Volume 11, Issue 7, February 11, 2019

CDC Science Clips: Volume 11, Issue 7, February 11, 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 collaborate with CDC Vital Signs by featuring scientific articles from the latest issue on Tobacco Use Among Youth. The articles marked with an asterisk are general review articles which may be of particular interest to clinicians and public health professionals seeking background information in this area.

This issue also features scientific articles related to February’s CDC Public Health Grand Rounds, Preventing Childhood Lead Exposure.

  1. CDC Vital Signs
    • Substance Use and Abuse – Tobacco Use Among Youth
      1. *E-cigarette use among youth and young adultsCdc-pdf
        US Department of Health and Human Services .
        Atlanta, GA: US Department of Health and Human Services, CDC. 2016 .

        [No abstract]

      2. *Preventing tobacco use among youth and young adults
        US Department of Health and Human Services .
        Atlanta, GA: US Department of Health and Human Services, CDC. 2012 .

        [No abstract]

      3. Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students – United States, 2011-2018External
        Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA.
        MMWR Morb Mortal Wkly Rep. 2018 Nov 16;67(45):1276-1277.

        [No abstract]

      4. Electronic Cigarette Sales in the United States, 2013-2017External
        King BA, Gammon DG, Marynak KL, Rogers T.
        Jama. 2018 Oct 2;320(13):1379-1380.

        [No abstract]

      5. Public health consequences of e-cigarettesExternal
        National Academies of Sciences , Engineering , and Medicine .
        Washington, DC: The National Academies Press. 2018 .
        Millions of Americans use e-cigarettes. Despite their popularity, little is known about their health effects. Some suggest that e-cigarettes likely confer lower risk compared to combustible tobacco cigarettes, because they do not expose users to toxicants produced through combustion. Proponents of e-cigarette use also tout the potential benefits of e-cigarettes as devices that could help combustible tobacco cigarette smokers to quit and thereby reduce tobacco-related health risks. Others are concerned about the exposure to potentially toxic substances contained in e-cigarette emissions, especially in individuals who have never used tobacco products such as youth and young adults. Given their relatively recent introduction, there has been little time for a scientific body of evidence to develop on the health effects of e-cigarettes. Public Health Consequences of E-Cigarettes reviews and critically assesses the state of the emerging evidence about e-cigarettes and health. This report makes recommendations for the improvement of this research and highlights gaps that are a priority for future research.

      6. Best practices for comprehensive tobacco control programs – 2014
        US Department of Health and Human Services .
        Atlanta, GA: US Department of Health and Human Services, CDC. 2014 .
        CDC’s Best Practices for Comprehensive Tobacco Control Programs – 2014 is an evidence-based guide to help states build and maintain effective tobacco control programs to prevent and reduce tobacco use. This document updates Best Practices for Comprehensive Tobacco Control Programs – 2007. This updated edition describes an integrated approach to program development and provides recommended funding levels for effective state programs.

      7. The health consequences of smoking – 50 years of progressCdc-pdfExternal
        US Department of Health and Human Services .
        Atlanta, GA: US Department of Health and Human Services, CDC. 2014 .

        [No abstract]

      8. Surgeon General’s advisory on e-cigarette use among youthCdc-pdfExternal
        US Department of Health and Human Services .
        Washington, DC: US Department of Health and Human Services, Office of the Surgeon General. 2018 .

        [No abstract]

      9. Prevalence and correlates of JUUL use among a national sample of youth and young adultsExternal
        Vallone DM, Bennett M, Xiao H, Pitzer L, Hair EC.
        Tob Control. 2018 Oct 29.
        OBJECTIVE: To estimate the prevalence of JUUL use and identify demographic and psychosocial correlates of use among youth and young adults in the USA. METHODS: A national, probability-based sample was recruited via address-based sampling, with subsamples recruited from an existing probability-based online panel. Participants (N=14 379) ages 15-34 were surveyed about JUUL use, tobacco use, electronic nicotine delivery system (ENDS) harm perceptions, sensation seeking and demographic characteristics. Data were collected February-May 2018. Chi(2) analyses assessed differences in JUUL use by demographic and psychosocial characteristics. Logistic regressions identified significant correlates of ever and current JUUL use. RESULTS: Overall, 6.0% reported ever JUUL use, and 3.3% reported past 30-day (ie, current) use. Rates were higher among participants aged 15-17 and 18-21 years, with 9.5% and 11.2% reporting ever use, and 6.1% and 7.7% reporting current use, respectively. Among current users aged 15-17 years, 55.8% reported use on 3 or more days in the past month, and over a quarter reported use on 10-30 days. Significant correlates of use included younger age, white race, greater financial comfort, perceptions of ENDS as less harmful than cigarettes, household ENDS use, high sensation seeking and current combustible tobacco use. CONCLUSION: JUUL use was significantly higher among young people, with those under 21 having significantly higher odds of ever and current use. Frequency of use patterns suggest youth may not be experimenting with the device but using it regularly. Given the high nicotine content of JUUL, there is concern over the potential for addiction and other serious health consequences among young people. Findings suggest strong regulatory actions are needed to prevent youth and young adult uptake.

      10. Tobacco Product Use Among Middle and High School Students – United States, 2011-2017External
        Wang TW, Gentzke A, Sharapova S, Cullen KA, Ambrose BK, Jamal A.
        MMWR Morb Mortal Wkly Rep. 2018 Jun 8;67(22):629-633.
        Tobacco use is the leading cause of preventable disease and death in the United States, and nearly all tobacco use begins during youth and young adulthood (1,2). CDC and the Food and Drug Administration (FDA) analyzed data from the 2011-2017 National Youth Tobacco Surveys (NYTS)* to determine patterns of current (past 30-day) use of seven tobacco product types among U.S. middle school (grades 6-8) and high school (grades 9-12) students and estimate use nationwide. Among high school students, current use of any tobacco product decreased from 24.2% (estimated 3.69 million users) in 2011 to 19.6% (2.95 million) in 2017. Among middle school students, current use of any tobacco product decreased from 7.5% (0.87 million) in 2011 to 5.6% (0.67 million) in 2017. In 2017, electronic cigarettes (e-cigarettes) were the most commonly used tobacco product among high (11.7%; 1.73 million) and middle (3.3%; 0.39 million) school students. During 2016-2017, decreases in current use of hookah and pipe tobacco occurred among high school students, while decreases in current use of any tobacco product, e-cigarettes, and hookah occurred among middle school students. Current use of any combustible tobacco product, >/=2 tobacco products, cigarettes, cigars, smokeless tobacco, and bidis did not change among middle or high school students during 2016-2017. Comprehensive and sustained strategies can help prevent and reduce the use of all forms of tobacco products among U.S. youths (1,2).

  2. CDC Public Health Grand Rounds
    • Environmental Health – Childhood Lead Exposure
      1. WIC Participation and Blood Lead Levels among Children 1-5 Years: 2007-2014External
        Aoki Y, Brody DJ.
        Environ Health Perspect. 2018 Jun;126(6):067011.
        BACKGROUND: The CDC recommends a targeted strategy for childhood blood lead screening based on participation in federal programs, such as Medicaid and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Yet, there is scarcity of data on blood lead levels (BLLs) among WIC participants. OBJECTIVE: Our objective was to investigate whether children participating in WIC and not enrolled in Medicaid, who have not been targeted in the historical Medicaid-focused screening strategy, have higher BLLs than children in neither of these programs. METHODS: The analysis included 3,180 children 1-5 y of age in the National Health and Nutrition Examination Surveys conducted in 2007-2014. Log-binomial regression, which allows direct estimation of prevalence ratios, was used to examine associations between WIC participation (in conjunction with Medicaid enrollment) and having BLLs >/=5 mug/dL with adjustment for age (1-2 vs. 3-5 y). RESULTS: The percentage of children participating in “WIC only,” “Medicaid only,” “both WIC and Medicaid,” and “neither” were 18.9%, 10.8%, 25.4%, and 44.9%, respectively. “WIC only,” “Medicaid only,” and “both WIC and Medicaid” children were more likely to have BLLs >/=5 mug/dL than children who were not enrolled in either program, with adjusted prevalence ratios of 3.29 [95% confidence interval (CI): 1.19, 9.09], 4.56 (95% CI: 2.18, 9.55), and 2.58 (95% CI: 1.18, 5.63). CONCLUSIONS: Children participating in WIC but not Medicaid were more likely to have BLLs >/=5 mug/dL than children who were not enrolled in either program. These findings may inform public health recommendations and clinical practice guidelines.

      2. Spatial Surveillance of Childhood Lead Exposure in a Targeted Screening State: An Application of Generalized Additive Models in Denver, ColoradoExternal
        Berg K, Kuhn S, Van Dyke M.
        J Public Health Manag Pract. 2017 Sep/Oct;23 Suppl 5 Supplement, Environmental Public Health Tracking:S79-s92.
        CONTEXT: The targeted nature of Colorado’s childhood lead screening program presents several analytical issues that complicate routine epidemiologic surveillance. OBJECTIVES: To analyze spatial patterns of childhood lead exposure among children younger than 6 years, identifying areas of increased risk along with associated covariates. METHODS: We analyzed a spatial case-control data set of childhood lead poisoning using generalized additive models. Incident cases were represented by the residential locations of children younger than 6 years with confirmed elevated blood lead levels (EBLL) of 5 mug/dL or more recorded between calendar years 2010 and 2014, and controls were sampled from the population at risk. We modeled the effect of spatial location, adjusting for potential spatial confounders. We also adjusted for a number of covariates previously identified in the childhood lead poisoning literature to understand the ecologic-level drivers of spatial variation in risk. MAIN OUTCOME MEASURE(S): Crude and adjusted spatial odds ratios describing the relative frequency of lead poisoning among different locations in Denver, Colorado. RESULTS: We found evidence of statistically significant spatial clustering in incident cases of lead poisoning even after adjustment for age, sex, year, season, and spatially smoothed screening rate. Spatial confounder-adjusted odds ratios in the Denver study area ranged from 0.22 to 2.7. Adjusting for additional ecologic-level covariates effectively accounted for the observed spatial variation. We found that ecologic-level indicators of low socioeconomic status, Hispanic ethnicity, Asian race, and older housing age were all positively and significantly associated with an increased EBLL risk. CONCLUSION: Housing and socioeconomic factors continue to be the primary ecologic risk factors associated with childhood lead exposure and can be used to predict risk at a fine spatial resolution in the Denver study area. Our analysis demonstrates how other targeted screening states can be proactive about childhood lead surveillance within their major population centers and enhance the spatial specificity of lead mitigation efforts.

      3. Integrating Childhood and Adult Blood Lead Surveillance to Improve Identification and Intervention EffortsExternal
        Egan KB, Tsai RJ, Chuke SO.
        J Public Health Manag Pract. 2019 Jan/Feb;25 Suppl 1, Lead Poisoning Prevention:S98-s104.
        The Centers for Disease Control and Prevention (CDC) collects information on blood lead levels (BLLs) in the United States through the Childhood Blood Lead Surveillance (CBLS) system (<16 years of age) and the Adult Blood Lead Epidemiology and Surveillance (ABLES) program (>/=16 years of age). While both of these state-based national programs share the mutual goal of monitoring and reducing lead exposure in the US population, blood lead data for children and adults are maintained in separate data collection systems. This limits the ability to fully describe lead exposure in the US population across these 2 distinct population groups from sources such as take-home and maternal-child lead exposure. In addition, at the state level, having a unified system to collect, maintain, and analyze child and adult blood lead data provides a more efficient use of limited resources. Based on feedback from state partners, CDC is working to integrate CBLS and ABLES data collection systems at the national level. Several states have developed or are developing an integrated child and adult blood lead data collection system. We highlight efforts undertaken in Wisconsin, Minnesota, North Carolina, Iowa, and Oregon to investigate workplace and take-home lead exposure. Integrating blood lead surveillance data at the national level will enhance CDC’s ability to monitor sources of lead exposure from both the home and work environments including paint, water, soil, dust, consumer products, and lead-related industries. Together, an integrated child and adult blood lead surveillance system will offer a coordinated, comprehensive, and systematic public health approach to the surveillance and monitoring of reported BLLs across the US population.

      4. 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, Lead Poisoning Prevention: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.

      5. Elevated Blood Lead Levels in Children Associated With the Flint Drinking Water Crisis: A Spatial Analysis of Risk and Public Health ResponseExternal
        Hanna-Attisha M, LaChance J, Sadler RC, Champney Schnepp A.
        Am J Public Health. 2016 Feb;106(2):283-90.
        OBJECTIVES: We analyzed differences in pediatric elevated blood lead level incidence before and after Flint, Michigan, introduced a more corrosive water source into an aging water system without adequate corrosion control. METHODS: We reviewed blood lead levels for children younger than 5 years before (2013) and after (2015) water source change in Greater Flint, Michigan. We assessed the percentage of elevated blood lead levels in both time periods, and identified geographical locations through spatial analysis. RESULTS: Incidence of elevated blood lead levels increased from 2.4% to 4.9% (P < .05) after water source change, and neighborhoods with the highest water lead levels experienced a 6.6% increase. No significant change was seen outside the city. Geospatial analysis identified disadvantaged neighborhoods as having the greatest elevated blood lead level increases and informed response prioritization during the now-declared public health emergency. CONCLUSIONS: The percentage of children with elevated blood lead levels increased after water source change, particularly in socioeconomically disadvantaged neighborhoods. Water is a growing source of childhood lead exposure because of aging infrastructure.

