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Volume 12, Issue 17, June 2, 2020

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CDC Science Clips: Volume 12, Issue 17, June 2, 2020

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

This week Science Clips is pleased to feature articles from the CDC-organized Clinical Infectious Diseases supplement on “Plague and Bioterrorism Preparednessexternal icon.”

The introductory articleexternal icon notes:


“In this supplement of Clinical Infectious Diseases, organized by the Centers for Disease Control and Prevention, we have assembled a series of articles that address the most pressing questions related to plague. These articles, representing careful and diligent research efforts, have been curated to bring together an essential evidence base on the treatment of plague and considerations for special populations. . . . The aim with this work is to increase resilience and national security against plague by advancing scientific and medical knowledge in order to inform preparedness. This collection of foundational articles and the expertise behind them will provide a basis for efforts to augment defenses against plague in both the natural and intentional release settings and, hopefully, will spur future research.”

The report consists of these components:

  1. Key Scientific Articles in Featured Topic Areas
    Subject matter experts decide what topic to feature, and articles are selected from the last 3 to 6 months of published literature. Key topic coincides monthly with other CDC products (e.g. Vital Signs).The names of CDC authors are indicated in bold text.
    • Zoonotic and Vectorborne Diseases - Plague
      1. Plague: Still a threat, but evidence and preparedness are keys to fighting backexternal icon
        Adalja A, Nelson CA.
        Clin Infect Dis. 2020 May 21;70(Supplement_1):S1-s2.

      2. Effect of delaying treatment on efficacy of ciprofloxacin and levofloxacin in the African green monkey model of pneumonic plagueexternal icon
        Campbell JL, Fay MP, Lanning LL, Hewitt JA.
        Clin Infect Dis. 2020 May 21;70(Supplement_1):S60-s65.
        BACKGROUND: Ciprofloxacin and levofloxacin, 2 fluoroquinolone antimicrobials, are ≥90% effective for the treatment of inhalational plague when administered within 2-6 hours of fever onset in African green monkeys (AGM). Based on data in the AGM model, these antimicrobials were approved under the Food and Drug Administration's Animal Efficacy Rule. However, that data did not address the issue of how long treatment with these antimicrobials would remain effective after fever onset. METHODS: The AGM model of pneumonic plague was used to explore the effect of delaying treatment with ciprofloxacin and levofloxacin on efficacy. In 2 studies, AGMs were challenged with inhaled lethal doses of Yersinia pestis. Treatment with ciprofloxacin and levofloxacin was initiated from 0 to up to 30 hours after fever onset. RESULTS: Challenged animals all developed fever within 78 hours and were treated with ciprofloxacin (n = 27) or levofloxacin (n = 29) at various predetermined time points postfever. When administered 10 hours after fever onset, 10 days of ciprofloxacin and levofloxacin treatment remained very effective (90 or 100%, respectively). The efficacy of both antimicrobials declined as treatment initiation was further delayed. Statistical analyses estimated the treatment delay times at which half of the AGMs were no longer expected to survive as 19.7 hours for ciprofloxacin and 26.5 hours for levofloxacin. CONCLUSIONS: This study demonstrates that there is a narrow window following fever onset during which ciprofloxacin and levofloxacin are fully effective treatment options for pneumonic plague in AGMs. Since the timing of disease is similar in humans and AGMs, these AGM data are reasonably likely to predict response times for treatment in humans.

      3. Plague during pregnancy: A systematic reviewexternal icon
        Fleck-Derderian S, Nelson CA, Cooley KM, Russell Z, Godfred-Cato S, Oussayef NL, Oduyebo T, Rasmussen SA, Jamieson DJ, Meaney-Delman D.
        Clin Infect Dis. 2020 May 21;70(Supplement_1):S30-s36.
        BACKGROUND: Yersinia pestis continues to cause sporadic cases and outbreaks of plague worldwide and is considered a tier 1 bioterrorism select agent due to its potential for intentional use. Knowledge about the clinical manifestations of plague during pregnancy, specifically the maternal, fetal, and neonatal risks, is very limited. METHODS: We searched 12 literature databases, performed hand searches, and consulted plague experts to identify publications on plague during pregnancy. Articles were included if they reported a case of plague during pregnancy and at least 1 maternal or fetal outcome. RESULTS: Our search identified 6425 articles, of which 59 were eligible for inclusion and described 160 cases of plague among pregnant women. Most published cases occurred during the preantibiotic era. Among those treated with antimicrobials, the most commonly used were sulfonamides (75%) and streptomycin (54%). Among cases treated with antimicrobials, maternal mortality and fetal fatality were 29% and 62%, respectively; for untreated cases, maternal mortality and fetal fatality were 67% and 74%, respectively. Five cases demonstrated evidence of Y. pestis in fetal or neonatal tissues. CONCLUSIONS: Untreated Y. pestis infection during pregnancy is associated with a high risk of maternal mortality and pregnancy loss. Appropriate antimicrobial treatment can improve maternal survival, although even with antimicrobial treatment, there remains a high risk of pregnancy loss. Limited evidence suggests that maternal-fetal transmission of Y. pestis is possible, particularly in the absence of antimicrobial treatment. These results emphasize the need to treat or prophylax pregnant women with suspected plague with highly effective antimicrobials as quickly as possible.

