention first focused on MDR TB in the early 1990s when nosocomial outbreaks with high case fatality rates were reported in many countries. Prevalence data for MDR TB on a global scale first became available in 1997. In 2016, about 4.1% of estimated ~10.4 million new TB patients plus 19% of ~1 million previously treated patients, that is ~600,000 people develop MDR TB or rifampicin resistant TB; 250,000 die annually. Ten years ago, <5% of them were diagnosed and enrolled on treatment, increasing to about 21.6% in 2016, leaving much room for improvement. Over that same period of time, momentum has been building to combat MDR TB, including advances in diagnostics, therapeutics, and care; decentralizing patient-centered care coupled with social support; growing improvements in prevention of transmission; increasing use of highly effective antiretroviral treatment; communications, advocacy, and social mobilization; leadership and updated policy guidance. Taking into account long-term epidemiological trends, all of these factors coupled with funding from the Global Fund and other major donors, suggest we may be on the verge of accelerating declines in MDR TB morbidity and mortality. Extreme poverty, which allows tuberculosis to flourish, has actually decreased by about one billion people over the past 25 years. What is needed now is political will on the part of national governments to apply these advances diligently and further reductions in poverty, pushing epidemiological trends past the inflection point to the downward slope. All these can be accelerated with increased support for science leading to better diagnosis, treatment and an effective vaccine to sustain and accelerate the meager declines reported thus far.

      3. Proportion of incident HIV cases among men who have sex with men attributable to gonorrhea and chlamydia: A modeling analysisExternal
        Jones J, Weiss K, Mermin J, Dietz P, Rosenberg ES, Gift TL, Chesson H, Sullivan PS, Lyles C, Bernstein KT, Jenness SM.
        Sex Transm Dis. 2019 Jan 19.
        BACKGROUND: Sexually transmitted infections (STIs) are associated with an increased risk of HIV acquisition and transmission. We estimated the proportion of HIV incidence among men who have sex with men attributable to infection with the two most common bacterial STIs, Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT). METHODS: We used a stochastic, agent-based model of a sexual network of MSM with co-circulating HIV, NG, and CT infections. Relative risk (RR) multipliers, specific to anatomic site of infection, modified the risk of HIV transmission and acquisition based on STI status. We estimated the effect of NG and CT on HIV incidence overall and on HIV acquisition and HIV transmission separately. Each scenario was simulated for ten years. The population attributable fraction (PAF) was determined for each combination of RRs by comparing the incidence in the final year of a scenario to a scenario in which the RRs associated with NG and CT were set to 1.0. RESULTS: Overall, 10.4% (IQR: 7.9,12.4) of HIV infections were attributable to NG/CT infection. Then in sensitivity analyses, the PAF for HIV transmission ranged from 3.1% (IQR: 0.5, 5.2) to 20.4% (IQR: 17.8, 22.5) and the PAF for HIV acquisition ranged from 2.0% (IQR: -0.7, 4.3) to 13.8% (IQR: 11.7, 16.0). CONCLUSIONS: Despite challenges in estimating the causal impact of NG/CT on HIV risk, modeling is an alternative approach to quantifying plausible ranges of effects given uncertainty in the biological co-factors. Our estimates represent idealized public health interventions in which STI could be maximally prevented, setting targets for real-world STI interventions that seek to reduce HIV incidence. SUMMARY: Approximately 10% of incident HIV infections among MSM in the US are caused by prevalent gonorrhea or chlamydia infection.

      4. Impact of home-based HIV testing services on progress toward the UNAIDS 90-90-90 targets in a hyperendemic area of South AfricaExternal
        Lewis L, Maughan-Brown B, Grobler A, Cawood C, Khanyile D, Glenshaw M, Kharsany AB.
        J Acquir Immune Defic Syndr. 2019 Feb 1;80(2):135-144.
        BACKGROUND: In several subgroups of South Africa, the percentage of HIV-positive individuals aware of their status falls well below the UNAIDS 90% target. This study examined the impact that home-based HIV testing services (HBHTS) had on knowledge of status in a hyperendemic area of South Africa. METHODS: We analysed data from the second cross-sectional HIV Incidence Provincial Surveillance System survey (2015/2016), a representative sample (n = 10,236) of individuals aged 15-49 years. Participants completed a questionnaire, provided blood samples for laboratory testing (used to estimate HIV prevalence), and were offered HBHTS. The proportion of people living with HIV (n = 3870) made aware of their status through HBHTS was measured, and factors associated with HBHTS uptake were identified. RESULTS: Knowledge of HIV-positive status at the time of the survey was 62.9% among men and 73.4% among women. Through HBHTS, the percentage of HIV-positive men and women who knew their status rose to 74.2% and 80.5%, respectively. The largest impact was observed among youth (15-24 years). Knowledge of status increased from 36.6% to 59.3% and from 50.8% to 64.8% among young men and women, respectively. In addition, 51.4% of those who had previously never tested received their first test. Key reasons for declining HBHTS among undiagnosed HIV-positive individuals included fear and self-report of an HIV-negative status. CONCLUSIONS: HBHTS was effective in increasing awareness of HIV-positive status, particularly among youth, men, and those who had never tested. HBHTS could have a marked impact on progress toward the UNAIDS 90-90-90 targets within these subgroups.

      5. Feasibility and acceptability of the Modified Antiretroviral Treatment Access Study (MARTAS) intervention based on a pilot study in UkraineExternal
        Neduzhko O, Postnov O, Bingham T, Myers JJ, Flanigan T, Kiriazova T.
        J Int Assoc Provid AIDS Care. 2019 Jan-Dec;18:2325958218823257.
        We conducted a pilot of the Modified Antiretroviral Treatment Access Study (MARTAS), a linkage to HIV treatment intervention, prior to implementing a multisite randomized controlled trial (RCT) in Ukraine. The objectives of the pilot were to assess the feasibility and acceptability of the MARTAS intervention among a small sample of adults recently diagnosed with HIV at specialty clinics in the Mykolaiv region of Ukraine in 2015. The adapted intervention consisted of up to 6 individual-level sessions with a linkage coordinator (nurse) over a 90-day period. Overall, 22 persons participated in the pilot. On average, participants received 4.2 sessions and 14 participants linked to HIV care within 3 months of study enrollment. All 18 participants who completed the acceptability survey expressed high satisfaction with their interaction with their linkage coordinator. The results of the pilot demonstrated feasibility and acceptability of the MARTAS intervention in advance of a larger scale RCT in Ukraine.

      6. Viral suppression in a nationwide sample of HIV-infected children on antiretroviral therapy in RwandaExternal
        Nsanzimana S, McArdle F, Remera E, Mulindabigwi A, Ribakare M, Ndimubanzi P, Kayirangwa E, Baribwira C, Riedel DJ, Ntaganira J.
        Pediatr Infect Dis J. 2019 Feb;38(2):149-151.
        Rwanda has made significant progress in expanding pediatric antiretroviral treatment coverage. This was a nationwide, cross-sectional study of pediatric HIV suppression rates. Of 292 children on antiretroviral treatment >/=12 months, 68.8% achieved viral suppression < 40 copies/ml, respectively. Rwanda achieved good pediatric viral suppression rates, comparable to those from other resource-limited settings, yet more efforts are needed to achieve the UNAIDS 90-90-90 target.

      7. Role of public-private partnerships in achieving UNAIDS HIV treatment targetsExternal
        Shrivastava R, Fonjungo PN, Kebede Y, Bhimaraj R, Zavahir S, Mwangi C, Gadde R, Alexander H, Riley PL, Kim A, Nkengasong JN.
        BMC Health Serv Res. 2019 Jan 18;19(1):46.
        BACKGROUND: Despite progress towards achieving UNAIDS 90-90-90 goals, barriers persist in laboratory systems in sub-Saharan Africa (SSA) restricting scale up of early infant diagnosis (EID) and viral load (VL) test monitoring of patients on antiretroviral therapy. If these facilities and system challenges persist, they may undermine recorded gains and appropriate management of patients. The aim of this review is to identify Public Private Partnerships (PPP) in SSA that have resolved systemic barriers within the VL and EID treatment cascade and demonstrated impact in the scale up of VL and EID. METHODS: We queried five HIV and TB laboratory databases from 2007 to 2017 for studies related to laboratory system strengthening and PPP. We identified, screened and included PPPs that demonstrated evidence in alleviating known system level barriers to scale up national VL and EID testing programs. PPPs that improved associated systems from the point of viral load test request to the use of the test result for patient management were deemed eligible. RESULTS: We identified six PPPs collaborations with multiple activities in select countries that are contributing to address challenges to scale up national viral load programs. One of the six PPPs reached 14.5 million patients in remote communities and transported up to 400,000 specimens in a year. Another PPP enabled an unprecedented 94% of specimens to reach national laboratory through improved sample referral network and enabled a cost savings of 62%. Also PPPs reduced cost of reagents and enabled 300,000 tested infants to be enrolled in care as well as reduced turnaround time of reporting results by 50%. CONCLUSIONS: Our review identified the benefits, enabling factors, and associated challenges for public and private sectors to engage in PPPs. PPP contributions to laboratory systems strengthening are a model and present opportunities that can be leveraged to strengthen systems to achieve the UNAIDS 90-90-90 treatment targets for HIV/AIDS. Despite growing emphasis on engaging the private sector as a critical partner to address global disease burden, PPPs that specifically strengthen laboratories, the cornerstone of public health programs, remain largely untapped.

      8. Short-term effects and long-term cost-effectiveness of universal hepatitis C testing in prenatal careExternal
        Tasillo A, Eftekhari Yazdi G, Nolen S, Schillie S, Vellozzi C, Epstein R, Randall L, Salomon JA, Linas BP.
        Obstet Gynecol. 2019 Jan 8.
        OBJECTIVE: To estimate the clinical effects and cost-effectiveness of universal prenatal hepatitis C screening, and to calculate potential life expectancy, quality of life, and health care costs associated with universal prenatal hepatitis C screening and linkage to treatment. METHODS: Using a stochastic individual-level microsimulation model, we simulated the lifetimes of 250 million pregnant women matched at baseline with the U.S. childbearing population on age, injection drug use behaviors, and hepatitis C virus (HCV) infection status. Modeled outcomes included hepatitis C diagnosis, treatment and cure, lifetime health care costs, quality-adjusted life years (QALY) and incremental cost-effectiveness ratios comparing universal prenatal hepatitis C screening to current practice. We modeled whether neonates exposed to maternal HCV at birth were identified as such. RESULTS: Pregnant women with hepatitis C infection lived 1.21 years longer and had 16% lower HCV-attributable mortality with universal prenatal hepatitis C screening, which had an incremental cost-effectiveness ratio of $41,000 per QALY gained compared with current practice. Incremental cost-effectiveness ratios remained below $100,000 per QALY gained in most sensitivity analyses; notable exceptions included incremental cost-effectiveness ratios above $100,000 when assuming mean time to cirrhosis of 70 years, a cost greater than $500,000 per false positive diagnosis, or population HCV infection prevalence below 0.16%. Universal prenatal hepatitis C screening increased identification of neonates exposed to HCV at birth from 44% to 92%. CONCLUSIONS: In our model, universal prenatal hepatitis C screening improves health outcomes in women with HCV infection, improves identification of HCV exposure in neonates born at risk, and is cost-effective.

