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Volume 11, Issue 9, February 26, 2019


CDC Science Clips: Volume 11, Issue 9, February 26, 2019

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

  1. Top Articles of the Week

    Selected weekly by a senior CDC scientist from the standard sections listed below.

    The names of CDC authors are indicated in bold text.
    • Disease Reservoirs and Vectors
      • Citywide control of Aedes aegypti (Diptera: Culicidae) during the 2016 Zika epidemic by integrating community awareness, education, source reduction, larvicides, and mass mosquito trappingExternal
        Barrera R, Harris A, Hemme RR, Felix G, Nazario N, Munoz-Jordan JL, Rodriguez D, Miranda J, Soto E, Martinez S, Ryff K, Perez C, Acevedo V, Amador M, Waterman SH.
        J Med Entomol. 2019 Feb 12.
        This investigation was initiated to control Aedes aegypti and Zika virus transmission in Caguas City, Puerto Rico, during the 2016 epidemic using Integrated Vector Management (IVM), which included community awareness and education, source reduction, larviciding, and mass-trapping with autocidal gravid ovitraps (AGO). The epidemic peaked in August to October 2016 and waned after April 2017. There was a preintervention period in October/November 2016 and IVM lasted until August 2017. The area under treatment (23.1 km2) had 61,511 inhabitants and 25,363 buildings. The city was divided into eight even clusters and treated following a cluster randomized stepped-wedge design. We analyzed pools of female Ae. aegypti adults for RNA detection of dengue (DENV), chikungunya (CHIKV), and Zika (ZIKV) viruses using 360 surveillance AGO traps every week. Rainfall, temperature, and relative humidity were monitored in each cluster. Mosquito density significantly changed (generalized linear mixed model; F8, 14,588 = 296; P < 0.001) from 8.0 +/- 0.1 females per trap per week before the intervention to 2.1 +/- 0.04 after the percentage of buildings treated with traps was 60% and to 1.4 +/- 0.04 when coverage was above 80%. Out of a total 12,081 mosquito pools, there were 1 DENV-, 7 CHIKV-, and 49 ZIKV-positive pools from October 2016 to March 2017. Afterward, we found only one positive pool of DENV in July 2017. This investigation demonstrated that it was possible to scale up effective Ae. aegypti control to a medium-size city through IVM that included mass trapping of gravid Ae. aegypti females.

    • Healthcare Associated Infections
    • Immunity and Immunization
      • Experiences with rotavirus vaccines: can we improve rotavirus vaccine impact in developing countries?External
        Steele AD, Victor JC, Carey ME, Tate JE, Atherly DE, Pecenka C, Diaz Z, Parashar UD, Kirkwood CD.
        Hum Vaccin Immunother. 2019 Feb 8:1-13.
        Rotavirus vaccines have been introduced into over 95 countries globally and demonstrate substantial impact in reducing diarrheal mortality and diarrheal hospitalizations in young children. The vaccines are also considered by WHO as “very cost effective” interventions for young children, particularly in countries with high diarrheal disease burden. Yet the full potential impact of rotavirus immunization is yet to be realized. Large countries with big birth cohorts and where disease burden is high in Africa and Asia have not yet implemented rotavirus vaccines at all or at scale. Significant advances have been made demonstrating the impact of the vaccines in low- and lower-middle income countries, yet the modest effectiveness of the vaccines in these settings is challenging. Current research highlights these challenges and considers alternative strategies to overcome them, including alternative immunization schedules and host factors that may inform us of new opportunities.

    • Laboratory Sciences
      • A new approach to measure the resistance of fabric to liquid and viral penetrationExternal
        Li M, Furlong JL, Yorio PL, Portnoff L.
        PLoS One. 2019 ;14(2):e0211827.
        Protective clothing manufacturers routinely test their products for resistance to liquid and viral penetration. Several of the test methods specified by the American Society for Testing and Materials (ASTM) and the International Organization for Standardization (ISO) for penetration testing produce binary results (i.e. pass or fail), deliver imprecise pressure regulation, and do not record the location at which penetration events occur. Instead, our approach measures a continuous variable (time of penetration) during a slow and continuous increase of hydrostatic pressure and retains the location of penetration events. Using a fluorescent dye to enhance visual detection, we evaluate temporal and spatial patterns of penetration events. We then compare the time of liquid penetration with the time of penetration of two bacteriophages (Phi-X174 and MS2). For the fabric tested, the mean viral penetration occurred 0.29 minutes earlier than liquid penetration when solved by logistic regression. The breakthrough time of MS2 was not different from the Phi-X174 bacteriophage. The time of liquid penetration was a latent indicator of the time of viral penetration.

    • Nutritional Sciences
      • Food and beverage intake from 12 to 23 months by WIC statusExternal
        Hamner HC, Paolicelli C, Casavale KO, Haake M, Bartholomew A.
        Pediatrics. 2019 Feb 7.
        BACKGROUND: In 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) revised its food packages to align with updated nutrition science. Understanding how these revisions may impact current consumption patterns could be important. METHODS: Dietary data from the 2011-2014 NHANES were used to estimate the percentage of children who were aged 12 to 23 months consuming selected food and beverage categories on any given day by age and WIC status (children who were on WIC, those who were eligible for but not receiving WIC benefits, and those who were not eligible for WIC). RESULTS: Consumption of food and beverage categories differed by WIC status. On a given day, a lower percentage of children who were eligible for but did not receive WIC benefits consumed vegetables (excluding white potatoes; 42.3%) and grains (76.5%) compared with children who were participating in WIC (vegetables [excluding white potatoes]: 60.4%; grains: 85.5%) and those who were not eligible for WIC benefits (vegetables [excluding white potatoes]: 58.1%; grains: 87.2%; P < .05). A lower percentage of both children who were eligible for but not receiving WIC benefits and those who were participating in WIC consumed fruits (57.6% and 70.6%, respectively) and snacks (45.9% and 48.5%, respectively) than those who were not eligible for WIC (fruits: 86.4%; snacks: 69.1%; P < .05). A lower percentage of children who were receiving WIC consumed dairy than children who were not eligible for WIC (91.7% and 97.2%, respectively; P < .05). A higher percentage of those who were receiving WIC consumed 100% juice (70.6%) than children who were eligible for but not receiving WIC (51.6%) and children who were not eligible for WIC (50.8%; P < .05). CONCLUSIONS: Improving early WIC participation and retention could positively impact some diet-related disparities among young children who are eligible for WIC.

    • Occupational Safety and Health – Mining
      • Job autonomy & safety climate: examining associations in the mining industryExternal
        Haas E, Ryan M, Hoebbel C.
        Prof Saf. 2018 Dec;63(12):30-34.
        Perceptions of safety climate pertain to an organization’s prioritization of safety relative to other concerns, such as productivity or quality control (Naveh, Katz-Navon &amp; Stern, 2011; Zohar, 2000). Relating to what organizations may prioritize, safety climate also entails the kind of behaviors that are expected, supported and rewarded (Schneider, 1990). Characteristics of safety climate can impact workers’ own safety values, which, in turn, influence their behaviors (Naveh, et al., 2011). Further, a positive safety climate has been linked to less burnout and fewer errors, near-hits and incidents that result in lost time from work (Christian, Bradley, Wallace, et al., 2009; Nahrgang, Morgesun & Hofmann, 2011). In this sense, not only has safety climate been identified as a potential leading indicator of incident occurrence, but also evidence exists that a positive safety climate might strengthen the impact of job factors (e.g., job autonomy, supervisor support, coworker support) on workers’ proactive behavior (Bronkhorst, 2015), although these factors are not well understood (Parker, Axtell &amp; Turner, 2001). To that end, this article examines what role job autonomy, in particular, may have in forming workers’ perceptions and subsequent OSH performance on the job. The authors begin by defining autonomy in the workplace to provide a consistent platform for studying the term. Key Takeaways: 1. Job autonomy is among the most important features of organizational design that ensures job satisfaction and motivation. It is important to understand how job autonomy may support the safety climate and subsequent behaviors executed by workers. 2. The authors used two mine companies to compare workers’ perceptions of safety climate and personal levels of proactivity and compliance on the job, one that incorporated autonomous work processes and practices, and one that did not. 3. Job autonomy played a significant role in worker perceptions of their own proactive and compliant behaviors on the job, including taking initiative to address OSH problems, voicing concerns about OSH, and following rules and procedures. 4. The discussion provides insights into specific autonomous work processes to provide direction for companies that want to improve aspects of their organizational management of safety, health and risks on the job.

    • Reproductive Health
      • Venous thromboembolism among women initiating depot medroxyprogesterone acetate immediately postpartumExternal
        Tepper NK, Jeng G, Curtis KM, Boutot ME, Boulet SL, Whiteman MK.
        Obstet Gynecol. 2019 Feb 4.
        OBJECTIVE: To estimate the absolute and relative risk of venous thromboembolism (VTE) among women who initiate depot medroxyprogesterone acetate (DMPA) immediately postpartum compared with those who do not initiate hormonal contraception. METHODS: The IBM MarketScan Commercial Claims and Encounters databases were used to identify delivery hospitalizations among women aged 15-44 years during 2005 through 2014. Diagnosis, procedure, and drug codes were used to identify contraception, VTE, and potential confounding chronic or pregnancy-related conditions. Women who initiated DMPA during days 0 through 7 postpartum were compared with women who did not initiate hormonal contraception during days 0 through 7 postpartum. Women were followed from date of delivery through 12 weeks postpartum for the occurrence of VTE, with censoring at hormonal contraception initiation or prescription, hysterectomy, sterilization, or inpatient death. The incidence rate of VTE and 95% CIs were calculated within each group and the incidence rate ratio was calculated comparing the two groups. RESULTS: The unadjusted VTE incidence rate through 12 weeks postpartum was 0.42/10,000 women-days in the immediate postpartum DMPA group (34 events among 11,159 women contributing 805,999 days of follow-up) and 0.15/10,000 women-days in the control group (3,107 events among 3,102,011 women contributing 206,180,811 days of follow-up). The incidence rate ratio for VTE was 2.87 (95% CI 2.05-4.03) among women in the immediate postpartum DMPA group compared with women in the control group, adjusting for age alone. After adjusting for age and pregnancy-related and chronic conditions, the adjusted incidence rate ratio for VTE was 1.94 (95% CI 1.38-2.72) among women in the immediate postpartum DMPA group compared with women in the control group. CONCLUSION: Initiation of DMPA immediately postpartum is associated with a low incidence but an increased relative risk of VTE compared with nonuse of hormonal contraception.

    • Substance Use and Abuse
    • Zoonotic and Vectorborne Diseases
      • Perceptions and acceptability of an experimental Ebola vaccine among health care workers, frontline staff, and the general public during the 2014-2015 Ebola outbreak in Sierra LeoneExternal
        Jalloh MF, Jalloh MB, Albert A, Wolff B, Callis A, Ramakrishnan A, Cramer E, Sengeh P, Pratt SA, Conteh L, Hajjeh R, Bunnell R, Redd JT, Ekstrom AM, Nordenstedt H.
        Vaccine. 2019 Feb 9.
        INTRODUCTION: Experimental Ebola vaccines were introduced during the 2014-2015 Ebola outbreak in West Africa. Planning for the Sierra Leone Trial to Introduce a Vaccine against Ebola (STRIVE) was underway in late 2014. We examined hypothetical acceptability and perceptions of experimental Ebola vaccines among health care workers (HCWs), frontline workers, and the general public to guide ethical communication of risks and benefits of any experimental Ebola vaccine. METHODS: Between December 2014 and January 2015, we conducted in-depth interviews with public health leaders (N=31), focus groups with HCWs and frontline workers (N=20), and focus groups with members of the general public (N=15) in Western Area Urban, Western Area Rural, Port Loko, Bombali, and Tonkolili districts. Themes were identified using qualitative content analysis. RESULTS: Across all participant groups, not knowing the immediate and long-term effects of an experimental Ebola vaccine was the most serious concern. Some respondents feared that experimental vaccines may cause Ebola, lead to death, or result in other adverse events. Among HCWs, not knowing the level of protection provided by experimental Ebola vaccines was another concern. HCWs and frontline workers were motivated to help find a vaccine for Ebola to help end the outbreak. General public participants cited positive experiences with routine childhood immunization in Sierra Leone. DISCUSSION: Our formative assessment prior to STRIVE’s implementation in Sierra Leone helped identify concerns, motivations, and information gaps among potential participants of an experimental Ebola vaccine trial, at the time when an unprecedented outbreak was occurring in the country. The findings from this assessment were incorporated early in the process to guide ethical communication of risks and benefits when discussing informed consent for possible participation in the vaccine trial that was launched later in 2015.

      • Dengue virus is an under-recognised causative agent of acute encephalitis syndrome (AES): Results from a four year AES surveillance study of Japanese encephalitis in selected states of IndiaExternal
        Vasanthapuram R, Shahul Hameed SK, Desai A, Mani RS, Reddy V, Velayudhan A, Yadav R, Jain A, Saikia L, Borthakur AK, Mohan DG, Bandyopadhyay B, Bhattacharya N, Dhariwal AC, Sen PK, Venkatesh S, Prasad J, Laserson K, Srikantiah P.
        Int J Infect Dis. 2019 Jan 11.
        BACKGROUND: Acute encephalitis syndrome (AES) surveillance in India has indicated that Japanese encephalitis virus (JEV) accounts for 5-35% of AES cases annually; the etiology remains unknown in the remaining cases. We implemented comprehensive AES surveillance to identify other etiological agents of AES, with emphasis on dengue virus. METHODS: Serum and cerebrospinal fluid (CSF) specimens were collected from patients enrolled prospectively in AES surveillance from 2014-2017 at selected sites of three high burden states of India. All samples were initially tested for JEV IgM. Specimens negative for JEV by serology were tested for IgM to scrub typhus, dengue virus (DEN), and West Nile virus; all JEV IgM-negative CSF samples were tested by PCR for S. pneumoniae, N. meningitidis, H. influenzae, herpes simplex virus type 1, enteroviruses and DEN. RESULTS: Of 10,107 AES patients, an etiology could be established in 49.2% of patients including JEV (16%), scrub typhus (16%) and DEN (5.2%) as the top three agents. Amongst the DEN positive cases (359/6892), seven (2%) were positive only for dengue virus RNA: one in serum and six in CSF. CONCLUSION: Amongst the pathogens identified, dengue accounted for 5% of all AES cases and was one of the three common etiological agents. These results underscore the importance of including dengue virus in routine testing of AES cases.

  2. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Chronic Diseases and Conditions
      1. Sunburn prevalence among US adults, National Health Interview Survey 2005, 2010, and 2015External
        Holman DM, Ding H, Berkowitz Z, Hartman AM, Perna FM.
        J Am Acad Dermatol. 2019 Mar;80(3):817-820.

        [No abstract]

      2. Association of obesity with hearing impairment in adolescentsExternal
        Scinicariello F, Carroll Y, Eichwald J, Decker J, Breysse PN.
        Sci Rep. 2019 Feb 12;9(1):1877.
        Hearing loss (HL) is the third most common chronic physical condition in the United States. Obesity has become an increasingly important public health concern, as the prevalence in children, adolescents and adults has increased over the past few decades. The objectives of this study is to investigate whether obesity is associated with audiometric notches indicative of noise-induced hearing loss (NIHL), speech frequency hearing loss (SFHL), and high frequency hearing loss (HFHL) in adolescent participants of the National Health and Nutrition Examination Survey 2007-2010. The prevalence of overall audiometric notches in the adolescent population was 16.0% with higher prevalence in females than males. The prevalence of SFHL and HFHL were higher in males than females (SFHL, 7.3% vs. 5.4%, respectively; and HFHL 14.3% vs. 8.1%, respectively). Obese adolescents had a higher adjusted OR to have audiometric notches (OR = 1.93; 95% CI: 1.33-2.81) and HFHL (OR = 1.95; 95% CI: 1.19-3.21). Continued preventative efforts towards reducing obesity might also help to reduce the risk for HL and NIHL.