      4. Treatment of human plague: A systematic review of published aggregate data on antimicrobial efficacy, 1939-2019external icon
        Godfred-Cato S, Cooley KM, Fleck-Derderian S, Becksted HA, Russell Z, Meaney-Delman D, Mead PS, Nelson CA.
        Clin Infect Dis. 2020 May 21;70(Supplement_1):S11-s19.
        BACKGROUND: Plague, caused by the bacterium Yersinia pestis, has killed millions in historic pandemics and continues to cause sporadic outbreaks. Numerous antimicrobials are considered effective for treating plague; however, well-defined information on the relative efficacy of various treatments is lacking. We conducted a systematic review of published data on antimicrobial treatment of plague reported in aggregate. METHODS: We searched databases including Embase, Medline, CINAHL, Cochrane Library, and others for publications with terms related to plague and antimicrobials. Articles were included if they contained 1) a group of patients treated for plague, with outcomes reported by antimicrobial regimen, and 2) laboratory evidence of Y. pestis infection or an epidemiologic link to patients with laboratory evidence of Y. pestis. Case fatality rate by antimicrobial regimen was calculated. RESULTS: In total, 5837 articles were identified; among these, 26 articles published between 1939 and 2008 met inclusion criteria. A total of 2631 cases of human plague reported within these articles were included. Among cases classified by primary clinical form of plague, 93.6% were bubonic, 5.9% pneumonic, and 0.5% septicemic with associated case fatalities of 14.2%, 31.1%, and 20.0%, respectively. Case fatality rate among patients who received monotherapy with tetracyclines, chloramphenicol, aminoglycosides, or sulfonamides was 1.3%, 1.4%, 7.5%, and 20.2%, respectively. Fluoroquinolones were only given as part of combination therapy. Penicillin was associated with a case fatality rate of 75%. CONCLUSIONS: Tetracyclines, chloramphenicol, and aminoglycosides were associated with the lowest case fatality rates of all antimicrobials used for treatment of plague. Additional research is needed to determine the efficacy of fluoroquinolones as monotherapy.

      5. BACKGROUND: Additional treatment options for pneumonic plague, the most severe form of infection by Yersinia pestis, are needed, as past US Food and Drug Administration (FDA) approvals were not based on clinical trials that meet today's standards, and multiple drugs are sought to counter resistance or use in special populations. Due to the sporadic nature of outbreaks and the low number of pneumonic cases of disease, we sought FDA approval of antimicrobials for treatment under the Animal Efficacy Rule, where efficacy can be demonstrated in 1 or more well-characterized animal models that sufficiently represent human disease. METHODS: A model was developed in African green monkeys (AGMs) after challenge with a lethal dose of Y. pestis delivered as an aerosol, in 4 independent studies in 3 laboratories. The primary data points were bacteremia (daily), body temperature and heart rate (continuously monitored by telemetry), and survival. In antimicrobial efficacy studies, human-equivalent doses of gentamicin, ciprofloxacin, levofloxacin, and doxycycline were administered upon fever onset for 10 days. RESULTS: Disease in AGMs was similar to case reports of human disease. Fever was determined to be a reliable sign of disease and selected as a treatment trigger. Gentamicin was 60%-80% effective depending on the dose given to animals. Ciprofloxacin and levofloxacin were found to be >90% efficacious. These data were submitted to FDA and plague indications were approved. Doxycycline was less effective. CONCLUSIONS: The AGM model of pneumonic plague is reproducible, well-characterized, and mimics human disease. It has been used to support plague indications for fluoroquinolones and to test the efficacy of additional antimicrobials.

      6. Antimicrobial treatment patterns and illness outcome among United States patients with plague, 1942-2018external icon
        Kugeler KJ, Mead PS, Campbell SB, Nelson CA.
        Clin Infect Dis. 2020 May 21;70(Supplement_1):S20-s26.
        BACKGROUND: Plague is a rare and severe zoonotic illness with limited empiric evidence to support treatment recommendations. We summarize treatment information for all patients with plague in the United States (US) as collected under the auspices of public health surveillance. METHODS: We reviewed use of specific antimicrobials and illness outcome among cases of plague reported from 1942-2018. Antimicrobials were a priori classified into high-efficacy (aminoglycosides, tetracyclines, fluoroquinolones, sulfonamides, and chloramphenicol) and limited-efficacy classes (all others). Logistic regression models were created to describe associations between use of specific antimicrobial classes and illness outcome while controlling for potential confounding factors. RESULTS: Among 533 total reported plague cases during 1942-2018, 426 (80%) received high-efficacy antimicrobial therapy. Mortality differed significantly among those receiving high-efficacy therapy (9%) and only limited-efficacy therapy (51%). Aminoglycosides and tetracyclines were used more commonly than other classes, and their use was associated with increased odds of survival of plague. Gentamicin use was associated with higher mortality than streptomycin, and aminoglycoside use was linked to higher mortality than for tetracyclines. Fluoroquinolones have been used in treatment of >30% of patients in recent years and limited data suggest clinical effectiveness. CONCLUSIONS: Most US patients with plague have received effective antimicrobials. Aminoglycosides and tetracyclines substantially improve survival of plague, and fluoroquinolones may be equally as effective, yet lack sufficient data. Early recognition and early treatment with any of these antimicrobial classes remain the most important steps to improving survival of plague.

      7. Plague and pregnancy: Why special considerations are neededexternal icon
        Meaney-Delman D, Oussayef NL, Honein MA, Nelson CA.
        Clin Infect Dis. 2020 May 21;70(Supplement_1):S27-s29.
        Pregnant women are an important at-risk population to consider during public health emergencies. These women, like nonpregnant adults, may be faced with the risk of acquiring life-threatening infections during outbreaks or bioterrorism (BT) events and, in some cases, can experience increased severity of infection and higher morbidity compared with nonpregnant adults. Yersinia pestis, the bacterium that causes plague, is a highly pathogenic organism. There are 4 million births annually in the United States, and thus the unique needs of pregnant women and their infants should be considered in pre-event planning for a plague outbreak or BT event.