      6. A Spoonful of Lead: A 10-Year Look at Spices as a Potential Source of Lead ExposureExternal
        Hore P, Alex-Oni K, Sedlar S, Nagin D.
        J Public Health Manag Pract. 2019 Jan/Feb;25 Suppl 1, Lead Poisoning Prevention:S63-s70.
        CONTEXT: While lead-based paint and occupational lead hazards remain the primary sources of lead exposures among New York City’s lead-poisoned children and men, respectively, these are not the only possible lead sources. Certain consumer products are often implicated. Between 2008 and 2017, the New York City Department of Health and Mental Hygiene tested more than 3000 samples of consumer products during lead poisoning case investigations and surveys of local stores, and of these, spices were the most frequently tested (almost 40% of the samples). OBJECTIVES: To describe spice samples-types, origin, lead concentrations, and the implication of findings for public health programs and global food safety regulations. DESIGN: Descriptive study of lead contamination in spices systematically collected as part of lead poisoning investigations. SETTING AND PARTICIPANTS: A total of 1496 samples of more than 50 spices from 41 countries were collected during investigations of lead poisoning cases among New York City children and adults and local store surveys. RESULTS: More than 50% of the spice samples had detectable lead, and more than 30% had lead concentrations greater than 2 ppm. Average lead content in the spices was significantly higher for spices purchased abroad than in the United States. The highest concentrations of lead were found in spices purchased in the countries Georgia, Bangladesh, Pakistan, Nepal, and Morocco. CONCLUSIONS: Certain commonly used spices, particularly those purchased abroad in Georgia, Bangladesh, Pakistan, Nepal, and Morocco, can have very high lead levels, which can contribute to lead body burden. This underscores the need to develop comprehensive interventions that educate consumers and initiate intergovernmental efforts for stricter global food regulations.

      7. Low-level environmental lead exposure and children’s intellectual function: an international pooled analysisExternal
        Lanphear BP, Hornung R, Khoury J, Yolton K, Baghurst P, Bellinger DC, Canfield RL, Dietrich KN, Bornschein R, Greene T, Rothenberg SJ, Needleman HL, Schnaas L, Wasserman G, Graziano J, Roberts R.
        Environ Health Perspect. 2005 Jul;113(7):894-9.
        Lead is a confirmed neurotoxin, but questions remain about lead-associated intellectual deficits at blood lead levels < 10 microg/dL and whether lower exposures are, for a given change in exposure, associated with greater deficits. The objective of this study was to examine the association of intelligence test scores and blood lead concentration, especially for children who had maximal measured blood lead levels < 10 microg/dL. We examined data collected from 1,333 children who participated in seven international population-based longitudinal cohort studies, followed from birth or infancy until 5-10 years of age. The full-scale IQ score was the primary outcome measure. The geometric mean blood lead concentration of the children peaked at 17.8 microg/dL and declined to 9.4 microg/dL by 5-7 years of age; 244 (18%) children had a maximal blood lead concentration < 10 microg/dL, and 103 (8%) had a maximal blood lead concentration < 7.5 microg/dL. After adjustment for covariates, we found an inverse relationship between blood lead concentration and IQ score. Using a log-linear model, we found a 6.9 IQ point decrement [95% confidence interval (CI), 4.2-9.4] associated with an increase in concurrent blood lead levels from 2.4 to 30 microg/dL. The estimated IQ point decrements associated with an increase in blood lead from 2.4 to 10 microg/dL, 10 to 20 microg/dL, and 20 to 30 microg/dL were 3.9 (95% CI, 2.4-5.3), 1.9 (95% CI, 1.2-2.6), and 1.1 (95% CI, 0.7-1.5), respectively. For a given increase in blood lead, the lead-associated intellectual decrement for children with a maximal blood lead level < 7.5 microg/dL was significantly greater than that observed for those with a maximal blood lead level > or = 7.5 microg/dL (p = 0.015). We conclude that environmental lead exposure in children who have maximal blood lead levels < 7.5 microg/dL is associated with intellectual deficits.

      8. Assessing Child Lead Poisoning Case Ascertainment in the US, 1999-2010External
        Roberts EM, Madrigal D, Valle J, King G, Kite L.
        Pediatrics. 2017 May;139(5).
        OBJECTIVES: To compare prevalence estimates for blood lead level >/=10.0 mug/dL (elevated blood lead level [EBLL]) with numbers reported to the Centers for Disease Control and Prevention (CDC) for children 12 months to 5 years of age from 1999 to 2010 on a state-by-state basis. METHODS: State-specific prevalence estimates were generated based on the continuous NHANES according to newly available statistical protocols. Counts of case reports were based on the 39 states (including the District of Columbia) reporting to the CDC Childhood Lead Poisoning Prevention Program during the study period. Analyses were conducted both including and excluding states and years of nonreporting to the CDC. RESULTS: Approximately 1.2 million cases of EBLL are believed to have occurred in this period, but 607 000 (50%) were reported to the CDC. Including only states and years for which reporting was complete, the reporting rate was 64%. Pediatric care providers in 23 of 39 reporting states identified fewer than half of their children with EBLL. Although the greatest numbers of reported cases were from the Northeast and Midwest, the greatest numbers based on prevalence estimates occurred in the South. In southern and western states engaged in reporting, roughly 3 times as many children with EBLL were missed than were diagnosed. CONCLUSIONS: Based on the best available estimates, undertesting of blood lead levels by pediatric care providers appears to be endemic in many states.

      9. 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.

      10. Childhood Lead Poisoning: A Perpetual Environmental Justice Issue?External
        Whitehead LS, Buchanan SD.
        J Public Health Manag Pract. 2019 Jan/Feb;25 Suppl 1, Lead Poisoning Prevention:S115-s120.
        As the amount of lead in the environment has significantly decreased with the removal of lead in gasoline and paint, the United States has made great strides in preventing lead poisoning or reducing levels of lead in young children’s blood. Even so, lead exposure is not equal for all children-low-income and minority children continue to bear a disproportionate burden of exposure primarily through contact with deteriorating lead-based paint from older housing and potentially through drinking contaminated water resulting from failing leaded pipes, as evidenced by the recent events in Flint, Michigan. These facts suggest that childhood lead poisoning is an environmental justice issue worthy of public health consideration and action; “environmental justice” is focused on identifying and addressing disproportionately high and adverse effects of environmental hazards on low-income and minority communities. The question remains, however, as to whether addressing the quality-of-life “risk” factors associated with lead poisoning might eventually lead to reduction in exposure, as well as potentially resulting in adverse health effects. Utilizing an environmental justice framework and examining this issue through a multidimensional environmental justice lens, we contemplated the quality-of-life factors that may essentially predispose minority children and their families to lead poisoning. Specifically, we examined American Community Survey data (2012-2016) focused on comparing race/ethnicity with other sociodemographic variables known to be associated with risks for childhood lead poisoning. The results provide thought-provoking context for making progress toward eliminating lead poisoning as a major environmental justice concern.

      11. Early childhood lead exposure and academic achievement: evidence from Detroit public schools, 2008-2010External
        Zhang N, Baker HW, Tufts M, Raymond RE, Salihu H, Elliott MR.
        Am J Public Health. 2013 Mar;103(3):e72-7.
        OBJECTIVES: We assessed the long-term effect of early childhood lead exposure on academic achievement in mathematics, science, and reading among elementary and junior high school children. METHODS: We linked early childhood blood lead testing surveillance data from the Detroit Department of Health and Wellness Promotion to educational testing data from the Detroit, Michigan, public schools. We used the linked data to investigate the effect of early childhood lead exposure on academic achievement among school-aged children, both marginally and adjusted for grade level, gender, race, language, maternal education, and socioeconomic status. RESULTS: High blood lead levels before age 6 years were strongly associated with poor academic achievement in grades 3, 5, and 8. The odds of scoring less than proficient for those whose blood lead levels were greater than 10 micrograms per deciliter were more than twice the odds for those whose blood lead levels were less than 1 micrograms per deciliter after adjustment for potential confounders. CONCLUSIONS: Early childhood lead exposure was negatively associated with academic achievement in elementary and junior high school, after adjusting for key potential confounders. The control of lead poisoning should focus on primary prevention of lead exposure in children and development of special education programs for students with lead poisoning.

  3. 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. Eye care utilization among insured people with diabetes, U.S. 2010-2014External
        Benoit SR, Swenor B, Geiss LS, Gregg EW, Saaddine JB.
        Diabetes Care. 2019 Jan 24.
        OBJECTIVE: Diabetic retinopathy (DR) is the leading cause of blindness among working-age adults, and although screening with eye exams is effective, screening rates are low. We evaluated eye exam visits over a 5-year period in a large population of insured patients 10-64 years of age with diabetes. RESEARCH DESIGN AND METHODS: We used claims data from IBM Watson Health to identify patients with diabetes and continuous insurance coverage from 2010 to 2014. Diabetes and DR were defined using ICD-9 Clinical Modification codes. We calculated eye exam visit frequency by diabetes type over a 5-year period and estimated period prevalence and cumulative incidence of DR among those receiving an eye exam. RESULTS: Among the 298,383 insured patients with type 2 and no diagnosed DR, almost half had no eye exam visits over the 5-year period and only 15.3% met the American Diabetes Association (ADA) recommendations for annual or biennial eye exams. For the 2,949 patients with type 1 diabetes, one-third had no eye exam visits and 26.3% met ADA recommendations. The 5-year period prevalence and cumulative incidence of DR was 24.4% and 15.8% for patients with type 2 diabetes, respectively, and 54.0% and 33.4% for patients with type 1 diabetes. CONCLUSIONS: The frequency of eye exams was alarmingly low, adding to the abundant literature that systemic changes in health care may be needed to detect and prevent vision-threatening eye disease among people with diabetes.

      2. Changes in older adults’ oral health and disparities: 1999 to 2004 and 2011 to 2016External
        Griffin SO, Griffin PM, Li CH, Bailey WD, Brunson D, Jones JA.
        J Am Geriatr Soc. 2019 Jan 30.
        OBJECTIVES: To examine changes in tooth loss and untreated tooth decay among older low-income and higher-income US adults and whether disparities have persisted. DESIGN: Sequential cross-sectional study using nationally representative data. SETTING: The 1999 to 2004 and 2011 to 2016 National Health and Nutrition Examination Survey. PARTICIPANTS: Noninstitutionalized US adults, aged 65 years and older (N = 3539 for 1999-2004, and N = 3514 for 2011-2016). MEASUREMENTS: Differences in prevalence of tooth loss (having 19 teeth or fewer, 8 teeth or fewer, and no teeth) and untreated decay and mean number of decayed and missing teeth (DMT) between low- and high-income adults 65 years and older in each survey and changes between surveys. Adjusted prevalence and count outcomes were estimated with logistic and negative binomial regression models, respectively. Models controlled for sociodemographic characteristics and smoking status. Reported findings are significant at P < .05. RESULTS: In 2011 to 2016, unadjusted prevalence of having 19 teeth or fewer, 8 teeth or fewer, no teeth, and untreated decay among low-income adults 65 years and older was 50.6%, 42.0%, 28.6%, and 28.6%, respectively. Multivariate analyses indicated that although most tooth loss measures improved between surveys for both income groups, tooth loss among low-income adults remained at almost twice that among higher-income adults. The disparity in untreated decay prevalence in 2011 to 2016, 15.2 percentage points (26.1% vs 10.9% for low vs high income) was twice that in 1999 to 2004, 8.5 percentage points (22.9% vs 14.4% for low vs high income). DMT decreased for both groups, with lower-income adults having about five more affected teeth in both surveys. CONCLUSION: Tooth loss is decreasing, but differential access to restorative care by income appears to have increased.

      3. Use of toothpaste and toothbrushing patterns among children and adolescents – United States, 2013-2016External
        Thornton-Evans G, Junger ML, Lin M, Wei L, Espinoza L, Beltran-Aguilar E.
        MMWR Morb Mortal Wkly Rep. 2019 Feb 1;68(4):87-90.
        Fluoride use is one of the main factors responsible for the decline in prevalence and severity of dental caries and cavities (tooth decay) in the United States (1). Brushing children’s teeth is recommended when the first tooth erupts, as early as 6 months, and the first dental visit should occur no later than age 1 year (2-4). However, ingestion of too much fluoride while teeth are developing can result in visibly detectable changes in enamel structure such as discoloration and pitting (dental fluorosis) (1). Therefore, CDC recommends that children begin using fluoride toothpaste at age 2 years. Children aged <3 years should use a smear the size of a rice grain, and children aged >3 years should use no more than a pea-sized amount (0.25 g) until age 6 years, by which time the swallowing reflex has developed sufficiently to prevent inadvertent ingestion. Questions on toothbrushing practices and toothpaste use among children and adolescents were included in the questionnaire component of the National Health and Nutrition Examination Survey (NHANES) for the first time beginning in the 2013-2014 cycle. This study estimates patterns of toothbrushing and toothpaste use among children and adolescents by analyzing parents’ or caregivers’ responses to questions about when the child started to brush teeth, age the child started to use toothpaste, frequency of toothbrushing each day, and amount of toothpaste currently used or used at time of survey. Analysis of 2013-2016 data found that >38% of children aged 3-6 years used more toothpaste than that recommended by CDC and other professional organizations. In addition, nearly 80% of children aged 3-15 years started brushing later than recommended. Parents and caregivers can play a role in ensuring that children are brushing often enough and using the recommended amount of toothpaste.