      9. Impacts of federal prevention funding on reported gonorrhea and chlamydia ratesExternal
        Williams AM, Kreisel K, Chesson HW.
        Am J Prev Med. 2019 Jan 15.
        INTRODUCTION: The Centers for Disease Control and Prevention allocates funds annually to jurisdictions nationwide for sexually transmitted infection prevention activities. The objective of this study was to assess the effectiveness of federal sexually transmitted infection prevention funding for reducing rates of reported sexually transmitted infections. METHODS: In 2017-2018, finite distributed lag regression models were estimated to assess the impact of sexually transmitted infection prevention funding (in 2016 dollars per capita) on reported chlamydia rates from 2000 to 2016 and reported gonorrhea rates from 1981 to 2016. Including lagged funding measures allowed for assessing the impact of funding over time. Controls for state-level socioeconomic factors, such as poverty rates, were included. RESULTS: Results from the main model indicate that a 1% increase in annual funding would cumulatively decrease chlamydia and gonorrhea rates by 0.17% (p<0.10) and 0.33% (p<0.05), respectively. Results were similar when stratified by sex, with significant decreases in rates of reported chlamydia and gonorrhea in males of 0.33% and 0.34% (both p<0.05) respectively, and in rates of reported gonorrhea in females of 0.32% (p<0.05). The results were generally consistent across alternative model specifications and other robustness tests. CONCLUSIONS: The significant inverse associations between federal sexually transmitted infection prevention funding and rates of reported chlamydia and gonorrhea suggest that federally funded sexually transmitted infection prevention activities have a discernable effect on reducing the burden of sexually transmitted infections. The reported sexually transmitted infection rate in a given year depends more on prevention funding in previous years than on prevention funding in the current year, demonstrating the importance of accounting for lagged funding effects.

    • Disaster Control and Emergency Services
      1. The Infectious Disease Network (IDN): Development and use for evaluation of potential Ebola cases in GeorgiaExternal
        Turner AK, Wages RK, Nadeau K, Edison L, Prince PF, Doss ER, Drenzek C, O’Neal P.
        Disaster Med Public Health Prep. 2018 Dec;12(6):765-771.
        In response to the 2014 Ebola virus disease (EVD) outbreak in West Africa, the Georgia Department of Public Health developed the Infectious Disease Network (IDN) based on an EVD preparedness needs assessment of hospitals and Emergency Medical Services (EMS) providers. The network consists of 12 hospitals and 16 EMS providers with staff specially trained to provide a coordinated response and utilize appropriate personal protective equipment (PPE) for the transport or treatment of a suspected or confirmed serious communicable disease patient. To become a part of the network, each hospital and EMS provider had to demonstrate EVD capabilities in areas such as infection control, PPE, waste management, staffing and ongoing training, and patient transport and placement. To establish the network, the Georgia Department of Public Health provided training and equipment for EMS personnel, evaluated hospitals for EVD capabilities, structured communication flow, and defined responsibilities among partners. Since March 2015, the IDN has been used to transport, treat, and/or evaluate suspected or confirmed serious communicable disease cases while ensuring health care worker safety. Integrated infectious disease response systems among hospitals and EMS providers are critical to ensuring health care worker safety, and preventing or mitigating a serious communicable disease outbreak. (Disaster Med Public Health Preparedness. 2018;12:765-771).

    • Disease Reservoirs and Vectors
      1. Bloodmeal host selection of Culex quinquefasciatus (Diptera: Culicidae) in Las Vegas, Nevada, United StatesExternal
        Hannon ER, Jackson KC, Biggerstaff BJ, Raman V, Komar N.
        J Med Entomol. 2019 Jan 22.
        St. Louis encephalitis virus (SLEV) and West Nile virus (WNV) have recently emerged in the southwestern United States. Surveillance for arboviruses in Las Vegas, NV, detected a surge of SLEV activity in the southern house mosquito (Culex quinquefasciatus Say) during 2016. To identify candidate avian amplifiers, we assessed the identification, viral infection, and immune status of vertebrate hosts for 195 blood-engorged Cx. quinquefasciatus mosquitoes collected in August and September 2016. Bloodmeals were identified from 164 engorged abdomens, representing 19 species of birds and three species of mammals. No SLEV or WNV viremia was detected, but one mosquito tested positive for Culex flavivirus. House finch (Haemorhous mexicanus) (Muller) was the most common bloodmeal, followed by domestic chicken (Gallus gallus) (Linnaeus), American robin (Turdus migratorius) L., house sparrow (Passer domesticus) (L.), great-tailed grackle (Quiscalus mexicanus) (Gmelin), northern mockingbird (Mimus polyglottos) (L.) and mourning dove (Zenaida macroura) (L.). SLEV-reactive antibodies were detected in six identified bloodmeals and WNV-reactive antibodies were detected in 33. House sparrow and house finch were the most likely hosts to show previous exposure to SLEV and WNV, respectively. Over-utilization by Cx. quinquefasciatus for bloodmeal hosts was observed primarily among robin, finch and sparrow, all species that roost communally. House finch stands out as a candidate important amplifier for both SLEV and WNV because of its preference by mosquito vectors, and high competence for closely related virus strains. While implicated in previous outbreaks as an important mosquito vector, Cx. quinquefasciatus feeds infrequently on mammals in Las Vegas, indicating a low risk for bridge transmission to humans.

      2. Phylogenetic sister clades Bartonella and Brucella within the order Rhizobiales present some common biological characteristics as well as evident differences in adaptations to their mammalian reservoirs. We reviewed published data on Bartonella and Brucella infections in wild carnivores to compare the ecology of these bacteria in relatively similar host environments. Arthropod vectors are the main mechanism for Bartonella species transmission between mammalian hosts. The role of arthropods in transmission of Brucella remains disputed, however experimental studies and reported detection of Brucella in arthropods indicate potential vector transmission. More commonly, transmission of Brucella occurs via contact exposure to infected animals or the environment contaminated with their discharges. Of 26 species of carnivores tested for both Bartonella and Brucella, 58% harbored either. Among them were bobcats, African lions, golden jackals, coyotes, wolves, foxes, striped skunks, sea otters, raccoons, and harbor seals. The most common species of Bartonella in wild carnivores was B. henselae, found in 23 species, followed by B. rochalimae in 12, B. clarridgeiae in ten, and B. vinsonii subsp. berkhoffii in seven. Among Brucella species, Br. abortus was reported in over 30 terrestrial carnivore species, followed by Br. canis in seven. Marine carnivores, such as seals and sea lions, can host Br. pinnipedialis. In contrast, there is no evidence of a Bartonella strain specific for marine mammals. Bartonella species are present practically in every sampled species of wild felids, but of 14 Brucella studies of felids, only five reported Brucella and those were limited to detection of antibodies. We found no reports of Bartonella in bears while Brucella was detected in these animals. There is evident host-specificity of Bartonella species in wild carnivores (e.g., B. henselae in felids and B. vinsonii subsp. berkhoffii in canids). A co-adaptation of Brucella with terrestrial wild carnivore hosts is not as straightforward as in domestic animals. Wild carnivores often carry the same pathogens as their domesticated relatives (cats and dogs), but the risk of exposure varies widely because of differences in biology, distribution, and historical interactions.

      3. Bioabsorption and effectiveness of long-lasting permethrin-treated uniforms over three months among North Carolina outdoor workersExternal
        Sullivan KM, Poffley A, Funkhouser S, Driver J, Ross J, Ospina M, Calafat AM, Beard CB, White A, Balanay JA, Richards S, Dyer M, Mather TN, Meshnick S.
        Parasit Vectors. 2019 Jan 23;12(1):52.
        BACKGROUND: Vector-borne diseases are an important cause of morbidity and mortality in the USA. Effective, convenient prevention methods are needed. Long-lasting permethrin-impregnated (LLPI) clothing can prevent tick bites, however, additional information is needed on the real-world effectiveness and safety of this preventative measure. METHODS: In this pilot study, we recruited state and county park employees from North Carolina to wear LLPI uniforms for three months during the summer of 2016. We collected spot urine samples for biomonitoring of permethrin metabolites at one week, one month and three months after first use of the LLPI uniform. Following three months of wear, we collected pants and socks and analyzed them for permethrin content and mortality to ticks and mosquitoes. RESULTS: Thirteen park employees were included in the analysis. Bioactive amounts of permethrin remained in all clothing swatches tested, although there was great variability. Tick mortality was high, with 78% of pant and 88% of sock swatches having mean knockdown percentages >/= 85%. In contrast, mosquito mortality was low. Over the study period, the absorbed dosage of permethrin averaged < 4 mug/kg/d of body weight based on measurements of three metabolites. CONCLUSIONS: LLPI clothing retained permethrin and bioactivity against ticks after three months of use in real-world conditions. The estimated absorbed dosage of permethrin was well below the U.S. EPA level of concern, suggesting that LLPI clothing can be used safely by outdoor workers for tick bite prevention.