      8. Antimicrobial treatment of human plague: A systematic review of the literature on individual cases, 1937-2019external icon
        Nelson CA, Fleck-Derderian S, Cooley KM, Meaney-Delman D, Becksted HA, Russell Z, Renaud B, Bertherat E, Mead PS.
        Clin Infect Dis. 2020 May 21;70(Supplement_1):S3-s10.
        BACKGROUND: Yersinia pestis remains endemic in Africa, Asia, and the Americas and is a known bioterrorism agent. Treatment with aminoglycosides such as streptomycin or gentamicin is effective when initiated early in illness but can have serious side effects. Alternatives such as fluoroquinolones, tetracyclines, and sulfonamides are potentially safer but lack robust human data on efficacy. METHODS: We searched PubMed Central, Medline, Embase, and other databases for articles in any language with terms related to plague and antimicrobials. Articles that contained case-level information on antimicrobial treatment and patient outcome were included. We abstracted information related to patient demographics, clinical features, treatment, and fatality. RESULTS: Among 5837 articles screened, we found 762 published cases of treated plague reported from 1937 to 2019. Fifty-nine percent were male; median age was 22 years (range, 8 days-80 years). The case fatality rate was 20% overall. Most patients had primary bubonic (63%), pneumonic (21%), or septicemic (5%) plague, with associated case fatality rates of 17%, 27%, and 38%, respectively. Among those treated with an aminoglycoside (n = 407 [53%]), the case fatality rate was 13%. Among those treated with a sulfonamide (n = 322 [42%]), tetracycline (n = 171 [22%]), or fluoroquinolone (n = 61 [8%]), fatality was 23%, 10%, and 12%, respectively. Case fatality rate did not substantially differ between patients treated with 1 vs 2 classes of antimicrobials considered to be effective for plague. CONCLUSIONS: In addition to aminoglycosides, other classes of antimicrobials including tetracyclines, fluoroquinolones, and sulfonamides are effective for plague treatment, although publication bias and low numbers in certain treatment groups may limit interpretation.

      9. Safety of antimicrobials during pregnancy: A systematic review of antimicrobials considered for treatment and postexposure prophylaxis of plagueexternal icon
        Yu PA, Tran EL, Parker CM, Kim HJ, Yee EL, Smith PW, Russell Z, Nelson CA, Broussard CS, Yu YC, Meaney-Delman D.
        Clin Infect Dis. 2020 May 21;70(Supplement_1):S37-s50.
        BACKGROUND: The safety profile of antimicrobials used during pregnancy is one important consideration in the decision on how to treat and provide postexposure prophylaxis (PEP) for plague during pregnancy. METHODS: We searched 5 scientific literature databases for primary sources on the safety of 9 antimicrobials considered for plague during pregnancy (amikacin, gentamicin, plazomicin, streptomycin, tobramycin, chloramphenicol, doxycycline, sulfadiazine, and trimethoprim-sulfamethoxazole [TMP-SMX]) and abstracted data on maternal, pregnancy, and fetal/neonatal outcomes. RESULTS: Of 13 052 articles identified, 66 studies (case-control, case series, cohort, and randomized studies) and 96 case reports were included, totaling 27 751 prenatal exposures to amikacin (n = 9), gentamicin (n = 345), plazomicin (n = 0), streptomycin (n = 285), tobramycin (n = 43), chloramphenicol (n = 246), doxycycline (n = 2351), sulfadiazine (n = 870), and TMP-SMX (n = 23 602). Hearing or vestibular deficits were reported in 18/121 (15%) children and 17/109 (16%) pregnant women following prenatal streptomycin exposure. First trimester chloramphenicol exposure was associated with an elevated risk of an undescended testis (odds ratio [OR] 5.9, 95% confidence interval [CI] 1.2-28.7). Doxycycline was associated with cardiovascular malformations (OR 2.4, 95% CI 1.2-4.7) in 1 study and spontaneous abortion (OR 2.8, 95% CI 1.9-4.1) in a separate study. First trimester exposure to TMP-SMX was associated with increased risk of neural tube defects (pooled OR 2.5, 95% CI 1.4-4.3), spontaneous abortion (OR 3.5, 95% CI 2.3-5.6), preterm birth (OR 1.5, 95% CI 1.1-2.1), and small for gestational age (OR 1.6, 95% CI 1.2-2.2). No other statistically significant associations were reported. CONCLUSIONS: For most antimicrobials reviewed, adverse maternal/fetal/neonatal outcomes were not observed consistently. Prenatal exposure to streptomycin and TMP-SMX was associated with select birth defects in some studies. Based on limited data, chloramphenicol and doxycycline may be associated with adverse pregnancy or neonatal outcomes; however, more data are needed to confirm these associations. Antimicrobials should be used for treatment and PEP of plague during pregnancy; the choice of antimicrobials may be influenced by these data as well as information about the risks of plague during pregnancy.


  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. Filling the public health science gaps for diabetes with natural experimentsexternal icon
        Gregg EW, Duru OK, Shi L, Mangione CM, Siegel KR, Ramsay A, Thornton PL, Clauser S, Ali MK.
        Med Care. 2020 Jun;58 Suppl 6 Suppl 1:S1-s3.

      2. Extensive tooth loss can lead to poor diet resulting in weight loss or obesity (1). It can also detract from physical appearance and impede speech, factors that can restrict social contact, inhibit intimacy, and lower self-esteem (1). Chronic medical conditions and oral conditions share common risk factors (2). Persons with chronic conditions are more likely to have untreated dental disease, which can result in tooth loss. Three measures of tooth loss during 1999-2004 and 2011-2016 were estimated by comparing data from the National Health and Nutrition Examination Survey (NHANES) for each period among adults aged >/=50 years with selected chronic conditions.* The three measures were 1) edentulism (having no teeth); 2) severe tooth loss (having eight or fewer teeth) (3); and 3) lacking functional dentition (having <20 teeth out of 28, which is considered a full set for the purpose of NHANES assessments) (4). During 2011-2016, prevalences of edentulism and severe tooth loss were >/=50% higher among adults with fair or poor general health, rheumatoid arthritis, asthma, diabetes, emphysema, heart disease, liver condition, or stroke than among those with those adults without the chronic condition. Lack of functional dentition was also more prevalent among adults with chronic conditions than among persons without these conditions. Tooth loss is preventable with self-care and routine dental visits (1). To encourage these behaviors, public health professionals can educate the public about the association between having a chronic condition and tooth loss, and primary care providers can educate their patients about the importance of healthy behaviors and screen and refer them for needed dental care.