      3. Receipt of preventive care services among US adults with inflammatory bowel disease, 2015-2016External
        Xu F, Dahlhamer JM, Terlizzi EP, Wheaton AG, Croft JB.
        Dig Dis Sci. 2019 Feb 12.
        BACKGROUND: Previous reports suggest that adults with inflammatory bowel disease (IBD) receive suboptimal preventive care. AIMS: The population-based study compared the receipt of these services by US adults with and without IBD. METHODS: Adults aged >/= 18 years with IBD (1.2%) and without IBD were identified from the 2015 and 2016 National Health Interview Survey (n = 66,610). Age-standardized prevalence of doctor visits, receipt of medical advice, and selected preventive care was calculated for adults with and without IBD. The model-adjusted prevalence ratios were estimated for receipt of preventive care associated with IBD. RESULTS: The prevalence of a doctor visit in the past 12 months was significantly higher among adults with IBD than those without. IBD was also associated with significantly higher prevalence of receiving medical advice about smoking cessation (83.9% vs. 66.4%) and diet (42.9% vs. 32.1%), having colon cancer screening in the past 12 months (44.0% vs. 26.7%), having ever had an HIV test (51.5% vs. 45.4%) or pneumococcal vaccine (75.3% vs. 64.0%), having received a tetanus vaccine in the past 10 years (72.0% vs. 61.8%), and having received a flu vaccine in the past 12 months (48.4% vs. 41.0%), but was not significantly associated with receiving cervical cancer screening and hepatitis A and B vaccines. CONCLUSIONS: Adults with IBD were more likely to receive many types of preventive care than adults without IBD. The findings can inform healthcare policy makers to make strategic decisions that enhance multidisciplinary coordination from various medical specialties to ensure optimal preventive care for IBD patients.

    • Communicable Diseases
      1. Notes from the field: Circulating vaccine-derived poliovirus type 1 and outbreak response – Papua New Guinea, 2018External
        Bauri M, Wilkinson AL, Ropa B, Feldon K, Snider CJ, Anand A, Tallis G, Boualam L, Grabovac V, Avagyan T, Reza MS, Mekonnen D, Zhang Z, Thorley BR, Shimizu H, Apostol LN, Takashima Y.
        MMWR Morb Mortal Wkly Rep. 2019 Feb 8;68(5):119-120.

        [No abstract]

      2. Introduction and evaluation of multidrug-resistant tuberculosis supplemental surveillance in the United StatesCdc-pdfExternal
        Belanger A, Morris SB, Brostrom R, Yost D, Goswami N, Oxtoby M, Moore M, Westenhouse J, Barry PM, Shah NS.
        J Clin Tuberc Other Mycobact Dis. 2019 ;15.
        The current tuberculosis (TB) case reporting system for the United States, the Report of Verified Case of TB (RVCT), has minimal capture of multidrug-resistant (MDR) TB treatment and adverse events. Data were abstracted in five states using the form for 13 MDR TB patients during 2012-2015. The Centers for Disease Control and Prevention Guidelines for Evaluating Public Health Surveillance Systems were used to evaluate attributes of the form. Unstructured interviews with pilot sites and stakeholders provided qualitative feedback. The form was acceptable, simple, stable, representative, and provided high-quality data but was not flexible or timely. For the 13 patients on whom data were collected, the median duration of treatment with an injectable medication was 216 days (IQR 203-252). Six (46%) patients reported a side effect requiring a medication change and eight (62%) had a side effect present at treatment completion. A standardized MDR TB supplemental surveillance form was well received by stakeholders whose feedback was critical to making modifications. The finalized form will be implemented nationally in 2020 and will provide MDR TB treatment and morbidity data in the United States to help ensure patients with MDR TB receive the most effective treatment regimens with the least toxic drugs.

      3. Update: Influenza activity – United States, September 30, 2018-February 2, 2019External
        Blanton L, Dugan VG, Abd Elal AI, Alabi N, Barnes J, Brammer L, Budd AP, Burns E, Cummings CN, Garg S, Garten R, Gubareva L, Kniss K, Kramer N, O’Halloran A, Reed C, Rolfes M, Sessions W, Taylor C, Xu X, Fry AM, Wentworth DE, Katz J, Jernigan D.
        MMWR Morb Mortal Wkly Rep. 2019 Feb 15;68(6):125-134.
        CDC collects, compiles, and analyzes data on influenza activity and viruses in the United States. During September 30, 2018-February 2, 2019,* influenza activity(dagger) in the United States was low during October and November, increased in late December, and remained elevated through early February. As of February 2, 2019, this has been a low-severity influenza season (1), with a lower percentage of outpatient visits for influenza-like illness (ILI), lower rates of hospitalization, and fewer deaths attributed to pneumonia and influenza, compared with recent seasons. Influenza-associated hospitalization rates among children are similar to those observed in influenza A(H1N1)pdm09 predominant seasons; 28 influenza-associated pediatric deaths occurring during the 2018-19 season have been reported to CDC. Whereas influenza A(H1N1)pdm09 viruses predominated in most areas of the country, influenza A(H3N2) viruses have predominated in the southeastern United States, and in recent weeks accounted for a growing proportion of influenza viruses detected in several other regions. Small numbers of influenza B viruses (<3% of all influenza-positive tests performed by public health laboratories) also were reported. The majority of the influenza viruses characterized antigenically are similar to the cell culture-propagated reference viruses representing the 2018-19 Northern Hemisphere influenza vaccine viruses. Health care providers should continue to offer and encourage vaccination to all unvaccinated persons aged >/=6 months as long as influenza viruses are circulating. Finally, regardless of vaccination status, it is important that persons with confirmed or suspected influenza who have severe, complicated, or progressive illness; who require hospitalization; or who are at high risk for influenza complications be treated with antiviral medications.

      4. Birth cohort studies assessing norovirus infection and immunity in young children: A reviewExternal
        Cannon JL, Lopman BA, Payne DC, Vinje J.
        Clin Infect Dis. 2019 Feb 12.
        Globally, noroviruses are among the foremost causes of acute diarrheal disease, yet there are many unanswered questions on norovirus immunity, particularly following natural infection in young children during the first 2 years of life when the disease burden is highest. We conducted a literature review on birth cohort studies assessing norovirus infections in children from birth to early childhood. Data on infection, immunity, and risk factors are summarized from 10 community-based birth cohort studies conducted in low- and middle-income countries. Up to 90% of children experienced atleast one norovirus infection and up to 70% experienced norovirus-associated diarrhea, most often affecting children 6 months of age and older. Data from these studies help to fill critical knowledge gaps for vaccine development, yet study design and methodological differences limit comparison between studies, particularly for immunity and risk factors for disease. Considerations for conducting future birth cohort studies on norovirus are discussed.

      5. Moderate-to-high levels of pretreatment HIV drug resistance in KwaZulu-Natal Province, South AfricaExternal
        Chimukangara B, Kharsany AB, Lessells RJ, Naidoo K, Rhee SY, Manasa J, Graf T, Lewis L, Cawood C, Khanyile D, Diallo K, Ayalew KA, Shafer RW, Hunt G, Pillay D, Abdool SK, de Oliveira T.
        AIDS Res Hum Retroviruses. 2019 Feb;35(2):129-138.
        There is evidence of increasing levels of pretreatment HIV drug resistance (PDR) in Southern Africa. We used data from two large population-based HIV surveillance studies to estimate prevalence of PDR in KwaZulu-Natal, the province with the highest HIV prevalence in South Africa. Sanger sequencing was performed on samples obtained from a longitudinal HIV surveillance program (study A, 2013-2014) and the HIV Incidence Provincial Surveillance System (study B, 2014-2015). Sequences were included for adult HIV positive participants (age >/=15 years for study A, age 15-49 years for study B) with no documented prior exposure to antiretroviral therapy (ART). Overall and drug class-specific PDR was estimated using the World Health Organization 2009 surveillance drug resistance mutation (SDRM) list, and phylogenetic analysis was performed to establish evidence of drug resistance transmission linkage. A total of 1,845 sequences were analyzed (611 study A; 1,234 study B). An overall PDR prevalence of 9.2% [95% confidence interval (CI) 7.0-11.7] was observed for study A and 11.0% (95% CI 8.9-13.2) for study B. In study B, the prevalence of non-nucleoside reverse-transcriptase inhibitor (NNRTI) PDR exceeded 10% for sequences collected in 2014 (10.2%, 95% CI 7.5-12.9). The most prevalent SDRMs were K103NS (7.5%), M184VI (2.4%), and V106AM (1.4%). There was no evidence of large transmission chains of drug-resistant virus. High level NNRTI PDR (>10%) suggests a need to modify the standard first-line ART regimen and to focus attention on improving the quality of HIV prevention, treatment, and care.

      6. Temporal patterns in chlamydia repeat testing in MassachusettsCdc-pdfExternal
        Dee EC, Hsu KK, Kruskal BA, Menchaca JT, Zambarano B, Cocoros N, Herrick B, Weiss MD, Hafer E, Erani D, Josephson M, Young J, Torrone EA, Flagg EW, Klompas M.
        Am J Prev Med. 2019 ;56(3):458-463.
        Introduction: National guidelines recommend test-of-cure for pregnant women and test-of-reinfection for all patients with chlamydia infections in order to interrupt transmission and prevent adverse sequelae for patients, partners, and newborns. Little is known about retesting and positivity rates, and whether they are changing over time, particularly in private sector practices. Methods: Electronic health record data on patients with chlamydia tests were extracted from three independent clinical practice groups serving approximately equal to 20% of the Massachusetts population. Records were extracted using the Electronic medical record Support for Public Health platform (esphealth.org). These data were analyzed for temporal trends in annual repeat testing rates by using generalized estimating equations after index positive chlamydia tests between 2010 and 2015 and for differences in intervals to first repeat tests among pregnant females, non-pregnant females, and males. Data extraction and analysis were performed during calendar years 2017 and 2018. Results: An index positive C. trachomatis result was identified for 972 pregnant female cases, 10,309 non-pregnant female cases, and 4,973 male cases. Test-of-cure 3-5 weeks after an index positive test occurred in 37% of pregnant females. Test-of-reinfection 8?16 weeks after an index positive test occurred in 39% of pregnant females, 18% of non-pregnant females, and 9% of males. There were no significant increases in test-of-cure or test-of-reinfection rates from 2010 to 2015. Among cases with repeat tests, 16% of pregnant females, 15% of non-pregnant females, and 16% of males had positive results. Conclusions: Chlamydia test-of-cure and test-of-reinfection rates are low, with no evidence of improvement over time. There are substantial opportunities to improve adherence to chlamydia repeat testing recommendations.

      7. Transmission patterns in a low HIV-morbidity state – Wisconsin, 2014-2017External
        Grande KM, Schumann CL, Banez Ocfemia MC, Vergeront JM, Wertheim JO, Oster AM.
        MMWR Morb Mortal Wkly Rep. 2019 Feb 15;68(6):149-152.
        Public health interviews (i.e., partner services), during which persons with diagnosed human immunodeficiency virus (HIV) infection name their sexual or needle-sharing partners (named partners), are used to identify HIV transmission networks to guide and prioritize HIV prevention activities. HIV sequence data, generated from provider-ordered drug resistance testing, can be used to understand characteristics of molecular clusters, a group of sequences for which each sequence is highly similar (linked) to all other sequences, and assess whether named partners are plausible HIV transmission partners. Although molecular data in higher HIV-morbidity states have been analyzed (1-3), few analyses exist for lower morbidity states (4), such as Wisconsin, which reported 4.6 HIV diagnoses per 100,000 persons aged >/=13 years in 2016 (5). The Wisconsin Division of Public Health (DPH) analyzed HIV sequence data generated from provider-ordered drug resistance testing and collected through routine HIV surveillance to identify molecular clusters and describe demographic and transmission risk characteristics among pairs of persons whose sequences were highly genetically similar (i.e., molecular linkages). In addition, overlap between partner linkages identified during public health interviews and molecular linkages was assessed. Overall, characteristics of molecular clusters in Wisconsin mirrored those from states with more HIV diagnoses, particularly in that most molecular linkages were observed among persons of the same race (78.2% of non-Hispanic blacks [blacks] linked to other blacks), the same transmission risk (90.2% of men who have sex with men [MSM] linked to other MSM), and the same age group (59.2% of persons aged 20-29 years linked to other persons aged 20-29 years). Among named partner linkages identified during interviews in which both persons also had a reported sequence, overlap of named partner and molecular linkages was moderate: 33.8% of named partners were plausible transmission partners according to available molecular data. Analysis of HIV sequence data is a useful tool for characterizing transmission patterns not immediately apparent using traditional public health interview data, even in a state with lower HIV morbidity. Prevention recommendations generated from national data (e.g., targeting preexposure prophylaxis for HIV-negative persons at high risk and implementing measures to maintain viral suppression among persons with HIV infection) also are relevant in a lower HIV-morbidity state.

      8. Notes from the field: Assessment of state-level influenza season severity – Minnesota and Utah, 2017-18 influenza seasonExternal
        Hughes MM, Doyle JD, McCaffrey K, McMahon M, Spencer M, Martin K, Reed GM, Carmack AE, Garg S, Rolfes M, Reed C, Biggerstaff M.
        MMWR Morb Mortal Wkly Rep. 2019 Feb 15;68(6):165-166.

        [No abstract]

      9. During 2013-2017, the national annual rate of reported primary and secondary (P&S) syphilis cases in the United States increased 72.7%, from 5.5 to 9.5 cases per 100,000 population (1). The highest rates of P&S syphilis are seen among gay, bisexual, and other men who have sex with men (collectively referred to as MSM) (2), and MSM continued to account for the majority of cases in 2017 (1). However, during 2013-2017, the P&S syphilis rate among women increased 155.6% (from 0.9 to 2.3 cases per 100,000 women), and the rate among all men increased 65.7% (from 10.2 to 16.9 cases per 100,000 men), indicating increasing transmission between men and women in addition to increasing transmission between men (1). To further understand these trends, CDC analyzed national P&S syphilis surveillance data for 2013-2017 and assessed the percentage of cases among women, men who have sex with women only (MSW), and MSM who reported drug-related risk behaviors during the past 12 months. Among women and MSW with P&S syphilis, reported use of methamphetamine, injection drugs, and heroin more than doubled during 2013-2017. In 2017, 16.6% of women with P&S syphilis used methamphetamine, 10.5% used injection drugs, and 5.8% used heroin during the preceding 12 months. Similar trends were seen among MSW, but not among MSM. These findings indicate that a substantial percentage of heterosexual syphilis transmission is occurring among persons who use these drugs, particularly methamphetamine. Collaboration between sexually transmitted disease (STD) control programs and partners that provide substance use disorder services will be important to address recent increases in heterosexual syphilis.

      10. Get Yourself Tested (GYT) goes to high school: Adapted STD prevention campaign and associated student use of clinic STD testing servicesExternal
        Liddon N, Carver L, Robin L, Harper C, Murray C, Habel M, Lesesne C.
        Sex Transm Dis. 2019 Feb 6.
        BACKGROUND: In an attempt to increase high school students’ STD testing ratesrates, the Centers for Disease Control and Prevention’s Division of Adolescent and School Health partnered with ICF and Chicago Public Schools (CPS) to adapt and implement the “GYT: Get Yourself Tested” health marketing campaign for a high school. METHODS: Clinic record data and student retrospective self-report surveys (n=193) tested for differences between the GYT intervention school and a comparison school on a number of outcomes including HIV and STD testing. RESULTS: Clinic record data showed that testing increased significantly more for the intervention than the comparison school during the GYT implementation period (B = 2.9, SE = 1.1, p < 0.05). Furthermore, the odds of being tested at the referral clinic were more than four times (OR=4.4) as high for students in the campaign school than for those in the comparison school (95% CI = 2.3 – 8.2). Survey data did not show increased self-reported testing but, more students in the GYT school (92.7%) were aware of where to receive free, low-cost, or affordable HIV and STD testing than students in the comparison school (76.0%) (p<.01). Among sexually experienced students (n=142), significantly more from the campaign school reported that they intended to test for STDs in the next 3 months (48.4% strongly agree and 33.2% agree) compared to those at the comparison school (27.4% strongly agree and 32.9% agree) (p<.05). CONCLUSIONS: Our pilot suggests that a student-led GYT campaign in high schools may successfully increase STD testing of students. Although some of the findings from this pilot evaluation are promising, they are limited and broader implementation and evaluation is needed. Future evaluation efforts can include more rigorous study designs, multiple schools or districts, longer campaign and evaluation across an entire school or calendar year, or in combination with other school-based testing strategies like a mass school-based screening event.