    • Environmental Health
      1. Ethylbenzene and styrene exposure in the United States based on urinary mandelic acid and phenylglyoxylic acid: NHANES 2005-2006 and 2011-2012External
        Capella KM, Roland K, Geldner N, Rey deCastro B, De Jesus VR, van Bemmel D, Blount BC.
        Environ Res. 2019 Jan 10;171:101-110.
        Ethylbenzene and styrene are air toxicants with widespread nonoccupational exposure sources, including tobacco smoke and diet. Ethylbenzene and styrene (EB/S) exposure was quantified from their common metabolites measured in spot urine samples obtained from participants (>/=6 years old) in the 2005-2006 and 2011-2012 cycles of the National Health and Nutrition Examination Survey (NHANES; N = 4690). EB/S metabolites mandelic acid (MA) and phenylglyoxylic acid (PGA) were measured using ultra-high performance liquid chromatography coupled with electrospray ionization tandem mass spectrometry (UPLC-ESI-MS/MS). MA and PGA were detected in 98.9% and 90.6% of tested urine specimens, respectively. Exclusive smokers had 2-fold and 1.6-fold higher median urinary MA and PGA, respectively, compared with non-users. Sampleweighted regression analysis among exclusive smokers showed that smoking 0.5 pack cigarettes per day significantly increased MA (+97.9mug/L) and PGA (+69.3mug/L), controlling for potential confounders. In comparison, exposure from the median daily dietary intake of grain products increased MA by 1.95mug/L and was not associated with statistically significant changes in urinary PGA levels. Conversely, consuming vegetables and fruit was associated with decreased MA and PGA. These results confirm tobacco smoke as a major source of ethylbenzene and styrene exposure for the general U.S. population.

      2. CDC’s Lead Poisoning Prevention Program: A long-standing responsibility and commitment to protect children from lead exposureExternal
        Ettinger AS, Leonard ML, Mason J.
        J Public Health Manag Pract. 2019 Jan/Feb;25 Suppl 1:S5-s12.
        The Centers for Disease Control and Prevention’s (CDC’s) Childhood Lead Poisoning Prevention Program (CLPPP) serves as the nation’s public health leader and resource on strategies, policies, and practices aimed at preventing lead exposure in young children. CDC supports and advises state and local public health agencies and works with other federal agencies and partners to achieve the Healthy People 2020 objective of eliminating childhood lead exposure as a public health concern. Primary prevention-the removal of lead hazards from the environment before a child is exposed-is the most effective way to ensure that children do not experience the harmful effects of lead exposure. Blood lead screening tests and secondary prevention remain an essential safety net for children who may be exposed to lead. CDC’s key programmatic strategy is to strengthen blood lead surveillance by supporting state and local programs to improve blood lead screening test rates, identify high-risk populations, and ensure effective follow-up for children with elevated blood lead levels. Surveillance plays a central role in helping measure the collective progress of federal, state, and local public health agencies in protecting children from lead, as well as enhancing our ability to target population-based interventions for primary prevention to those areas at highest risk. The CDC CLPPP has been at the front line of efforts to protect children from lead exposure and the resulting adverse health effects over the last 3 decades. As we chart our path for the future, we will continue to learn from past successes and challenges, incorporate new evidence and lessons learned, and work closely with federal, state, local, and nonprofit partners, experts in academia, and the community to advance the overarching goal of eliminating lead exposure in children.

      3. The Flint Water Crisis: A coordinated public health emergency response and recovery initiativeExternal
        Ruckart PZ, Ettinger AS, Hanna-Attisha M, Jones N, Davis SI, Breysse PN.
        J Public Health Manag Pract. 2019 Jan/Feb;25 Suppl 1, Lead Poisoning Prevention:S84-s90.
        CONTEXT: The City of Flint was already distressed because of decades of financial decline when an estimated 140 000 individuals were exposed to lead and other contaminants in drinking water. In April 2014, Flint’s drinking water source was changed from Great Lakes’ Lake Huron (which was provided by the Detroit Water and Sewerage Department) to the Flint River without necessary corrosion control treatment to prevent lead release from pipes and plumbing. Lead exposure can damage children’s brains and nervous systems, lead to slow growth and development, and result in learning, behavior, hearing, and speech problems. After the involvement of concerned residents and independent researchers, Flint was reconnected to the Detroit water system on October 16, 2015. A federal emergency was declared in January 2016. PROGRAM: The Centers for Disease Control and Prevention provided assistance and support for response and recovery efforts including coordinating effective health messaging; assessing lead exposure; providing guidance on blood lead screening protocols; and identifying and linking community members to appropriate follow-up services.In response to the crisis in Flint, Congress funded the Centers for Disease Control and Prevention to establish a federal advisory committee; enhance Childhood Lead Poisoning Prevention Program activities; and support a voluntary Flint lead exposure registry. The registry, funded through a grant to Michigan State University, is designed to identify eligible participants and ensure robust registry data; monitor health, child development, service utilization, and ongoing lead exposure; improve service delivery to lead-exposed individuals; and coordinate with other community and federally funded programs in Flint. The registry is also collaborating to make Flint “lead-free” and to share best practices with other communities. DISCUSSION: The Flint water crisis highlights the need for improved risk communication strategies, and environmental health infrastructure, enhanced surveillance, and primary prevention to identify and respond to environmental threats to the public’s health. Collecting data is important to facilitate action and decision making to prevent lead poisoning. Partnerships can help guide innovative strategies for primary lead prevention, raise awareness, extend outreach and communication efforts, and promote a shared sense of ownership.

    • Food Safety
      1. Notes from the Field: Outbreak of listeriosis likely associated with prepackaged caramel apples – United States, 2017External
        Marus JR, Bidol S, Altman SM, Oni O, Parker-Strobe N, Otto M, Pereira E, Buchholz A, Huffman J, Conrad AR, Wise ME.
        MMWR Morb Mortal Wkly Rep. 2019 Jan 25;68(3):76-77.

        [No abstract]

    • Global Health
      1. Militaries and global health: peace, conflict, and disaster responseExternal
        Michaud J, Moss K, Licina D, Waldman R, Kamradt-Scott A, Bartee M, Lim M, Williamson J, Burkle F, Polyak CS, Thomson N, Heymann DL, Lillywhite L.
        Lancet. 2019 Jan 19;393(10168):276-286.
        Many countries show a growing willingness to use militaries in support of global health efforts. This Series paper summarises the varied roles, responsibilities, and approaches of militaries in global health, drawing on examples and case studies across peacetime, conflict, and disaster response environments. Militaries have many capabilities applicable to global health, ranging from research, surveillance, and medical expertise to rapidly deployable, large-scale assets for logistics, transportation, and security. Despite this large range of capabilities, militaries also have limitations when engaging in global health activities. Militaries focus on strategic, operational, and tactical objectives that support their security and defence missions, which can conflict with humanitarian and global health equity objectives. Guidelines-both within and outside militaries-for military engagement in global health are often lacking, as are structured opportunities for military and civilian organisations to engage one another. We summarise policies that can help close the gap between military and civilian actors to catalyse the contributions of all participants to enhance global health.

      2. Scurvy outbreak among South Sudanese adolescents and young men – Kakuma refugee camp, Kenya, 2017-2018External
        Ververs M, Muriithi JW, Burton A, Burton JW, Lawi AO.
        MMWR Morb Mortal Wkly Rep. 2019 Jan 25;68(3):72-75.
        Scurvy is a relatively rare micronutrient deficiency disease that can occur among refugees dependent on food aid (1). Inadequate access to fresh fruits and vegetables in refugee camps can result in scurvy (2,3). Kakuma Refugee Camp in Kenya’s Turkana District is home to 148,000 refugees, mostly from Somalia and South Sudan, who receive food assistance. In August 2017, a number of South Sudanese adolescent and young adult male refugees were evaluated at a health clinic in the camp for calf pain, chest pain, and gingival swelling. Because the symptoms were nonspecific, no diagnosis was made, and some patients received antibiotics and analgesics. All were managed as outpatients, but symptoms did not improve. During subsequent months, more young men with similar symptoms were reported. On January 20, 2018, the United Nations High Commissioner for Refugees (UNHCR) was informed and conducted clinical examinations. Signs and symptoms included lower limb pain and swelling (in some cases involving joints), lethargy, fatigue, gingival swelling and pain, hyperkeratotic skin changes, and chest pain. Based on these clinical findings, micronutrient deficiency, particularly vitamin C deficiency (scurvy), was considered a possible diagnosis, and an investigation of a possible outbreak was conducted. The suspected scurvy cases all occurred in young men from South Sudan who were living and cooking together in one geographic section of the camp. All patients who received treatment with vitamin C noted improvement of symptoms within <1 week. Patients were provided with food and cash assistance, the latter to allow dietary diversification (i.e., fresh fruits and vegetables). However, both forms of assistance were inadequate to allow access to sufficient amount of calories and the dietary diversification needed for intake of micronutrients, such as vitamin C. It is important to consider these needs when determining the amount of food or cash assistance provided to adolescents and young adult male refugees.

    • Health Economics
      1. Cost of community-based HIV testing activities to reach saturation in BotswanaExternal
        Lasry A, Bachanas P, Suraratdecha C, Alwano MG, Behel S, Pals S, Block L, Moore J.
        AIDS Behav. 2019 Jan 23.
        In Botswana, 85% of persons living with HIV are aware of their status. We performed an economic analysis of HIV testing activities implemented during intensive campaigns, in 11 communities, between April 2015 and March 2016, through the Botswana Combination Prevention Project. The total cost was $1,098,312, or $99,847 per community, with 60% attributable to home-based testing and 40% attributable to mobile testing. The cost per person tested was $44, and $671 per person testing positive (2017 USD). Labor costs comprised 64% of total costs. In areas of high HIV prevalence and treatment coverage, the cost of untargeted home-based testing may be inflated by the efforts required to assess the testing eligibility of clients who are HIV-positive and on ART. Home-based and mobile testing delivered though an intensive community-based campaign allowed the identification of HIV positive persons, who may not access health facilities, at a cost comparable to other studies.