      3. PURPOSE: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides free cervical cancer screening to low-income women. This study estimated the health benefits gained in terms of life years (LYs) saved and quality-adjusted life years (QALYs) gained if cervical cancer screening by the NBCCEDP increased to reach more eligible women. METHODS: Data from Surveillance, Epidemiology, and End Results, NBCCEDP, and Medical Expenditure Panel Surveys were used. LYs saved and QALYs gained/100,000 women were estimated using modeling methods. They were used to predict additional health benefits gained if screening by the NBCCEDP increased from 6.5% up to 10-25% of the eligible women. RESULTS: Overall, per 100,000 women screened by the NBCCEDP, 1,731 LYs were saved and 1,608 QALYs were gained. For white women, 1,926 LYs were saved and 1,780 QALYs were gained/100,000 women screened by the NBCCEDP. For black women, 1,506 LYs were saved and 1,300 QALYs were gained/100,000 women screened. If the proportion of eligible women screened by the NBCCEDP increased to 10-25%, the estimated health benefits would range from 6,626-34,896 LYs saved and 6,153-32,407 QALYs gained. CONCLUSIONS: The reported estimates emphasize the value of cervical cancer screening program by extending LE in low-income women. Further, it demonstrates that screening a higher percentage of eligible women in the NBCCEDP may yield more health benefits.

    • Communicable Diseases
      1. Improvements in retention in care and HIV viral suppression among persons with HIV and comorbid mental health conditions: Patient-centered HIV care modelexternal icon
        Byrd KK, Hardnett F, Hou JG, Clay PG, Suzuki S, Camp NM, Shankle MD, Weidle PJ, Taitel MS.
        AIDS Behav. 2020 May 15.
        The Patient-centered HIV Care Model (PCHCM) integrated community-based pharmacists with medical providers and required sharing of patient clinical information and collaborative therapy-related action planning. We determined the proportions of participants with HIV and mental health conditions who were retained in care and the proportion virally suppressed, pre- and post-implementation. Overall, we found a relative 13% improvement in both retention [60% to 68% (p = 0.009)] and viral suppression [79% to 90% (p < 0.001)]. Notable improvements were seen among persons triply diagnosed with HIV, mental illness and substance use [+ 36% (50% to 68%, p = 0.036) and + 32% (66% to 86%, p = 0.001) in retention and viral suppression, respectively]. There were no differences in the proportions of persons adherent to psychiatric medications, pre- to post-implementation, nor were there differences in the proportions of persons retained in care or virally suppressed by psychiatric medication adherence, post-implementation. PCHCM demonstrated that collaborations between community-based pharmacists and medical providers can improve HIV care continuum outcomes among persons with mental health conditions.

      2. Sudor Anglicus: an epidemic targeting the autonomic nervous systemexternal icon
        Cheshire WP, van Gerpen JA, Sejvar JJ.
        Clin Auton Res. 2020 May 20.
        Renaissance England witnessed a series of brief epidemics of a rapid and often fatal illness, the predominant feature of which was a disturbance of the autonomic nervous system. Profuse sweating was both an emblematic and ominous sign of this Sudor Anglicus. Its story is medically fascinating as well as historically noteworthy. Possible sites of pathological involvement include the hypothalamus, serotonergic neurons in the brainstem or spinal cord, autonomic ganglia, peripheral sympathetic nerves, neuroeffector junctions, or eccrine glands. Of candidate etiologic agents, a virus is most likely, given the seasonal variation, geographic clustering, and pattern of spread of the epidemics. Hantaviruses, enteroviruses, influenza, and others provide clinical comparisons, but a definitive match with known viruses has remained elusive.

      3. Confidential, accessible point-of-care sexual health services to support the participation of key populations in biobehavioural surveys: Lessons for Papua New Guinea and other settings where reach of key populations is limitedexternal icon
        Kelly-Hanku A, Redman-MacLaren M, Boli-Neo R, Nosi S, Ase S, Aeno H, Nembari J, Amos A, Gabuzzi J, Kupul M, Williie B, Narokobi R, Hou P, Pekon S, Kaldor JM, Badman SG, Vallely AJ, Hakim AJ.
        PLoS One. 2020 ;15(5):e0233026.
        To achieve the UNAIDS 90-90-90 targets at a national level, many countries must accelerate service coverage among key populations. To do this, key population programs have adopted methods similar to those used in respondent-driven sampling (RDS) to expand reach. A deeper understanding of factors from RDS surveys that enhance health service engagement can improve key population programs. To understand the in-depth lives of key populations, acceptance of expanded point-of-care biological testing and determine drivers of participation in RDS surveys, we conducted semi-structured interviews with 111 key population participants (12-65 years) were purposefully selected from six biobehavioral surveys (BBS) in three cities in Papua New Guinea. Key populations were female sex workers, men who have sex with men, and transgender women. Four reasons motivated individuals to participate in the BBS: peer referrals; private, confidential, and stigma-free study facilities; "one-stop shop" services that provided multiple tests and with same-day results, sexually transmitted infection treatment, and referrals; and the desire to know ones' health status. Biobehavioral surveys, and programs offering key population services can incorporate the approach we used to facilitate key population engagement in the HIV cascade.

      4. An investigation of early syphilis among men who have sex with men: Alaska, 2018: Findings from a 2018 rapid ethnographic assessmentexternal icon
        Loosier PS, Carry M, Fasula A, Hatfield-Timajchy K, Jones SA, Harvill J, Smith T, McLaughlin J.
        J Community Health. 2020 May 14.
        The state of Alaska had a sharp increase in cases of primary and secondary syphilis among gay, bisexual, and other men who have sex with men (GBMSM) in 2018, centered in Anchorage. A rapid ethnographic assessment was conducted in October 2018 to examine contextual factors contributing to local increases in syphilis. The assessment team conducted qualitative interviews with 64 (N=49 interviews) key informants in Anchorage and Matanuska-Susitna Valley identified through the STD/HIV program at the Alaska Department of Health and Social Services, Division of Public Health (ADPH): ADPH staff (n = 11; 22%) Medical Providers (n = 18; 37%), Community-Based Organizations/Partners (n = 9; 18%), and GBMSM Community Members (n = 11; 22%). This project was deemed exempt from IRB review. Primary factors affecting syphilis transmission, care, and treatment among GBMSM were: (1) Low awareness about the current syphilis outbreak and ambivalence about syphilis and other STIs; (2) Aspects of sexual partnering such as travel, tourism, and the use of online sites and apps to facilitate anonymous sex and multiple (both sequential/concurrent) partnering; (3) The synergistic effects of substance use, homelessness, and transactional sex; (4) Choosing condomless sex; and (5) Challenges accessing healthcare, including the ability to find appropriate and culturally competent care. Syphilis increases may have been influenced by factors which spanned multiple sectors of the Anchorage community, including individual behavior, community-level risk and protective factors, and use of and interactions with resources offered by ADPH, community-based organizations, and medical providers.