      11. Low rates of NRTI and NNRTI drug resistance among participants in the Botswana combination prevention program (BCPP) trialExternal
        Moyo S, Gaseitsiwe S, Zahralban-Steele M, Maruapula D, Nkhisang T, Mokaleng B, Mohammed T, Ditlhako TR, Bareng OT, Mokgethi TP, van Widenfelt E, Pretorius-Holme M, Mine MO, Raizes E, Yankinda EK, Wirth KE, Gaolathe T, Makhema JM, Lockman S, Essex M, Novitsky V.
        Aids. 2019 Feb 7.
        BACKGROUND: Scale-up of antiretroviral therapy (ART) and introduction of treat-all strategy necessitates population-level monitoring of acquired HIV drug resistance (ADR) and pre-treatment drug resistance (PDR) mutations. METHODS: Blood samples were collected from 4,973 HIV-positive individuals residing in 30 communities across Botswana who participated in the Botswana Combination Prevention Project (BCPP) in 2013-2018. HIV sequences were obtained by long-range HIV genotyping. Major drug-resistance mutations (DRMs) and surveillance drug resistance mutations (SDRMs) associated with nucleoside reverse transcriptase inhibitors (NRTI) and non-nucleoside reverse transcriptase inhibitors (NNRTI) were analyzed according to the Stanford University HIV Drug Resistance Database. Viral sequences were screened for G-to-A hypermutations (HM). A threshold of 2% was used for HM adjustment. Viral suppression was considered at HIV-1 RNA load </=400 copies/mL. RESULTS: Among 4,973 participants with HIV-1C sequences, ART data were available for 4,927 (99%) including 3,858 (78%) on ART. Among those on ART, 3,435 had viral load data and 3,297 (96%) were virologically suppressed. Among 1069 (22%) HIV-infected individuals not on ART, we found NRTI- and NNRTI-associated SDRMs were found in 1.5% (95% confidence interval (CI): 1.0-2.5%) and 2.9% (95% CI: 2.0-4.2%), respectively. Of the 138 (4%) of individuals who had detectable HIV-1 RNA, we found NRTI- and NNRTI-associated drug resistance mutations in 16% (95% CI: 10-25%) and 33% (95% CI: 25-42%), respectively. CONCLUSIONS: We found a low prevalence of NRTI- and NNRTI-associated PDR-resistance mutations among residents of rural and peri-urban communities across Botswana. However, individuals on ART with detectable virus had ADR NRTI and NNRTI mutations above 15%.

      12. Evidence for household transmission of rotavirus in the United States, 2011-2016External
        Wikswo ME, Parashar UD, Lopman B, Selvarangan R, Harrison CJ, Azimi PH, Boom JA, Sahni LC, Englund JA, Klein EJ, Staat MA, McNeal MM, Halasa N, Chappell J, Weinberg GA, Szilagyi PG, Esona MD, Bowen MD, Payne DC.
        J Pediatric Infect Dis Soc. 2019 Feb 7.
        Background: Rotavirus is a leading cause of acute gastroenteritis (AGE) in children and is highly transmissible. In this study, we assessed the presence of AGE in household contacts (HHCs) of pediatric patients with laboratory-confirmed rotavirus. Methods: Between December 2011 and June 2016, children aged 14 days to 11 years with AGE were enrolled at 1 of 7 hospitals or emergency departments as part of the New Vaccine Surveillance Network. Parental interviews, medical and vaccination records, and stool specimens were collected at enrollment. Stool was tested for rotavirus by an enzyme immunoassay and confirmed by real-time or conventional reverse transcription-polymerase chain reaction assay or repeated enzyme immunoassay. Follow-up telephone interviews were conducted to assess AGE in HHCs the week after the enrolled child’s illness. A mixed-effects multivariate model was used to calculate odds ratios. Results: Overall, 829 rotavirus-positive subjects and 8858 rotavirus-negative subjects were enrolled. Households of rotavirus-positive subjects were more likely to report AGE illness in >/=1 HHC than were rotavirus-negative households (35% vs 20%, respectively; P < .0001). A total of 466 (16%) HHCs of rotavirus-positive subjects reported AGE illness. Of the 466 ill HHCs, 107 (23%) sought healthcare; 6 (6%) of these encounters resulted in hospitalization. HHCs who were <5 years old (odds ratio, 2.2 [P = .004]) were more likely to report AGE illness than those in other age groups. In addition, 144 households reported out-of-pocket expenses (median, $20; range, $2-$640) necessary to care for an ill HHC. Conclusions: Rotavirus-associated AGE in children can lead to significant disease burden in HHCs, especially in children aged <5 years. Prevention of pediatric rotavirus illness, notably through vaccination, can prevent additional illnesses in HHCs.

    • Disease Reservoirs and Vectors
      1. Exome-wide association of deltamethrin resistance in Aedes aegypti from MexicoExternal
        Saavedra-Rodriguez K, Campbell CL, Lenhart A, Penilla P, Lozano-Fuentes S, Black WC.
        Insect Mol Biol. 2019 Feb 13.
        Aedes aegypti is the major vector of a number of arboviruses that cause disease in humans. Without vaccines or pharmaceuticals, pyrethroid insecticides remain the major tool for public health protection. Pyrethroid resistance is now widespread. Replacement substitutions in the voltage-gated sodium channel (vgsc) that reduce the stability of pyrethroid binding account for most of the resistance but metabolic mechanisms also inactivate pyrethroids. High-throughput sequencing and the Ae. aegypti L5 annotated physical map has allowed interrogation of the exome for genes and single nucleotide polymorphisms (SNPs) associated with pyrethroid resistance. We exposed females from Mexico to a deltamethrin discriminating dose to designate them as resistant (active after 1 h) or susceptible (knocked down with no recovery after 4 h). The vgsc on chromosome 3 had the highest association, followed by genes proximal to vgsc. We identified potential detoxification genes located singly (e.g. HPX8C) or within clusters in chromosome 2 (three esterase clusters, two of CYP) and chromosome 3 (one cluster of 16 CYP325 and seven CYP9 genes). Deltamethrin resistance in Ae. aegypti is associated with mutations in the vgsc gene and a large assortment of genes. This article is protected by copyright. All rights reserved.

    • Drug Safety
      1. Antibiotic prescribing for children in United States emergency departments: 2009-2014Cdc-pdfExternal
        Poole NM, Shapiro DJ, Fleming-Dutra KE, Hicks LA, Hersh AL, Kronman MP.
        Pediatrics. 2019 Jan 8.
        OBJECTIVES: To characterize and compare ambulatory antibiotic prescribing for children in US pediatric and nonpediatric emergency departments (EDs). METHODS: A cross-sectional retrospective study of patients aged 0 to 17 years discharged from EDs in the United States was conducted by using the 2009-2014 National Hospital Ambulatory Medical Care Survey ED data. We estimated the proportion of ED visits resulting in antibiotic prescriptions, stratified by antibiotic spectrum, class, diagnosis, and ED type (“pediatric” defined as >75% of visits by patients aged 0-17 years, versus “nonpediatric”). Multivariable logistic regression was used to determine factors independently associated with first-line, guideline-concordant prescribing for acute otitis media, pharyngitis, and sinusitis. RESULTS: In 2009-2014, of the 29 million mean annual ED visits by children, 14% (95% confidence interval [CI]: 10%-20%) occurred at pediatric EDs. Antibiotics overall were prescribed more frequently in nonpediatric than pediatric ED visits (24% vs 20%, P < .01). Antibiotic prescribing frequencies were stable over time. Of all antibiotics prescribed, 44% (95% CI: 42%-45%) were broad spectrum, and 32% (95% CI: 30%-34%, 2.1 million per year) were generally not indicated. Compared with pediatric EDs, nonpediatric EDs had a higher frequency of prescribing macrolides (18% vs 8%, P < .0001) and a lower frequency of first-line, guideline-concordant prescribing for the respiratory conditions studied (77% vs 87%, P < .001). CONCLUSIONS: Children are prescribed almost 7 million antibiotic prescriptions in EDs annually, primarily in nonpediatric EDs. Pediatric antibiotic stewardship efforts should expand to nonpediatric EDs nationwide, particularly regarding avoidance of antibiotic prescribing for conditions for which antibiotics are not indicated, reducing macrolide prescriptions, and increasing first-line, guideline-concordant prescribing.

    • Environmental Health
      1. A 5-step land reuse and redevelopment model: Resources to spur local initiativesExternal
        Berman L, Ballogg M, Erdal S.
        J Environ Health. 2019 Feb;81(6):36-38.

        [No abstract]

      2. Lead elimination for the 21st centuryExternal
        Breysse PN.
        J Public Health Manag Pract. 2019 Jan/Feb;25 Suppl 1, Lead Poisoning Prevention:S3-s4.

        [No abstract]

      3. Control of lead sources in the United States, 1970-2017: Public health progress and current challenges to eliminating lead exposureExternal
        Dignam T, Kaufmann RB, LeStourgeon L, Brown MJ.
        J Public Health Manag Pract. 2019 Jan/Feb;25 Suppl 1, Lead Poisoning Prevention:S13-s22.
        CONTEXT: During the past 45 years, exposure to lead has declined dramatically in the United States. This sustained decline is measured by blood and environmental lead levels and achieved through control of lead sources, emission reductions, federal regulations, and applied public health efforts. OBJECTIVE: Explore regulatory factors that contributed to the decrease in exposure to lead among the US population since 1970. DESIGN/SETTING: We present historical information about the control of lead sources and the reduction of emissions through regulatory and selected applied public health efforts, which have contributed to decreases in lead exposure in the United States. Sources of lead exposure, exposure pathways, blood lead measurements, and special populations at risk are described. RESULTS: From 1976-1980 to 2015-2016, the geometric mean blood lead level (BLL) of the US population aged 1 to 74 years dropped from 12.8 to 0.82 mug/dL, a decline of 93.6%. Yet, an estimated 500 000 children aged 1 to 5 years have BLLs at or above the blood lead reference value of 5 microg/dL established by the Centers for Disease Control and Prevention. Low levels of exposure can lead to adverse health effects. There is no safe level of lead exposure, and child BLLs less than 10 mug/dL are known to adversely affect IQ and behavior. When the exposure source is known, approximately 95% of BLLs of 25 microg/dL or higher are work-related among US adults. Despite much progress in reducing exposure to lead in the United States, there are challenges to eliminating exposure. CONCLUSIONS: There are future challenges, particularly from the inequitable distribution of lead hazards among some communities. Maintaining federal, state, and local capacity to identify and respond to populations at high risk can help eliminate lead exposure as a public health problem. The results of this review show that the use of strong evidence-based programs and practices, as well as regulatory authority, can help control or eliminate lead hazards before children and adults are exposed.

      4. INTRODUCTION: Indoor air quality in day care centers (DCCs) is an emerging research topic nowadays. Indoor air pollutants such as particulate matter (PM) and microbes have been linked to respiratory health effects in children, particularly asthma-related symptoms such as night coughs and wheezing due to early exposure to indoor air contaminants. OBJECTIVE: The aim of this study was to determine the association between wheezing symptoms among toddlers attending DCCs and indoor particulate matter, PM10, PM2.5, and microbial count level in urban DCCs in the District of Seremban, Malaysia. METHODS: Data collection was carried out at 10 DCCs located in the urban area of Seremban. Modified validated questionnaires were distributed to parents to obtain their children’s health symptoms. The parameters measured were indoor PM2.5, PM10, carbon monoxide, total bacteria count, total fungus count, temperature, air velocity, and relative humidity using the National Institute for Occupational Safety and Health analytical method. RESULTS: All 10 DCCs investigated had at least one indoor air quality parameter exceeding the acceptable level of standard guidelines. The prevalence of toddlers having wheezing symptoms was 18.9%. There was a significant different in mean concentration of PM2.5 and total bacteria count between those with and those without wheezing symptoms (P = 0.02, P = 0.006). CONCLUSIONS: Urban DCCs are exposed to many air pollutants that may enter their buildings from various adjacent sources. The particle concentrations and presence of microbes in DCCs might increase the risk of exposed children for respiratory diseases, particularly asthma, in their later life.

      5. Identifying and chronicling childhood lead poisoning prevention program achievements with “success stories”External
        Lockamy-Kassim E, Friedberg J, Newby C, Lecours C, Credle K, Leonard M.
        J Public Health Manag Pract. 2019 Jan/Feb;25 Suppl 1, Lead Poisoning Prevention:S111-s114.
        Success stories showcase a public health program’s progress toward achieving population health objectives. The Centers for Disease Control and Prevention’s (CDC’s) Childhood Lead Poisoning Prevention Program (CLPPP) develops “success stories” in partnership with state and local cooperative agreement recipients as one way to highlight lead poisoning prevention achievements. Success stories can be used to inform policy makers, stakeholders, and the general public. Over time, the process for collecting and developing CLPPP “successes” has evolved. Early efforts to collect success stories from funded recipients resulted in broad or unfocused reports that diminished the program’s perceived impact. CDC’s CLPPP revised the approach to success story development in order to better articulate the context, intervention or activity, and results related to programs’ successes. The new approach results in stronger products ensuring that both CDC and program recipients can use the success stories to demonstrate achievement of key program objectives. We describe how success stories can be used to identify, chronicle, and mobilize public health program achievements using the example of lead poisoning prevention. Success stories allow programs to increase mission awareness, build stakeholder support, generate community interest, and collectively demonstrate progress toward meeting national program objectives.

      6. Evaluation of the implementation of CDC’s Health Alert related to the FDA LeadCare recall from the state health department perspectiveExternal
        Trinh E, Mason J.
        J Public Health Manag Pract. 2019 Jan/Feb;25 Suppl 1, Lead Poisoning Prevention:S105-s110.
        On May 17, 2017, the Food and Drug Administration (FDA) issued a safety recall for the Magellan Diagnostics’ LeadCare Testing Systems due to the potential for inaccurately low blood lead test results when used with venous blood samples. The Centers for Disease Control and Prevention (CDC) announced a health alert with retesting recommendations because those with a blood lead level of concern may have been missed and not connected to the appropriate follow-up services. A qualitative evaluation of 9 state childhood lead poisoning prevention programs’ experiences is presented in this report. Interviewees reported using a variety of media and notification methods to inform key stakeholders about the recall and recommendations. Challenges experienced by programs in responding to retesting recommendations include incomplete and out-of-date lists of LeadCare users; missing or inaccurate information in their surveillance database; not having large laboratories and hospitals consider contacting persons for retesting to be within their purview; and having limited staff members to conduct emergency response activities. Two of the 9 states report subsequent challenges with their retesting rates. The retesting recommendations were generally viewed positively. The interviewees’ comments provide insight into steps CDC might take to better serve state and local lead programs. Programs’ experiences have led to a better understanding of the roles of their program when emergency events occur, their relationship with stakeholders as related to the blood lead testing and reporting process, and areas of improvement in surveillance databases. Public health agencies at all levels have important roles to play in preventing lead exposures and providing needed services when exposures occur. Programs may achieve long-term benefits by improving surveillance systems and having a better understanding of laboratory practices. CDC will continue to provide timely information and recommendations to state and local public health agencies to inform both routine and emergency response activities.

      7. Elevated blood lead levels in adults – Missouri, 2013External
        Victory KR, Braun CR, de Perio MA, Calvert GM, Alarcon W.
        Am J Ind Med. 2019 Feb 11.
        BACKGROUND: Over 90% of adults with elevated blood lead levels (BLLs) in the United States are exposed occupationally. Missouri historically has been among the states with the highest prevalence rates of elevated BLLs. We characterized cases of elevated BLLs among Missouri adults to target preventive interventions. METHODS: We reviewed 2013 data on Missouri residents >/=16 years from the Missouri Adult Blood Lead Epidemiology and Surveillance system and analyzed characteristics of those with elevated BLLs. We used the contemporaneous CDC definition of elevated BLL as >/=10 mug/dL. RESULTS: Of the 15 123 residents with a BLL in 2013 (median: 1.5 mug/dL, range: 0-151 mug/dL), 3145 (21%) had BLLs >/=10 mug/dL. Occupational exposures accounted for the majority of residents (n = 3099, 98%) with elevated BLLs, mostly in battery manufacturing (n = 1373, 44%) and lead mining (n = 821, 26%) industries. CONCLUSIONS: Our findings highlight the need for focused interventions targeting battery manufacturing and lead mining, the high-risk industries, to further reduce overexposures to lead.