    • Healthcare Associated Infections
      1. Characteristics of deceased solid organ donors and screening results for hepatitis B, C, and human immunodeficiency viruses – United States, 2010-2017External
        Abara WE, Collier MG, Moorman A, Bixler D, Jones J, Annambhotla P, Bowman J, Levi ME, Brooks JT, Basavaraju SV.
        MMWR Morb Mortal Wkly Rep. 2019 Jan 25;68(3):61-66.
        The ongoing U.S. opioid crisis has resulted in an increase in drug overdose deaths and acute hepatitis C virus (HCV) infections, with young persons (who might be eligible organ donors) most affected. In 2013, the Public Health Service released a revised guideline to reduce the risk for unintended organ transplantation-associated hepatitis B virus (HBV), HCV, and human immunodeficiency virus (HIV) transmission (1). The guideline describes criteria to categorize donors at increased risk (increased risk donors [IRDs]) for transmitting these viruses to recipients (1). It also recommends universal donor testing for HBV, HCV, and HIV. CDC analyzed deceased donor data for the period 2010-2017 reported to the Organ Procurement and Transplantation Network for IRDs and standard risk donors (SRDs) (i.e., donors who do not meet any of the criteria for increased risk designation). During this period, the proportion of IRDs increased approximately 200%, from 8.9% to 26.3%; the percentage with drug intoxication reported as the mechanism of death also increased approximately 200%, from 4.3% to 13.4%; and the proportion of these donors with reported injection drug use (IDU) increased approximately 500%, from 1.3% to 8.0%. Compared with SRDs, IRDs were significantly more likely to have positive HBV and HCV screening results. These findings demonstrate the continuing need for identifying viral bloodborne pathogen infection risk factors among deceased donors to reduce the risk for transmission, monitor posttransplant infection in recipients, and offer treatment if infection occurs.

      2. Group A Streptococcus outbreak among residents and employees of two skilled nursing facilities: North Carolina, 2017External
        Palladino KJ, Morrison T, Chochua S, Bowers L, MacFarquhar JK.
        Am J Infect Control. 2019 Jan 17.
        In this report, we summarize the results of surveillance, on-site assessments, and molecular analysis conducted as part of a group A Streptococcus outbreak investigation in 2 skilled nursing facilities. We identified cases in 24 individuals (6 deaths) and infection prevention deficiencies. Isolates from 14 individuals represented the globally emergent clade 3 emm89 strain. Molecular analysis suggests that the 2 outbreaks were related. Wound care practices and 1 symptomatic shared employee may have facilitated transmission. Strict adherence to infection prevention practices is needed to prevent group A Streptococcus transmission.

    • Immunity and Immunization
      1. Factors associated with rotavirus vaccine coverageExternal
        Aliabadi N, Wikswo ME, Tate JE, Cortese MM, Szilagyi PG, Staat MA, Weinberg GA, Halasa NB, Boom JA, Selvarangan R, Englund JA, Azimi PH, Klein EJ, Moffatt ME, Harrison CJ, Sahni LC, Stewart LS, Bernstein DI, Parashar UD, Payne DC.
        Pediatrics. 2019 Jan 17.
        BACKGROUND: Rotavirus vaccines (RVVs) were included in the US immunization program in 2006 and are coadministered with the diphtheria-tetanus-acellular pertussis (DTaP) vaccine, yet their coverage lags behind DTaP. We assessed timing, initiation, and completion of the RVV series among children enrolled in active gastroenteritis surveillance at 7 US medical institutions during 2014-2016. METHODS: We compared coverage and timing of each vaccine series and analyzed characteristics associated with RVV initiation and completion. We report odds ratios (ORs) and 95% confidence intervals (CIs) from multivariable logistic regression models. RESULTS: We enrolled 10 603 children. In 2015, >/=1 dose coverage was 91% for RVV and 97% for DTaP. Seven percent of children received their first DTaP vaccine at age >/=15 weeks versus 4% for RVV (P </= .001). Recent birth years (2013-2016) were associated with higher odds of RVV initiation (OR = 5.72; 95% CI 4.43-7.39), whereas preterm birth (OR = 0.32; 95% CI 0.24-0.41), older age at DTaP initiation (OR 0.85; 95% CI 0.80-0.91), income between $50 000 and $100 000 (OR = 0.56; 95% CI 0.40-0.78), and higher maternal education (OR = 0.52; 95% CI 0.36-0.74) were associated with lower odds. Once RVV was initiated, recent birth years (2013-2016; OR = 1.57 [95% CI 1.32-1.88]) and higher maternal education (OR = 1.31; 95% CI 1.07-1.60) were associated with higher odds of RVV completion, whereas preterm birth (OR = 0.76; 95% CI 0.62-0.94), African American race (OR = 0.82; 95% CI 0.70-0.97) and public or no insurance (OR = 0.75; 95% CI 0.60-0.93) were associated with lower odds. Regional differences existed. CONCLUSIONS: RVV coverage remains lower than that for the DTaP vaccine. Timely DTaP administration may help improve RVV coverage.

      2. Kinetics of antibody response to influenza vaccination in renal transplant recipientsExternal
        Gangappa S, Wrammert J, Wang D, Li ZN, Liepkalns JS, Cao W, Chen J, Levine MZ, Stevens J, Sambhara S, Begley B, Mehta A, Pearson TC, Ahmed R, Larsen CP.
        Transpl Immunol. 2019 Jan 18.
        Annual vaccination is routinely used in organ transplant recipients for immunization against seasonal influenza. However, detailed analysis of the kinetics of vaccine-induced immune responses in this population is lacking. In this study, we investigated the kinetics of vaccine strains-specific antibody responses to trivalent influenza vaccine in a group of renal transplant recipients and a control group. First, we found that the geometric mean hemagglutination inhibition titer against all 3 vaccine strains in the transplant cohort was significantly low when compared to control subjects. Next, whereas the control group sera showed significantly higher HA-specific IgG and isotype IgG1 antibodies at all four time points, a similar increase in the transplant group was delayed until day 28. Interestingly, within the transplant group, subjects receiving belatacept/MMF/prednisone-based regimen had significantly lower levels of total IgG and HA-specific IgG when compared to tacrolimus/MMF/prednisone-based regimen. Even though IgG-ASC response in both cohorts peaked at day 7 post-vaccination, the frequency of IgG-ASC was significantly low in the transplant group. Taken together, our studies show delayed kinetics and lower levels of influenza vaccine-specific antibody responses in renal transplant recipients and, more importantly, indicate the need to probe and improve current vaccination strategies in renal transplant recipients.

      3. Assessing baloxavir susceptibility of influenza viruses circulating in the United States during the 2016/17 and 2017/18 seasonsExternal
        Gubareva LV, Mishin VP, Patel MC, Chesnokov A, Nguyen HT, De La Cruz J, Spencer S, Campbell AP, Sinner M, Reid H, Garten R, Katz JM, Fry AM, Barnes J, Wentworth DE.
        Euro Surveill. 2019 Jan;24(3).
        The anti-influenza therapeutic baloxavir targets cap-dependent endonuclease activity of polymerase acidic (PA) protein. We monitored baloxavir susceptibility in the United States with next generation sequencing analysis supplemented by phenotypic one-cycle infection assay. Analysis of PA sequences of 6,891 influenza A and B viruses collected during 2016/17 and 2017/18 seasons showed amino acid substitutions: I38L (two A(H1N1)pdm09 viruses), E23G (two A(H1N1)pdm09 viruses) and I38M (one A(H3N2) virus); conferring 4-10-fold reduced susceptibility to baloxavir.

      4. Risk factors and attack rates of seasonal influenza infection: Results of the Southern Hemisphere Influenza and Vaccine Effectiveness Research and Surveillance (SHIVERS) Seroepidemiologic Cohort StudyExternal
        Huang QS, Bandaranayake D, Wood T, Newbern EC, Seeds R, Ralston J, Waite B, Bissielo A, Prasad N, Todd A, Jelley L, Gunn W, McNicholas A, Metz T, Lawrence S, Collis E, Retter A, Wong SS, Webby R, Bocacao J, Haubrock J, Mackereth G, Turner N, McArdle B, Cameron J, Reynolds EG, Baker MG, Grant CC, McArthur C, Roberts S, Trenholme A, Wong C, Taylor S, Thomas P, Duque J, Gross D, Thompson MG, Widdowson MA.
        J Infect Dis. 2019 Jan 9;219(3):347-357.
        Background: Understanding the attack rate of influenza infection and the proportion who become ill by risk group is key to implementing prevention measures. While population-based studies of antihemagglutinin antibody responses have been described previously, studies examining both antihemagglutinin and antineuraminidase antibodies are lacking. Methods: In 2015, we conducted a seroepidemiologic cohort study of individuals randomly selected from a population in New Zealand. We tested paired sera for hemagglutination inhibition (HAI) or neuraminidase inhibition (NAI) titers for seroconversion. We followed participants weekly and performed influenza polymerase chain reaction (PCR) for those reporting influenza-like illness (ILI). Results: Influenza infection (either HAI or NAI seroconversion) was found in 321 (35% [95% confidence interval, 32%-38%]) of 911 unvaccinated participants, of whom 100 (31%) seroconverted to NAI alone. Young children and Pacific peoples experienced the highest influenza infection attack rates, but overall only a quarter of all infected reported influenza PCR-confirmed ILI, and one-quarter of these sought medical attention. Seroconversion to NAI alone was higher among children aged <5 years vs those aged >/=5 years (14% vs 4%; P < .001) and among those with influenza B vs A(H3N2) virus infections (7% vs 0.3%; P < .001). Conclusions: Measurement of antineuraminidase antibodies in addition to antihemagglutinin antibodies may be important in capturing the true influenza infection rates.

      5. INTRODUCTION: 9-valent human papillomavirus vaccine (9vHPV) was approved by the Food and Drug Administration (FDA) in December 2014. 9vHPV is not recommended during pregnancy, but some women of childbearing age may be inadvertently exposed. This study aims to evaluate reports submitted to the Vaccine Adverse Event Reporting System (VAERS) of pregnant women exposed to 9vHPV. METHODS: We searched the VAERS database, a national post-licensure vaccine safety surveillance system, for reports of pregnant women vaccinated with 9vHPV in the United States between December 10, 2014 and December 31, 2017. Disproportionate reporting of adverse events (AEs) was assessed using proportional reporting ratios (PRRs). RESULTS: A total of 82 pregnancy reports were identified. Sixty reports (73.2%) did not describe an AE and were submitted only to report the vaccine exposure during pregnancy. The most frequently reported pregnancy-specific AE was spontaneous abortion (n=3; 3.7%), followed by vaginal bleeding (n=2; 2.4%). Among non-pregnancy-specific AEs, injection site reaction (n=3; 3.7%) was most common. No disproportionate reporting of any AE was found. DISCUSSION: No unexpected AEs were observed among these pregnancy reports.