      5. Impact of community treatment with ivermectin for the control of scabies on the prevalence of antibodies to Strongyloides stercoralis in childrenexternal icon
        Marks M, Gwyn S, Toloka H, Kositz C, Asugeni J, Asugeni R, Diau J, Kaldor JM, Romani L, Redman-MacLaren M, MacLaren D, Solomon AW, Mabey DC, Steer AC, Martin D.
        Clin Infect Dis. 2020 May 18.
        Prevalence of antibodies to Strongyloides stercoralis was measured in 0-12-year-olds using a bead-based immunoassay before and after ivermectin mass drug administration (MDA) for scabies in the Solomon Islands. Seroprevalence was 9.3% before and 5.1% after MDA (p = 0.019), demonstrating collateral benefits of ivermectin MDA in this setting.

      6. Estimating the catchment population and incidence of severe acute respiratory infections in a district hospital in Bousse, Burkina Fasoexternal icon
        Milucky JL, Compaore T, Obulbiga F, Cowman G, Whitney CG, Bicaba B.
        J Glob Health. 2020 Jun;10(1):010422.
        Background: The primary cause of death in Burkina Faso is lower respiratory tract infections, accounting for 1 in 7 deaths. The Ministry of Health is building surveillance for severe acute respiratory infections (SARI) in four districts. This study sought to determine the catchment area of the Bousse district hospital and to describe disease burden of individuals hospitalized for SARI. Methods: Data were collected from hospital log books to identify individuals with a SARI diagnosis during 2015 and 2016. Residence of SARI patients was recorded to determine the catchment area of the hospital. Population data were used to estimate SARI incidence rates. Results: Investigators reviewed logs for 3034 hospital admissions; 885 SARI cases were identified. Five communes were identified as the hospital catchment area, with 770 SARI patients residing in these communes. The SARI incidence rate (IR) for all ages was 136 (95% confidence interval (CI) = 115, 161) and 266 (95% CI = 236, 300) cases per 100 000 population for 2015 and 2016, respectively. Children <1 (RI = 1111 cases per 100 000, 95% CI = 1047, 1178, and RI = 2425 cases per 100 000, 95% CI = 2330, 2524) and adults >/=65 years old (RI = 377 cases per 100 000, 95% CI = 341, 417, and RI = 816 cases per 100 000, 95% CI = 762, 874) had the highest burden of disease for 2015 and 2016, respectively. Conclusion: Our analysis found high rates of SARI, especially among children <1 year of age, and marked variation in incidence between the years studied. These baseline data and the method developed will be useful for the new SARI surveillance system.

      7. Outbreak investigation of COVID-19 among residents and staff of an independent and assisted living community for older adults in Seattle, Washingtonexternal icon
        Roxby AC, Greninger AL, Hatfield KM, Lynch JB, Dellit TH, James A, Taylor J, Page LC, Kimball A, Arons M, Munanga A, Stone N, Jernigan JA, Reddy SC, Lewis J, Cohen SA, Jerome KR, Duchin JS, Neme S.
        JAMA Intern Med. 2020 May 21.
        Importance: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused epidemic spread of coronavirus disease 2019 (COVID-19) in the Seattle, Washington, metropolitan area, with morbidity and mortality concentrated among residents of skilled nursing facilities. The prevalence of COVID-19 among older adults in independent/assisted living is not understood. Objectives: To conduct surveillance for SARS-CoV-2 and describe symptoms of COVID-19 among residents and staff of an independent/assisted living community. Design, Setting, and Participants: In March 2020, public health surveillance of staff and residents was conducted on site at an assisted and independent living residence for older adults in Seattle, Washington, after exposure to 2 residents who were hospitalized with COVID-19. Exposures: Surveillance for SARS-CoV-2 infection in a congregate setting implementing social isolation and infection prevention protocols. Main Outcomes and Measures: SARS-CoV-2 real-time polymerase chain reaction was performed on nasopharyngeal swabs from residents and staff; a symptom questionnaire was completed assessing fever, cough, and other symptoms for the preceding 14 days. Residents were retested for SARS-CoV-2 7 days after initial screening. Results: Testing was performed on 80 residents; 62 were women (77%), with mean age of 86 (range, 69-102) years. SARS-CoV-2 was detected in 3 of 80 residents (3.8%); none felt ill, 1 male resident reported resolved cough and 1 loose stool during the preceding 14 days. Virus was also detected in 2 of 62 staff (3.2%); both were symptomatic. One week later, resident SARS-CoV-2 testing was repeated and 1 new infection detected (asymptomatic). All residents remained in isolation and were clinically stable 14 days after the second test. Conclusions and Relevance: Detection of SARS-CoV-2 in asymptomatic residents highlights challenges in protecting older adults living in congregate settings. In this study, symptom screening failed to identify residents with infections and all 4 residents with SARS-CoV-2 remained asymptomatic after 14 days. Although 1 asymptomatic infection was found on retesting, a widespread facility outbreak was avoided. Compared with skilled nursing settings, in assisted/independent living communities, early surveillance to identify asymptomatic persons among residents and staff, in combination with adherence to recommended preventive strategies, may reduce viral spread.