    • Food Safety
      1. Differences among incidence rates of invasive listeriosis in the U.S. FoodNet population by age, sex, race/ethnicity, and pregnancy status, 2008-2016External
        Pohl AM, Pouillot R, Bazaco MC, Wolpert BJ, Healy JM, Bruce BB, Laughlin ME, Hunter JC, Dunn JR, Hurd S, Rowlands JV, Saupe A, Vugia DJ, Van Doren JM.
        Foodborne Pathog Dis. 2019 Feb 8.
        Listeria monocytogenes is a foodborne pathogen that disproportionally affects pregnant females, older adults, and immunocompromised individuals. Using U.S. Foodborne Diseases Active Surveillance Network (FoodNet) surveillance data, we examined listeriosis incidence rates and rate ratios (RRs) by age, sex, race/ethnicity, and pregnancy status across three periods from 2008 to 2016, as recent incidence trends in U.S. subgroups had not been evaluated. The invasive listeriosis annual incidence rate per 100,000 for 2008-2016 was 0.28 cases among the general population (excluding pregnant females), and 3.73 cases among pregnant females. For adults >/=70 years, the annual incidence rate per 100,000 was 1.33 cases. No significant change in estimated listeriosis incidence was found over the 2008-2016 period, except for a small, but significantly lower pregnancy-associated rate in 2011-2013 when compared with 2008-2010. Among the nonpregnancy-associated cases, RRs increased with age from 0.43 (95% confidence interval: 0.25-0.73) for 0- to 14-year olds to 44.9 (33.5-60.0) for >/=85-year olds, compared with 15- to 44-year olds. Males had an incidence of 1.28 (1.12-1.45) times that of females. Compared with non-Hispanic whites, the incidence was 1.57 (1.18-1.20) times higher among non-Hispanic Asians, 1.49 (1.22-1.83) among non-Hispanic blacks, and 1.73 (1.15-2.62) among Hispanics. Among females of childbearing age, non-Hispanic Asian females had 2.72 (1.51-4.89) and Hispanic females 3.13 (2.12-4.89) times higher incidence than non-Hispanic whites. We observed a higher percentage of deaths among older patient groups compared with 15- to 44-year olds. This study is the first characterizing higher RRs for listeriosis in the United States among non-Hispanic blacks and Asians compared with non-Hispanic whites. This information for public health risk managers may spur further research to understand if differences in listeriosis rates relate to differences in consumption patterns of foods with higher contamination levels, food handling practices, comorbidities, immunodeficiencies, health care access, or other factors.

    • Genetics and Genomics
      1. Next-generation sequencing of infectious pathogensExternal
        Gwinn M, MacCannell D, Armstrong GL.
        Jama. 2019 Feb 14.

        [No abstract]

      2. Using deep learning to identify translational research in genomic medicine beyond bench to bedsideExternal
        Hsu YY, Clyne M, Wei CH, Khoury MJ, Lu Z.
        Database (Oxford). 2019 Jan 1;2019.
        Tracking scientific research publications on the evaluation, utility and implementation of genomic applications is critical for the translation of basic research to impact clinical and population health. In this work, we utilize state-of-the-art machine learning approaches to identify translational research in genomics beyond bench to bedside from the biomedical literature. We apply the convolutional neural networks (CNNs) and support vector machines (SVMs) to the bench/bedside article classification on the weekly manual annotation data of the Public Health Genomics Knowledge Base database. Both classifiers employ salient features to determine the probability of curation-eligible publications, which can effectively reduce the workload of manual triage and curation process. We applied the CNNs and SVMs to an independent test set (n = 400), and the models achieved the F-measure of 0.80 and 0.74, respectively. We further tested the CNNs, which perform better results, on the routine annotation pipeline for 2 weeks and significantly reduced the effort and retrieved more appropriate research articles. Our approaches provide direct insight into the automated curation of genomic translational research beyond bench to bedside. The machine learning classifiers are found to be helpful for annotators to enhance the efficiency of manual curation.

      3. First draft genome sequence of Leishmania (Viannia) lainsoni strain 216-34, isolated from a Peruvian clinical caseExternal
        Lin W, Batra D, Narayanan V, Rowe LA, Sheth M, Zheng Y, Juieng P, Loparev V, de Almeida M.
        Microbiol Resour Announc. 2019 Feb;8(6).
        We present here the first draft genome sequence of Leishmania (Viannia) lainsoni strain 216-34, sequenced using PacBio and MiSeq platforms. PacBio contigs were generated from de novo assemblies using CANU version 1.6 and polished using Illumina reads.

    • Health Economics
      1. Economics of community health workers for chronic disease: Findings from Community Guide Systematic ReviewsCdc-pdfExternal
        Jacob V, Chattopadhyay SK, Hopkins DP, Reynolds JA, Xiong KZ, Jones CD, Rodriguez BJ, Proia KK, Pronk NP, Clymer JM, Goetzel RZ.
        Am J Prev Med. 2019 ;56(3):e95-e106.
        Context: Cardiovascular disease in the U.S. accounted for healthcare cost and productivity losses of $330 billion in 2013?2014 and diabetes accounted for $327 billion in 2017. The impact is disproportionate on minority and low-SES populations. This paper examines the available evidence on cost, economic benefit, and cost effectiveness of interventions that engage community health workers to prevent cardiovascular disease, prevent type 2 diabetes, and manage type 2 diabetes. Evidence acquisition: Literature from the inception of databases through July 2016 was searched for studies with economic information, yielding nine studies in cardiovascular disease prevention, seven studies in type 2 diabetes prevention, and 13 studies in type 2 diabetes management. Analyses were done in 2017. Monetary values are reported in 2016 U.S. dollars. Evidence synthesis: The median intervention cost per patient per year was $329 for cardiovascular disease prevention, $600 for type 2 diabetes prevention, and $571 for type 2 diabetes management. The median change in healthcare cost per patient per year was -$82 for cardiovascular disease prevention and -$72 for type 2 diabetes management. For type 2 diabetes prevention, one study saw no change and another reported -$1,242 for healthcare cost. One study reported a favorable 1.8 return on investment from engaging community health workers for cardiovascular disease prevention. Median cost per quality-adjusted life year gained was $17,670 for cardiovascular disease prevention, $17,138 (mean) for type 2 diabetes prevention, and $35,837 for type 2 diabetes management. Conclusions: Interventions engaging community health workers are cost effective for cardiovascular disease prevention and type 2 diabetes management, based on a conservative $50,000 benchmark for cost per quality-adjusted life year gained. Two cost per quality-adjusted life year estimates for type 2 diabetes prevention were far below the $50,000 benchmark.

    • Healthcare Associated Infections
      1. Decolonization to reduce postdischarge infection risk among MRSA carriersExternal
        Huang SS, Singh R, McKinnell JA, Park S, Gombosev A, Eells SJ, Gillen DL, Kim D, Rashid S, Macias-Gil R, Bolaris MA, Tjoa T, Cao C, Hong SS, Lequieu J, Cui E, Chang J, He J, Evans K, Peterson E, Simpson G, Robinson P, Choi C, Bailey CC, Leo JD, Amin A, Goldmann D, Jernigan JA, Platt R, Septimus E, Weinstein RA, Hayden MK, Miller LG.
        N Engl J Med. 2019 Feb 14;380(7):638-650.
        BACKGROUND: Hospitalized patients who are colonized with methicillin-resistant Staphylococcus aureus (MRSA) are at high risk for infection after discharge. METHODS: We conducted a multicenter, randomized, controlled trial of postdischarge hygiene education, as compared with education plus decolonization, in patients colonized with MRSA (carriers). Decolonization involved chlorhexidine mouthwash, baths or showers with chlorhexidine, and nasal mupirocin for 5 days twice per month for 6 months. Participants were followed for 1 year. The primary outcome was MRSA infection as defined according to Centers for Disease Control and Prevention (CDC) criteria. Secondary outcomes included MRSA infection determined on the basis of clinical judgment, infection from any cause, and infection-related hospitalization. All analyses were performed with the use of proportional-hazards models in the per-protocol population (all participants who underwent randomization, met the inclusion criteria, and survived beyond the recruitment hospitalization) and as-treated population (participants stratified according to adherence). RESULTS: In the per-protocol population, MRSA infection occurred in 98 of 1063 participants (9.2%) in the education group and in 67 of 1058 (6.3%) in the decolonization group; 84.8% of the MRSA infections led to hospitalization. Infection from any cause occurred in 23.7% of the participants in the education group and 19.6% of those in the decolonization group; 85.8% of the infections led to hospitalization. The hazard of MRSA infection was significantly lower in the decolonization group than in the education group (hazard ratio, 0.70; 95% confidence interval [CI], 0.52 to 0.96; P=0.03; number needed to treat to prevent one infection, 30; 95% CI, 18 to 230); this lower hazard led to a lower risk of hospitalization due to MRSA infection (hazard ratio, 0.71; 95% CI, 0.51 to 0.99). The decolonization group had lower likelihoods of clinically judged infection from any cause (hazard ratio, 0.83; 95% CI, 0.70 to 0.99) and infection-related hospitalization (hazard ratio, 0.76; 95% CI, 0.62 to 0.93); treatment effects for secondary outcomes should be interpreted with caution owing to a lack of prespecified adjustment for multiple comparisons. In as-treated analyses, participants in the decolonization group who adhered fully to the regimen had 44% fewer MRSA infections than the education group (hazard ratio, 0.56; 95% CI, 0.36 to 0.86) and had 40% fewer infections from any cause (hazard ratio, 0.60; 95% CI, 0.46 to 0.78). Side effects (all mild) occurred in 4.2% of the participants. CONCLUSIONS: Postdischarge MRSA decolonization with chlorhexidine and mupirocin led to a 30% lower risk of MRSA infection than education alone. (Funded by the AHRQ Healthcare-Associated Infections Program and others; ClinicalTrials.gov number, NCT01209234 .).

      2. The SHIELD Orange County Project – multi drug-resistant organism (MDRO) prevalence in 21 nursing homes and long term acute care facilities in southern CaliforniaExternal
        McKinnell JA, Singh RD, Miller LG, Kleinman K, Gussin G, He J, Saavedra R, Dutciuc TD, Estevez M, Chang J, Heim L, Yamaguchi S, Custodio H, Gohil SK, Park S, Tam S, Robinson PA, Tjoa T, Nguyen J, Evans KD, Bittencourt CE, Lee BY, Mueller LE, Bartsch SM, Jernigan JA, Slayton RB, Stone ND, Zahn M, Mor V, McConeghy K, Baier RR, Janssen L, O’Donnell K, Weinstein RA, Hayden MK, Coady MH, Bhattarai M, Peterson EM, Huang SS.
        Clin Infect Dis. 2019 Feb 11.
        Background: Multidrug-resistant organisms (MDROs) spread between hospitals, nursing homes (NH), and long-term acute care facilities (LTACs) via patient transfers. SHIELD OC is a regional public health collaborative involving decolonization at 38 healthcare facilities selected based upon their high degree of patient sharing. We report baseline MDRO prevalence in 21 NH/LTACs. Methods: A random sample of 50 adults for 21 NH/LTACs (18 NHs, 3 LTACs) were screened for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum beta-lactamase producing organisms (ESBL), and carbapenem-resistant Enterobacteriaceae (CRE) using nares, skin (axilla/groin), and peri-rectal swabs. Facility and resident characteristics associated with MDRO carriage were assessed using multivariable models clustering by person and facility. Results: Prevalence of MDROs was 65% in NHs and 80% in LTACs. The most common MDROs in NHs were MRSA (42%) and ESBL (34%); in LTACs they were VRE (55%) and ESBL (38%). CRE prevalence was higher in facilities that manage ventilated LTAC patients and NH residents (8% vs. <1%, p<0.001). MDRO status was known for 18% of NH residents and 49% of LTAC patients. MDRO colonized adults commonly harbored additional MDROs (54% MDRO+ NH residents and 62% MDRO+ LTACs patients). History of MRSA [OR=1.7 C.I. (1.2, 2.4),p=0.004], VRE [OR=2.1 C.I.(1.2, 3.8),p=0.01], ESBL [OR=1.6 C.I.(1.1, 2.3),p=0.03] and diabetes [OR=1.3 C.I.(1.0, 1.7),p=0.03] were associated with any MDRO carriage. Conclusions: The majority of NH residents and LTACs patients harbor MDROs. MDRO status is frequently unknown to the facility. The high MDRO prevalence highlights the need for prevention efforts in NH/LTACs as part of regional efforts to control MDRO spread.

    • Immunity and Immunization
      1. Principal controversies in vaccine safety in the United StatesExternal
        DeStefano F, Bodenstab HM, Offit PA.
        Clin Infect Dis. 2019 Feb 12.
        Concerns about vaccine safety can lead to decreased acceptance of vaccines and resurgence of vaccine-preventable diseases. We summarize the key evidence on some of the main current vaccine safety controversies in the United States, including: 1) MMR vaccine and autism; 2) thimerosal, a mercury-based vaccine preservative, and the risk of neurodevelopmental disorders; 3) vaccine-induced Guillain-Barre Syndrome (GBS); 4) vaccine-induced autoimmune diseases; 5) safety of HPV vaccine; 6) aluminum adjuvant-induced autoimmune diseases and other disorders; and 7) too many vaccines given early in life predisposing children to health and developmental problems. A possible small increased risk of GBS following influenza vaccination has been identified, but the magnitude of the increase is less than the risk of GBS following influenza infection. Otherwise, the biological and epidemiologic evidence does not support any of the reviewed vaccine safety concerns.

      2. Recommendations of the Advisory Committee on Immunization Practices for use of hepatitis A vaccine for persons experiencing homelessnessExternal
        Doshani M, Weng M, Moore KL, Romero JR, Nelson NP.
        MMWR Morb Mortal Wkly Rep. 2019 Feb 15;68(6):153-156.
        Hepatitis A (HepA) vaccination is recommended routinely for children at age 12-23 months, for persons who are at increased risk for hepatitis A virus (HAV) infection, and for any person wishing to obtain immunity. Persons at increased risk for HAV infection include international travelers to areas with high or intermediate hepatitis A endemicity, men who have sex with men, users of injection and noninjection drugs, persons with chronic liver disease, person with clotting factor disorders, persons who work with HAV-infected primates or with HAV in a research laboratory setting, and persons who anticipate close contact with an international adoptee from a country of high or interme-diate endemicity (1-3). Persons experiencing homelessness are also at higher risk for HAV infection and severe infection-associated outcomes. On October 24, 2018, the Advisory Committee on Immunization Practices (ACIP)* recommended that all persons aged 1 year and older experiencing homelessness be routinely immunized against HAV. The ACIP Hepatitis Vaccines Work Group conducted a systematic review of the evidence for administering vaccine to persons experiencing homelessness, which included a set of criteria assessing the benefits and adverse events associated with vaccination. HepA vaccines are highly immunogenic, and >95% of immunocompetent adults develop protective antibody within 4 weeks of receipt of 1 dose of the vaccine (1). HAV infections are acquired primarily by the fecal-oral route by either person-to-person transmission or via ingestion of contaminated food or water. Among persons experiencing homelessness, effective implementation of alternative strategies to prevent exposure to HAV, such as strict hand hygiene, is difficult because of living conditions among persons in this population. Integrating routine HepA vaccination into health care services for persons experiencing homelessness can reduce the size of the at-risk population over time and thereby reduce the risk for large-scale outbreaks.

      3. Interim estimates of 2018-19 seasonal influenza vaccine effectiveness – United States, February 2019External
        Doyle JD, Chung JR, Kim SS, Gaglani M, Raiyani C, Zimmerman RK, Nowalk MP, Jackson ML, Jackson LA, Monto AS, Martin ET, Belongia EA, McLean HQ, Foust A, Sessions W, Berman L, Garten RJ, Barnes JR, Wentworth DE, Fry AM, Patel MM, Flannery B.
        MMWR Morb Mortal Wkly Rep. 2019 Feb 15;68(6):135-139.
        In the United States, annual vaccination against seasonal influenza is recommended for all persons aged >/=6 months (https://www.cdc.gov/flu/protect/whoshouldvax.htm). Effectiveness of seasonal influenza vaccine varies by season. During each influenza season since 2004-05, CDC has estimated the effectiveness of seasonal influenza vaccine to prevent laboratory-confirmed influenza associated with medically attended acute respiratory illness (ARI). This interim report uses data from 3,254 children and adults enrolled in the U.S. Influenza Vaccine Effectiveness Network (U.S. Flu VE Network) during November 23, 2018-February 2, 2019. During this period, overall adjusted vaccine effectiveness against all influenza virus infection associated with medically attended ARI was 47% (95% confidence interval [CI] = 34%-57%). For children aged 6 months-17 years, overall vaccine effectiveness was 61% (44%-73%). Seventy-four percent of influenza A infections for which subtype information was available were caused by A(H1N1)pdm09 viruses. Vaccine effectiveness was estimated to be 46% (30%-58%) against illness caused by influenza A(H1N1)pdm09 viruses. CDC recommends that health care providers continue to administer influenza vaccine because influenza activity is ongoing and the vaccine can still prevent illness, hospitalization, and death associated with currently circulating influenza viruses, or other influenza viruses that might circulate later in the season. During the 2017-18 influenza season, in which influenza A(H3N2) predominated, vaccination was estimated to prevent 7.1 million illnesses, 3.7 million medical visits, 109,000 hospitalizations, and 8,000 deaths (1). Vaccination can also reduce the severity of influenza-associated illness (2). Persons aged >/=6 months who have not yet been vaccinated this season should be vaccinated.