    • Communicable Diseases
      1. Contributions of traditional and HIV-related risk factors on non-AIDS-defining cancer, myocardial infarction, and end-stage liver and renal diseases in adults with HIV in the USA and Canada: a collaboration of cohort studiesExternal
        Althoff KN, Gebo KA, Moore RD, Boyd CM, Justice AC, Wong C, Lucas GM, Klein MB, Kitahata MM, Crane H, Silverberg MJ, Gill MJ, Mathews WC, Dubrow R, Horberg MA, Rabkin CS, Klein DB, Lo Re V, Sterling TR, Desir FA, Lichtenstein K, Willig J, Rachlis AR, Kirk GD, Anastos K, Palella FJ, Thorne JE, Eron J, Jacobson LP, Napravnik S, Achenbach C, Mayor AM, Patel P, Buchacz K, Jing Y, Gange SJ.
        Lancet HIV. 2019 Jan 22.
        BACKGROUND: Adults with HIV have an increased burden of non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, and end-stage renal disease. The objective of this study was to estimate the population attributable fractions (PAFs) of preventable or modifiable HIV-related and traditional risk factors for non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, and end-stage renal disease outcomes. METHODS: We included participants receiving care in academic and community-based outpatient HIV clinical cohorts in the USA and Canada from Jan 1, 2000, to Dec 31, 2014, who contributed to the North American AIDS Cohort Collaboration on Research and Design and who had validated non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, or end-stage renal disease outcomes. Traditional risk factors were tobacco smoking, hypertension, elevated total cholesterol, type 2 diabetes, renal impairment (stage 4 chronic kidney disease), and hepatitis C virus and hepatitis B virus infections. HIV-related risk factors were low CD4 count (<200 cells per muL), detectable plasma HIV RNA (>400 copies per mL), and history of a clinical AIDS diagnosis. PAFs and 95% CIs were estimated to quantify the proportion of outcomes that could be avoided if the risk factor was prevented. FINDINGS: In each of the study populations for the four outcomes (1405 of 61 500 had non-AIDS-defining cancer, 347 of 29 515 had myocardial infarctions, 387 of 35 044 had end-stage liver disease events, and 255 of 35 620 had end-stage renal disease events), about 17% were older than 50 years at study entry, about 50% were non-white, and about 80% were men. Preventing smoking would avoid 24% (95% CI 13-35) of these cancers and 37% (7-66) of the myocardial infarctions. Preventing elevated total cholesterol and hypertension would avoid the greatest proportion of myocardial infarctions: 44% (30-58) for cholesterol and 42% (28-56) for hypertension. For liver disease, the PAF was greatest for hepatitis C infection (33%; 95% CI 17-48). For renal disease, the PAF was greatest for hypertension (39%; 26-51) followed by elevated total cholesterol (22%; 13-31), detectable HIV RNA (19; 9-31), and low CD4 cell count (13%; 4-21). INTERPRETATION: The substantial proportion of non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, and end-stage renal disease outcomes that could be prevented with interventions on traditional risk factors elevates the importance of screening for these risk factors, improving the effectiveness of prevention (or modification) of these risk factors, and creating sustainable care models to implement such interventions during the decades of life of adults living with HIV who are receiving care. FUNDING: National Institutes of Health, US Centers for Disease Control and Prevention, the US Agency for Healthcare Research and Quality, the US Health Resources and Services Administration, the Canadian Institutes of Health Research, the Ontario Ministry of Health and Long Term Care, and the Government of Alberta.

      2. INTRODUCTION: Voluntary medical male circumcision (VMMC) reduces the risk of HIV infection in heterosexual men and has long-term indirect protection for women, yet VMMC uptake in South Africa remains low (49.8%) in men (25-49 years). We explored the attitude and willingness of women to start conversations on VMMC with their sexual partners in a South African peri-urban setting to increase VMMC uptake. METHODS: Thirty women with median age of 30 years (inter-quartile range 26-33 years) were interviewed in a language of their choice. Key questions included: types of approach to use, gender roles, benefits and barriers to introducing the topic of VMMC, and perceptions of VMMC. Interviews were digitally-recorded, transcribed, and translated. Through a standard iterative process, a codebook was developed (QSR NVIVO 10 software) and inductive thematic analysis applied. RESULTS: Most women were willing talk to their sexual partners about circumcision, but indicated that the decision to circumcise remained that of their sexual partner. Women felt that they should encourage their partners, show more interest in circumcision, be patient, speak in a caring and respectful tone, choose a correct time when their partner was relaxed and talk in a private space about VMMC. Using magazine/newspaper articles, pamphlets or advertisements were identified as tools that could aid their discussion. Substantial barriers to initiating conversations on VMMC included accusations by partner on infidelity, fear of gender-based violence, cultural restrictions and hesitation to speak to a mature partner about circumcision. CONCLUSIONS: Women need to ensure that before talking to their partner about circumcision, the environment and approach that they use are conducive. Female social network forums could be used to educate women on conversation techniques, skills to use when talking to their partners and how to address communication challenges about circumcision. Involvement of women in VMMC awareness campaigns could encourage circumcision uptake among men.

      3. Ocular syphilis and human immunodeficiency virus coinfection among syphilis patients in North Carolina, 2014-2016External
        Cope AB, Mobley VL, Oliver SE, Larson M, Dzialowy N, Maxwell J, Rinsky JL, Peterman TA, Fleischauer A, Samoff E.
        Sex Transm Dis. 2019 Feb;46(2):80-85.
        BACKGROUND: Ocular syphilis (OS) has been associated with human immunodeficiency virus (HIV) coinfection previously. We compared demographic and clinical characteristics of syphilis patients with and without HIV to identify risk factors for developing OS. METHODS: We reviewed all syphilis cases (early and late) reported to the North Carolina Division of Public Health during 2014 to 2016 and categorized HIV status (positive, negative, unknown) and OS status based on report of ocular symptoms with no other defined etiology. We estimated prevalence ratios (PR) and 95% confidence intervals (CI) for OS by HIV status. Among syphilis patients with HIV, we compared viral loads and CD4 cell counts by OS status. We compared symptom resolution by HIV status for a subset of OS patients. RESULTS: Among 7123 confirmed syphilis cases, 2846 (39.9%) were living with HIV, 109 (1.5%) had OS, and 59 (0.8%) had both. Ocular syphilis was more prevalent in syphilis patients with HIV compared to HIV-negative/unknown-status patients (PR, 1.8; 95% CI, 1.2-2.6). Compared with other patients with HIV, the prevalence of OS was higher in patients with viral loads greater than 200 copies/mL (1.7; 1.0-2.8) and in patients with a CD4 count of 200 cells/mL or less (PR, 2.3; 95% CI, 1.3-4.2). Among 11 patients with severe OS, 9 (81.8%) were HIV-positive. Among 39 interviewed OS patients, OS symptom resolution was similar for HIV-positive (70.0%) and HIV-negative/unknown-status (68.4%) patients. CONCLUSIONS: Syphilis patients with HIV were nearly twice as likely to report OS symptoms as were patients without documented HIV. Human immunodeficiency virus-related immunodeficiency possibly increases the risk of OS development in co-infected patients.

      4. Global review of the age distribution of rotavirus disease in children aged <5 years before the introduction of rotavirus vaccinationExternal
        Hasso-Agopsowicz M, Ladva CN, Lopman B, Sanderson C, Cohen AL, Tate JE, Riveros X, Henao-Restrepo AM, Clark A.
        Clin Infect Dis. 2019 Jan 28.
        We sought datasets with granular age distributions of rotavirus-positive presentations among children <5 years of age, before the introduction of rotavirus vaccines. We identified 117 datasets and fit parametric age distributions to each country dataset and mortality stratum and calculated the median age, and cumulative proportion of rotavirus gastroenteritis events expected to occur at ages between birth and 5.0 years. The median age of rotavirus-positive hospital admissions was 38 weeks (inter-quartile range IQR: 25-58) in countries with very high child mortality and 65 weeks (IQR: 40-107) in countries with very low/low child mortality. In countries with very high child mortality 69% of rotavirus-positive admissions <5 years were in the first year of life, with 3% by 10 weeks, 8% by 15 weeks and 27% by 26 weeks. This information is critical for assessing the potential benefits of alternative rotavirus vaccination schedules in different countries, and for monitoring programme impact.

      5. [No abstract]

      6. Population size estimation of venue-based female sex workers in Ho Chi Minh City, Vietnam: Capture-recapture exerciseExternal
        Le G, Khuu N, Tieu VT, Nguyen PD, Luong HT, Pham QD, Tran HP, Nguyen TV, Morgan M, Abdul-Quader AS.
        JMIR Public Health Surveill. 2019 Jan 29;5(1):e10906.
        BACKGROUND: There is limited population size estimation of female sex workers (FSWs) in Ho Chi Minh City (HCMC)-the largest city in Vietnam. Only 1 population size estimation among venue-based female sex workers (VFSWs) was conducted in 2012 in HCMC. Appropriate estimates of the sizes of key populations are critical for resource allocation to prevent HIV infection. OBJECTIVE: The aim of this study was to estimate the population size of the VFSWs from December 2016 to January 2017 in HCMC, Vietnam. METHODS: A multistage capture-recapture study was conducted in HCMC. The capture procedures included selection of districts using stratified probability proportion to size, mapping to identify venues, approaching all VFSWs to screen their eligibility, and then distribution of a unique object (a small pink makeup bag) to all eligible VFSWs in all identified venues. The recapture exercise included equal probability random selection of a sample of venues from the initial mapping and then approaching FSWs in those venues to determine the number and proportion of women who received the unique object. The proportion and associated confidence bounds, calculated using sampling weights and accounting for study design, were then divided by the number of objects distributed to calculate the number of VFSWs in the selected districts. This was then multiplied by the inverse of the proportion of districts selected to calculate the number of VFSWs in HCMC as a whole. RESULTS: Out of 24 districts, 6 were selected for the study. Mapping identified 573 venues across which 2317 unique objects were distributed in the first capture. During the recapture round, 103 venues were selected and 645 VFSWs were approached and interviewed. Of those, 570 VFSWs reported receiving the unique object during the capture round. Total estimated VFSWs in the 6 selected districts were 2616 (95% CI 2445-3014), accounting for the fact that only 25% (6/24) of total districts were selected gives an overall estimate of 10,465 (95% CI 9782-12,055) VFSWs in HCMC. CONCLUSIONS: The capture-recapture exercise provided an estimated number of VFSWs in HCMC. However, for planning HIV prevention and care service needs among all FSWs, studies are needed to assess the number of sex workers who are not venue-based, including those who use social media platforms to sell services.

      7. Under-reporting of diagnosed tuberculosis to the national surveillance system in China: an inventory study in nine counties in 2015External
        Li T, Shewade HD, Soe KT, Rainey JJ, Zhang H, Du X, Wang L.
        BMJ Open. 2019 Jan 28;9(1):e021529.
        OBJECTIVE: The WHO estimates that almost 40% of patients diagnosed with tuberculosis (TB) are not reported. We implemented this study to assess TB under-reporting and delayed treatment registration in nine counties in China. DESIGN: A retrospective inventory study (record review). SETTING: Counties were selected using purposive sampling from nine provinces distributed across eastern, central and western regions of China in 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: Under-reporting was calculated as the percentage of patients with TB not reported to TB Information Management System (TBIMS) within 6 months of diagnosis. Delayed registration was estimated as the percentage of reported cases initiating treatment 7 or more days after diagnosis. Multivariable logistic regression and an alpha level of 0.05 were used to examine factors associated with these outcomes. RESULTS: Of the 5606 patients with TB identified from project health facilities and social insurance systems, 1082 (19.3%) were not reported to TBIMS. Of the 4524 patients successfully reported, 1416 (31.3%) were not registered for treatment within 7 days of diagnosis. Children, TB pleurisy, patients diagnosed in the eastern and central regions and patients with a TB diagnosis recorded in either health facilities or social insurance system-but not both-were statistically more likely to be unreported. Delayed treatment registration was more likely for previously treated patients with TB, patients with negative or unknown sputum results and for patients diagnosed in the eastern region. CONCLUSION: Almost one in every five patients diagnosed with TB in this study was unknown to local or national TB control programmes. We recommend strengthening TB data management practices, particularly in the eastern and central regions, and developing specific guidelines for reporting paediatric TB and TB pleurisy. Patient education and follow-up by diagnosing facilities could improve timely treatment registration. Additional studies are needed to assess under-reporting elsewhere in China.

      8. [No abstract]

      9. Update on the epidemiology of coccidioidomycosis in the United StatesExternal
        McCotter OZ, Benedict K, Engelthaler DM, Komatsu K, Lucas KD, Mohle-Boetani JC, Oltean H, Vugia D, Chiller TM, Sondermeyer Cooksey GL, Nguyen A, Roe CC, Wheeler C, Sunenshine R.
        Med Mycol. 2019 Feb 1;57(Supplement_1):S30-s40.
        The incidence of reported coccidioidomycosis in the past two decades has increased greatly; monitoring its changing epidemiology is essential for understanding its burden on patients and the healthcare system and for identifying opportunities for prevention and education. We provide an update on recent coccidioidomycosis trends and public health efforts nationally and in Arizona, California, and Washington State. In Arizona, enhanced surveillance shows that coccidioidomycosis continues to be associated with substantial morbidity. California reported its highest yearly number of cases ever in 2016 and has implemented interventions to reduce coccidioidomycosis in the prison population by excluding certain inmates from residing in prisons in high-risk areas. Coccidioidomycosis is emerging in Washington State, where phylogenetic analyses confirm the existence of a unique Coccidioides clade. Additional studies of the molecular epidemiology of Coccidioides will improve understanding its expanding endemic range. Ongoing public health collaborations and future research priorities are focused on characterizing geographic risk, particularly in the context of environmental change; identifying further risk reduction strategies for high-risk groups; and improving reporting of cases to public health agencies.