      8. Feasibility of social distancing practices in US schools to reduce influenza transmission during a pandemicexternal icon
        Uscher-Pines L, Schwartz HL, Ahmed F, Zheteyeva Y, Tamargo Leschitz J, Pillemer F, Faherty L, Uzicanin A.
        J Public Health Manag Pract. 2020 Jul/Aug;26(4):357-370.
        BACKGROUND: Schools are socially dense environments, and school-based outbreaks often predate and fuel community-wide transmission of seasonal and pandemic influenza. While preemptive school closures can effectively reduce influenza transmission, they are disruptive and currently recommended only for pandemics. We assessed the feasibility of implementing other social distancing practices in K-12 schools as a first step in seeking an alternative to preemptive school closures. METHODS: We conducted 36 focus groups with education and public health officials across the United States. We identified and characterized themes and compared feasibility of practices by primary versus secondary school and region of the United States. RESULTS: Participants discussed 29 school practices (25 within-school practices implemented as part of the school day and 4 reduced-schedule practices that impact school hours). Participants reported that elementary schools commonly implement several within-school practices as part of routine operations such as homeroom stay, restriction of hall movement, and staggering of recess times. Because of routine implementation and limited use of individualized schedules within elementary schools, within-school practices were generally felt to be more feasible for elementary schools than secondary schools. Of reduced-schedule practices, shortening the school week and the school day was considered the most feasible; however, reduced-schedule practices were generally perceived to be less feasible than within-school practices for all grade levels. CONCLUSIONS: Our findings suggest that schools have many options to increase social distance other than closing. Future research should evaluate which of these seemingly feasible practices are effective in reducing influenza transmission in schools and surrounding communities.

      9. Evaluation of a program to improve linkage to and retention in care among refugees with hepatitis B virus infection - three U.S. cities, 2006-2018external icon
        Young J, Payton C, Walker P, White D, Brandeland M, Kumar GS, Jentes ES, Settgast A, DeSilva M.
        MMWR Morb Mortal Wkly Rep. 2020 May 29;69(21):647-650.
        An estimated 257 million persons worldwide have chronic hepatitis B virus (HBV) infection (1). CDC recommends HBV testing for persons from countries with intermediate to high HBV prevalence (>/=2%), including newly arriving refugees (2). Complications of chronic HBV infection include liver cirrhosis and hepatocellular carcinoma, which develop in 15%-25% of untreated adults infected in infancy or childhood (3). HBV-infected patients require regular monitoring for both infection and sequelae. Several studies have evaluated initial linkage to HBV care for both refugee and nonrefugee immigrant populations (4-9), but none contained standardized definitions for either linkage to or long-term retention in care for chronic HBV-infected refugees. To assess chronic HBV care, three urban sites that perform refugee domestic medical examinations and provide primary care collaborated in a quality improvement evaluation. Sites performed chart reviews and prospective outreach to refugees with positive test results for presumed HBV infection during domestic medical examinations. Linkage to care (29%-53%), retention in care (11%-21%), and outreach efforts (22%-71% could not be located) demonstrated poor access to initial and ongoing HBV care. Retrospective outreach was low-yield. Interventions that focus on prospective outreach and addressing issues related to access to care might improve linkage to and retention in care.

    • Disaster Control and Emergency Services
      1. Strategies for optimizing the supply of N95 filtering facepiece respirators during the coronavirus disease 2019 (COVID-19) pandemicexternal icon
        de Perio MA, Dowell CH, Delaney LJ, Radonovich LJ, Kuhar D, Gupta N, Patel A, Pillai SK, D'Alessandro M.
        Disaster Med Public Health Prep. 2020 May 19:1-23.
        N95 respirators are the personal protective equipment most often used to control exposures to infections transmitted via the airborne route. Supplies of N95 respirators can become depleted during pandemics or when otherwise in high demand. In this paper, we offer strategies for optimizing supplies of N95 respirators in healthcare settings while maximizing the level of protection offered to healthcare personnel when there is limited supply in the United States during the Coronavirus Disease 2019 (COVID-19) pandemic. The strategies are intended for use by professionals who manage respiratory protection programs, occupational health services, and infection prevention programs in healthcare facilities to protect healthcare personnel from job-related risks of exposure to infectious respiratory illnesses. Consultation with federal, state, and local public health officials is also important. We use the framework of surge capacity and the occupational health and safety hierarchy of controls approach to discuss specific engineering control, administrative control, and personal protective equipment measures that may help in optimizing N95 respirator supplies.

    • Disease Reservoirs and Vectors
      1. Unexpected rabies variant identified in kinkajou (Potos flavus), Mato Grosso, Brazilexternal icon
        Dell'Armelina Rocha PR, Velasco-Villa A, de Lima EM, Salomoni A, Fusaro A, da Conceição Souza E, Negreiros RL, Zafino VL, Zamperin G, Leopardi S, Monne I, Benedictis P.
        Emerg Microbes Infect. 2020 Dec;9(1):851-854.
        A second case of a novel rabies variant described once in a capuchin monkey from Mato Grosso, Brazil, was discovered in a rabid wild kinkajou from the same region, indicating a public health risk following exposure to either of the two animals.

      2. Ecology and epidemiology of tickborne pathogens, Washington, USA, 2011-2016external icon
        Dykstra EA, Oltean HN, Kangiser D, Marsden-Haug N, Rich SM, Xu G, Lee MK, Morshed MG, Graham CB, Eisen RJ.
        Emerg Infect Dis. 2020 Apr;26(4):648-657.
        Tickborne diseases are rare in Washington, USA, and the ecology of these pathogens is poorly understood. We integrated surveillance data from humans and ticks to better describe their epidemiology and ecology. During 2011-2016, a total of 202 tickborne disease cases were reported in Washington residents. Of these, 68 (34%) were autochthonous, including cases of Lyme disease, Rocky Mountain spotted fever, tickborne relapsing fever, and tularemia. During May 2011-December 2016, we collected 977 host-seeking ticks, including Ixodes pacificus, I. angustus, I. spinipalpis, I. auritulus, Dermacentor andersoni, and D. variabilis ticks. The prevalence of Borrelia burgdorferi sensu stricto in I. pacificus ticks was 4.0%; of B. burgdorferi sensu lato, 3.8%; of B. miyamotoi, 4.4%; and of Anaplasma phagocytophilum, 1.9%. We did not detect Rickettsia rickettsii in either Dermacentor species. Case-patient histories and detection of pathogens in field-collected ticks indicate that several tickborne pathogens are endemic to Washington.