      4. BACKGROUND: Trivalent adjuvanted influenza vaccine (aIIV3; Fluad(R)) was approved in the United States (U.S.) in 2015 for adults aged >/=65years and has been in use since the 2016-17 influenza season. METHODS: We analyzed U.S. reports for aIIV3 submitted from July 1, 2016 through June 30, 2018 to the Vaccine Adverse Event Reporting System (VAERS), a national spontaneous reporting system. Medical records were reviewed for serious reports. Among individuals >/=65years of age, the relative frequency of the most commonly reported adverse events (AEs) after aIIV3 were compared with non-adjuvanted inactivated influenza vaccines given to adults aged >/=65years, high-dose trivalent influenza vaccine (IIV3-HD) and trivalent or quadrivalent vaccines (IIV3/IIV4). Data mining analyses were undertaken to identify whether AEs for aIIV3 occurred disproportionately more than expected compared to all influenza vaccines. RESULTS: VAERS received 630 reports after aIIV3, of which 521 (83%) were in adults aged >/=65years; 79 (13%) in persons <65years and in 30 (5%) reports age was missing; 19 (3%) reports were serious, including two deaths (0.4%) related to myocardial infarction and Sjogren’s syndrome. The most common AEs reported in adults aged >/=65years were injection site pain (21%) and erythema (18%), with similar proportions reported for IIV3-HD (17% and 19%, respectively) and for IIV3/IIV4 (15%, each). Except for reports related to vaccination of inappropriate age (n=79) and syringe malfunction (n=6), data mining did not identify other disproportionately reported AEs. CONCLUSIONS: Although our review of aIIV3 in VAERS did not identify any unexpected health conditions of concern, we observed more than twice the expected number of reports with administration of the vaccine to persons outside of the age range for which the vaccine is approved in the U.S. Health care providers should be educated on the age groups for whom aIIV3 is recommended.

      5. In October 2018, the Advisory Committee on Immunization Practices (ACIP)* voted to recommend approval of the Recommended Immunization Schedule for Adults, Aged 19 Years or Older, United States, 2019. The 2019 adult immunization schedule, available at https://www.cdc.gov/vaccines/schedules,(dagger) summarizes ACIP recommendations in two tables and accompanying notes. The 2019 adult immunization schedule has been approved by the CDC Director, the American College of Physicians, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Nurse-Midwives.

      6. Rotavirus vaccines were introduced in the United States in 2006, and in the years since they have fundamentally altered the seasonality of rotavirus infection and have shifted disease outbreaks from annual epidemics to biennial epidemics. We investigated whether season and year of birth have emerged as risk factors for rotavirus or have affected vaccine performance. We constructed a retrospective birth cohort of US children under age 5 years using the 2001-2014 MarketScan database (Truven Health Analytics, Chicago, Illinois). We evaluated the associations of season of birth, even/odd year of birth, and interactions with vaccination. We fitted Cox proportional hazards models to estimate the hazard of rotavirus hospitalization according to calendar year of birth and season of birth assessed for interaction with vaccination. After the introduction of rotavirus vaccine, we observed monotonically decreasing rates of rotavirus hospitalization for each subsequent birth cohort but a biennial incidence pattern by calendar year. In the postvaccine period, children born in odd calendar years had a higher hazard of rotavirus hospitalization than those born in even years. Children born in winter had the highest hazard of hospitalization but also had greater vaccine effectiveness than children born in spring, summer, or fall. With the emergence of a strong biennial pattern of disease following vaccine introduction, the timing of a child’s birth has become a risk factor for rotavirus infection.

      7. Effect of previous-season influenza vaccination on serologic response in children during 3 seasons, 2013-2014 through 2015-2016External
        McLean HQ, King JP, Talley P, Flannery B, Spencer S, Levine MZ, Friedrich TC, Belongia EA.
        J Pediatric Infect Dis Soc. 2019 Feb 13.
        Background: The effects of repeated influenza vaccination in children are not well understood. In this study, we evaluated previous vaccination effects on antibody response after vaccination with trivalent inactivated influenza vaccine (IIV) or quadrivalent live-attenuated influenza vaccine (LAIV) among school-aged children (5-17 years) across 3 seasons. Methods: Children were enrolled in the fall of 2013, 2014, and 2015. The participants received IIV or LAIV according to parent preference (2013-2014) or our randomization scheme (2014-2015). All study children received IIV in 2015-2016. Hemagglutination-inhibition assays measured antibody response to egg-grown vaccine strains from prevaccination and postvaccination serum samples. Geometric mean titers (GMTs) and increases in GMTs from before to after vaccination (geometric mean fold rise [GMFR]) were estimated from repeated-measures linear mixed models. Results: We enrolled 161 children in 2013-2014, 128 in 2014-2015, and 126 in 2015-2016. Among the IIV recipients, responses to the influenza A(H1N1)pdm09 and B vaccine strains were lowest among children who had received a previous-season IIV. The GMFRs for strains A(H1N1)pdm09 and B were 1.5 to 2.3 for previous-season IIV and 4.3 to 12.9 for previous-season LAIV or no previous vaccine. GMFRs were lower for strain A(H3N2), and differences according to previous-season vaccination history were smaller and not significant in most seasons. Most children had a post-IIV vaccination titer of >/=40 for vaccine strains in all seasons, regardless of previous-season vaccination history. Little to no increase in antibody levels was observed after vaccination with LAIV. Conclusions: Serologic response to vaccination was greatest for IIV, but previous-season vaccination modified IIV response to A(H1N1)pdm09 and B. Influenza A(H3N2) responses were low in all groups, and LAIV generated minimal serologic response against all strains.

      8. Vaccination practices among obstetrician/gynecologists for non-pregnant patientsCdc-pdfExternal
        O’Leary ST, Riley LE, Lindley MC, Allison MA, Crane LA, Hurley LP, Beaty BL, Brtnikova M, Collins M, Albert AP, Fisher AK, Jiles AJ, Kempe A.
        Am J Prev Med. 2019 ;56(3):429-436.
        Introduction: Many non-pregnant women see obstetrician-gynecologists as their sole source of medical care, yet little is known about vaccination practices of obstetrician-gynecologists for non-pregnant patients. The objectives were to assess, among a national sample of obstetrician-gynecologists, practices related to vaccine delivery in non-pregnant patients and factors associated with stocking and administering more than three different vaccines to non-pregnant patients. Methods: E-mail and mail surveys were administered July-October 2015, with analyses performed during October-November 2015 and April-June 2018. Results: The response rate was 73% (353/482). Human papillomavirus (92%); influenza (82%); and tetanus, diphtheria, acellular pertussis vaccines (50%) were the vaccines most commonly assessed, with the remaining vaccines assessed by <40% of respondents. Vaccines most commonly administered by obstetrician-gynecologists to non-pregnant patients included human papillomavirus (81%); influenza (70%); and tetanus, diphtheria, acellular pertussis (54%). The remaining vaccines were administered by <30% of obstetrician-gynecologists. Factors associated with routinely administering more than three vaccines to non-pregnant patients included working in a hospital-, public health- or university-associated clinic (RR=1.87, 95% CI=1.35, 2.58, referent to private practice); a larger practice (more than five providers; RR=1.54, 95% CI=1.05, 2.27); perceiving fewer financial barriers (RR=0.74, 95% CI=0.57, 0.96); fewer practice-associated barriers (RR=0.71, 95% CI=0.55, 0.92); and greater patient barriers (RR=1.62, 95% CI=1.33, 1.98). Conclusions: Human papillomavirus; influenza; and tetanus, diphtheria, acellular pertussis vaccines are the only vaccines routinely assessed and administered to non-pregnant patients by most obstetrician-gynecologists. Given their role as the sole source of care for many women, obstetrician-gynecologists could make a positive impact on the vaccination status of their non-pregnant patients.

      9. Improving HPV vaccine delivery at school-based health centersExternal
        Oliver K, McCorkell C, Pister I, Majid N, Benkel DH, Zucker JR.
        Hum Vaccin Immunother. 2019 Feb 8.
        OBJECTIVE: To identify characteristics associated with human papilloma virus (HPV) vaccination rates, describe barriers and facilitators to vaccine uptake and the potential role for clinician-to-clinician Assessment, Feedback, Incentives, and eXchange (AFIX) visits in school-based health centers (SBHCs). METHODS: We conducted clinician-to-clinician AFIX visits at 24 New York City (NYC) high-school and middle-school SBHCs with up-to-date adolescent vaccination rates below 40%. Using NYC’s immunization information system, we assessed HPV initiation and series completion rates at the time of AFIX visit and follow-up three to five months later. We analyzed responses to a questionnaire and summarized interviews to identify barriers and facilitators to HPV immunization practices and quality improvement (QI) implementation. RESULTS: Baseline initiation and completion rates were 76% and 43% for high schools, and 81% and 45% for middle schools. SBHCs that allowed adolescent self-consent or did not require separate vaccine consent had higher baseline rates, but was not statistically significant. Barriers to series completion included challenges with scheduling and appointment compliance. At follow-up, high school SBHCs increased HPV vaccine initiation by 2.9 percentage points (p < 0.01) and series completion by 2.7 percentage points (p < 0.05). There was no statistically significant increase at middle school SBHCs. Most SBHCs (88%) chose reminder/recall systems as a QI strategy. Fewer than half (42%) implemented their QI strategy. CONCLUSIONS: We identified barriers to HPV vaccine series completion at our sample of SBHCs. Clinician-to-clinician AFIX visits may help improve vaccination rates and encourage providers to address barriers, including streamlining consent processes for HPV vaccination.

      10. Evaluation of correlates of protection against influenza A(H3N2) and A(H1N1)pdm09 infection: Applications to the hospitalized patient populationExternal
        Petrie JG, Martin ET, Truscon R, Johnson E, Cheng CK, McSpadden EJ, Malosh RE, Lauring AS, Lamerato LE, Eichelberger MC, Ferdinands JM, Monto AS.
        Vaccine. 2019 Feb 6.
        BACKGROUND: Influenza vaccines are important for prevention of influenza-associated hospitalization. However, the effectiveness of influenza vaccines can vary by year and influenza type and subtype and mechanisms underlying this variation are incompletely understood. Assessments of serologic correlates of protection can support interpretation of influenza vaccine effectiveness in hospitalized populations. METHODS: We enrolled adults hospitalized for treatment of acute respiratory illnesses during the 2014-2015 and 2015-2016 influenza seasons whose symptoms began <10days prior to enrollment. Influenza infection status was determined by RT-PCR. Influenza vaccination status was defined by self-report and medical record/registry documentation. Serum specimens collected at hospital admission were tested in hemagglutination-inhibition (HAI) and neuraminidase-inhibition (NAI) assays. We evaluated how well antibody measured in these specimens represented pre-infection immune status, and measured associations between antibody and influenza vaccination and infection. RESULTS: Serum specimens were retrieved for 315 participants enrolled during the 2014-2015 season and 339 participants during the 2015-2016 season. Specimens were collected within 3days of illness onset from 65% of participants. Geometric mean titers (GMTs) did not vary by the number of days from illness onset to specimen collection among influenza positive participants suggesting that measured antibody was representative of pre-infection immune status rather than a de novo response to infection. In both seasons, vaccinated participants had higher HAI and NAI GMTs than unvaccinated. HAI titers against the 2014-2015 A(H3N2) vaccine strain did not correlate with protection from infection with antigenically-drifted A(H3N2) viruses that circulated that season. In contrast, higher HAI titers against the A(H1N1)pdm09 vaccine strain were associated with reduced odds of A(H1N1)pdm09 infection in 2015-2016. CONCLUSIONS: Serum collected shortly after illness onset at hospital admission can be used to assess correlates of protection against influenza infection. Broader implementation of similar studies would provide an opportunity to understand the successes and shortcomings of current influenza vaccines.

      11. At its October 2018 meeting, the Advisory Committee on Immunization Practices (ACIP)* voted to recommend approval of the Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, United States, 2019. The 2019 child and adolescent immunization schedule summarizes ACIP recommendations, including several changes from the 2018 immunization schedule,(dagger) on the cover page, three tables, and notes found on the CDC immunization schedule website (https://www.cdc.gov/vaccines/schedules/index.html). This immunization schedule is recommended by ACIP and approved by the CDC Director, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists. Health care providers are advised to use the tables and the notes together.

      12. Despite recommendations for vaccinating adults and widespread availability of immunization services (e.g., pharmacy venues, workplace wellness clinics), vaccination rates in the United States remain low. The U.S. National Adult Immunization Plan identified the development of quality measures as a priority and key strategy to address low adult vaccination coverage rates. The use of quality measures can provide incentives for increased utilization of preventive services. To address the lack of adult immunization measures, the National Adult and Influenza Immunization Summit, a coalition of adult immunization partners led by the Immunization Action Coalition, Centers for Disease Control and Prevention, and National Vaccine Program Office, spearheaded efforts to (1) identify gaps and priorities in adult immunization quality performance measurement; (2) explore feasibility of data collection on adult immunizations through pilot testing and engaging stakeholders; and (3) develop and test quality measure specifications. This paper outlines the process by which a public-private partnership drove the development of two adult immunization performance measures-an adult immunization status measure for influenza, tetanus and diphtheria (Td) and/or tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap), herpes zoster and pneumococcal vaccines, and a prenatal immunization status measure for influenza and Tdap vaccinations in pregnant women. These measures have recently been added to the 2019 Healthcare Effectiveness Data and Information Set (HEDIS(R)), a widely used set of performance measures reportable by private health plans.

      13. Rotavirus vaccines set to make inroads in AsiaExternal
        Steele AD, Parashar UD.
        Clin Infect Dis. 2019 Feb 13.

        [No abstract]

    • Injury and Violence
      1. Childhood violence is associated with forced sexual initiation among girls and young women in Malawi: A cross-sectional surveyExternal
        Swedo EA, Sumner SA, Msungama W, Massetti GM, Kalanda M, Saul J, Auld AF, Hillis SD.
        J Pediatr. 2019 Feb 6.
        OBJECTIVE: To describe associations between childhood violence and forced sexual initiation in young Malawian females. STUDY DESIGN: We analyzed data from 595 women and girls who were 13-24 years old who ever had sex and participated in Malawi’s 2013 Violence Against Children Survey, a nationally representative household survey. We estimated the overall prevalence of forced sexual initiation and identified subgroups with highest prevalences. Using logistic regression, we examined childhood violence and other independent predictors of forced sexual initiation. RESULTS: The overall prevalence of forced sexual initiation was 38.9% among Malawian girls and young women who ever had sex. More than one-half of those aged 13-17 years at time of survey (52.0%), unmarried (64.6%), or experiencing emotional violence in childhood (56.9%) reported forced sexual initiation. After adjustment, independent predictors of forced sexual initiation included being unmarried (aOR, 3.54; 95% CI, 1.22-10.27) and any emotional violence (aOR, 2.47; 95% CI, 1.45-4.24). Those experiencing emotional violence alone (aOR, 3.04; 95% CI: 1.01-9.12), emotional violence in combination with physical or nonpenetrative sexual violence (aOR, 2.50; 95% CI, 1.23-5.09), and emotional violence in combination with physical and nonpenetrative sexual violence (aOR, 2.61; 95% CI, 1.20-5.67) had an increased independent odds of forced sexual initiation. CONCLUSIONS: Experiences of forced sexual initiation are common among Malawian females. Emotional violence is strongly associated with forced sexual initiation, alone and in combination with other forms of childhood violence. The relationship between emotional violence and forced sexual initiation highlights the importance of comprehensive strategies to prevent childhood violence.