      6. Association of presence of a school nurse with increased sixth-grade immunization rates in low-income Arizona schools in 2014-2015External
        McCullough JM, Sunenshine R, Rusinak R, Mead P, England B.
        J Sch Nurs. 2019 Jan 22:1059840518824639.
        School nurses often play large roles in implementation of school vaccination requirements aimed at controlling the spread of communicable disease. We analyzed the association between the presence of a school nurse and school-level vaccination rates in Arizona. Using school-level data from Arizona sixth-grade schools ( n = 749), we regressed average sixth-grade school-level immunization rates on presence of a school nurse (registered nurse [RN] or licensed practical nurse [LPN]) and school-level socioeconomic status (SES), controlling for other school- and district-level characteristics. Schools with a nurse had higher overall vaccination rates than those without a nurse (96.1% vs. 95.0%, p < .01). For schools in the lowest SES quartile, the presence of a school nurse was associated with approximately 2 percentage point higher immunization rates. These findings add to the growing literature that defines the impact of school nurses on student health status and outcomes, emphasizing the value of school nurses, especially in lower SES schools.

      7. Genetic Meningococcal Antigen Typing System (gMATS): A genotyping tool that predicts 4CMenB strain coverage worldwideExternal
        Muzzi A, Brozzi A, Serino L, Bodini M, Abad R, Caugant D, Comanducci M, Lemos AP, Gorla MC, Krizova P, Mikula C, Mulhall R, Nissen M, Nohynek H, Simoes MJ, Skoczynska A, Stefanelli P, Taha MK, Toropainen M, Tzanakaki G, Vadivelu-Pechai K, Watson P, Vazquez JA, Rajam G, Rappuoli R, Borrow R, Medini D.
        Vaccine. 2019 Jan 17.
        BACKGROUND: The Meningococcal Antigen Typing System (MATS) was developed to identify meningococcus group B strains with a high likelihood of being covered by the 4CMenB vaccine, but is limited by the requirement for viable isolates from culture-confirmed cases. We examined if antigen genotyping could complement MATS in predicting strain coverage by the 4CMenB vaccine. METHODS: From a panel of 3912 MATS-typed invasive meningococcal disease isolates collected in England and Wales in 2007-2008, 2014-2015 and 2015-2016, and in 16 other countries in 2000-2015, 3481 isolates were also characterized by antigen genotyping. Individual associations between antigen genotypes and MATS coverage for each 4CMenB component were used to define a genetic MATS (gMATS). gMATS estimates were compared with England and Wales human complement serum bactericidal assay (hSBA) data and vaccine effectiveness (VE) data from England. RESULTS: Overall, 81% of the strain panel had genetically predictable MATS coverage, with 92% accuracy and highly concordant results across national panels (Lin’s accuracy coefficient, 0.98; root-mean-square deviation, 6%). England and Wales strain coverage estimates were 72-73% by genotyping (66-73% by MATS), underestimating hSBA values after four vaccine doses (88%) and VE after two doses (83%). The gMATS predicted strain coverage in other countries was 58-88%. CONCLUSIONS: gMATS can replace MATS in predicting 4CMenB strain coverage in four out of five cases, without requiring a cultivable isolate, and is open to further improvement. Both methods underestimated VE in England. Strain coverage predictions in other countries matched or exceeded England and Wales estimates.

      8. Estimating vaccine effectiveness against hospitalized influenza during pregnancy: Multicountry protocol for a retrospective cohort studyExternal
        Naleway AL, Ball S, Kwong JC, Wyant BE, Katz MA, Regan AK, Russell ML, Klein NP, Chung H, Simmonds KA, Azziz-Baumgartner E, Feldman BS, Levy A, Fell DB, Drews SJ, Garg S, Effler P, Barda N, Irving SA, Shifflett P, Jackson ML, Thompson MG.
        JMIR Res Protoc. 2019 Jan 21;8(1):e11333.
        BACKGROUND: Although pregnant women are believed to have elevated risks of severe influenza infection and are targeted for influenza vaccination, no study to date has examined influenza vaccine effectiveness (IVE) against laboratory-confirmed influenza-associated hospitalizations during pregnancy, primarily because this outcome poses many methodological challenges. OBJECTIVE: The Pregnancy Influenza Vaccine Effectiveness Network (PREVENT) was formed in 2016 as an international collaboration with the Centers for Disease Control and Prevention; Abt Associates; and study sites in Australia, Canada, Israel, and the United States. The primary goal of this collaboration is to estimate IVE in preventing acute respiratory or febrile illness (ARFI) hospitalizations associated with laboratory-confirmed influenza virus infection during pregnancy. Secondary aims include (1) describing the incidence, clinical course, and severity of influenza-associated ARFI hospitalization during pregnancy; (2) comparing the characteristics of ARFI-hospitalized pregnant women who were tested for influenza with those who were not tested; (3) describing influenza vaccination coverage in pregnant women; and (4) comparing birth outcomes among women with laboratory-confirmed influenza-associated hospitalization versus other noninfluenza ARFI hospitalizations. METHODS: For an initial assessment of IVE, sites identified a retrospective cohort of pregnant women aged from 18 to 50 years whose pregnancies overlapped with local influenza seasons from 2010 to 2016. Pregnancies were defined as those that ended in a live birth or stillbirth of at least 20 weeks gestation. The analytic sample for the primary IVE analysis was restricted to pregnant women who were hospitalized for ARFI during site-specific influenza seasons and clinically tested for influenza virus infection using real-time reverse transcription polymerase chain reaction. RESULTS: We identified approximately 2 million women whose pregnancies overlapped with influenza seasons; 550,344 had at least one hospitalization during this time. After restricting to women who were hospitalized for ARFI and tested for influenza, the IVE analytic sample included 1005 women. CONCLUSIONS: In addition to addressing the primary question about the effectiveness of influenza vaccination, PREVENT data will address other important knowledge gaps including understanding the incidence, clinical course, and severity of influenza-related hospitalizations during pregnancy. The data infrastructure and international partnerships created for these analyses may be useful and informative for future influenza studies. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/11333.

      9. Can vaccination coverage be improved by reducing missed opportunities for vaccination? Findings from assessments in Chad and Malawi using the new WHO methodologyExternal
        Ogbuanu IU, Li AJ, Anya BM, Tamadji M, Chirwa G, Chiwaya KW, Djalal ME, Cheikh D, Machekanyanga Z, Okeibunor J, Sanderson C, Mihigo R.
        PLoS One. 2019 ;14(1):e0210648.
        BACKGROUND: In 2015, the World Health Organization (WHO) updated the global methodology for assessing and reducing missed opportunities for vaccination (MOV), when eligible children have contact with the health system but are not vaccinated. This paper presents the results of two pilot assessments conducted in Chad and Malawi. METHODS: Using the ten-step global WHO MOV strategy, we purposively selected districts and health facilities, with non-probabilistic sampling of <24 month old children for exit interviews of caregivers and self-administered knowledge, attitudes, and practices (KAP) surveys of health workers. MOV were calculated based on a child’s documented vaccination history (i.e., from a home-based record (HBR) or a health facility vaccination register), including selected vaccines in the national schedule. RESULTS: Respondents included caregivers of 353 children in Chad and of 580 children in Malawi. Among those with documented vaccination history, 82% (195/238) were eligible for vaccination in Chad and 47% (225/483) in Malawi. Among eligible children, 51% (99/195) in Chad, and 66% (149/225) in Malawi had one or more MOV on the survey date. During non-vaccination visits, 77% (24/31) of children eligible for vaccination in Chad and 92% (119/129) in Malawi had a MOV compared to 46% (75/164) and 31% (30/96) during vaccination visits, respectively. Among health workers, 92% in Chad and 88% in Malawi were unable to correctly identify valid contraindications for vaccination. CONCLUSION: The new MOV tool was able to characterize the type and potential causes of MOV. In both countries, the findings of the assessments point to two major barriers to full vaccination of eligible children-a lack of coordination between vaccination and curative health services and incomplete vaccination during vaccination visits. National immunization programs should explore tailored efforts to improve health worker practices and to increase vaccine delivery by making better use of existing health service contacts.

    • Injury and Violence
      1. Introduction: Unrestrained drivers and passengers represent almost half of all passenger vehicle occupant deaths in the United States. The current study assessed the relationship between the belief about importance of seat belt use and the behavior of always wearing a seat belt. Method: Data from 2012 ConsumerStyles were analyzed separately for front and rear passenger seating positions. Multivariable regression models were constructed to identify the association between seat belt belief and behavior (i.e., always wears seat belt) among adults. Models controlled for type of state seat belt law (primary, secondary, or none). Results: Seat belt use was higher in front passenger seats (86.1%) than in rear passenger seats (61.6%). Similarly, belief that seat belt use was very important was higher in reference to the front passenger seat (84.2%) versus the rear passenger seat (70.5%). For the front passenger seat, belief was significantly associated with seat belt use in states with both primary enforcement laws (adjPR 1.64) and secondary enforcement laws (adjPR 2.77). For the rear passenger seat, belief was also significantly associated with seat belt use, and two 2-way interactions were observed (belief by sex, belief by region). Conclusions: Despite overall high rates of seat belt use in the United States, certain groups are less likely to buckle up than others. The study findings suggest that efforts to increase seat belt use among high-risk populations, such as those who live in states with secondary or no seat belt laws and those who ride in rear seats (which include people who utilize taxis or ride-hailing vehicles) could benefit from interventions designed to strengthen beliefs related to the benefits of seat belt use. Practical applications: Future research that uses a theoretical framework to better understand the relationship between beliefs and behavior may inform interventions to improve seat belt use.

      2. Characteristics of school-associated youth homicides – United States, 1994-2018External
        Holland KM, Hall JE, Wang J, Gaylor EM, Johnson LL, Shelby D, Simon TR.
        MMWR Morb Mortal Wkly Rep. 2019 Jan 25;68(3):53-60.
        To understand trends and characteristics in school-associated homicides involving youths, data from CDC’s School-Associated Violent Death Surveillance System were analyzed for 393 single-victim incidents that occurred during July 1994-June 2016 and 38 multiple-victim incidents (resulting in 121 youth homicides) during July 1994-June 2018. School-associated homicides consistently represent <2% of all youth homicides in the United States (1,2). The overall 22-year trend for single-victim homicide rates did not change significantly. However, multiple-victim incidence rates increased significantly from July 2009 to June 2018. Many school-associated homicides, particularly single-victim incidents, are similar to youth homicides unrelated to schools, often involving male, racial/ethnic minority youth victims, and occurring in urban settings. The majority of both single-victim (62.8%) and multiple-victim (95.0%) homicides were from a firearm-related injury. A comprehensive approach to violence prevention is needed to reduce risk for violence on and off school grounds.