      10. Collaborative efforts to forecast seasonal influenza in the United States, 2015-2016External
        McGowan CJ, Biggerstaff M, Johansson M, Apfeldorf KM, Ben-Nun M, Brooks L, Convertino M, Erraguntla M, Farrow DC, Freeze J, Ghosh S, Hyun S, Kandula S, Lega J, Liu Y, Michaud N, Morita H, Niemi J, Ramakrishnan N, Ray EL, Reich NG, Riley P, Shaman J, Tibshirani R, Vespignani A, Zhang Q, Reed C.
        Sci Rep. 2019 Jan 24;9(1):683.
        Since 2013, the Centers for Disease Control and Prevention (CDC) has hosted an annual influenza season forecasting challenge. The 2015-2016 challenge consisted of weekly probabilistic forecasts of multiple targets, including fourteen models submitted by eleven teams. Forecast skill was evaluated using a modified logarithmic score. We averaged submitted forecasts into a mean ensemble model and compared them against predictions based on historical trends. Forecast skill was highest for seasonal peak intensity and short-term forecasts, while forecast skill for timing of season onset and peak week was generally low. Higher forecast skill was associated with team participation in previous influenza forecasting challenges and utilization of ensemble forecasting techniques. The mean ensemble consistently performed well and outperformed historical trend predictions. CDC and contributing teams will continue to advance influenza forecasting and work to improve the accuracy and reliability of forecasts to facilitate increased incorporation into public health response efforts.

      11. Influenza associated outcomes among pregnant, post-partum, and non-pregnant women of reproductive ageExternal
        Prasad N, Huang QS, Wood T, Aminisani N, McArthur C, Baker MG, Seeds R, Thompson MG, Widdowson MA, Newbern EC.
        J Infect Dis. 2019 Jan 23.
        Background: Pregnant women are prioritised for seasonal influenza vaccination however, evidence on influenza risk during pregnancy used to inform these policies is limited. Methods: Individual-level administrative datasets and active surveillance data were joined to estimate influenza-associated hospitalisation and outpatient visit rates by pregnancy, post-partum and trimester status. Results: During 2012-2015, 46 (17.7%) of 260 influenza-confirmed acute respiratory hospitalisations and 13 (4.4%) of 294 influenza-confirmed outpatient visits were among pregnant and post-partum women. Pregnant and post-partum women experienced higher rates of influenza hospitalisation compared with non-pregnant women overall (Rate Ratio [RR] 3.4; 95% Confidence Interval [CI] 2.5-4.7) and by trimester (1st: 2.5; 95%CI 1.2-5.4; 2nd: 3.9; 95%CI 2.4-6.3; 3rd: 4.8; 95%CI 3.0-7.7; post-partum: 0.7; 95%CI 3.0-7.7). Influenza A viruses were associated with increased risk (A(H1N1)pdm09: 5.3; 95%CI 3.2-8.7 and A(H3N2): 3.0; 95%CI 1.8-5.0), but not influenza B (1.8; 95%CI 0.7-4.6). Influenza hospitalisation rates in pregnancy were significantly higher for Maori women (RR 3.2; 95% CI 1.3-8.4) compared with women of European/Other ethnicity. Similar risks for influenza-confirmed outpatient visits were not observed. Conclusion: Seasonal influenza poses higher risks of hospitalisation on pregnant women in all trimesters when compared with non-pregnant women. Hospitalisation rates vary by influenza type and ethnicity among pregnant women.

      12. HIV partner service delivery among blacks or African Americans – United States, 2016External
        Rao S, Song W, Mulatu MS, Rorie M, O’Connor K, Scales L.
        MMWR Morb Mortal Wkly Rep. 2019 Feb 1;68(4):81-86.
        Identifying persons with human immunodeficiency virus (HIV) infection who are unaware of their infection status, linking them to HIV care, and reducing racial/ethnic disparities are important national HIV prevention goals (1). Blacks/African Americans (blacks)* are disproportionately affected by HIV infection in the United States. Although blacks represent 13% of the U.S. population (2), in 2017, 44% of diagnoses of HIV infection were in blacks, and the rate of new diagnoses in blacks (41.1 per 100,000 persons) was approximately eight times that of non-Hispanic whites (5.1) (3). HIV partner services are offered by health officials to persons with diagnosed HIV infection (index patients) and their sex- or needle-sharing partners, who are notified of their potential HIV exposure and offered HIV testing and related services (4). CDC analyzed 2016 data from the National HIV Prevention Program Monitoring and Evaluation system submitted by 59 health departments.(dagger) Among 49,266 index patients identified as potential candidates for partner services, 21,191 (43%) were black. The percentage of black index patients interviewed for partner services (76%) was higher than that for all index patients combined (73%). Among the 11,088 black partners named by index patients, 78% were notified of their potential HIV exposure. Fewer than half (47%) of those notified were tested for HIV infection. Among those tested, one in six (17%) received a new HIV diagnosis. The prevalence of newly diagnosed HIV infection was particularly high among black partners who were gay, bisexual, and other men who have sex with men (MSM) (37%) and transgender persons (38%). Effective implementation of partner services is important to identify HIV infection, link patients to care or reengage them in care, and provide prevention services to reduce HIV transmission.

      13. Community-based organization adaptations to the changing HIV prevention and care landscape in the southern United StatesExternal
        Shapatava E, Rios A, Shelley G, Milan J, Smith S, Uhl G.
        AIDS Educ Prev. 2018 December;30(6):516-527.
        Community-based organizations (CBOs) provide HIV prevention services throughout the United States, including the South where HIV/AIDS burden is high. We assessed Southern CBO response to changes in the HIV prevention landscape, including the National HIV/AIDS Strategy, and the Centers for Disease Control and Prevention’s (CDC’s) High Impact Prevention. Both strategies aim to improve outcomes for people living with or at high risk for HIV. Inductive qualitative analysis of interviews and consultations with CBOs, capacity building assistance providers, and CDC staff revealed CBOs are building clinical service capacity and cross-agency partnerships to adapt, but face inadequate or reduced funding. A holistic approach to HIV prevention and care in the South is critical, where stigma and other socio-structural factors limit health care options for persons affected by HIV. Health care organizations may benefit by partnering with CBOs because CBOs have the skillsets and community rapport to effectively improve health outcomes of persons living with HIV.

      14. Lessons learned from the implementation of HIV biological-behavioral surveys of key populations in the CaribbeanExternal
        Volkmann T, Chase M, Lockard AM, Henningham D, Albalak R.
        AIDS Educ Prev. 2018 December;30(6):528-541.
        In the Caribbean region, HIV prevalence is high among key population (KP) groups, such as sex workers and men who have sex with men. However, there is a lack of high-quality, population-level data estimating HIV prevalence and population sizes of KPs. The President’s Emergency Plan for AIDS Relief has funded and completed five bio-behavioral surveillance (BBS) surveys using respondent-driven sampling methodology to target KP in the English-speaking Caribbean region. We describe the experience of implementing bio-behavioral surveys in the Caribbean region and document the context, processes, successes, and challenges, and make recommendations for future survey implementation. Successes include the provision of estimates of nationally representative HIV data and KP size estimates to improve HIV programming and provision of tools for routinization of BBS. Challenges include small KP sizes, the legal context, and the cost and speed of implementation. Future bio-behavioral surveys should include well-planned formative assessments and stakeholder involvement.

      15. BACKGROUND: Chronic hepatitis C (CHC) is a leading cause of morbidity and mortality and has imposed a high health care burden in the United States. Direct-acting antiviral (DAA) regimens are well tolerated and highly effective for CHC therapy but were initially marketed at a high price. Studies of their real-world use with a nationwide population are limited. OBJECTIVE: To examine patient characteristics, treatment adherence, effectiveness, and health care costs in a large U.S. population with commercial and Medicare supplemental insurance plans who received simeprevir (SIM), sofosbuvir (SOF), or ledipasvir/sofosbuvir (LED/SOF) during the years 2013-2015. METHODS: Patients with at least 1 diagnosis code for CHC and at least 1 claim for SIM, SOF, or LED/SOF prescriptions were selected. The date of the first claim for SIM, SOF, or LED/SOF was defined as the index date. Analyses were stratified by 4 regimens: SOF + SIM +/- ribavirin (RBV), SOF + peginterferon alpha-2a or 2b (PEG) + RBV, SOF + RBV, and LED/SOF +/- RBV. Adherence was defined by the proportion of days covered (PDC) >/= 80%. Sustained virologic response (SVR12) was defined as a hepatitis C virus (HCV) RNA load of </= 25 IU/mL measured at >/= 12 weeks following the end of the days supply of the last DAA refill. Health care costs such as DAA drug costs and medical costs (inpatient costs plus outpatient costs) were described. RESULTS: Of 10,808 CHC patients, approximately two thirds were male, and mean age was 55 years. The proportion of patients with compensated cirrhosis among each regimen ranged from 7.4% in LED/SOF +/- RBV to 13.8% in SOF + SIM +/- RBV, and the proportion of patients with decompensated cirrhosis ranged from 3.9% in LED/SOF +/- RBV to 10.7% in SOF + SIM +/- RBV. The majority of patients (89.0%) used the newer regimen LED/SOF +/- RBV in 2015. Adherence rates were estimated at 80.5%, 81.5%, 85.7%, and 91.4% for SOF + SIM +/- RBV (n = 1,761); SOF + PEG + RBV (n = 1,314); SOF + RBV (n = 1,994); and LED/SOF +/- RBV (n = 5,739), respectively. Regimen-specific adherence predictors included sex, age group, payer type, health plan, and treatment option with RBV. Being born during 1945-1965, liver disease severity, and Charlson Comorbidity Index levels did not predict adherence in any regimen. Overall SVR12 was 92.6% in 203 patients with available HCV RNA results: 100% (41/41) in SOF + SIM +/- RBV; 83.3% (25/30) in SOF + PEG + RBV; 90.6% (29/32) in SOF + RBV; and 93% (93/100) in LED/SOF +/- RBV. While the drug costs for these DAA regimens were initially high, they had decreased 18.9% (P < 0.001) during 2013-2015. Medical costs decreased 9.2% (P < 0.001) 1 year after the index dates. CONCLUSIONS: These results indicate that DAA drug costs decreased steadily during 2013-2015 and that 89% of patients on SOF-based DAA regimens took newer, lower-cost regimens with adherence rates above 80%. Available data show that SVR12 rates were close to those obtained in clinical studies. Medical costs also significantly decreased 1 year after the index dates. DISCLOSURES: No outside funding supported this study. All authors are U.S. federal employees of the Centers for Disease Control and Prevention. The authors declare that they have no competing interests. The findings and conclusions in this research are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

    • Disaster Control and Emergency Services
      1. After a nuclear detonation, workers and volunteers providing first aid, decontamination, and population monitoring in public shelters and community reception centers will potentially be exposed to radiation from people they are assisting who may be contaminated with radioactive fallout. A state-of-the-art computer-aided design program and radiation transport modeling software were used to estimate external radiation dose to workers in three different exposure scenarios: performing radiation surveys/decontamination, first aid, and triage duties. Calculated dose rates were highest for workers performing radiation surveys due to the relative proximity to the contaminated individual. Estimated cumulative doses were nontrivial but below the occupational dose limit established for normal operations by the Occupational Safety and Health Administration.

    • Disease Reservoirs and Vectors
      1. Vgsc-interacting proteins are genetically associated with pyrethroid resistance in Aedes aegyptiExternal
        Campbell CL, Saavedra-Rodriguez K, Kubik TD, Lenhart A, Lozano-Fuentes S, Black WC.
        PLoS One. 2019 ;14(1):e0211497.
        Association mapping of factors that condition pyrethroid resistance in Aedes aegypti has consistently identified genes in multiple functional groups. Toward better understanding of the mechanisms involved, we examined high throughput sequencing data (HTS) from two Aedes aegypti aegypti collections from Merida, Yucatan, Mexico treated with either permethrin or deltamethrin. Exome capture enrichment for coding regions and the AaegL5 annotation were used to identify genes statistically associated with resistance. The frequencies of single nucleotide polymorphisms (SNPs) were compared between resistant and susceptible mosquito pools using a contingency chi2 analysis. The -log10(chi2 p value) was calculated at each SNP site, with a weighted average determined from all sites in each gene. Genes with -log10(chi2 p value) >/= 4.0 and present among all 3 treatment groups were subjected to gene set enrichment analysis (GSEA). We found that several functional groups were enriched compared to all coding genes. These categories were transport, signal transduction and metabolism, in order from highest to lowest statistical significance. Strikingly, 21 genes with demonstrated association to synaptic function were identified. In the high association group (n = 1,053 genes), several genes were identified that also genetically or physically interact with the voltage-gated sodium channel (VGSC). These genes were eg., CHARLATAN (CHL), a transcriptional regulator, several ankyrin-domain proteins, PUMILIO (PUM), a translational repressor, and NEDD4 (E3 ubiquitin-protein ligase). There were 13 genes that ranked among the top 10%: these included VGSC; CINGULIN, a predicted neuronal gap junction protein, and the aedine ortholog of NERVY (NVY), a transcriptional regulator. Silencing of CHL and NVY followed by standard permethrin bottle bioassays validated their association with permethrin resistance. Importantly, VGSC levels were also reduced about 50% in chl- or nvy-dsRNA treated mosquitoes. These results are consistent with the contribution of a variety of neuronal pathways to pyrethroid resistance in Ae. aegypti.