    • Laboratory Sciences
      1. Effect of age, high-fat diet, and rat strain on serum biomarkers and telomere length and global DNA methylation in peripheral blood mononuclear cellsExternal
        Antonini JM, Kodali V, Meighan TG, Roach KA, Roberts JR, Salmen R, Boyce GR, Zeidler-Erdely PC, Kashon M, Erdely A, Shoeb M.
        Sci Rep. 2019 Feb 13;9(1):1996.
        The objective of the current study was to determine if age, diet, and genetic disposition (animal strain) in an animal model had early effects on specific molecular markers in circulating peripheral blood mononuclear cells (PBMCs). Three strains [Sprague-Dawley (SD), Fischer 344 (F344), and Brown-Norway (BN)] of male rats were maintained on a high-fat (HF) or regular diet. Blood was collected at 4, 12, and 24 wk to assess chemistry and to recover PBMCs. Triglycerides and body weight gain increased at all time points in the HF diet group for each strain. Telomere length in PBMCs decreased in the HF diet group compared to the regular diet group up to 24 wk in all strains. Telomere length decreased in PBMCs at 24 wk compared to baseline in all strains, indicating an age-related effect. These findings highlight that diet and age cause changes in PBMCs recovered from different strains of rats. The next tier of studies will examine the contribution of an occupational exposure (e.g., welding fume inhalation) in combination with diet, age, and strain, to assess changes in the molecular responses of isolated PBMCs. In addition, studies involving lifestyle exposure (e.g., tobacco smoke) are in the planning stages and will assess the long-term effects of exposure in our animal model.

      2. LAMP: A CDC program to ensure the quality of blood-lead laboratory measurementsExternal
        Caldwell KL, Cheng PY, Vance KA, Makhmudov A, Jarrett JM, Caudill SP, Ho DP, Jones RL.
        J Public Health Manag Pract. 2019 Jan/Feb;25 Suppl 1, Lead Poisoning Prevention:S23-s30.
        CONTEXT: The Lead and Multielement Proficiency (LAMP) program is an external quality assurance program promoting high-quality blood-lead measurements. OBJECTIVES: To investigate the ability of US laboratories, participating in the Centers for Disease Control and Prevention (CDC) LAMP program to accurately measure blood-lead levels (BLL) 0.70 to 47.5 mug/dL using evaluation criteria of +/-2 mug/dL or 10%, whichever is greater. METHODS: The CDC distributes bovine blood specimens to participating laboratories 4 times per year. We evaluated participant performance over 5 challenges on samples with BLL between 0.70 and 47.5 mug/dL. The CDC sent 15 pooled samples (3 samples shipped in 5 rounds) to US laboratories. The LAMP laboratories used 3 primary technologies to analyze lead in blood: inductively coupled plasma mass spectrometry, graphite furnace atomic absorption spectroscopy, and LeadCare technologies based on anodic stripping voltammetry. Laboratories reported their BLL analytical results to the CDC. The LAMP uses these results to provide performance feedback to the laboratories. SETTING: The CDC sent blood samples to approximately 50 US laboratories for lead analysis. PARTICIPANTS: Of the approximately 200 laboratories enrolled in LAMP, 38 to 46 US laboratories provided data used in this report (January 2017 to March 2018). RESULTS: Laboratory precision ranged from 0.26 mug/dL for inductively coupled plasma mass spectrometry to 1.50 mug/dL for LeadCare instruments. All participating US LAMP laboratories reported accurate BLL for 89% of challenge samples, using the +/-2 mug/dL or 10% evaluation criteria. CONCLUSIONS: Laboratories participating in the CDC’s LAMP program can accurately measure blood lead using the current Clinical Laboratory Improvement Amendments of 1988 guidance of +/-4 mug/dL or +/-10%, with a success rate of 96%. However, when we apply limits of +/-2 mug/dL or +/-10%, the success rate drops to 89%. When challenged with samples that have target values between 3 and 5 mug/dL, nearly 100% of reported results fall within +/-4 mug/dL, while 5% of the results fall outside of the acceptability criteria used by the CDC’s LAMP program. As public health focuses on lower blood lead levels, laboratories must evaluate their ability to successfully meet these analytical challenges surrounding successfully measuring blood lead. In addition proposed CLIA guidelines (+/-2 mug/dL or 10%) would be achievable performance by a majority of US laboratories participating in the LAMP program.

      3. Noroviruses are recognized as the leading cause of acute gastroenteritis globally. With improved molecular diagnostics developed over the last two decades, archived clinical specimens are increasingly used to investigate the historic prevalence and molecular epidemiology of human norovirus. Yet the impact of long-term storage on viral integrity in clinical specimens has not been evaluated. In this study, we retested 994 stool specimens collected between 1996 and 2017 that originally tested norovirus-positive to quantify the loss of norovirus RT-PCR positivity with increasing sample storage time at 4 degrees C. In all, 79% of samples tested positive after retesting, but there was an approximate 3% decline in the positivity ratio and 4% decline in the percentage of samples that could be genotyped with each additional year of sample storage. For samples that were originally quantified by real-time RT-PCR (collected between 2003-2017), there was an estimated 1-log loss of viral titer occurring every 7 years of sample storage. Few samples contained PCR inhibitors, assessed using a MS2 extraction control, indicating that loss of RT-PCR signal was due primarily to loss of viral RNA integrity after long-term storage of stool samples at 4 degrees C. Our results indicate that norovirus positive stool samples can be stored with minimal loss in RT-PCR positivity when stored less than a decade. Longer periods of storage may impair norovirus detection, potentially impacting historic estimates of norovirus prevalence and molecular epidemiology if derived by testing archival clinical specimens.

      4. Mutations present in a low-passage Zika virus isolate result in attenuated pathogenesis in miceExternal
        Duggal NK, McDonald EM, Weger-Lucarelli J, Hawks SA, Ritter JM, Romo H, Ebel GD, Brault AC.
        Virology. 2019 Feb 7;530:19-26.
        Zika virus (ZIKV) infection can result in neurological disorders including Congenital Zika Syndrome in infants exposed to the virus in utero. Pregnant women can be infected by mosquito bite as well as by sexual transmission from infected men. Herein, the variants of ZIKV within the male reproductive tract and ejaculates were assessed in inoculated mice. We identified two non-synonymous variants at positions E-V330L and NS1-W98G. These variants were also present in the passage three PRVABC59 isolate and infectious clone relative to the patient serum PRVABC59 sequence. In subsequent studies, ZIKV E-330L was less pathogenic in mice than ZIKV E-330V as evident by increased average survival times. In Vero cells, ZIKV E-330L/NS1-98G outcompeted ZIKV E-330V/NS1-98W within 3 passages. These results suggest that the E-330L/NS1-98G variants are attenuating in mice and were enriched during cell culture passaging. Cell culture propagation of ZIKV could significantly affect animal model development and vaccine efficacy studies.

      5. Late effects of total body irradiation on hematopoietic recovery and immune function in rhesus macaquesExternal
        Hale LP, Rajam G, Carlone GM, Jiang C, Owzar K, Dugan G, Caudell D, Chao N, Cline JM, Register TC, Sempowski GD.
        PLoS One. 2019 ;14(2):e0210663.
        While exposure to radiation can be lifesaving in certain settings, it can also potentially result in long-lasting adverse effects, particularly to hematopoietic and immune cells. This study investigated hematopoietic recovery and immune function in rhesus macaques Cross-sectionally (at a single time point) 2 to 5 years after exposure to a single large dose (6.5 to 8.4 Gray) of total body radiation (TBI) derived from linear accelerator-derived photons (2 MeV, 80 cGy/minute) or Cobalt 60-derived gamma irradiation (60 cGy/min). Hematopoietic recovery was assessed through measurement of complete blood counts, lymphocyte subpopulation analysis, and thymus function assessment. Capacity to mount specific antibody responses against rabies, Streptococcus pneumoniae, and tetanus antigens was determined 2 years after TBI. Irradiated macaques showed increased white blood cells, decreased platelets, and decreased frequencies of peripheral blood T cells. Effects of prior radiation on production and export of new T cells by the thymus was dependent on age at the time of analysis, with evidence of interaction with radiation dose for CD8+ T cells. Irradiated and control animals mounted similar mean antibody responses to proteins from tetanus and rabies and to 10 of 11 serotype-specific pneumococcal polysaccharides. However, irradiated animals uniformly failed to make antibodies against polysaccharides from serotype 5 pneumococci, in contrast to the robust responses of non-irradiated controls. Trends toward decreased serum levels of anti-tetanus IgM and slower peak antibody responses to rabies were also observed. Taken together, these data show that dose-related changes in peripheral blood cells and immune responses to both novel and recall antigens can be detected 2 to 5 years after exposure to whole body radiation. Longer term follow-up data on this cohort and independent validation will be helpful to determine whether these changes persist or whether additional changes become evident with increasing time since radiation, particularly as animals begin to develop aging-related changes in immune function.

      6. Comparison of FTD(R) respiratory pathogens 33 and a singleplex CDC assay for the detection of respiratory viruses: A study from CameroonExternal
        Kenmoe S, Tcharnenwa C, Monamele GC, Kengne CN, Ripa MN, Whitaker B, Alroy KA, Balajee SA, Njouom R.
        Diagn Microbiol Infect Dis. 2019 Jan 16.
        INTRODUCTION: This study compares the detection of 14 common respiratory viruses by two different real-time reverse transcription polymerase chain reaction (rRT-PCR) methods: in house singleplex tests developed by the Centers for Disease Control and Prevention and the commercially available Fast Track Diagnostic (FTD(R)) Respiratory Pathogens 33 multiplex test. METHODS: A total of 217 nasopharyngeal swabs were analyzed using CDC singleplex rRT-PCR and FTD(R) Respiratory Pathogens 33 multiplex assays, for the detection of 14 respiratory viruses. RESULTS: The results showed that 179/217 (82.5%) samples were positive with the singleplex method and 183/217 (84.3%) with the FTD(R) Respiratory Pathogens 33 multiplex test. Excellent or satisfactory agreement was obtained for all viruses (k>0.6) except Parainfluenzavirus 4 (k=0.24) and influenza B (k=0.51). CONCLUSION: Although the multiplex FTD kits were more expensive than the singleplex assay, the FTD kits yielded rapid results in a shorter timeframe, increasing efficiency of diagnosis.

      7. OBJECTIVES: Laser Doppler blood flow measurements have been used for diagnosis or detection of peripheral vascular dysfunction. This study used a rat tail model of vibration-induced vascular injury to determine how laser Doppler measurements were affected by acute and repeated exposures to vibration, and to identify changes in the Doppler signal that were associated with the exposure. METHODS: Blood flow was measured immediately after a single exposure to vibration, or before vibration exposure on days 1, 5, 10, 15, and 20 of a 20 days exposure. RESULTS: After a single exposure to vibration, average tail blood flow was reduced. With 20 days of exposure, there was a reduction in the amplitude of the arterial pulse on days 10 to 20 in vibrated rats and days 15 to 20 in control rats. CONCLUSIONS: More detailed statistical analyses of laser Doppler data may be needed to identify early changes in peripheral circulation after exposure to vibration.

      8. In the decade and a half since the introduction of next-generation sequencing (NGS), the technical feasibility, cost, and overall utility of sequencing have changed dramatically, including applications for infectious disease epidemiology. Massively parallel sequencing technologies have decreased the cost of sequencing by more than 6 orders or magnitude over this time, with a corresponding increase in data generation and complexity. This review provides an overview of the basic principles, chemistry, and operational mechanics of current sequencing technologies, including both conventional Sanger and NGS approaches. As the generation of large amounts of sequence data becomes increasingly routine, the role of bioinformatics in data analysis and reporting becomes all the more critical, and the successful deployment of NGS in public health settings requires careful consideration of changing information technology, bioinformatics, workforce, and regulatory requirements. While there remain important challenges to the sustainable implementation of NGS in public health, in terms of both laboratory and bioinformatics capacity, the impact of these technologies on infectious disease surveillance and outbreak investigations has been nothing short of revolutionary. Understanding the important role that NGS plays in modern public health laboratory practice is critical, as is the need to ensure appropriate workforce, infrastructure, facilities, and funding consideration for routine NGS applications, future innovation, and rapidly scaling NGS-based infectious disease surveillance and outbreak response activities. *This article is part of a curated collection.

      9. Macrophage activation marker soluble CD163 associated with fatal and severe Ebola virus disease in humansCdc-pdfExternal
        McElroy AK, Shrivastava-Ranjan P, Harmon JR, Martines RB, Silva-Flannery L, Flietstra TD, Kraft CS, Mehta AK, Lyon GM, Varkey JB, Ribner BS, Nichol ST, Zaki SR, Spiropoulou CF.
        Emerg Infect Dis. 2019 Feb;25(2):290-298.
        Ebola virus disease (EVD) is associated with elevated cytokine levels, and hypercytokinemia is more pronounced in fatal cases. This type of hyperinflammatory state is reminiscent of 2 rheumatologic disorders known as macrophage activation syndrome and hemophagocytic lymphohistiocytosis, which are characterized by macrophage and T-cell activation. An evaluation of 2 cohorts of patients with EVD revealed that a marker of macrophage activation (sCD163) but not T-cell activation (sCD25) was associated with severe and fatal EVD. Furthermore, substantial immunoreactivity of host tissues to a CD163-specific antibody, predominantly in areas of extensive immunostaining for Ebola virus antigens, was observed in fatal cases. These data suggest that host macrophage activation contributes to EVD pathogenesis and that directed antiinflammatory therapies could be beneficial in the treatment of EVD.

      10. Development of a standardized Sanger-based method for partial sequencing and genotyping dengue virusesExternal
        Santiago GA, Gonzalez GL, Cruz-Lopez F, Munoz-Jordan JL.
        J Clin Microbiol. 2019 Feb 13.
        The global expansion of dengue viruses (DENV-1-4) has contributed to the divergence, transmission, and establishment of genetic lineages of epidemiological concern; however, tracking phylogenetic relationships of these virus is not always possible due to inability of standardized sequencing procedures in resource-limited public health laboratories Consequently, public genomic data banks contain inadequate representation of geographical regions and historical periods. In order to improve detection of DENV-1-4 lineages, we report the development of a serotype-specific Sanger-based method standardized to sequence DENV-1-4 directly from clinical samples using universal primers that detect most DENV genotypes. The resulting envelope protein coding sequences are analyzed for genotyping with phylogenetic methods. We evaluated the performance of this method by detecting, amplifying, and sequencing 54 contemporary DENV isolates, including 29 clinical samples, representing a variety of genotypes of epidemiological importance and global presence. All specimens were sequenced successfully and phylogenetic reconstructions resulted in the expected genotype classification. To further improve genomic surveillance in dengue endemic regions, this method was transferred to 16 public health laboratories in 13 Latin American countries, to date. Our objective is to provide an accessible method that facilitates the integration of genomics with dengue surveillance.

      11. Insights into the unique nature of the East Asian clade of the emerging pathogenic yeast, candida aurisExternal
        Welsh RM, Sexton DJ, Forsberg K, Vallabhaneni S, Litvintseva A.
        J Clin Microbiol. 2019 Feb 13.
        The emerging yeast Candida auris can be highly drug resistant, cause invasive infections, and large outbreaks. C. auris went from an unknown pathogen a decade ago to being reported in over thirty countries on six continents. C. auris consists of four discrete clades, based on where the first isolates of the clade were reported: South Asian (Clade I), East Asian (Clade II), African (Clade III), and South American (Clade IV). These have unique genetic and biochemical characteristics, which are important to understand and inform the global response to C. auris Clade II has been underrepresented in the literature despite being the first one discovered. In this issue of the Journal of Clinical Microbiology, Y. J. Kwon et al. (J Clin Microbiol 57:e01624-18, 2019, https://doi.org/10.1128/JCM.01624-18) describe the largest collection of clinical isolates from Clade II, which is also the longest running span of clinical cases, 20 years, from any single region to date. Clade II appears to have a propensity for the ear that is uncharacteristic of the other clades, which typically cause invasive infections and large-scale outbreaks. This study provides new information on an understudied lineage of C. auris and has important implications for future surveillance.