      3. Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students – 19 states and large urban school districts, 2017External
        Johns MM, Lowry R, Andrzejewski J, Barrios LC, Demissie Z, McManus T, Rasberry CN, Robin L, Underwood JM.
        MMWR Morb Mortal Wkly Rep. 2019 Jan 25;68(3):67-71.
        Transgender youths (those whose gender identity* does not align with their sex(dagger)) experience disparities in violence victimization, substance use, suicide risk, and sexual risk compared with their cisgender peers (those whose gender identity does align with their sex) (1-3). Yet few large-scale assessments of these disparities among high school students exist. The Youth Risk Behavior Survey (YRBS) is conducted biennially among local, state, and nationally representative samples of U.S. high school students in grades 9-12. In 2017, 10 states (Colorado, Delaware, Hawaii, Maine, Maryland, Massachusetts, Michigan, Rhode Island, Vermont, Wisconsin) and nine large urban school districts (Boston, Broward County, Cleveland, Detroit, District of Columbia, Los Angeles, New York City, San Diego, San Francisco) piloted a measure of transgender identity. Using pooled data from these 19 sites, the prevalence of transgender identity was assessed, and relationships between transgender identity and violence victimization, substance use, suicide risk, and sexual risk behaviors were evaluated using logistic regression. Compared with cisgender males and cisgender females, transgender students were more likely to report violence victimization, substance use, and suicide risk, and, although more likely to report some sexual risk behaviors, were also more likely to be tested for human immunodeficiency virus (HIV) infection. These findings indicate a need for intervention efforts to improve health outcomes among transgender youths.

      4. Repeat self-inflicted injury among U.S. youth in a large medical claims databaseExternal
        Peterson C, Xu L, Leemis RW, Stone DM.
        Am J Prev Med. 2019 Jan 15.
        INTRODUCTION: This study describes characteristics of nonfatal self-inflicted injuries and incidence of repeat self-inflicted injuries among a large convenience sample of youth (aged 10-24 years) with Medicaid or commercial insurance. METHODS: In 2018, Truven Health MarketScan medical claims data were used to identify youth with a self-inflicted injury in 2013 (or index self-inflicted injury) diagnosed in any inpatient or outpatient setting. Patients with 2 years of healthcare claims data (1 year before/after index self-inflicted injury) were assessed. Patient and injury characteristics, repeat self-inflicted injuries </=1 year, time to repeat self-inflicted injury, and number of emergency department and urgent care facility visits per patient are reported. A regression model assessed factors associated with repeat self-inflicted injuries. RESULTS: Among 4,681 self-inflicted injury patients, 70% were female. More than 71% of patients were treated for comorbidities (50% for depression) </=1 year preceding the index self-inflicted injury. Poisoning was the most common index self-inflicted injury mechanism (60% of patients). Approximately 52% of patients had one or more emergency department visit and 1% had one or more urgent care facility visit, respectively, during the 2-year observation period. More than 11% of patients repeated self-inflicted injury </=1 year (and 3% </=7 days). Repeat self-inflicted injury was associated with younger patient age, being female, a self-inflicted injury event preceding the index self-inflicted injury, index self-inflicted injury treatment setting, and patient comorbidities. CONCLUSIONS: Approximately one in ten youth repeated self-inflicted injury within 1 year and nearly half of youth with clinically treated self-inflicted injuries never received care in hospitals or emergency departments. Physicians and families should be aware of risk factors for repeat self-inflicted injury, including mental health comorbidities. Multilevel strategies are needed to prevent youth self-inflicted injuries.

      5. Introduction: Given the growing research on potential adverse outcomes related to concussion and other serious brain injuries and the increased susceptibility for concussion among youth athletes, primary prevention is vital to protect the health and safety of this population. The purpose of this study is to summarize the current research on risk factors and primary concussion prevention strategies focused on specific youth sports, and to identify research gaps. Methods: A literature search was conducted using six electronic databases. A scoping review method was used to identify studies that addressed risk factors or primary concussion prevention strategies focused on youth athletes (ages 5-18 years) in six sports (football, ice hockey, soccer, lacrosse, basketball, and wrestling). Results: Of the 18 publications identified, the publications focused on risk factors (N = 11), policy (N = 1), rule changes (N = 3), education (N = 2), equipment (N = 2), and playing technique (N = 0). Some articles had information related to multiple topics. Conclusions: Current research on concussion prevention has primarily been focused on risk factors. There are a dearth of studies that examine primary concussion prevention in sports. When studies do exist, most focus on football and ice hockey. Only a small number of studies focus solely on risk factors or primary prevention in soccer, lacrosse, basketball, and wrestling-all sports in which concussions are common. Practical applications: This scoping review summarizes current research on concussion risk factors and primary prevention strategies in specific sports focused on youth athletes and identifies research gaps to help inform future efforts.

    • Laboratory Sciences
      1. Characterising the costs of the Global Polio Laboratory Network: a survey-based analysisExternal
        Duintjer Tebbens RJ, Diop OM, Pallansch MA, Oberste MS, Thompson KM.
        BMJ Open. 2019 Jan 21;9(1):e023290.
        OBJECTIVE: To characterise the costs, including for environmental surveillance (ES), of the Global Polio Laboratory Network (GPLN) that provides laboratory support to the Global Polio Eradication Initiative (GPEI). DESIGN AND PARTICIPANTS: We conducted a survey of the network across 92 countries of the 146 GPLN laboratories plus three non-GPLN laboratories that concentrate environmental samples to collect information about their activities, characteristics and costs during 2016. We estimate the total costs using regression of reported responses and complementing the findings with GPEI data. RESULTS: We received responses from 132 (89%) of the 149 laboratories, with variable response rates for individual questions. We estimate that processing samples of patients with acute flaccid paralysis leads to total costs of approximately $28 million per year (2016 US$) based on extrapolation from reported costs of $16 million, of which 61% were supported by internal (national) funds. Fifty-nine (45%) of the 132 responding laboratories reported supporting ES and we estimate an additional $5.3 million of recurring costs for ES activities performed by the laboratories. The reported costs do not include an estimated additional $10 million of annual global and regional costs to coordinate and support the GPLN. On average, the staff supported by funding for polio in the responding laboratories spent 30% of their time on non-polio activities. We estimate total costs for laboratory support of approximately $43 million (note that this estimate does not include any field or other non-laboratory costs of polio surveillance). CONCLUSIONS: Although countries contribute significantly to the GPLN financing, many laboratories currently depend on GPEI funds, and these laboratories also support the laboratory component of surveillance activities for other diseases. Sustaining critical global surveillance for polioviruses and transitioning support for other disease programmes will require continued significant funding after polio certification.

      2. Background Liquid chromatography-tandem mass spectrometry (LC-MSMS) for simultaneous analysis of multiple microbial secondary metabolites (MSMs) is potentially subject to interference by matrix components. Methods We examined potential matrix effects (MEs) in analyses of 31 MSMs using ultraperformance LC-MSMS. Twenty-one dust aliquots from three buildings (seven aliquots/building) were spiked with seven concentrations of each of the MSMs (6.2 pg/microl-900pg/microl) and then extracted. Another set of 21 aliquots were first extracted and then, the extract was spiked with the same concentrations. We added deepoxy-deoxynivalenol (DOM) to all aliquots as a universal internal standard. Ten microliters of the extract was injected into the ultraperformance LC-MSMS. ME was calculated by subtracting the percentage of the response of analyte in spiked extract to that in neat standard from 100. Spiked extract results were used to create a matrix-matched calibration (MMC) curve for estimating MSM concentration in dust spiked before extraction. Results Analysis of variance was used to examine effects of compound (MSM), building and concentration on response. MEs (range: 63.4%-99.97%) significantly differed by MSM (p<0.01) and building (p<0.05). Mean percent recoveries adjusted with DOM and the MMC method were 246.3% (SD=226.0) and 86.3% (SD=70.7), respectively. Conclusion We found that dust MEs resulted in substantial underestimation in quantifying MSMs and that DOM was not an optimal universal internal standard for the adjustment but that the MMC method resulted in more accurate and precise recovery compared with DOM. More research on adjustment methods for dust MEs in the simultaneous analyses of multiple MSMs using LC-MSMS is warranted.

      3. Taxonomy of the order Bunyavirales: second update 2018External
        Maes P, Adkins S, Alkhovsky SV, Avsic-Zupanc T, Ballinger MJ, Bente DA, Beer M, Bergeron E, Blair CD, Briese T, Buchmeier MJ, Burt FJ, Calisher CH, Charrel RN, Choi IR, Clegg JC, de la Torre JC, de Lamballerie X, DeRisi JL, Digiaro M, Drebot M, Ebihara H, Elbeaino T, Ergunay K, Fulhorst CF, Garrison AR, Gao GF, Gonzalez JJ, Groschup MH, Gunther S, Haenni AL, Hall RA, Hewson R, Hughes HR, Jain RK, Jonson MG, Junglen S, Klempa B, Klingstrom J, Kormelink R, Lambert AJ, Langevin SA, Lukashevich IS, Marklewitz M, Martelli GP, Mielke-Ehret N, Mirazimi A, Muhlbach HP, Naidu R, Nunes MR, Palacios G, Papa A, Paweska JT, Peters CJ, Plyusnin A, Radoshitzky SR, Resende RO, Romanowski V, Sall AA, Salvato MS, Sasaya T, Schmaljohn C, Shi X, Shirako Y, Simmonds P, Sironi M, Song JW, Spengler JR, Stenglein MD, Tesh RB, Turina M, Wei T, Whitfield AE, Yeh SD, Zerbini FM, Zhang YZ, Zhou X, Kuhn JH.
        Arch Virol. 2019 Jan 20.
        In October 2018, the order Bunyavirales was amended by inclusion of the family Arenaviridae, abolishment of three families, creation of three new families, 19 new genera, and 14 new species, and renaming of three genera and 22 species. This article presents the updated taxonomy of the order Bunyavirales as now accepted by the International Committee on Taxonomy of Viruses (ICTV).