      2. Contrasting patterns of gene expression indicate differing pyrethroid resistance mechanisms across the range of the New World malaria vector Anopheles albimanusExternal
        Mackenzie-Impoinvil L, Weedall GD, Lol JC, Pinto J, Vizcaino L, Dzuris N, Riveron J, Padilla N, Wondji C, Lenhart A.
        PLoS One. 2019 ;14(1):e0210586.
        Decades of unmanaged insecticide use and routine exposure to agrochemicals have left many populations of malaria vectors in the Americas resistant to multiple classes of insecticides, including pyrethroids. The molecular basis of pyrethroid resistance is relatively uncharacterised in American malaria vectors, preventing the design of suitable resistance management strategies. Using whole transcriptome sequencing, we characterized the mechanisms of pyrethroid resistance in Anopheles albimanus from Peru and Guatemala. An. albimanus were phenotyped as either deltamethrin or alpha-cypermethrin resistant. RNA from 1) resistant, 2) unexposed, and 3) a susceptible laboratory strain of An. albimanus was sequenced and analyzed using RNA-Seq. Expression profiles of the three groups were compared based on the current annotation of the An. albimanus reference genome. Several candidate genes associated with pyrethroid resistance in other malaria vectors were found to be overexpressed in resistant An. albimanus. In addition, gene ontology terms related to serine-type endopeptidase activity, extracellular activity and chitin metabolic process were also commonly overexpressed in the field caught resistant and unexposed samples from both Peru and Guatemala when compared to the susceptible strain. The cytochrome P450 CYP9K1 was overexpressed 14x in deltamethrin and 8x in alpha-cypermethrin-resistant samples from Peru and 2x in deltamethrin-resistant samples from Guatemala, relative to the susceptible laboratory strain. CYP6P5 was overexpressed 68x in deltamethrin-resistant samples from Peru but not in deltamethrin-resistant samples from Guatemala. When comparing overexpressed genes between deltamethrin-resistant and alpha-cypermethrin-resistant samples from Peru, a single P450 gene, CYP4C26, was overexpressed 9.8x (p<0.05) in alpha-cypermethrin-resistant samples. In Peruvian deltamethrin-resistant samples, the knockdown resistance mutation (kdr) variant alleles at position 1014 were rare, with approximately 5% frequency, but in the alpha-cypermethrin-resistant samples, the frequency of these alleles was approximately 15-30%. Functional validation of the candidate genes and the kdr mutation as a resistance marker for alpha-cypermethrin will confirm the role of these mechanisms in conferring pyrethroid resistance.

    • Environmental Health
      1. Correlates of exposure to phenols, parabens, and triclocarban in the Study of Environment, Lifestyle and FibroidsExternal
        Bethea TN, Wesselink AK, Weuve J, McClean MD, Hauser R, Williams PL, Ye X, Calafat AM, Baird DD, Wise LA.
        J Expo Sci Environ Epidemiol. 2019 Jan 28.
        We performed a cross-sectional analysis to identify correlates of urinary concentrations of seven phenols (bisphenols A, F, and S; 2,4-dichlorophenol; 2,5-dichlorophenol; benzophenone-3; triclosan), triclocarban, and four parabens (butyl, ethyl, methyl, and propyl). We analyzed baseline data from 766 participants in the Study of Environment, Lifestyle, and Fibroids, a prospective cohort study of 1693 Black women aged 23-34 years residing in Detroit, Michigan (2010-2012). We collected data on demographic, behavioral, and anthropometric factors via telephone interviews, clinic visits, and self-administered questionnaires. For each biomarker, we used linear regression models to estimate mean differences in log-transformed, creatinine-corrected concentrations across factors of interest. Each biomarker was detected in >50% of participants. Median creatinine-corrected concentrations were the highest for methyl paraben (116.8 mug/g creatinine), propyl paraben (16.8 mug/g creatinine), and benzophenone-3 (13.4 mug/g creatinine). Variables most strongly associated with biomarker concentrations included season of urine collection, education, and body mass index (BMI). BMI was positively associated with bisphenol A and S and triclocarban concentrations and inversely associated with butyl and methyl paraben concentrations. In this cohort of Black women, exposure to phenols, parabens, and triclocarban was prevalent and several factors were associated with biomarker concentrations.

    • Genetics and Genomics
      1. Coccidioides ecology and genomicsExternal
        Barker BM, Litvintseva AP, Riquelme M, Vargas-Gastelum L.
        Med Mycol. 2019 Feb 1;57(Supplement_1):S21-s29.
        Although the natural history and ecology of Coccidioides spp. have been studied for over 100 years, many fundamental questions about this fungus remain unanswered. Two of the most challenging aspects of the study of Coccidioides have been the undefined ecological niche and the outdated geographic distribution maps dating from midcentury. This review details the history of Coccidioides ecological research, and discusses current strategies and advances in understanding Coccidioides genetics and ecology.

      2. Complete genome sequence of Nocardia farcinica W6977(T) obtained by combining Illumina and PacBio readsExternal
        Gulvik CA, Arthur RA, Humrighouse BW, Batra D, Rowe LA, Lasker BA, McQuiston JR.
        Microbiol Resour Announc. 2019 Jan;8(3).
        The complete genome sequence of the Nocardia farcinica type strain was obtained by combining Illumina HiSeq and PacBio reads, producing a single 6.29-Mb chromosome and 2 circular plasmids. Bioinformatic analysis identified 5,991 coding sequences, including putative genes for virulence, microbial resistance, transposons, and biosynthesis gene clusters.

      3. Draft genome sequences for dual-toxin-producing Clostridium botulinum strainsExternal
        Halpin JL, Dykes JK, Luquez C.
        Microbiol Resour Announc. 2019 Jan;8(4).
        Here, we present draft genome sequences for three Clostridium botulinum strains that produce multiple botulinum toxin serotypes. Strains that produce two toxins are rare; however, one of these strains produces subtype B5 and F2 toxins, and two of the strains produce subtype A4 and B5 toxins.

      4. Draft genome sequences of eight Vibrio sp. Clinical isolates from across the United States that form a basal sister clade to Vibrio choleraeExternal
        Liang K, Islam MT, Hussain N, Winkjer NS, Im MS, Rowe LA, Tarr CL, Boucher Y.
        Microbiol Resour Announc. 2019 Jan;8(3).
        We sequenced the genomes of eight isolates from various regions of the United States. These isolates form a monophyletic cluster clearly related to but distinct from Vibrio cholerae. Phylogenetic and genomic analyses suggest that they represent a basal lineage highly divergent from Vibrio cholerae or a novel species.

    • Healthcare Associated Infections
      1. The role of wound care in 2 group A streptococcal outbreaks in a Chicago skilled nursing facility, 20152016External
        Ahmed SS, Diebold KE, Brandvold JM, Ewaidah SS, Black S, Ogundimu A, Li Z, Stone ND, Van Beneden CA.
        Open Forum Infect Dis. 2018 Jul;5(7):ofy145.
        Two consecutive outbreaks of group A Streptococcus (GAS) infections occurred from 2015-2016 among residents of a Chicago skilled nursing facility. Evaluation of wound care practices proved crucial for identifying transmission factors and implementing prevention measures. We demonstrated shedding of GAS on settle plates during care of a colonized wound.

      2. Assessing the social cost and benefits of a national requirement establishing antibiotic stewardship programs to prevent Clostridioides difficile infection in US hospitalsExternal
        Scott RD, Slayton RB, Lessa FC, Baggs J, Culler SD, McDonald LC, Jernigan JA.
        Antimicrob Resist Infect Control. 2019 ;8:17.
        Backgound: Economic evaluations of interventions to prevent healthcare-associated infections in the United States rarely take the societal perspective and thus ignore the potential benefits of morbidity and mortality risk reductions. Using new Department of Health and Human Services guidelines for regulatory impact analysis, we developed a cost-benefit analyses of a national multifaceted, in-hospital Clostridioides difficile infection prevention program (including staffing an antibiotic stewardship program) that incorporated value of statistical life estimates to obtain economic values associated with morbidity and mortality risk reductions. Methods: We used a net present value model to assess costs and benefits associated with antibiotic stewardship programs. Model inputs included treatment costs, intervention costs, healthcare-associated Clostridioides difficile infection cases, attributable deaths, and the value of statistical life which was used to estimate the economic value of morbidity and mortality risk reductions. Results: From 2015 to 2020, total net benefits of the intervention to the healthcare system range from $300 million to $7.6 billion when values for morbidity and mortality risk reductions are ignored. Including these values, the net social benefits of the intervention range from $21 billion to $624 billion with the annualized net benefit of $25.5 billion under our most likely outcome scenario. Conclusions: Incorporating the economic value of morbidity and mortality risk reductions in economic evaluations of healthcare-associated infections will significantly increase the benefits resulting from prevention.

    • Immunity and Immunization
      1. Infrequent transmission of monovalent human rotavirus vaccine virus to household contacts of vaccinated infants in MalawiExternal
        Bennett A, Pollock L, Jere KC, Pitzer VE, Lopman B, Parashar U, Everett D, Heyderman RS, Bar-Zeev N, Cunliffe NA, Iturriza-Gomara M.
        J Infect Dis. 2019 Jan 24.
        Horizontal transmission of rotavirus vaccine virus may contribute to indirect effects of rotavirus vaccine, but data are lacking from low-income countries. Serial stool samples were obtained from Malawian infants who received 2 doses of monovalent human rotavirus vaccine (RV1) (days 4, 6, 8, and 10 after vaccination) and from their household contacts (8-10 days after vaccine). RV1 vaccine virus in stool was detected using semiquantitative real-time reverse-transcription polymerase chain reaction. RV1 fecal shedding was detected in 41 of 60 vaccinated infants (68%) and in 2 of 147 household contacts (1.4%). Horizontal transmission of vaccine virus within households is unlikely to make a major contribution to RV1 indirect effects in Malawi.

      2. Effectiveness of seasonal influenza vaccination of children in Senegal during a year of vaccine mismatch: a cluster-randomized trialExternal
        Diallo A, Diop OM, Diop D, Niang MN, Sugimoto JD, Ortiz JR, Faye EH, Diarra B, Goudiaby D, Lewis KD, Emery SL, Zangeneh SZ, Lafond KE, Sokhna C, Halloran ME, Widdowson MA, Neuzil KM, Victor JC.
        Clin Infect Dis. 2019 Jan 28.
        Background: Population effects of influenza vaccination of children have not been extensively studied, especially in tropical developing countries. In rural Senegal, we assessed the total (primary objective) and indirect effectiveness of inactivated influenza vaccine, trivalent (IIV3). Methods: In this double-blind, cluster-randomized trial, villages were randomly allocated (1:1) for high-coverage vaccination of children aged 6 months through 10 years with 2008-09 northern hemisphere IIV3 or inactivated polio vaccine (IPV). Vaccinees were monitored for serious adverse events. All village residents, vaccinated and unvaccinated, were monitored for signs and symptoms of influenza illness using weekly home visits and surveillance in designated clinics. The primary outcome was all laboratory-confirmed symptomatic influenza. Results: Between May 23 and July 11, 2009, 20 villages were randomized, and 66.5% of age-eligible children were enrolled (3918 in IIV3 villages and 3848 in IPV villages). Follow-up continued until May 28, 2010. Four unrelated serious adverse events were identified. Among vaccinees, total effectiveness against illness caused by seasonal influenza virus (presumed all drifted A/H3N2 based on antigenic characterization data) circulating at high rates among children was 43.6% (95% CI, 18.6% to 60.9%). Indirect effectiveness against seasonal A/H3N2 was 15.4% (95% CI, -22.0% to 41.3%). Total effectiveness against illness caused by pandemic influenza virus (A/H1N1pdm09) was -52.1% (95% CI, -177.2% to 16.6%). Conclusions: IIV3 provided statistically significant, moderate protection to children in Senegal against circulating pre-2010 seasonal influenza strains but not against A/H1N1pdm09 not included in the vaccine. No indirect effects were measured. Further study in low resource populations is warranted.

      3. BACKGROUND: In 2017, the Cambodia Ministry of Health introduced human papillomavirus (HPV) vaccine through primarily school-based vaccination targeting 9-year-old girls. Vaccination with a two-dose series of HPV vaccine took place in six districts in two provinces as a demonstration program, to better understand HPV vaccine delivery in Cambodia. METHODS: We conducted a community-based coverage survey using a one-stage sampling design to evaluate dose-specific vaccination coverage among eligible girls (those born in 2007 and residents in the areas targeted by the campaign). The household-level survey also assessed factors associated with vaccine acceptability and communication strategies. Trained data collectors interviewed caregivers and girls using a standard questionnaire; vaccination cards and health facility records were reviewed. RESULTS: Of the 7594 households visited in the two provinces, 315 girls were enrolled in the survey (188 in Siem Reap; 127 in Svay Rieng). Documented two-dose HPV vaccination coverage was 84% (95% confidence interval [CI]: 78-88%) overall [85% (95% CI: 78-90%) in Siem Reap; 82% (95% CI: 73-88%) in Svay Rieng.] Almost all girls (>99%) were reported to be enrolled in school and over 90% of respondents reported receipt of vaccine in school. Knowledge of HPV infection and associated diseases was poor among caregivers and girls; however, 58% of caregivers reported “protection from cervical cancer” as the primary reason for the girl receiving vaccine. No serious adverse events after immunization were reported. CONCLUSIONS: The HPV vaccine demonstration program in Cambodia achieved high two-dose coverage among eligible girls in both provinces targeted for vaccination in 2017, through primarily school-based vaccination. High school enrollment and strong microplanning and coordination were seen throughout the campaign. Cambodia will use lessons learned from this demonstration program to prepare for national introduction of HPV vaccine.