    • Environmental Health
      1. Smoke alarms and carbon monoxide alarms in households with children, Puerto Rico, 2010external icon
        Chen J, Dignam T, Yip F, Garcia BR, Blanton C, Brown MJ, Sircar K.
        J Prim Prev. 2020 Jun;41(3):279-295.
        In 2017, Puerto Rico sustained extensive damage from Hurricane Maria, increasing the risk of fires and carbon monoxide (CO) poisonings. Using a population-based, in-person survey of households with children less than 6 years old in Puerto Rico, we collected data in 2010 concerning the presence of smoke alarms and CO alarms in these households. We generated national estimates by extrapolating the number of households in each stratum using data from the 2010 Census. We determined which household characteristics predicted the presence of these alarms. Of 355 households analyzed, 31% had functional smoke alarms, or an estimated 109,773 households territory wide. The presence of smoke alarms was associated with living in multifamily housing and no child in the household receiving government medical insurance. Public housing or publicly subsidized housing, as compared to owner-occupied housing and unsubsidized rental housing, was associated with having a functional smoke alarm in households with children aged less than 6 years. Based on only six houses having CO alarms, we estimated only 7685 (2%) households had CO alarms. The low prevalence of functional smoke or CO alarms 7 years before Hurricane Maria is unfortunate and should be remedied by ensuring that such alarms are widely installed in current rebuilding activities.

      2. Parental preconception and prenatal urinary bisphenol A and paraben concentrations and child behaviorexternal icon
        Skarha J, Messerlian C, Bellinger D, Minguez-Alarcon L, Romano ME, Ford JB, Williams PL, Calafat AM, Hauser R, Braun JM.
        Environ Epidemiol. 2020 .
        Background: Epidemiologic studies suggest that prenatal urinary bisphenol A (BPA) concentrations are associated with childhood behavior problems, but there is limited research on prenatal paraben concentrations. In rodent offspring, preconception maternal BPA exposure caused behavioral problems and paraben exposure impacted sperm quality. However, the effects of parental preconception and prenatal BPA and paraben exposure on children's neurodevelopment are unknown. Method(s): The Environment and Reproductive Health (EARTH) Study is a prospective cohort of couples from a fertility clinic at Massachusetts General Hospital. The Centers for Disease Control and Prevention (CDC) quantified BPA, butylparaben, ethylparaben, methylparaben, and propylparaben concentrations in multiple urine samples collected before conception and during pregnancy. From the eligible parents (N = 220), we enrolled 158 children between 2 and 9 years of age. The parents completed the Behavior-Assessment-System-for-Children-2 (BASC-2). We estimated covariate-adjusted associations of average parental preconception and prenatal ln-transformed urinary BPA and sum of paraben concentrations (&Sum;paraben) with BASC-2 scores using linear regression with generalized estimating equations. Result(s): Median urinary BPA and SIGMAparaben concentrations were 1.2 and 189 mug/L in mothers preconception and 1.7 and 25 mug/L in fathers preconception, respectively. Among all children, parental BPA and &Sum;paraben concentrations were not associated with BASC-2 behavioral symptoms index, internalizing, or externalizing problems scores. Point estimates ranged from -1.5 to 1.4 with wide 95% confidence intervals that included the null value. Conclusion(s): In this fertility clinic cohort, parental preconception and maternal prenatal BPA and paraben concentrations were not associated with problem behaviors among children. However, our small sample sizes reduced the precision of our results.

    • Epidemiology and Surveillance
      1. Comparisons of estimates from the Behavioral Risk Factor Surveillance System and other national health surveys, 2011−2016external icon
        Hsia J, Zhao G, Town M, Ren J, Okoro CA, Pierannunzi C, Garvin W.
        Am J Prev Med. 2020 ;58(6):e181-e190.
        Introduction: The Behavioral Risk Factor Surveillance System (BRFSS) is composed of telephone surveys that collect state data from non-institutionalized U.S. adults regarding health-related risk behaviors and chronic health conditions. A new design was implemented in 2011 to include participants on cellular telephones. It is important to validate estimates since 2011. Methods: A total of 10 key and widely used variables between BRFSS and the National Health and Nutrition Examination Survey (NHANES) or National Health Interview Survey (NHIS) in 2011−2016 were compared. Data analysis was conducted in 2018. Results: Between BRFSS and NHANES, similar linear time trends of prevalences or means were found for 8 of 9 studied variables. There were no significant differences in the prevalences of the following variables: self-reported fair/poor health, ever told have diabetes, and ever told to have hypertension. In trend comparison of BRFSS versus NHIS, interactions of prevalence between survey and time period were not found for 5 variables: current smoking, self-reported fair/poor health, ever told have diabetes, and self-reported height and weight. Although there were significant differences in many estimates between BRFSS and either NHANES or NHIS, the absolute differences across years were rather small. Conclusions: Comparing BRFSS time trends with those of 2 national benchmark surveys in 10 key and widely used variables suggests that the trends of prevalences (or means) from BRFSS, NHANES, and NHIS are mostly similar. For many variables, despite statistically significant differences in the prevalences (or means) between surveys, absolute differences in most cases were small and not meaningful from a public health surveillance perspective.

    • Food Safety
      1. Retail deli characteristics associated with sanitizing solution concentrationsexternal icon
        Holst M, Brown LG, Hoover ER, Julian E, Faw BV, Hedeen N, McKelvey W, Nicholas D, Ripley D, McKelvey W.
        J Food Prot. 2020 May 18.
        Listeria monocytogenes (L. mono) is commonly found in retail deli environments. Proper types and concentrations of sanitizers must be used to eliminate this pathogen from surfaces and reduce the consumer's risk for infection. In 2012, the CDC's Environmental Health Specialists Network completed a study on practices in retail delis that can help prevent cross-contamination and growth of L. mono. This report focuses on the sanitizing solution used by delis, given its importance to cleaning and reducing pathogen contamination in retail food environments. In this study, we identified deli, manager, and worker characteristics associated with use of improper concentrations of sanitizing solution used to wipe down food contact surfaces. Results indicate that 22.8% of sanitizing solutions used for wiping food contact surfaces were at improper concentrations. Independent delis were more likely to use improper concentrations of sanitizing solution, as were delis that sold fewer chubs (plastic tubes of meat) per week. Counter-intuitively, improper sanitizing solution concentration was associated with required food safety training for managers; additional analyses suggest that this relationship is significant for independent, but not chain, delis. It is important to emphasize cleaning and sanitizing education and focus food safety efforts on independent and smaller delis.