      12. Development of a finger adapter method for testing and evaluating vibration-reducing gloves and materialsExternal
        Xu XS, Welcome DE, Warren CM, McDowell TW, Dong RG.
        Measurement (Lond). 2019 ;137:362-374.
        The objective of this study was to develop a convenient and reliable adapter method for testing and evaluating vibration-reducing (VR) gloves and VR materials at the fingers. The general requirements and technical specifications for the design of the new adapter were based on our previous studies of hand-held adapters for vibration measurement and a conceptual model of the fingers-adapter-glove-handle system developed in this study. Two thicknesses (2 mm and 3 mm) of the adapter beam were fabricated using a 3-D printer. Each adapter is a thin beam equipped with a miniature tri-axial accelerometer (1.1 g) mounted at its center, with a total weight </= 2.2 g. To measure glove vibration transmissibility, the adapter is held with two gloved fingers; a finger is positioned on each side of the accelerometer. Each end of the adapter beam is slotted between the glove material and the finger. A series of experiments was conducted to evaluate this two-fingers-held adapter method by measuring the transmissibility of typical VR gloves and a sample VR material. The experimental results indicate that the major resonant frequency of the lightweight adapter on the VR material (>/=800 Hz) is much higher than the resonant frequencies of the gloved fingers grasping a cylindrical handle (</=300 Hz). The experimental results were repeatable across the test treatments. The basic characteristics of the measured glove vibration transmissibility are consistent with the theoretical predictions based on the biodynamics of the gloved fingers-hand-arm system. The results suggest that VR glove fingers can effectively reduce only high-frequency vibration, and VR effectiveness can be increased by reducing the finger contact force. This study also demonstrated that the finger adapter method can be combined with the palm adapter method prescribed in the standardized glove test, which can double the test efficiency without substantially increasing the expense of the test.

      13. Conjugal transfer, whole genome sequencing, and plasmid analysis of four mcr-1-bearing Isolates from U.S. patientsExternal
        Zhu W, Lawsin A, Lindsey RL, Batra D, Knipe K, Yoo BB, Perry KA, Rowe LA, Lonsway D, Waters MS, Rasheed JK, Halpin AL.
        Antimicrob Agents Chemother. 2019 Feb 11.
        Four Enterobacteriaceae clinical isolates bearing mcr-1 gene-harboring plasmids were characterized. All isolates demonstrated the ability to transfer colistin resistance to E. coli; plasmids were stable in conjugants after multiple passages on non-selective media. mcr-1 was located on an IncX4 (n=3) or IncN (n=1) plasmid. The IncN plasmid harbored 13 additional antimicrobial resistance genes. Results indicate the mcr-1-bearing plasmids in this study are highly transferable in vitro and stable in the recipients.

    • Maternal and Child Health
      1. Actions in support of newborn screening for critical congenital heart disease – United States, 2011-2018External
        Glidewell J, Grosse SD, Riehle-Colarusso T, Pinto N, Hudson J, Daskalov R, Gaviglio A, Darby E, Singh S, Sontag M.
        MMWR Morb Mortal Wkly Rep. 2019 Feb 8;68(5):107-111.
        In 2011, the U.S. Department of Health and Human Services added critical congenital heart disease (CCHD), which occurs in two of every 1,000 births, to the list of conditions recommended to states for universal newborn screening (1). Without early detection, infants with CCHD are at risk for substantial morbidity and death in the first weeks and months of life (2). Based on 2007-2013 data, deaths from CCHD and other cardiac causes in infants aged <6 months significantly declined in infants born in eight states after they had fully implemented mandated newborn CCHD screening policies by June 2013 (3). CDC collaborated with the American Academy of Pediatrics (AAP) and the Association of Public Health Laboratories’ Newborn Screening Technical Assistance and Evaluation Program (NewSTEPs) to update a 2015 report (4) on states’ actions toward adopting and implementing policies supporting CCHD newborn screening. In 2018, all 50 states and the District of Columbia (DC) had implemented CCHD screening policies, and, with one exception, all states mandated that screening be done (California mandates that screening be offered). However, not all states had data systems in place for tracking all screening results and outcomes. Ongoing evaluation activities, which rely on screening data, could help identify program improvement opportunities and monitor the impact of early identification of CCHD.

      2. ASD screening with the Child Behavior Checklist/1.5-5 in the Study to Explore Early DevelopmentExternal
        Levy SE, Rescorla LA, Chittams JL, Kral TJ, Moody EJ, Pandey J, Pinto-Martin JA, Pomykacz AT, Ramirez A, Reyes N, Rosenberg CR, Schieve L, Thompson A, Young L, Zhang J, Wiggins L.
        J Autism Dev Disord. 2019 Feb 9.
        We analyzed CBCL/1(1/2)-5 Pervasive Developmental Problems (DSM-PDP) scores in 3- to 5-year-olds from the Study to Explore Early Development (SEED), a multi-site case control study, with the objective to discriminate children with ASD (N = 656) from children with Developmental Delay (DD) (N = 646), children with Developmental Delay (DD) plus ASD features (DD-AF) (N = 284), and population controls (POP) (N = 827). ASD diagnosis was confirmed with the ADOS and ADI-R. With a cut-point of T >/= 65, sensitivity was 80% for ASD, with specificity varying across groups: POP (0.93), DD-noAF (0.85), and DD-AF (0.50). One-way ANOVA yielded a large group effect (eta(2) = 0.50). Our results support the CBCL/1(1/2)-5’s as a time-efficient ASD screener for identifying preschoolers needing further evaluation.

      3. Sleep problems in 2- to 5-year-olds with autism spectrum disorder and other developmental delaysExternal
        Reynolds AM, Soke GN, Sabourin KR, Hepburn S, Katz T, Wiggins LD, Schieve LA, Levy SE.
        Pediatrics. 2019 Feb 11.
        BACKGROUND: Sleep problems can impact daytime behavior, quality of life, and overall health. We compared sleep habits in young children with autism spectrum disorder (ASD) and other developmental delays and disorders and in children from the general population (POP). METHODS: We included 2- to 5-year-old children whose parent completed all items on the Children’s Sleep Habits Questionnaire (CSHQ) in a multisite case-control study: 522 children with ASD; 228 children with other developmental delays and disorders with autism spectrum disorder characteristics (DD w/ASD); 534 children with other developmental delays and disorders without autism spectrum disorder characteristics (DD w/o ASD); and 703 POP. Multivariable analysis of variance compared CSHQ mean total score (TS) and subscale scores between groups. Logistic regression analysis examined group differences by using TS cutoffs of 41 and 48. Analyses were adjusted for covariates. RESULTS: Mean CSHQ TS for children in each group: ASD (48.5); DD w/ASD (50.4); DD w/o ASD (44.4); and POP (43.3). Differences between children with ASD and both children with DD w/o ASD and POP were statistically significant. Using a TS cutoff of 48, the proportion of children with sleep problems was significantly higher in children in the ASD group versus DD w/o ASD and POP groups (adjusted odds ratios [95% confidence intervals]: 2.12 [1.57 to 2.87] and 2.37 [1.75 to 3.22], respectively). CONCLUSIONS: Sleep problems are more than twice as common in young children with ASD and DD w/ASD. Screening for sleep problems is important in young children to facilitate provision of appropriate interventions.

      4. Prenatal, perinatal, and neonatal factors associated with self-injurious behaviors in children with autism spectrum disorderExternal
        Soke GN, Rosenberg SA, Hamman RF, Fingerlin TE, Rosenberg CR, Carpenter L, Lee LC, Giarelli E, Wiggins LD, Durkin MS, DiGuiseppi C.
        Res Autism Spectr Disord. 2019 May;61:1-9.
        Background: Studies that examine the role of factors documented before self-injurious behaviors (SIB) occur are important in establishing a temporal relationship between these factors and SIB. Using data from a population-based surveillance system of 8-year-olds with autism spectrum disorder (ASD), we: (1) explored potential associations between SIB and prenatal, perinatal, and neonatal factors identified from birth certificates, and 2) validated associations between SIB and developmental, behavioral, medical factors accounting for the above prenatal, perinatal, and neonatal factors. Method(s): We included 4343 children from the Autism and Developmental Disabilities Monitoring Network from the 2000, 2006, and 2008 surveillance years. Prenatal, perinatal and neonatal characteristics were obtained from birth certificates. SIB and other potential risk factors were abstracted from children’s health or education records. The associations between SIB and various potential risk factors were tested using non-linear mixed models. Result(s): Lower maternal educational attainment (adjusted odds-ratio [aOR]: 1.35 [95% confidence interval 1.10-1.67]), prenatal maternal cigarette smoking (1.47 [1.09-1.98]), and electronic fetal monitoring during labor (1.70 [1.02-2.84]) were associated with SIB. In addition, we validated previous associations between SIB and developmental regression, lower IQ, behavioral, sensory and sleep problems, co-occurring developmental and psychiatric diagnoses. Conclusion(s): The associations between SIB and maternal smoking, low maternal education attainment may be due to various factors, including low SES and limited access to specialized ASD services. Electronic fetal monitoring may be a marker for unmeasured perinatal complications. Findings reported in this study have implications for better understanding of factors associated with SIB to guide prevention and interventions.

    • Medicine
      1. Is surgical volume still the most accurate indicator of blood usage in the United States?External
        Savinkina A, Sapiano MR, Berger J, Basavaraju SV.
        Transfusion. 2019 Feb 10.
        BACKGROUND: Estimates of blood collection and use in the United States derived from the National Blood Collection and Utilization Survey (NBCUS) call for application of robust statistical methods in the analysis of survey data. Since 1993, annual inpatient surgical volume has been used as the main stratification variable for sampling and estimation. However, recent NBCUS results have shown a decrease in blood use in surgical settings, raising the possibility that inpatient surgical volume may no longer be the optimal stratification variable. The objective of this study is to explore factors affecting hospital blood utilization. STUDY DESIGN AND METHODS: A multivariate generalized linear regression with a negative binomial distribution was used to determine which hospital characteristics best explained allogeneic red blood cell (RBC) use, using data from the 2015 NBCUS to determine hospital blood use and the 2013 annual American Hospital Association database to identify hospital characteristics. RESULTS: Annual inpatient surgical volume explained the most variation in allogeneic RBC use among hospitals (pseudo-R(2) of 70.8%). Additional variables, such as presence of an oncology service, were also statistically significant in the models but explained little additional variability in blood use. CONCLUSION: These findings suggest that annual inpatient surgical volume is an appropriate indicator for estimating blood utilization in the United States. As trends in blood utilization continue to evolve, ongoing analytic efforts to understand indicators of blood use are necessary.

    • Nutritional Sciences
      1. Dietary supplement use among infants and toddlers aged <24 months in the United States, NHANES 2007-2014External
        Gahche JJ, Herrick KA, Potischman N, Bailey RL, Ahluwalia N, Dwyer JT.
        J Nutr. 2019 Feb 9.
        Background: Limited nationally representative data are available on dietary supplement (DS) use and resulting nutrient exposures among infants and toddlers. Objective: This study evaluated DS use among US infants and toddlers to characterize DS use, estimate nutrient intake from DSs, and assess trends in DS use over time. Methods: Using nationally representative data from NHANES (2007-2014) and trends over time (1999-2014), we estimated prevalence of DS use and types of products used for US infants and toddlers aged <2 y (n = 2823). We estimated median daily intakes of vitamins and minerals consumed via DSs for all participants aged <2 y, by age groups (0-11.9 mo and 12.0-23.9 mo), and by feeding practices for infants 0-5.9 mo. Results: Overall, 18.2% (95% CI: 16.2%, 20.3%) of infants and toddlers used >/=1 DS in the past 30 d. Use was lower among infants (0-5.9 mo: 14.6%; 95% CI: 11.5%, 18.1%; 6-11.9 mo: 11.6%; 95% CI: 8.8%, 15.0%) than among toddlers (12-23.9 mo: 23.3%; 95% CI: 20.4%, 26.3%). The most commonly reported DSs were vitamin D and multivitamin infant drops for those <12 mo, and chewable multivitamin products for toddlers (12-23.9 mo). The nutrients most frequently consumed from DSs were vitamins D, A, C, and E for those <2 y; for infants <6 mo, a higher percentage of those fed breast milk than those fed formula consumed these nutrients via DSs. DS use remained steady for infants (6-11.9 mo) and toddlers from 1999-2002 to 2011-2014, but increased from 7% to 20% for infants aged 0-5.9 mo. Conclusions: One in 5 infants and toddlers aged <2 y use >/=1 DS. Future studies should examine total nutrient intake from foods, beverages, and DSs to evaluate nutrient adequacy overall and by nutrient source.

      2. Integrating micronutrient status assessment into the 2015-2016 Malawi Demographic and Health Survey: A qualitative evaluationExternal
        Rhodes EC, Hennink M, Jefferds ME, Williams AM, Suchdev PS, Mapango C, Nyirenda E, Mshali G, Tripp K.
        Matern Child Nutr. 2019 Jan;15 Suppl 1:e12734.
        Demand for national-level micronutrient status data continues to grow, yet little is known about the implementation of different approaches for collecting these data. We conducted an evaluation of the process of linking the 2015-2016 Malawi Demographic and Health Survey (MDHS) and 2015-2016 Malawi Micronutrient Survey (MNS). We conducted 24 in-depth interviews with stakeholders from the Malawi government and international agencies and field staff. Interview questions explored perceptions of what worked and what was challenging during three phases of implementation: preparation; data collection; and data analysis, reporting, and dissemination. Data were analysed using thematic analysis. Results showed that there was strong government interest to integrate the MDHS and MNS. Perceived benefits included potential cost savings and lower respondent burden. However, government and international agency stakeholders did not view the linkage of the surveys to be a fully integrated approach. The lack of full integration produced challenges throughout implementation, such as complex field logistics and duplication in nutrition indicators assessed and reported. Some stakeholders believed integration was not attainable primarily due to timing. The MDHS and MNS were originally designed as stand-alone surveys, and planning for each survey was at an advanced stage once the government sought to integrate the surveys. Additionally, the MNS could not be incorporated as a module within the MDHS given the complexity of the MNS data collection and short timeframe for planning. These findings can inform decisions about implementing the next MNS and may be transferable to other countries that are conducting micronutrient surveys to address data gaps.

    • Public Health Leadership and Management
      1. Building state and local public health capacity in syndromic surveillance through an online community of practiceExternal
        Gould DW, Lamb E, Dearth S, Collier K.
        Public Health Rep. 2019 Feb 14:33354919828713.

        [No abstract]

    • Public Health, General
      1. “Back to the future”: Time for a renaissance of public health engineeringExternal
        Gelting RJ, Chapra SC, Nevin PE, Harvey DE, Gute DM.
        Int J Environ Res Public Health. 2019 Jan 29;16(3).
        Public health has always been, and remains, an interdisciplinary field, and engineering was closely aligned with public health for many years. Indeed, the branch of engineering that has been known at various times as sanitary engineering, public health engineering, or environmental engineering was integral to the emergence of public health as a distinct discipline. However, in the United States (U.S.) during the 20th century, the academic preparation and practice of this branch of engineering became largely separated from public health. Various factors contributed to this separation, including an evolution in leadership roles within public health; increasing specialization within public health; and the emerging environmental movement, which led to the creation of the U.S. Environmental Protection Agency (EPA), with its emphasis on the natural environment. In this paper, we consider these factors in turn. We also present a case study example of public health engineering in current practice in the U.S. that has had large-scale positive health impacts through improving water and sanitation services in Native American and Alaska Native communities. We also consider briefly how to educate engineers to work in public health in the modern world, and the benefits and challenges associated with that process. We close by discussing the global implications of public health engineering and the need to re-integrate engineering into public health practice and strengthen the connection between the two fields.