      4. Postlicensure safety surveillance of recombinant Zoster vaccine (Shingrix) – United States, October 2017-June 2018External
        Hesse EM, Shimabukuro TT, Su JR, Hibbs BF, Dooling KL, Goud R, Lewis P, Ng CS, Cano MV.
        MMWR Morb Mortal Wkly Rep. 2019 Feb 1;68(4):91-94.
        Recombinant zoster vaccine (RZV; Shingrix), an adjuvanted glycoprotein vaccine, was licensed by the Food and Drug Administration (FDA) and recommended by the Advisory Committee on Immunization Practices for adults aged >/=50 years in October 2017 (1). The previously licensed live-attenuated zoster vaccine (ZVL; Zostavax) is recommended for adults aged >/=60 years. RZV is administered intramuscularly as a 2-dose series, with an interval of 2-6 months between doses. In prelicensure clinical trials, 85% of 6,773 vaccinated study participants reported local or systemic reactions after receiving RZV, with approximately 17% experiencing a grade 3 reaction (erythema or induration >3.5 inches or systemic symptoms that interfere with normal activity). However, rates of serious adverse events (i.e., hospitalization, prolongation of existing hospitalization, life-threatening illness, permanent disability, congenital anomaly or birth defect, or death) were similar in the RZV and placebo groups (2). After licensure, CDC and FDA began safety monitoring of RZV in the Vaccine Adverse Event Reporting System (VAERS) (3). During the first 8 months of use, when approximately 3.2 million RZV doses were distributed (GlaxoSmithKline, personal communication, 2018), VAERS received a total of 4,381 reports of adverse events, 130 (3.0%) of which were classified as serious. Commonly reported signs and symptoms included pyrexia (fever) (1,034; 23.6%), injection site pain (985; 22.5%), and injection site erythema (880; 20.1%). No unexpected patterns were detected in reports of adverse events or serious adverse events. Findings from early monitoring of RZV are consistent with the safety profile observed in prelicensure clinical trials.

      5. Notes From The Field: Mumps outbreak in a recently vaccinated population – Kosrae, Federated States of Micronesia, August-December, 2017External
        McKay SL, Kambui A, Taulung LA, Tippins A, Eckert M, Wharton AK, McNall RJ, Hickman C, Hancock WT, Apaisam C, Judicpa P, Patel M, Routh J.
        MMWR Morb Mortal Wkly Rep. 2019 Feb 1;68(4):95-96.

        [No abstract]

      6. Streptococcus pneumoniae colonization after introduction of 13-valent pneumococcal conjugate vaccine for US adults 65 years of age and older, 2015-2016External
        Milucky J, Carvalho MG, Rouphael N, Bennett NM, Talbot HK, Harrison LH, Farley MM, Walston J, Pimenta F, Lessa FC.
        Vaccine. 2019 Jan 23.
        BACKGROUND: Vaccination of children with 13-valent pneumococcal conjugate vaccine (PCV13) led to declines in vaccine-type pneumococcal nasopharyngeal carriage among adults through indirect effects. In August 2014, PCV13 immunization of all U.S. adults >/=65years of age was recommended. This study sought to define prevalence and serotype distribution of pneumococcal carriage among adults >/=65years of age and to describe risk factors for colonization soon after introduction of PCV13 in adults. METHODS: A cross-sectional survey of non-institutionalized U.S. adults >/=65years of age was conducted in four states in 2015-2016. Demographic information, risk factors for disease, PCV13 vaccination history, and nasopharyngeal (NP) and oropharyngeal (OP) swabs were collected. NP and OP swabs were processed separately and pneumococcal isolates were serotyped by Quellung reaction. Antimicrobial susceptibility of pneumococcal isolates was performed. NP swabs also underwent real-time PCR for pneumococcal detection and serotyping. RESULTS: Of 2989 participants, 45.3% (1354/2989) had been vaccinated with PCV13. Fifty-five (1.8%) carried pneumococcus (45 identified by culture and 10 by real-time PCR only) and PCV13 serotypes were found in eight (0.3%) participants. Almost half (22/45) of pneumococcal isolates were not susceptible to at least one of the antibiotics tested. Vaccine-type carriage among vaccinated and unvaccinated individuals was similar (0.2% vs. 0.1%, respectively). Respiratory symptoms were associated with higher odds of pneumococcal colonization (adjusted OR: 2.1; 95% CI=1.1-3.8). CONCLUSIONS: Pneumococcal carriage among non-institutionalized adults >/=65years of age was very low. Less than 0.5% of both vaccinated and unvaccinated individuals in our study carried vaccine-type serotypes. Over a decade of PCV vaccination of children likely led to indirect effects in adults. However, given the low vaccine-type carriage rates we observed in an already high PCV13 adult coverage setting, it is difficult to attribute our findings to the direct versus indirect effects of PCV13 on adult carriage.

      7. Outcomes for nitazoxanide treatment in a case series of patients with primary immunodeficiencies and rubella virus-associated granulomaExternal
        Perelygina L, Buchbinder D, Dorsey MJ, Eloit M, Hauck F, Hautala T, Moshous D, Uriarte I, Deripapa E, Icenogle J, Sullivan KE.
        J Clin Immunol. 2019 Jan 24.
        PURPOSE: Nitazoxanide was recently reported as having in vitro effectiveness against the rubella virus. Immunodeficiency-related vaccine-derived rubella occurs in some patients who have an inherited immunodeficiency and who received the MMR vaccine. This study investigated the in vivo effectiveness of nitazoxanide therapy. METHODS: This is a retrospective analysis of seven patients treated with nitazoxanide as salvage therapy for immunodeficiency-related vaccine-derived rubella infection. The patients were recruited from an ongoing rubella detection surveillance project. RESULTS: Seven patients with persistent rubella were treated with nitazoxanide and one demonstrated significant clinical improvement. Two additional patients exhibited diminished viral capsid production with one patient having transient slowing of progression. The cohort overall generally had low T cell counts and had a high burden of comorbidities. There were three deaths. Two deaths were from PML and one was related to hematopoietic stem cell transplantation. CONCLUSIONS: Nitazoxanide has limited in vivo anti-viral effects for immunodeficiency-related vaccine-derived rubella. Most patients did not exhibit clinical improvement.

      8. Effectiveness of 10-valent pneumococcal conjugate vaccine against vaccine-type invasive pneumococcal disease in PakistanExternal
        Riaz A, Mohiuddin S, Husain S, Yousafzai MT, Sajid M, Kabir F, Rehman NU, Mirza W, Salam B, Nadeem N, Pardhan K, Khan KM, Raza SJ, Arif F, Iqbal K, Zuberi HK, Whitney CG, Omer SB, Zaidi AK, Ali A.
        Int J Infect Dis. 2018 Dec 18;80:28-33.
        OBJECTIVE: To assess the effectiveness of 10-valent pneumococcal conjugate vaccine (PCV10) against invasive pneumococcal disease (IPD) due to vaccine serotypes of Streptococcus pneumoniae post introduction of the vaccine into the routine immunization program in Pakistan. METHODS: A matched case-control study was conducted at 16 hospitals in Sindh Province, Pakistan. Children aged <5years (eligible to receive PCV10) who presented with radiographically confirmed pneumonia and/or meningitis were enrolled as cases. PCR for the lytA gene was conducted on blood (for radiographic pneumonia) and cerebrospinal fluid (for meningitis) samples to detect S. pneumoniae. The proportion of IPD due to vaccine serotypes (including vaccine-related serogroups) was determined through serial multiplex PCR. For each case, at least five controls were enrolled from children hospitalized at the same institution, matched for age, district, and season. RESULTS: Of 92 IPD patients enrolled during July 2013 to March 2017, 24 (26.0%) had disease caused by vaccine serotypes. Most case (87.5% of 24) and control (66.4% of 134) children had not received any PCV10 doses. The estimated effectiveness of PCV10 against vaccine-type IPD was 72.7% (95% confidence interval (CI) -7.2% to 92.6%) with at least one dose, 78.8% (95% CI -11.9% to 96.0%) for at least two doses, and 81.9% (95% CI -55.7% to 97.9%) for all three doses of vaccine. CONCLUSIONS: The vaccine effectiveness point estimates for PCV10 were high and increased with increasing number of doses. However, vaccine effectiveness estimates did not reach statistical significance, possibly due to low power. The findings indicate the likely impact of vaccine in reducing the burden of vaccine-type IPD if vaccine uptake can be improved.

    • Injury and Violence
      1. Lifetime number of perpetrators and victim-offender relationship status per U.S. victim of intimate partner, sexual violence, or stalkingExternal
        Peterson C, Liu Y, Merrick M, Basile KC, Simon TR.
        J Interpers Violence. 2019 Jan 24:886260518824648.
        The aim of this study was to describe the U.S. population-level prevalence of multiple perpetrator types (intimate partner, acquaintance, stranger, person of authority, or family member) per victim and to describe the prevalence of victim-offender relationship status combinations. Authors analyzed U.S. nationally representative data from noninstitutionalized adult respondents with self-reported lifetime exposure to intimate partner violence, sexual violence, or stalking in the 2012 National Intimate Partner and Sexual Violence Survey (NISVS). An estimated 142 million U.S. adults had some lifetime exposure to intimate partner violence, sexual violence, or stalking. An estimated 55 million victims (39% of total victims) had more than one perpetrator type during their lifetimes. A significantly higher proportion of female victims reported more than one perpetrator type compared with male victims (49% vs. 27%). Among both female and male victims with >1 perpetrator type, the most prevalent victim-offender relationship status combinations all included an intimate partner perpetrator. Many victims of interpersonal violence are subject to multiple perpetrator types during their lifetimes. Prevention strategies that address polyvictimization and protect victims from additional perpetrators can have a substantial and beneficial societal impact. Research on victim experiences to inform prevention strategies is strengthened by comprehensively accounting for lifetime victimizations.

      2. Alcohol and marijuana use among young injured drivers in Arizona, 2008-2014External
        Shults RA, Jones JM, Komatsu KK, Sauber-Schatz EK.
        Traffic Inj Prev. 2019 Jan 25:1-6.
        OBJECTIVE: We examined alcohol and marijuana use among injured drivers aged 16-20 years evaluated at Arizona level 1 trauma centers during 2008-2014. METHODS: Using data from the Arizona State Trauma Registry, we conducted a descriptive analysis of blood alcohol concentration (BAC) and qualitative test results (positive or negative) for delta-9-tetrahydrocannabinol (THC) by year of age, sex, race, ethnicity, injury severity, seat belt use, motorcycle helmet use, and type of vehicle driven. To explore compliance with Arizona’s motorcycle helmet law requiring helmet use for riders <18 years old, we examined helmet use by age. RESULTS: Data on 5,069 injured young drivers were analyzed; the annual number of injured drivers declined by 41% during the 7-year study period. Among the 76% (n = 3,849) of drivers with BAC results, 19% tested positive, indicating that at least 15% of all drivers had positive BACs. Eighty-two percent of the BAC-positive drivers had BACs >/=0.08 g/dL, the illegal threshold for drivers aged >/=21 years. Among the 49% (n = 2,476) of drivers with THC results, 30% tested positive, indicating that at least 14% of all drivers were THC-positive. American Indians and blacks had the highest proportion of THC-tested drivers with positive THC results (38%). In addition, 28% of tested American Indians had positive results for both substances, more than twice the proportion seen in all other race or ethnic groups. Crude prevalence ratios suggested that drivers who tested positive for alcohol or THC were less likely than those who tested negative to wear a helmet or seat belt, further increasing their injury risk. Helmet use among motorcyclists was lower among 16- and 17-year-old riders compared to 18- to 20-year-olds, despite Arizona’s motorcycle helmet law requiring riders aged <18 years to wear a helmet. CONCLUSIONS: About 1 in 4 injured drivers aged 16-20 years tested positive for alcohol, THC, or both substances. Most drivers with positive BACs were legally intoxicated (BAC >/=0.08 g/dL). All substance-using young drivers in this study were candidates for substance abuse screening and possible referral to treatment. Broader enforcement of existing laws targeting underage access to alcohol and alcohol-impaired driving could further reduce injuries among young Arizona drivers. To further reduce crash-related injuries and fatalities among all road users, the state could consider implementing a primary enforcement seat belt law and a universal motorcycle helmet law.

    • Laboratory Sciences
      1. PCR-based method for S. flexneri serotyping: International multicenter validationExternal
        Brengi SP, Sun Q, Bolanos H, Duarte F, Jenkins C, Pichel M, Shahnaij M, Sowers EG, Strockbine N, Talukder KA, Derado G, Vinas MR, Kam KM, Xu J.
        J Clin Microbiol. 2019 Jan 30.
        Shigella is a leading cause of human diarrheal disease worldwide with S. flexneri being the most frequently isolated in developing countries. This serogroup is presently classified into 19 serotypes worldwide. We report here a Multicenter Validation of a Multiplex PCR based-strategy previously developed by Sun et al. (doi: 10.1128/JCM.01259-11) for molecular serotyping of S. flexneri This study was performed by seven international laboratories, with a panel of 71 blinded strains as well as 279 strains collected from each own local culture collections. This collaborative work found high extent of agreement among laboratories, calculated through IRR measures for PCR test, proven its robustness. It was also observed agreement with traditional method (serology) in all laboratories for 14 serotypes studied, while specific genetic events could be responsible for the discrepancies among methodologies in other five serotypes as determined by PCR product sequencing in most of the cases. This work provided an empirical frame that allowed the use of this molecular method to serotype S. flexneri, and showed several advantages over the traditional method of serological typing. These included overcoming the problem of availability of suitable antisera in testing laboratories, as well as facilitated the analysis of multiple samples at the same time. The method is also less time consuming for completion, and easier to implement in routine laboratories. We recommend that this PCR be adopted, as it is a reliable diagnostic and characterization methodology that can be used globally for laboratory-based shigellae surveillance.