      4. Taxonomy of the order Mononegavirales: second update 2018External
        Maes P, Amarasinghe GK, Ayllon MA, Basler CF, Bavari S, Blasdell KR, Briese T, Brown PA, Bukreyev A, Balkema-Buschmann A, Buchholz UJ, Chandran K, Crozier I, de Swart RL, Dietzgen RG, Dolnik O, Domier LL, Drexler JF, Durrwald R, Dundon WG, Duprex WP, Dye JM, Easton AJ, Fooks AR, Formenty PB, Fouchier RA, Freitas-Astua J, Ghedin E, Griffiths A, Hewson R, Horie M, Hurwitz JL, Hyndman TH, Jiang D, Kobinger GP, Kondo H, Kurath G, Kuzmin IV, Lamb RA, Lee B, Leroy EM, Li J, Marzano SL, Muhlberger E, Netesov SV, Nowotny N, Palacios G, Palyi B, Paweska JT, Payne SL, Rima BK, Rota P, Rubbenstroth D, Simmonds P, Smither SJ, Song Q, Song T, Spann K, Stenglein MD, Stone DM, Takada A, Tesh RB, Tomonaga K, Tordo N, Towner JS, van den Hoogen B, Vasilakis N, Wahl V, Walker PJ, Wang D, Wang LF, Whitfield AE, Williams JV, Ye G, Zerbini FM, Zhang YZ, Kuhn JH.
        Arch Virol. 2019 Jan 20.
        In October 2018, the order Mononegavirales was amended by the establishment of three new families and three new genera, abolishment of two genera, and creation of 28 novel species. This article presents the updated taxonomy of the order Mononegavirales as now accepted by the International Committee on Taxonomy of Viruses (ICTV).

      5. Reduced frequency of resistance-type exercise training promotes adaptation of the aged skeletal muscle microenvironmentExternal
        Naimo MA, Rader EP, Ensey J, Kashon ML, Baker BA.
        J Appl Physiol (1985). 2019 Jan 24.
        The purpose of this study was to characterize the growth and remodeling molecular signaling response in aged skeletal muscle following one month of “resistance-type exercise” training. Male Fisher344x Brown Norway hybrid rats aged 3 (young) and 30 months (old) underwent stretch-shortening contraction (SSC) loading two or three days per week; muscles were removed 72 hours post-training. Young rats SSC-loaded three (Y3x) or two days per week (Y2x) adapted via increased work performance. Old rats SSC-loaded three days per week (O3x) maladapted via decreased negative work; however, old rats SSC-loaded two days per week (O2x) adapted through improved negative and positive work. Y3x, Y2x, and O2x, but not O3x, displayed hypertrophy via larger fiber area and myonuclear domains. Y3x, Y2x, and O2x differentially expressed 19, 30, and 8 PI3K-AKT genes, respectively, whereas O3x only expressed two. Bioinformatics analysis revealed that rats in the adapting groups presented growth and remodeling processes (i.e. increased protein synthesis), whereas O3x demonstrated inflammatory signaling. In conclusion, reducing SSC-loading frequency in aged rodents positively influences the molecular signaling microenvironment, promoting muscle adaptation.

      6. Streptococcus infantis, Streptococcus mitis, and Streptococcus oralis strains with highly similar cps5 loci and antigenic relatedness to serotype 5 pneumococciExternal
        Pimenta F, Gertz RE, Park SH, Kim E, Moura I, Milucky J, Rouphael N, Farley MM, Harrison LH, Bennett NM, Bigogo G, Feikin DR, Breiman R, Lessa FC, Whitney CG, Rajam G, Schiffer J, da Gloria Carvalho M, Beall B.
        Front Microbiol. 2018 ;9:3199.
        Streptococcus pneumoniae is a highly impactful bacterial pathogen on a global scale. The principal pneumococcal virulence factor and target of effective vaccines is its polysaccharide capsule, of which there are many structurally distinct forms. Here, we describe four distinct strains of three Mitis group commensal species (Streptococcus infantis, Streptococcus mitis, and Streptococcus oralis) recovered from upper respiratory tract specimens from adults in Kenya and the United States that were PCR-positive for the pneumococcal serotype 5 specific gene, wzy5. For each of the four strains, the 15 genes comprising the capsular polysaccharide biosynthetic gene cluster (cps5) shared the same order found in serotype 5 pneumococci, and each of the serotype 5-specific genes from the serotype 5 pneumococcal reference strain shared 76-99% sequence identity with the non-pneumococcal counterparts. Double-diffusion experiments demonstrated specific reactivity of the non-pneumococcal strains with pneumococcal serotype 5 typing sera. Antiserum raised against S. mitis strain KE67013 specifically reacted with serotype 5 pneumococci for a positive Quellung reaction and stimulated serotype 5 specific opsonophagocytic killing of pneumococci. Four additional commensal strains, identified using PCR serotyping assays on pharyngeal specimens, revealed loci highly homologous to those of pneumococci of serotypes 12F, 15A, 18C, and 33F. These data, in particular the species and strain diversity shown for serotype 5, highlight the existence of a broad non-pneumococcal species reservoir in the upper respiratory tract for the expression of capsular polysaccharides that are structurally related or identical to those corresponding to epidemiologically significant serotypes. Very little is known about the genetic and antigenic capsular diversity among the vast array of commensal streptococcal strains that represent multiple diverse species. The discovery of serotype 5 strains within three different commensal species suggests that extensive capsular serologic overlap exists between pneumococci and other members of the diverse Mitis group. These findings may have implications for our current understanding of naturally acquired immunity to S. pneumoniae and pneumococcal serotype distributions in different global regions. Further characterization of commensal strains carrying homologs of serotype-specific genes previously thought to be specific for pneumococci of known serotypes may shed light on the evolution of these important loci.

      7. Can mentorship improve laboratory quality? A case study from influenza diagnostic laboratories in Southeast EuropeExternal
        Polansky L, Chester S, Warren M, Aden T, Kennedy P, Spivey-Blackford S, Moen A.
        BMC Health Serv Res. 2019 Jan 18;19(1):49.
        BACKGROUND: Strengthening the quality of laboratory diagnostics is a key part of building global health capacity. In 2015, the Centers for Disease Control and Prevention (CDC), the Southeast European Center for Surveillance and Control of Infectious Diseases (SECID), WHO European Regional Office (WHO EURO) and American Public Health Laboratories (APHL) collaborated to address laboratory quality training needs in Southeast Europe. Together, they developed a quality assurance (QA) mentorship program for six national laboratories (Laboratories A-E) in five countries utilizing APHL international consultants. The primary goal of the mentorship program was to help laboratories become recognized by WHO as National Influenza Centers (NICs). The program aimed to do this by strengthening influenza laboratory capacity by implementing quality management systems (QMS) action steps. After 1 year, we evaluated participants’ progress by the proportion of QMS action steps they had successfully implemented, as well as the value of mentorship as perceived by laboratory mentees, mentors, and primary program stakeholders from SECID and WHO EURO. METHODS: To understand perceived value we used the qualitative method of semi-structured interviews, applying grounded theory to the thematic analysis. RESULTS: Mentees showed clear progress, having completed 32 to 68% [median: 62%] of planned QMS action steps in their laboratories. In regards to the perceived value of the program, we found strong evidence that laboratory mentorship enhances laboratory quality improvement by promoting accountability to QMS implementation, raising awareness of the importance of QMS, and fostering collaborative problem solving. CONCLUSION: In conclusion, we found that significant accomplishments can be achieved when QA programs provide dedicated technical mentorship for QMS implementation. Since the start of the mentoring, Laboratory “B” has achieved NIC recognition by WHO, while two other labs made substantial progress and are scheduled for recognition in 2018. In the future, we recommend that mentorship is more inclusive of laboratory directors, and that programs evaluate the amount of staff time needed for mentorship activities, including lab-based assessments and mentoring.

      8. Simultaneous extraction of mRNA and microRNA from whole blood stabilized in tempus tubesExternal
        Richards J, Unger ER, Rajeevan MS.
        BMC Res Notes. 2019 Jan 18;12(1):39.
        OBJECTIVE: Studies of mRNA and miRNA expression profiling increasingly use stabilized whole blood. Commercial RNA extraction kits do not provide information about the simultaneous recovery of both mRNA and miRNA. This study evaluated yield, quality, integrity and representation of mRNA and miRNA from whole blood stabilized in Tempus tubes using three RNA extraction kits; two filter-based (Tempus and Norgen) and one bead-based (MagMax; manual vs. semi-automated, and with and without DNase treatment). RESULTS: All RNA extraction kits and methods resulted in similar yields of mRNA (total RNA yield, quality, integrity and representation) whereas there were differences in yields of miRNA. MagMax, either manual or semi-automated, with or without DNase treatment, yielded 1.6-2.2-fold more miRNA than Tempus and Norgen kits. In addition, MagMax and Norgen methods gave greater than 12-fold more and 3.3-fold less enrichment of specific miRNA targets, respectively, in comparison to Tempus extraction reagents. This study identified MagMax kit for simultaneous recovery of both mRNA and miRNA from whole blood collected in Tempus tubes.

    • Nutritional Sciences
      1. Integrating small-quantity lipid-based nutrient supplements (SQ-LNS) into infant and young child feeding (IYCF) programs can increase consumption of essential nutrients among children in vulnerable populations; however, few studies have assessed the impact of integrated IYCF-SQ-LNS programs on IYCF practices. A two-year, enhanced IYCF intervention targeting pregnant women and infants (0-12 months) was implemented in a health zone in the Democratic Republic of Congo (DRC). The enhanced IYCF intervention included community- and facility-based counselling for mothers on handwashing, SQ-LNS and IYCF practices, plus monthly SQ-LNS distributions for children 6-12 months; a control zone received the national IYCF program (facility-based IYCF counselling with no SQ-LNS distributions). Cross-sectional pre- and post-intervention surveys (n=650 and 638 in intervention and control areas at baseline; n=654 and 653 in each area at endline, respectively) were conducted in mothers of children 6-18 months representative of both zones. Difference-in-difference (DiD) analyses used mixed linear regression models. There were significantly greater increases in the proportion of mothers in the intervention (versus control) zone who reported: initiating breastfeeding within 1hr. of birth [Adj. DiD (95%CI): +56.4% (49.3, 63.4), p<0.001], waiting until 6 months to introduce water [+66.9% (60.6, 73.2), p<0.001] and complementary foods [+56.4% (49.3, 63.4), p<0.001], feeding the minimum meal frequency the previous day [+9.2% (2.7, 15.7), p=0.005]; feeding the child in a separate bowl [+9.7% (2.2, 17.2), p=0.01]; awareness of anemia [+16.9% (10.4, 23.3), p<0.001]; owning soap [+14.9% (8.3, 21.5), p<0.001]; and washing hands after defecating and before cooking and feeding the child the previous day [+10.5% (5.8, 15.2), +12.5% (9.3, 15.6) and +15.0% (11.2, 18.8) respectively, p<0.001 for all)]. The enhanced IYCF intervention in the DRC was associated with an improvement in several important IYCF practices, but was not associated with a change in dietary diversity (minimum dietary diversity and minimum acceptable diet remained below 10% in both zones without significant differences between zones). The provision of fortified complementary foods, such as SQ-LNS, may be an important source of micro- and macro-nutrients for young children in areas with high rates of poverty and limited access to diverse foods. Future research should verify the potential of integrated IYCF-SQ-LNS to improve IYCF practices, and ultimately children’s nutritional status.