    • Reproductive Health
      1. Factors associated with provision of depot medroxyprogesterone acetate to adolescents by U.S. health care providersExternal
        Ermias Y, Morgan IA, Curtis KM, Whiteman MK, Horton LG, Zapata LB.
        Contraception. 2019 Feb 11.
        OBJECTIVE: Identify factors associated with healthcare providers’ frequency of depot medroxyprogesterone acetate (DMPA) provision to adolescents. STUDY DESIGN: We analyzed data from surveys mailed to a nationally representative sample of public-sector providers and office-based physicians (n=1984). We estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of factors associated with frequent DMPA provision to adolescents in the past year. RESULTS: Although most providers (>95%) considered DMPA safe for adolescents, fewer reported frequent provision (89% of public-sector providers; 64% of office-based physicians). Among public-sector providers, factors associated with lower odds of frequent provision included working in settings without Title X funding (aOR 0.44, 95% CI 0.30-0.64), reporting primary care as their primary clinical focus versus reproductive or adolescent health (aOR 0.42, 95% CI 0.28-0.61), and providing fewer patients with family planning services. Among office-based physicians, factors associated with lower odds of frequent provision included specializing in obstetrics/gynecology (aOR 0.50, 95% CI 0.27-0.91) and family medicine (aOR 0.21, 95% CI 0.09-0.47) versus adolescent medicine, completing training>/=15 versus<5years ago (aOR 0.27, 95% CI 0.09-0.83), and reporting that 0-24% of patients pay with Medicaid or other government healthcare assistance versus>/=50% (aOR 0.23, 95% CI 0.09-0.61). The reason most commonly reported by providers for infrequent DMPA provision was patient preference for another method. CONCLUSIONS: While most providers reported frequently providing DMPA to adolescents, training on evidence-based recommendations for contraception, focused on subgroups of providers with lower odds of frequent DMPA provision, may increase adolescents’ access to contraception. IMPLICATIONS: Although>95% of providers considered depot medroxyprogesterone (DMPA) a safe contraceptive for adolescents, only 89% of public-sector providers and 64% of office-based physicians reported frequently providing DMPA to adolescents. Provider training on evidence-based recommendations for contraception counseling and provision may increase adolescents’ access to DMPA and all methods of contraception.

    • Substance Use and Abuse
      1. Biomarkers of exposure among U.S. Adult cigar smokers: Population Assessment of Tobacco and Health (PATH) Study Wave 1 (2013-2014)External
        Chang CM, Rostron BL, Chang JT, Corey CG, Kimmel HL, Sosnoff CS, Goniewicz ML, Edwards KC, Hatsukami DK, Wang Y, Del Valle-Pinero AY, Yang M, Travers MJ, Arnstein S, Taylor K, Conway K, Ambrose BK, Borek N, Hyland A, Wang L, Blount BC, van Bemmel DM.
        Cancer Epidemiol Biomarkers Prev. 2019 Feb 7.
        BACKGROUND: Given the diverse cigar market and limited data on biomarker patterns by cigar type, we compared biomarkers of nicotine and tobacco toxicants among cigar smokers and other groups. METHODS: Using Wave 1 urinary biomarker data from 5,604 adults in the Population Assessment of Tobacco and Health (PATH) Study, we compared geometric mean concentrations among cigar-only smokers (all cigars and separately for traditional, cigarillo, and filtered cigars), cigarette-only smokers, dual cigar/cigarette smokers, and never users of tobacco. We calculated geometric mean ratios (GMR) comparing groups with never users adjusting for sex, age, race/ethnicity, education and creatinine. RESULTS: Some day cigar-only smokers had lower biomarker concentrations than every day cigar-only smokers but higher than never users. Every day cigar-only smokers (n=61) had lower TNE-2 (cotinine+trans-3′-hydroxycotinine) compared to every day cigarette-only (n=2217;p<0.0001) and dual cigar/cigarette smokers (n=601;p<0.0001). Several biomarkers, including NNAL (NNK metabolite) and CYMA (metabolite of acrylonitrile), were comparable in these groups. In exploratory analyses, every day filtered cigar-only (n=7) smokers had higher biomarker concentrations compared to every day traditional cigar-only smokers (n=12) and cigarillo-only smokers (n=24). Every day smokers of each cigar type were similar to exclusive cigarette smokers. For some biomarkers, particularly for every day filtered cigar-only smokers, concentrations were higher. CONCLUSIONS: For some biomarkers, every day cigar-only smokers were comparable to every day cigarette-only smokers. Exploratory analyses suggest that biomarkers vary by cigar type with every day filtered cigar-only smokers having the highest concentrations. IMPACT: High exposure to harmful constituents among cigar smokers is a continuing health issue.

      2. Vital Signs: Tobacco product use among middle and high school students – United States, 2011-2018External
        Gentzke AS, Creamer M, Cullen KA, Ambrose BK, Willis G, Jamal A, King BA.
        MMWR Morb Mortal Wkly Rep. 2019 Feb 15;68(6):157-164.
        INTRODUCTION: Tobacco use is the leading cause of preventable disease and death in the United States; nearly all tobacco product use begins during youth and young adulthood. METHODS: CDC, the Food and Drug Administration, and the National Cancer Institute analyzed data from the 2011-2018 National Youth Tobacco Surveys to estimate tobacco product use among U.S. middle and high school students. Prevalence estimates of current (past 30-day) use of seven tobacco products were assessed; differences over time were analyzed using multivariable regression (2011-2018) or t-test (2017-2018). RESULTS: In 2018, current use of any tobacco product was reported by 27.1% of high school students (4.04 million) and 7.2% of middle school students (840,000); electronic cigarettes (e-cigarettes) were the most commonly used product among high school (20.8%; 3.05 million) and middle school (4.9%; 570,000) students. Use of any tobacco product overall did not change significantly during 2011-2018 among either school level. During 2017-2018, current use of any tobacco product increased 38.3% (from 19.6% to 27.1%) among high school students and 28.6% (from 5.6% to 7.2%) among middle school students; e-cigarette use increased 77.8% (from 11.7% to 20.8%) among high school students and 48.5% (from 3.3% to 4.9%) among middle school students. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: A considerable increase in e-cigarette use among U.S. youths, coupled with no change in use of other tobacco products during 2017-2018, has erased recent progress in reducing overall tobacco product use among youths. The sustained implementation of comprehensive tobacco control strategies, in coordination with Food and Drug Administration regulation of tobacco products, can prevent and reduce the use of all forms of tobacco products among U.S. youths.

      3. Variability in urine dilution complicates urine cannabinoid test interpretation. Normalizing urine cannabinoid concentrations to specific gravity (SG) or creatinine was proposed to account for donors’ hydration states. In this study all urine voids were individually collected from 8 frequent and 8 occasional cannabis users for up to 85 h after each received on separate occasions 50.6 mg Delta9-tetrahydrocannabinol (THC) by smoking, vaporization and oral ingestion in a randomized, within-subject, double-blind, double-dummy, placebo-controlled protocol. Each urine void was analyzed for 11 cannabinoids and phase I and II metabolites by LC-MS/MS, SG and creatinine. Normalized urine concentrations were log10 transformed to create normal distributions, and Pearson correlation coefficients determined the degree of association between the two normalization methods. Repeated-measures linear regression determined if the degree of association differed by frequent or occasional cannabis use, or route of administration after adjusting for gender and time since dosing. Of 1880 urine samples examined, only 11-nor-9-carboxy-THC (THCCOOH), THCCOOH-glucuronide, THC-glucuronide and 11-nor-9-carboxy-Delta9-tetrahydrocannabivarin (THCVCOOH) were greater than the method’s limits of quantification. Associations between SG- and creatinine-normalized concentrations exceeded 0.90. Repeated-measures regression analysis found small but statistically significant differences in degree of association between normalization methods for THCCOOH and THCCOOH-glucuronide in frequent vs. occasional smokers, and in THCVCOOH and THC-glucuronide by route of administration. For the first time, SG- and creatinine-normalized urine cannabinoid concentrations were evaluated in frequent and occasional cannabis users and following oral, smoked and inhaled cannabis. Both normalization methods reduced variability improving interpretation of urine cannabinoid concentrations and methods were strongly correlated.

    • Zoonotic and Vectorborne Diseases
      1. Epidemiologic and ecologic investigations of monkeypox, Likouala Department, Republic of the Congo, 2017External
        Doshi RH, Guagliardo SA, Doty JB, Babeaux AD, Matheny A, Burgado J, Townsend MB, Morgan CN, Satheshkumar PS, Ndakala N, Kanjingankolo T, Kitembo L, Malekani J, Kalemba L, Pukuta E, N’Kaya T, Kangoula F, Moses C, McCollum AM, Reynolds MG, Mombouli JV, Nakazawa Y, Petersen BW.
        Emerg Infect Dis. 2019 Feb;25(2):281-289.
        Monkeypox, caused by a zoonotic orthopoxvirus, is endemic in Central and West Africa. Monkeypox has been sporadically reported in the Republic of the Congo. During March 22-April 5, 2017, we investigated 43 suspected human monkeypox cases. We interviewed suspected case-patients and collected dried blood strips and vesicular and crust specimens (active lesions), which we tested for orthopoxvirus antibodies by ELISA and monkeypox virus and varicella zoster virus DNA by PCR. An ecologic investigation was conducted around Manfouete, and specimens from 105 small mammals were tested for anti-orthopoxvirus antibodies or DNA. Among the suspected human cases, 22 met the confirmed, probable, and possible case definitions. Only 18 patients had available dried blood strips; 100% were IgG positive, and 88.9% (16/18) were IgM positive. Among animals, only specimens from Cricetomys giant pouched rats showed presence of orthopoxvirus antibodies, adding evidence to this species’ involvement in the transmission and maintenance of monkeypox virus in nature.

      2. Zika virus IgM detection and neutralizing antibody profiles 12-19 months after illness onsetExternal
        Griffin I, Martin SW, Fischer M, Chambers TV, Kosoy O, Falise A, Ponomareva O, Gillis LD, Blackmore C, Jean R.
        Emerg Infect Dis. 2019 Feb;25(2):299-303.
        Data on the duration of detectable Zika virus-specific IgM in infected persons are limited. Neutralizing antibody cross-reactivity occurs between Zika virus and related flaviviruses, but the degree to which this confounds diagnosis is uncertain. We tested serum specimens collected 12-19 months after illness onset from patients with confirmed Zika virus disease for Zika virus IgM and Zika virus and dengue virus neutralizing antibodies. Among 62 participants, 45 (73%) had detectable Zika virus IgM and 12 (19%) had an equivocal result. Although all patients tested had Zika virus neutralizing antibodies, 39 (63%) also had neutralizing antibodies against dengue virus; of those, 12 (19%) had <4-fold difference between Zika virus and dengue virus titers, and 5 (8%) had dengue virus titer >4-fold higher than Zika virus titer. Prolonged detection of IgM and neutralizing antibody cross-reactivity make it difficult to determine the timing of Zika virus infection and differentiate between related flaviviruses.

      3. Lassa fever in travelers from West Africa, 1969-2016External
        Kofman A, Choi MJ, Rollin PE.
        Emerg Infect Dis. 2019 Feb;25(2):245-248.
        Lassa virus is a rodentborne arenavirus responsible for human cases of Lassa fever, a viral hemorrhagic fever, in West Africa and in travelers arriving to non-Lassa-endemic countries from West Africa. We describe a retrospective review performed through literature search of clinical and epidemiologic characteristics of all imported Lassa fever cases worldwide during 1969-2016. Our findings demonstrate that approximately half of imported cases had distinctive clinical features (defined as fever and >1 of the following: pharyngitis, sore throat, tonsillitis, conjunctivitis, oropharyngeal ulcers, or proteinuria). Delays in clinical suspicion of this diagnosis were common. In addition, no secondary transmission of Lassa fever to contacts of patients with low-risk exposures occurred, and infection of high-risk contacts was rare. Future public health investigations of such cases should focus on timely recognition of distinctive clinical features, earlier treatment of patients, and targeted public health responses focused on high-risk contacts.

      4. Seroprevalence of Heartland virus antibodies in blood donors, northwestern Missouri, USAExternal
        Lindsey NP, Menitove JE, Biggerstaff BJ, Turabelidze G, Parton P, Peck K, Basile AJ, Kosoy OI, Fischer M, Staples JE.
        Emerg Infect Dis. 2019 Feb;25(2):358-360.
        We estimated the seroprevalence of Heartland virus antibodies to be 0.9% (95% CI 0.4%-4.2%) in a convenience sample of blood donors from northwestern Missouri, USA, where human cases and infected ticks have been identified. Although these findings suggest that some past human infections were undetected, the estimated prevalence is low.

      5. Rift Valley fever virus exposure amongst farmers, farm workers, and veterinary professionals in central South AfricaExternal
        Msimang V, Thompson PN, Jansen van Vuren P, Tempia S, Cordel C, Kgaladi J, Khosa J, Burt FJ, Liang J, Rostal MK, Karesh WB, Paweska JT.
        Viruses. 2019 Feb 7;11(2).
        Rift Valley fever (RVF) is a re-emerging arboviral disease of public health and veterinary importance in Africa and the Arabian Peninsula. Major RVF epidemics were documented in South Africa in 1950(-)1951, 1974(-)1975, and 2010(-)2011. The number of individuals infected during these outbreaks has, however, not been accurately estimated. A total of 823 people in close occupational contact with livestock were interviewed and sampled over a six-month period in 2015(-)2016 within a 40,000 km(2) study area encompassing parts of the Free State and Northern Cape provinces that were affected during the 2010(-)2011 outbreak. Seroprevalence of RVF virus (RVFV) was 9.1% (95% Confidence Interval (CI95%): 7.2(-)11.5%) in people working or residing on livestock or game farms and 8.0% in veterinary professionals. The highest seroprevalence (SP = 15.4%; CI95%: 11.4(-)20.3%) was detected in older age groups (>/=40 years old) that had experienced more than one known large epidemic compared to the younger participants (SP = 4.3%; CI95%: 2.6(-)7.3%). The highest seroprevalence was in addition found in people who injected animals, collected blood samples (Odds ratio (OR) = 2.3; CI95%: 1.0(-)5.3), slaughtered animals (OR = 3.9; CI95%: 1.2(-)12.9) and consumed meat from an animal found dead (OR = 3.1; CI95%: 1.5(-)6.6), or worked on farms with dams for water storage (OR = 2.7; CI95%: 1.0(-)6.9). We estimated the number of historical RVFV infections of farm staff in the study area to be most likely 3849 and 95% credible interval between 2635 and 5374 based on seroprevalence of 9.1% and national census data. We conclude that human RVF cases were highly underdiagnosed and heterogeneously distributed. Improving precautions during injection, sample collection, slaughtering, and meat processing for consumption, and using personal protective equipment during outbreaks, could lower the risk of RVFV infection.

      6. Postmortem evidence of disseminated Zika virus infection in an adult patientExternal
        Rajahram GS, Hale G, Bhatnagar J, Hiu J, Thayan R, William T, Wong KT, Tambyah PA, Yeo TW.
        Int J Infect Dis. 2019 Feb 11.
        Zika virus infections in immunocompetent adults typically are asymptomatic or cause mild symptoms, but have also been associated with neurological complications including Guillain-Barre Syndrome. Zika virusassociated non-neurological fatalities in adults are rare. Herein, we describe a decedent with multiple commodities who developed an acute febrile illness with rash days prior to death. A post-mortem evaluation detected molecular evidence of disseminated Zika virus. Further testing by Zika virus in-situ hybridization identified genomic and replicative Zika viral RNA in renal tubular epithelial cells, and cardiomyocytes, providing insights into organ-specific viral reservoirs.

      7. Assessment of human-to-human transmissibility of avian influenza A(H7N9) virus across 5 waves by analyzing clusters of case patients in mainland China, 2013-2017External
        Wang X, Wu P, Pei Y, Tsang TK, Gu D, Wang W, Zhang J, Horby PW, Uyeki TM, Cowling BJ, Yu H.
        Clin Infect Dis. 2019 Feb 1;68(4):623-631.
        Background: The 2016-17 epidemic of human infections with avian influenza A(H7N9) virus was alarming, due to the surge in reported cases across a wide geographic area and the emergence of highly-pathogenic A(H7N9) viruses. Our study aimed to assess whether the human-to-human transmission risk of A(H7N9) virus has changed across the 5 waves since 2013. Methods: Data on human cases and clusters of A(H7N9) virus infection were collected from the World Health Organization, open access national and provincial reports, informal online sources, and published literature. We compared the epidemiological characteristics of sporadic and cluster cases, estimated the relative risk (RR) of infection in blood relatives and non-blood relatives, and estimated the bounds on the effective reproductive number (Re) across waves from 2013 through September 2017. Results: We identified 40 human clusters of A(H7N9) virus infection, with a median cluster size of 2 (range 2-3). The overall RR of infection in blood relatives versus non-blood relatives was 1.65 (95% confidence interval [CI]: 0.88, 3.09), and was not significantly different across waves (chi2 = 2.66, P = .617). The upper limit of Re for A(H7N9) virus was 0.12 (95% CI: 0.10, 0.14) and was not significantly different across waves (chi2 = 1.52, P = .822). Conclusions: The small cluster size and low Re suggest that human-to-human transmissibility of A(H7N9) virus has not changed over time and remains limited to date. Continuous assessment of A(H7N9) virus infections and human case clusters is of crucial importance for public health.

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