      2. Evaluation of multilocus sequence typing of Cyclospora cayetanensis based on microsatellite markersExternal
        Hofstetter JN, Nascimento FS, Park S, Casillas S, Herwaldt BL, Arrowood MJ, Qvarnstrom Y.
        Parasite. 2019 ;26:3.
        Cyclospora cayetanensis is a human parasite transmitted via ingestion of contaminated food or water. Cases of C. cayetanensis infection acquired in the United States often go unexplained, partly because of the difficulties associated with epidemiologic investigations of such cases and the lack of genotyping methods. A Multilocus Sequence Typing (MLST) method for C. cayetanensis based on five microsatellite loci amplified by nested PCR was described in 2016. The MLST loci had high variability, but many specimens could not be assigned a type because of poor DNA sequencing quality at one or more loci. We analyzed Cyclospora-positive stool specimens collected during 1997-2016 from 54 patients, including 51 from the United States. We noted limited inter-specimen variability for one locus (CYC15) and the frequent occurrence of unreadable DNA sequences for two loci (CYC3 and CYC13). Overall, using the remaining two loci (CYC21 and CYC22), we detected 17 different concatenated sequence types. For four of five clusters of epidemiologically linked cases for which we had specimens from >1 case-patient, the specimens associated with the same cluster had the same type. However, we also noted the same type for specimens that were geographically and temporally unrelated, indicating poor discriminatory power. Furthermore, many specimens had what appeared to be a mixture of sequence types at locus CYC22. We conclude that it may be difficult to substantially improve the performance of the MLST method because of the nucleotide repeat features of the markers, along with the frequent occurrence of mixed genotypes in Cyclospora infections.

      3. Initiation of pulmonary fibrosis after silica inhalation in rats is linked with dysfunctional shelterin complex and DNA damage responseExternal
        Shoeb M, Mustafa GM, Joseph P, Umbright C, Kodali V, Roach KA, Meighan T, Roberts JR, Erdely A, Antonini JM.
        Sci Rep. 2019 Jan 24;9(1):471.
        Occupational exposure to silica has been observed to cause pulmonary fibrosis and lung cancer through complex mechanisms. Telomeres, the nucleoprotein structures with repetitive (TTAGGG) sequences at the end of chromosomes, are a molecular “clock of life”, and alterations are associated with chronic disease. The shelterin complex (POT1, TRF1, TRF2, Tin2, Rap1, and POT1 and TPP1) plays an important role in maintaining telomere length and integrity, and any alteration in telomeres may activate DNA damage response (DDR) machinery resulting in telomere attrition. The goal of this study was to assess the effect of silica exposure on the regulation of the shelterin complex in an animal model. Male Fisher 344 rats were exposed by inhalation to Min-U-Sil 5 silica for 3, 6, or 12 wk at a concentration of 15 mg/m(3) for 6 hr/d for 5 consecutive d/wk. Expression of shelterin complex genes was assessed in the lungs at 16 hr after the end of each exposure. Also, the relationship between increased DNA damage protein (gammaH2AX) and expression of silica-induced fibrotic marker, alphaSMA, was evaluated. Our findings reveal new information about the dysregulation of shelterin complex after silica inhalation in rats, and how this pathway may lead to the initiation of silica-induced pulmonary fibrosis.

    • Maternal and Child Health
      1. Differences in length of stay and costs between comparable hospitalizations of patients with spina bifida with or without pressure injuriesExternal
        Wang Y, Ouyang L, Dicianno BE, Beierwaltes P, Valdez R, Thibadeau J, Bolen J.
        Arch Phys Med Rehabil. 2019 Jan 23.
        OBJECTIVE: To estimate differences in the length of stay and costs for comparable hospitalizations of patients with spina bifida (SB) with and without pressure injuries. DESIGN: Retrospective, cross-sectional, observational study. SETTING: Nationwide Inpatient Sample from years 2010 to 2014. PARTICIPANTS: Hospitalized patients with SB. Hospitalizations among patients with SB and pressure injuries (n=3888) were matched to hospitalizations among patients with SB but without pressure injuries (n=3888). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Differences in length of stay and total costs between the two groups. RESULTS: After successful matching, multivariate modelling of costs and length of stay on matched sample showed that hospitalizations with pressure injuries had an increased 1.2 inpatient days and excess average costs of $1,182. CONCLUSIONS: The estimated average cost of hospitalization increased by 10%, and the estimated average length of stay increased by 24% in the presence of pressure injuries among hospitalized patients with SB, compared with their peers without these injuries. These results highlight the substantial morbidity associated with pressure injuries, which are potentially preventable before or during hospitalizations among persons with SB.

      2. BACKGROUND: HIV, syphilis, malaria and anaemia are leading preventable causes of adverse pregnancy outcomes in sub-Saharan Africa yet testing coverage for conditions other than HIV is low. Availing point-of-care tests (POCTs) at rural antenatal health facilities (dispensaries) has the potential to improve access and timely treatment. Fundamental to the adoption of and adherence to new diagnostic approaches are healthcare workers’ and pregnant women’s (end-users) buy-in. A qualitative approach was used to capture end-users’ experiences of using POCTs for HIV, syphilis, malaria and anaemia to assess the appropriateness, acceptability and feasibility of integrated testing for ANC. METHODS: Seven dispensaries were purposively selected to implement integrated point-of-care testing for eight months in western Kenya. Semi-structured interviews were conducted with 18 healthcare workers (14 nurses, one clinical officer, two HIV testing counsellors, and one laboratory technician) who were trained, had experience doing integrated point-of-care testing, and were still working at the facilities 8-12 months after the intervention began. The interviews explored acceptability and relevance of POCTs to ANC, challenges with testing, training and supervision, and healthcare workers’ perspectives of client experiences. Twelve focus group discussions with 118 pregnant women who had attended a first ANC visit at the study facilities during the intervention were conducted to explore their knowledge of HIV, syphilis, malaria, and anaemia, experience of ANC point-of-care testing services, treatments received, relationships with healthcare workers, and experience of talking to partners about HIV and syphilis results. RESULTS: Healthcare workers reported that they enjoyed gaining new skills, were enthusiastic about using POCTs, and found them easy to use and appropriate to their practice. Initial concerns that performing additional testing would increase their workload in an already strained environment were resolved with experience and proficiency with the testing procedures. However, despite having the diagnostic tools, general health system challenges such as high client to healthcare worker volume ratio, stock-outs and poor working conditions challenged the delivery of adequate counselling and management of the four conditions. Pregnant women appreciated POCTs, but reported poor healthcare worker attitudes, drug stock-outs, and fear of HIV disclosure to their partners as shortcomings to their ANC experience in general. CONCLUSION: This study provides insights on the acceptability, appropriateness, and feasibility of integrating POCTs into ANC services among end-users. While the innovation was desired and perceived as beneficial, future scale-up efforts would need to address health system weaknesses if integrated testing and subsequent effective management of the four conditions are to be achieved.

    • Military Medicine and Health
      1. Outbreak of Chlamydia pneumoniae infections and X-ray-confirmed pneumonia in army trainees at Fort Leonard Wood, Missouri, 2014External
        Clemmons NS, Jordan NN, Brown AD, Kough EM, Pacha LA, Varner SM, Hawksworth AW, Myers CA, Gaydos JC.
        Mil Med. 2019 Jan 23.
        Introduction: Chlamydia pneumoniae (Cp) is a bacterium that causes pneumonia and other respiratory diseases. Fever may be present early but absent by time of presentation to clinic. Increases in X-ray-confirmed pneumonia (XCP) and laboratory-confirmed Cp infections were observed in new soldiers in training at Fort Leonard Wood (FLW), Missouri, early in 2014. These findings prompted a site assistance visit from the U.S. Army Public Health Command, Aberdeen Proving Ground, Maryland, with a review of available data and information to describe the outbreak, and inspections of barracks and training facilities and review of training practices to identify opportunities for interventions to reduce the risk of respiratory disease agent transmission. Materials and Methods: The study population was trainee soldiers at FLW in 2013-2014. Data from two acute respiratory disease surveillance systems were studied. A local surveillance system operated by the FLW General Leonard Wood Army Community Hospital Preventive Medicine Department tracked weekly chest X-rays taken and the numbers positive for pneumonia. A Naval Health Research Center, San Diego, California, laboratory-based Febrile Respiratory Illness Surveillance Program collected clinical data and nasal, or nasal and pharyngeal swabs, for nucleic acid amplification testing from up to 15 trainees/week with fever and either cough or sore throat. Up to 4 of the 15 specimens could be from afebrile patients with XCP. Specimens were tested for a variety of agents. Results: Monthly rates of XCP rose quickly in 2014 and peaked at 0.9/100 trainees in May. The percentage of the San Diego surveillance system specimens that were positive for Cp also increased quickly in 2014, peaking at 54% in May. During the first half of 2014, the San Diego program studied specimens from 141 ill trainees; 37% (52/141) were positive for Cp, making it the most common organism identified, followed by rhinoviruses (8%), influenza viruses (4%), Mycoplasma pneumoniae (2%), and adenoviruses (1%). The remaining specimens (48%) were negative for all respiratory pathogens. Only 12% (6/52) of Cp positive patients were febrile. Facilities inspections and review of training practices failed to identify variables that might be contributing to an increased risk of respiratory agent transmission. Conclusion: The XCP rate and the percentage of specimens positive for Cp increased in early 2014, peaking in May. Only 12% of trainees with laboratory-confirmed Cp were febrile. Historically, acute respiratory disease surveillance at military training centers focused on febrile diseases, particularly those caused by adenoviruses. With introduction of an adenovirus vaccine in late 2011, respiratory disease rates dropped with only sporadic occurrences of adenovirus-associated disease. In 2012, the San Diego surveillance program began providing data on multiple respiratory disease agents, in addition to adenoviruses and influenza viruses. Since then, Cp, rhinoviruses and Mycoplasma pneumoniae have frequently been detected in trainees with acute respiratory disease. Respiratory surveillance programs supporting Army training centers should be re-evaluated in this post-adenovirus vaccine era, to include assessment of the fever criterion for selecting patients for study, the value of chest X-ray surveillance and the value of rapidly providing laboratory results to inform provider decisions regarding antibiotic use.

    • Occupational Safety and Health
      1. Occupational coccidioidomycosis surveillance and recent outbreaks in CaliforniaExternal
        de Perio MA, Materna BL, Sondermeyer Cooksey GL, Vugia DJ, Su CP, Luckhaupt SE, McNary J, Wilken JA.
        Med Mycol. 2019 Feb 1;57(Supplement_1):S41-s45.
        Workers in Coccidioides-endemic areas performing soil-disturbing work or exposed to windy and dusty conditions are at increased risk for coccidioidomycosis. Four occupational coccidioidomycosis outbreaks from 2007 to 2014 in California are described, involving construction workers in a number of excavation projects and an outdoor filming event involving cast and crew. These outbreaks highlight the importance of identifying industries and occupations at high risk for coccidioidomycosis, conducting targeted occupational health surveillance to assess the burden of illness, developing and implementing prevention strategies, and setting research priorities.

      2. Auditory risk of exposure to ballistic N-waves from bulletsExternal
        Flamme GA, Murphy WJ.
        Int J Audiol. 2019 Feb;58(sup1):S58-s64.
        OBJECTIVE: Assessment of the auditory risk associated with sound from ballistic N-waves produced by a rifle bullet. DESIGN: Acoustical recordings of ballistic N-waves passing through a microphone array at 6.4 metres down range were analysed to determine (a) the trajectory of the bullet, (b) the distance between the trajectory and each microphone (less than 1.3 m), and (c) the numbers of permissible exposures according to both damage-risk criteria for impulsive noise in the current U.S. military standard (MIL-STD-1474E). STUDY SAMPLE: The gun was an AR-15 style semiautomatic rifle configured to fire a 0.50 calibre Beowulf(00AE) cartridge. Four sample shots were recorded for each of four microphone spacing conditions and five kinds of ammunition (80 shots in total). RESULTS: The ballistic N-waves recorded in this study would constitute a significant auditory risk to unprotected listeners at all distances sampled. The numbers of permissible exposures decreased as the distance to the bullet trajectory decreased, decreased with increased bullet length, and departed from linear increases as the bullet velocity increased. CONCLUSIONS: Unprotected exposure to a ballistic N-wave from a supersonic 0.50 calibre bullet presents a significant risk to hearing at distances of 6.4 metres down range and through trajectories within 1.2 metres of an ear.

      3. Employee attitudes about the impact of visitation dogs on a college campusExternal
        Foreman AM, Allison P, Poland M, Jean Meade B, Wirth O.
        Anthrozoos. 2019 ;32(1):35-50.
        Therapy and visitation dogs are becoming more common on college campuses to provide comfort and support to students, but little attention has been given to the concerns of faculty and staff who share space with the dogs in their workplaces. The purpose of this study was to assess the perceptions of faculty and staff with regard to both the benefits and the hazards (e.g., dander, bites, fleas) and risks associated with the presence of visitation dogs in their workplaces. One hundred and thirty-eight employees who worked in buildings with resident visitation dogs completed an online survey about their perceptions of the hazards and risks of the dogs and the effects of dogs on the wellbeing of both students and employees. In general, employees perceived that the dogs presented minimal risks, and most employees believed that they can reduce stress and provide comfort to students on campus. There were a few employees, however, who reported that the dogs did not improve the work environment and conferred no benefits to the staff or students. The findings of the present survey support the mostly positive attitudes that people have for dogs in the workplace, but they also highlight a potential challenge: accommodating individuals who believe very strongly that dogs do not belong in work environments.