    • Occupational Safety and Health
      1. Silicosis prevalence and incidence among Medicare beneficiariesExternal
        Casey ML, Mazurek JM.
        Am J Ind Med. 2019 Jan 18.
        INTRODUCTION: Existing epidemiologic information on silicosis relies on mortality data. METHODS: We analyzed health insurance claims and enrollment information from 49 923 987 fee-for-service (FFS) Medicare beneficiaries aged >/=65 from 1999 to 2014. Three different definitions were developed to identify silicosis cases and results are presented as ranges of values for the three definitions. RESULTS: Among FFS beneficiaries, 10 026-19 696 fit the silicosis case definitions (16-year prevalence: 20.1-39.5 per 100 000) with the highest prevalence among North American Natives (87.2-213.6 per 100 000) and those in New Mexico (83.9-203.4 per 100 000). The annual average prevalence had a significant (P < 0.05) 2-5% annual decline from 2005 to 2014. The average annual number of incident cases had a significant 3-16% annual decline from 2007 to 2014. CONCLUSIONS: Silicosis is a prevalent disease among Medicare beneficiaries aged >/=65, with variation across the country. Morbidity data from health insurance claims can provide a more complete picture of silicosis burden.

    • Statistics as Topic
      1. Discounting is the process by which outcomes lose value. Much of discounting research has focused on differences in the degree of discounting across various groups. This research has relied heavily on conventional null hypothesis significance tests that are familiar to psychologists, such as t-tests and ANOVAs. As discounting research questions have become more complex by simultaneously focusing on within-subject and between-group differences, conventional statistical testing is often not appropriate for the obtained data. Generalized estimating equations (GEE) are one type of mixed-effects model that are designed to handle autocorrelated data, such as within-subject repeated-measures data, and are therefore more appropriate for discounting data. To determine if GEE provides similar results as conventional statistical tests, we compared the techniques across 2,000 simulated data sets. The data sets were created using a Monte Carlo method based on an existing data set. Across the simulated data sets, the GEE and the conventional statistical tests generally provided similar patterns of results. As the GEE and more conventional statistical tests provide the same pattern of result, we suggest researchers use the GEE because it was designed to handle data that has the structure that is typical of discounting data.

    • Substance Use and Abuse
      1. Public health surveillance of prenatal opioid exposure in mothers and infantsExternal
        Honein MA, Boyle C, Redfield RR.
        Pediatrics. 2019 Jan 17.

        [No abstract]

      2. In 2010, the Centers for Disease Control and Prevention (CDC) funded communities to implement policy, systems, and environmental (PSE) changes under the Communities Putting Prevention to Work (CPPW) program to make it easier for people to make healthier choices to prevent chronic disease. Twenty-one of 50 funded communities implemented interventions intended to reduce tobacco use. To examine the potential cost-effectiveness of tobacco control changes implemented under CPPW from a healthcare system perspective, we compared program cost estimates with estimates of potential impacts. We used an existing simulation model, the Prevention Impacts Simulation Model (PRISM), to estimate the potential cumulative impact of CPPW tobacco interventions on deaths and medical costs averted through 2020. We collected data on the costs to implement CPPW tobacco interventions from 2010 to 2013. We adjusted all costs to 2010 dollars. CPPW tobacco interventions cost $130.5 million across all communities, with an average community cost of $6.2 million. We found $735 million in potentially averted medical costs cumulatively from 2010 through 2020 because of the CPPW-supported interventions. If the CPPW tobacco control PSE changes are sustained through 2020 without additional funding after 2013, we find that medical costs averted will likely exceed program costs by $604 million. Our results suggest that the medical costs averted through 2020 may more than offset the initial investment in CPPW tobacco control interventions, implying that such interventions may be cost saving, especially over the long term.

    • Zoonotic and Vectorborne Diseases
      1. Monkeypox transmission among international travelers – serious monkey business?External
        Angelo KM, Petersen BW, Hamer DH, Schwartz E, Brunette G.
        J Travel Med. 2019 Jan 18.

        [No abstract]

      2. Emerging and reemerging Aedes-transmitted arbovirus infections in the region of the Americas: Implications for health policyExternal
        Espinal MA, Andrus JK, Jauregui B, Waterman SH, Morens DM, Santos JI, Horstick O, Francis LA, Olson D.
        Am J Public Health. 2019 Jan 24:e1-e6.
        The increasing geographical spread and disease incidence of arboviral infections are among the greatest public health concerns in the Americas. The region has observed an increasing trend in dengue incidence in the last decades, evolving from low to hyperendemicity. Yellow fever incidence has also intensified in this period, expanding from sylvatic-restricted activity to urban outbreaks. Chikungunya started spreading pandemically in 2005 at an unprecedented pace, reaching the Americas in 2013. The following year, Zika also emerged in the region with an explosive outbreak, carrying devastating congenital abnormalities and neurologic disorders and becoming one of the greatest global health crises in years. The inadequate arbovirus surveillance in the region and the lack of serologic tests to differentiate among viruses poses substantial challenges. The evidence for vector control interventions remains weak. Clinical management remains the mainstay of arboviral disease control. Currently, only yellow fever and dengue vaccines are licensed in the Americas, with several candidate vaccines in clinical trials. The Global Arbovirus Group of Experts provides in this article an overview of progress, challenges, and recommendations on arboviral prevention and control for countries of the Americas. (Am J Public Health. Published online ahead of print January 24, 2019: e1-e6. doi:10.2105/AJPH.2018.304849).

      3. A genome-wide CRISPR screen identifies N-acetylglucosamine-1-phosphate transferase as a potential antiviral target for Ebola virusExternal
        Flint M, Chatterjee P, Lin DL, McMullan LK, Shrivastava-Ranjan P, Bergeron E, Lo MK, Welch SR, Nichol ST, Tai AW, Spiropoulou CF.
        Nat Commun. 2019 Jan 17;10(1):285.
        There are no approved therapies for Ebola virus infection. Here, to find potential therapeutic targets, we perform a screen for genes essential for Ebola virus (EBOV) infection. We identify GNPTAB, which encodes the alpha and beta subunits of N-acetylglucosamine-1-phosphate transferase. We show that EBOV infection of a GNPTAB knockout cell line is impaired, and that this is reversed by reconstituting GNPTAB expression. Fibroblasts from patients with mucolipidosis II, a disorder associated with mutations in GNPTAB, are refractory to EBOV, whereas cells from their healthy parents support infection. Impaired infection correlates with loss of the expression of cathepsin B, known to be essential for EBOV entry. GNPTAB activity is dependent upon proteolytic cleavage by the SKI-1/S1P protease. Inhibiting this protease with the small-molecule PF-429242 blocks EBOV entry and infection. Disruption of GNPTAB function may represent a strategy for a host-targeted therapy for EBOV.

      4. First laboratory-confirmed outbreak of human and animal Rift Valley Fever Virus in Uganda in 48 yearsExternal
        Shoemaker TR, Nyakarahuka L, Balinandi S, Ojwang J, Tumusiime A, Mulei S, Kyondo J, Lubwama B, Sekematte M, Namutebi A, Tusiime P, Monje F, Mayanja M, Ssendagire S, Dahlke M, Kyazze S, Wetaka M, Makumbi I, Borchert J, Zufan S, Patel K, Whitmer S, Brown S, Davis WG, Klena JD, Nichol ST, Rollin PE, Lutwama J.
        Am J Trop Med Hyg. 2019 Jan 21.
        In March 2016, an outbreak of Rift Valley fever (RVF) was identified in Kabale district, southwestern Uganda. A comprehensive outbreak investigation was initiated, including human, livestock, and mosquito vector investigations. Overall, four cases of acute, nonfatal human disease were identified, three by RVF virus (RVFV) reverse transcriptase polymerase chain reaction (RT-PCR), and one by IgM and IgG serology. Investigations of cattle, sheep, and goat samples from homes and villages of confirmed and probable RVF cases and the Kabale central abattoir found that eight of 83 (10%) animals were positive for RVFV by IgG serology; one goat from the home of a confirmed case tested positive by RT-PCR. Whole genome sequencing from three clinical specimens was performed and phylogenetic analysis inferred the relatedness of 2016 RVFV with the 2006-2007 Kenya-2 clade, suggesting previous introduction of RVFV into southwestern Uganda. An entomological survey identified three of 298 pools (1%) of Aedes and Coquillettidia species that were RVFV positive by RT-PCR. This was the first identification of RVFV in Uganda in 48 years and the 10(th) independent viral hemorrhagic fever outbreak to be confirmed in Uganda since 2010.

      5. Crimean-Congo hemorrhagic fever and expansion from endemic regionsExternal
        Spengler JR, Bergeron E, Spiropoulou CF.
        Curr Opin Virol. 2019 Jan 16;34:70-78.
        Crimean-Congo hemorrhagic fever (CCHF) is a virus-mediated hemorrhagic disease that occurs over a wide geographic region. In recent years, a variety of active and passive surveillance networks have improved our knowledge of areas with existing circulation of Crimean-Congo hemorrhagic fever virus (CCHFV), the etiologic agent of CCHF. These investigations aid in better defining the distribution of the virus. Expansion of a virus into new areas can occur through a variety of means, including introduction of infected humans, vectors, or animals. Here, these potential contributors to expansion of CCHFV into neighboring countries and geographically distant locations are reviewed, and the likelihood and possible implications of these events, based on known characteristics of the virus and its natural maintenance and transmission cycles are explored. Furthermore, this report discusses limitations in the currently described distribution of CCHFV, and the challenges in assessing viral circulation identified in a new region as geographic expansion of the virus.

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

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