      4. A large number of workers worldwide engage in shift work that can have significant influences upon the quality of working life. For most jurisdictions, setting and enforcing appropriate policies, regulations, and rules around shift work is considered essential to (a) prevent potentially negative consequences of shift work and (b) to improve worker health and well-being. However, the best ways to do this are often highly contested theoretical spaces and often culturally and historically bound. In this paper, we examine the regulatory approaches to regulating shift work in four different regions: Europe, North America, Australasia, and East Asia (Japan, China, and Korea). Despite the fact that social and cultural factors vary considerably across the regions, comparing regulatory frameworks and initiatives in one region can be instructive. Different approaches can minimally provide a contrast to stimulate discussion about custom and practice and, potentially, help us to develop new and innovative models to improve worker well-being and organizational productivity simultaneously. In this paper, our goal is not to develop or even advocate a “perfect” sets of regulations. Rather, it is to compare and contrast the diversity and changing landscape of current regulatory practices and to help organizations and regulators understand the costs and benefits of different approaches. For example, in recent years, many western countries have seen a shift away from prescriptive regulation toward more risk-based approaches. Advocates and critics vary considerably in what drove these changes and the benefit-cost analyses associated with their introduction. By understanding the different ways in which shift work can be regulated, it may be possible to learn from others and to better promote healthier and safer environments for shift-working individuals and workplaces.

      5. BACKGROUND: Alaska’s onshore seafood processing industry is economically vital and hazardous. METHODS: Accepted Alaska workers’ compensation claims data from 2014 to 2015 were manually reviewed and coded with the Occupational Injury and Illness Classification System and associated work activity. Workforce data were utilized to calculate rates. RESULTS: 2,889 claims of nonfatal injuries/illnesses were accepted for compensation. The average annual claim rate was 63 per 1000 workers. This was significantly higher than Alaska’s all-industry rate of 44 claims per 1000 workers (RR = 1.42, 95%CI = 1.37-1.48). The most frequently occurring injuries/illnesses, were by nature, sprains/strains/tears (993, 36%); by body part, upper limbs (1212, 43%); and by event, contact with objects/equipment (1020, 37%) and overexertion/bodily reaction (933, 34%). Incidents associated with seafood processing/canning/freezing (n = 818) frequently involved: repetitive motion; overexertion while handling pans, fish, and buckets; and contact with fish, pans, and machinery. CONCLUSIONS: Ergonomic and safety solutions should be implemented to prevent musculoskeletal injuries/illnesses.

      6. Total Worker Health(R) 2014-2018: The novel approach to worker safety, health, and well-being evolvesExternal
        Tamers SL, Chosewood LC, Childress A, Hudson H, Nigam J, Chang CC.
        Int J Environ Res Public Health. 2019 Jan 24;16(3).
        Background: The objective of this article is to provide an overview of and update on the Office for Total Worker Health((R)) (TWH) program of the Centers for Disease Control and Prevention’s National Institute for Occupational Safety and Health (CDC/NIOSH). Methods: This article describes the evolution of the TWH program from 2014 to 2018 and future steps and directions. Results: The TWH framework is defined as policies, programs, and practices that integrate protection from work-related safety and health hazards with promotion of injury and illness prevention efforts to advance worker well-being. Conclusions: The CDC/NIOSH TWH program continues to evolve in order to respond to demands for research, practice, policy, and capacity building information and solutions to the safety, health, and well-being challenges that workers and their employers face.

      7. A substantial body of literature indicates that shift workers have a significantly higher risk of workplace accidents and injuries, compared to workers in regular daytime schedules. This can be attributed to work during nights which require workers to stay awake during normal sleeping hours and sleep during natural waking hours, leading to circadian desynchronization, sleep disruption and cognitive impairment. A fatigue-risk trajectory model developed by Dawson and McCulloch has been used to describe the series of events which may precede fatigue-related incidents. This includes insufficient sleep opportunities, impaired sleep, fatigue-behavioral symptoms, and fatigue-related errors. The purpose of this paper is to provide examples of control measures along each level of the fatigue-risk trajectory, which include: (i) work scheduling strategies to include breaks for adequate sleep opportunities; (ii) training and educational programs to help workers make best use of recovery times for quality sleep; (iii) fatigue-detection devices to alert workers and safety managers of fatigue-related behaviors and errors. A brief introduction to Fatigue-Risk Management systems is also included as a long-term sustainable strategy to maintain shift worker health and safety. The key statements in this paper represent a consensus among the Working Time Society regarding a multi-level approach to managing occupational sleep-related fatigue.

    • Parasitic Diseases
      1. Prescriber practices and patient adherence to artemisinin-based combination therapy for the treatment of uncomplicated malaria in Guinea, 2016External
        Camara A, Moriarty LF, Guilavogui T, Diakite PS, Zoumanigui JS, Sidibe S, Bah I, Kaba I, Kourouma D, Zoumanigui K, Plucinski M.
        Malar J. 2019 Jan 25;18(1):23.
        BACKGROUND: The World Health Organization recommends the use of artemisinin-based combination therapy (ACT) to treat uncomplicated malaria for the control of malaria across the world. There are several types of ACT used across malaria-endemic countries, yet there is little information about preferences and adherence practices regarding different types of ACT. The objective of this study was to evaluate levels of adherence to two types of ACT, artemether-lumefantrine (AL) and artesunate + amodiaquine (ASAQ), for the treatment of uncomplicated malaria among prescribers and patients in Guinea in 2016. METHODS: The study included a review of records of malaria patients and three health-facility, cross-sectional surveys. Patients diagnosed with uncomplicated malaria and prescribed ACT (n = 1830) were recruited and visited in their home after receiving the medication and administered a questionnaire regarding ACT adherence. Prescribers (n = 115) and drug dispensers (n = 43) were recruited at the same public health facilities and administered questionnaires regarding prescribing practices and opinions regarding the national treatment policies and protocols. RESULTS: According to the registry review, 35.8% of all-cause consultations were recorded as malaria. Of these, 26.6% were diagnosed clinically without documentation of laboratory confirmation. The diagnosis of uncomplicated malaria represented 64.1% of malaria cases among children under 5 years and 74.9% of those 5 years of age and older. An ACT was prescribed for 83.5% of cases of uncomplicated malaria. Among participants in the study, ACT adherence was 95.4% (95% CI 94.4, 96.3). Overall, about one in four patients (23.4%; 95% CI 21.5, 25.3) reported experiencing adverse events. While patients prescribed ASAQ were significantly more likely to report experiencing adverse effects than patients on AL (p < 0.001), given the overall high adherence, there was no evidence of a statistically significant difference in adherence between AL and ASAQ. Patients 5 years or older who reported experiencing adverse events were more likely to be non-adherent. CONCLUSION: Although there were more reported adverse events associated with ASAQ when compared with AL, both prescribers and patients were found to be mostly adherent to ACT for the treatment of malaria, regardless of ACT type.

      2. Community knowledge and acceptance of indoor residual spraying for malaria prevention in Mozambique: a qualitative studyExternal
        Magaco A, Botao C, Nhassengo P, Saide M, Ubisse A, Chicumbe S, Zulliger R.
        Malar J. 2019 Jan 25;18(1):27.
        BACKGROUND: Malaria control remains a leading health challenge in Mozambique. Indoor residual spraying (IRS) is an effective strategy to control malaria transmission, but there are often barriers to reaching the coverage necessary for attaining maximum community protective effect of IRS. Mozambique recorded a high number of household refusals during the 2016 IRS campaign. This study sought to evaluate household and community factors related to the acceptability of IRS to inform strategies for future campaigns in Mozambique and the region. METHODS: A cross-sectional, qualitative study was conducted in eight urban and rural communities in two high malaria burden provinces in Mozambique. Data were collected through in-depth interviews with community members, leaders, sprayers, and representatives of district health directorates; focus group discussions with community members who accepted and who refused IRS during the 2016 campaign; systematic field observations; and informal conversations. Data were systematically coded and analysed using NVIVO-11((R)). RESULTS: A total of 61 interviews and 12 discussions were conducted. Community participants predominantly described IRS as safe, but many felt that it had limited efficacy. The main factors that participants mentioned as having influenced their IRS acceptance or refusal were: understanding of IRS; community leader level of support; characteristics of IRS programmatic implementation; environmental, political and historical factors. Specifically, IRS acceptance was higher when there was perceived community solidarity through IRS acceptance, desire to reduce the insect population in homes, trust in government and community satisfaction with past IRS campaign effectiveness. Participants who refused were mainly from urban districts and were more educated. The main barriers to acceptance were associated with selection and performance of spray operators, negative experiences from previous campaigns, political-partisan conflicts, difficulty in removing heavy or numerous household assets, and preference for insecticide-treated nets over IRS. CONCLUSIONS: Acceptance of IRS was influenced by diverse operational and contextual factors. As such, future IRS communications in targeted communities should emphasize the importance of high IRS coverage for promoting both familial and community health. Additionally, clear communications and engagement with community leaders during spray operator selection and spray implementation may help reduce barriers to IRS acceptance.

    • Public Health Leadership and Management
      1. Lessons from leading US Public Health Service physiciansExternal
        Iskander J, Ahluwalia J, Luckhaupt S, Lewis B.
        Mil Med. 2019 Jan 23.

        [No abstract]

    • Reproductive Health
      1. Safety of contraceptive use among women with congenital heart disease: A systematic reviewExternal
        Abarbanell G, Tepper NK, Farr SL.
        Congenit Heart Dis. 2019 Jan 25.
        OBJECTIVE: Women with congenital heart disease (CHD) are at increased risk of pregnancy complications and need information on safe, effective contraceptive methods to avoid unintended pregnancy. This systematic review examines evidence regarding safety of contraceptive use among women with CHD. METHODS: The PubMed database was searched for any peer-reviewed articles published through April 2018 that included safety outcomes associated with reversible contraceptive methods among women with CHD. RESULTS: Five articles met inclusion criteria: three studies comparing contraceptive users to nonusers and two noncomparative studies. Sample sizes ranged from 65 to 505 women with CHD. Two studies found a higher percent of thromboembolic complications among women with Fontan palliation or transposition of the great arteries using oral contraceptives. One study, among women with Fontan palliation, found no increased risk of thromboembolic complications between contraceptive users (not separated by type) and nonusers. Two studies found no endocarditis among intrauterine device users. CONCLUSIONS: There is a paucity of data regarding the safety of contraceptive methods among women with CHD. Limited evidence suggests an increased incidence of thromboembolic complications with use of oral contraceptives. Further studies are needed to evaluate contraceptive safety and quantify risk in this growing population. There is also limited data regarding the safety of contraceptive methods among women with CHD. Further information is needed to assist practitioners counseling women with CHD on safety of contraceptive methods.

      2. Application of an implementation science framework to policies on immediate postpartum long-acting reversible contraceptionExternal
        DeSisto CL, Kroelinger CD, Estrich C, Velonis A, Uesugi K, Goodman DA, Pliska E, Akbarali S, Rankin KM.
        Public Health Rep. 2019 Jan 30:33354918824329.
        OBJECTIVES:: Implementation science provides useful tools for guiding and evaluating the integration of evidence-based interventions with standard practice. The objective of our study was to demonstrate the usefulness of applying an implementation science framework-the Consolidated Framework for Implementation Research (CFIR)-to increase understanding of implementation of complex statewide public health initiatives, using the example of Medicaid immediate postpartum long-acting reversible contraception (LARC) policies. METHODS:: We conducted semistructured telephone interviews with the 13 state teams participating in the Immediate Postpartum LARC Learning Community. We asked teams to describe the implementation facilitators, barriers, and strategies in 8 focus areas of the Learning Community. We audio-recorded and transcribed interviews and then coded each interview according to the domains and constructs (ie, theoretical concepts) of the CFIR. RESULTS:: Cosmopolitanism (ie, networking with external organizations) was the most frequently coded construct of the framework. A related construct was networks and communications (ie, the nature and quality of social networks and formal and informal communications in an organization). Within the construct of cost, state teams identified barriers that were often unable to be overcome. Trialability (ie, ability to test the intervention on a small scale) and engaging champions (ie, attracting and involving persons who dedicate themselves to supporting the intervention in an organization) were among the most salient constructs of the framework and were the sources of many implementation strategies. CONCLUSIONS:: State leaders and program staff members may benefit from considering the CFIR domains and constructs in the planning, implementation, and evaluation of complex statewide public health initiatives.

    • Substance Use and Abuse
      1. Association of peer influence and access to tobacco products with U.S. youths’ support of tobacco 21 laws, 2015External
        Glover-Kudon R, Plunkett E, Lavinghouze R, Trivers KF, Wang X, Hu S, Homa DM.
        J Adolesc Health. 2019 Jan 24.
        PURPOSE: Tobacco 21 (T21) is a population-based strategy to prevent tobacco initiation. A majority of U.S. youths support T21; however, the extent to which individual, interpersonal, and community factors influence T21 support is uncertain. This study explored predictors of T21 support among U.S. youth. METHODS: We analyzed data from the 2015 National Youth Tobacco Survey (n = 17,683) to assess the association of peer influence and access to tobacco products on T21 support. We used multivariable logistic regression to calculate adjusted odds ratios (aORs) with 95% confidence intervals for T21 support. For tobacco nonusers, the model included peer influence along with covariates including sex, age, race/ethnicity, household tobacco use, and perceived harm. For tobacco users, the model included tobacco access sources (direct purchase, social sources, and other means), the aforementioned covariates, and tobacco product type. RESULTS: Among nonusers, students least receptive to peer influence (aOR = 2.5), those youngest in age (11-14 years, aOR = 2.3), and those who believe tobacco is dangerous (aOR = 2.5) had higher odds of T21 support. Among users, lower odds of T21 support were observed among those who purchased tobacco (aOR = .3) and accessed tobacco through social sources (aOR = .7) or other means (aOR = .6) in the past 30 days. Younger tobacco users (11-14 years, aOR = 2.2), black, non-Hispanic users (aOR = 3.8), e-cigarette users (aOR = 2.5), and users who believe that tobacco is dangerous (aOR = 2.8) had higher odds of T21 support. CONCLUSIONS: Low receptivity to peer influence and lack of access to tobacco products are associated with T21 support. Results underscore that T21 implementation may require a social-ecological approach.

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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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