      2. Restaurant policies and practices related to norovirus outbreak size and durationexternal icon
        Hoover ER, Hedeen N, Freeland A, Kambhampati A, Dewey-Mattia D, Scott KW, Hall A, Brown LG.
        J Food Prot. 2020 May 18.
        Norovirus is the leading cause of foodborne illness outbreaks in the United States, and restaurants are the most common setting of foodborne norovirus outbreaks. Therefore, prevention and control of restaurant-related foodborne norovirus outbreaks is critical to lowering the burden of foodborne illness in the United States. Data for 124 norovirus outbreaks and outbreak restaurants were obtained from Centers for Disease Control and Prevention (CDC) surveillance systems and analyzed to identify relationships between restaurant characteristics and outbreak size and duration. Findings showed that restaurant characteristics, policies, and practices were linked with both outbreak size and duration. Compared to their counterparts, restaurants that had smaller outbreaks had the following characteristics: managers received food safety certification; managers and workers received food safety training; food workers wore gloves; and restaurants had cleaning policies. In addition, restaurants that provided food safety training to managers, served food items requiring less complex food preparation, and had fewer managers had shorter outbreaks compared to their counterparts. These findings suggest that restaurant characteristics play a role in norovirus outbreak prevention and intervention; therefore, implementing food safety training, policies, and practices likely reduces norovirus transmission, leading to smaller or shorter outbreaks.

      3. Toxoplasmosis outbreak associated with Toxoplasma gondii-contaminated venison-high attack rate, unusual clinical presentation, and atypical genotypeexternal icon
        Schumacher AC, Elbadawi LI, DeSalvo T, Straily A, Ajzenberg D, Letzer D, Moldenhauer E, Handly TL, Hill D, Darde ML, Pomares C, Passebosc-Faure K, Bisgard K, Gomez CA, Press C, Smiley S, Montoya JG, Kazmierczak JJ.
        Clin Infect Dis. 2020 May 15.
        BACKGROUND: During 2017, in response to a physician's report, the Wisconsin Department of Health Services, Division of Public Health, began investigating an outbreak of febrile illness among attendees of a retreat where never frozen, intentionally undercooked, locally harvested venison was served. Preliminary testing tentatively identified the illness as toxoplasmosis. METHODS: Confirmatory human serology panels and testing of the venison to confirm and categorize the presence and type of Toxoplasma gondii were completed by French and American national reference laboratories. All 12 retreat attendees were interviewed; medical records were reviewed. RESULTS: All attendees were male; median age was 51 years (range: 22-75). After a median incubation period of 7 days, 9 (82%) of 11 exposed persons experienced illness lasting a median of 12 days. All 9 sought outpatient healthcare for symptoms including fever, chills, sweats, and headache (100%) and ocular disturbances (33%). Testing confirmed the illness as toxoplasmosis and venison as the infection source. Multiple laboratory results were atypical for toxoplasmosis, including transaminitis (86%), lymphocytopenia (88%), thrombocytopenia (38%), and leukopenia (63%). One exposed but asymptomatic person was seronegative; the other had immunity from prior infection. The T. gondii strain was identified as closely related to an atypical genotype (haplogroup 12, polymerase chain reaction restriction fragment length polymorphism genotype 5) common in North American wildlife but with previously uncharacterized human clinical manifestations. CONCLUSIONS: The T. gondii strain contaminating the venison might explain the unusual clinical presentations. In North America, clinicians and venison consumers should be aware of risk for severe or unusual presentations of acute toxoplasmosis after consuming undercooked game meat.

    • Health Disparities
      1. Racial and ethnic differences in women's HIV risk and attitudes towards pre-exposure prophylaxis (PrEP) in the context of the substance use, violence, and depression syndemicexternal icon
        Willie TC, Kershaw TS, Blackstock O, Galvao RW, Safon CB, Tekeste M, Ogburn DF, Wilbourn B, Modrakovic D, Taggart T, Kaplan C, Caldwell A, Calabrese SK.
        AIDS Care. 2020 May 14:1-10.
        Women with syndemic conditions, i.e., two or more co-occurring epidemics, are at elevated risk for HIV acquisition and are therefore prime candidates for pre-exposure prophylaxis (PrEP). However, PrEP uptake remains low among women, especially among Black and Hispanic women. This study examined associations of syndemic conditions with PrEP attitudes and HIV risk among women, and the moderating effect of race and ethnicity. In 2017, 271 non-Hispanic Black, non-Hispanic White, and Hispanic, PrEP-eligible women engaged in care at Planned Parenthood in the northeastern region of the U.S. completed an online survey. Participants reported syndemic conditions (i.e., intimate partner violence, depression, substance use), PrEP attitudes (e.g., PrEP interest), HIV sexual risk (e.g., multiple male sexual partners), and sociodemographics. Structural equation modeling was used to examine the effects of syndemic conditions on PrEP attitudes and HIV risk, and the moderating effect of race and ethnicity. Women with more syndemic conditions had a higher odds of reporting multiple male sexual partners. Syndemic conditions were positively associated with PrEP attitudes for Hispanic women than non-Hispanic Black and White women. Women with syndemic conditions, particularly Hispanic women, may be receptive to interventions promoting PrEP.

    • Health Economics
      1. Patient-provider discussions about out-of-pocket costs of cancer care in the U.Sexternal icon
        Rai A, Zheng Z, Zhao J, de Moor JS, Ekwueme DU, Yabroff KR.
        Am J Prev Med. 2020 May 14.
        INTRODUCTION: Despite the importance of cost-related discussions in cancer care, little is known about the prevalence or drivers of these discussions in clinical practice. This study estimates the prevalence and examines the correlates of cancer survivors' discussions about out-of-pocket costs of cancer care with providers. METHODS: The 2016 and 2017 Medical Expenditure Panel Survey Experiences with Cancer Surveys were used to identify 1,550 survivors who responded to the question on discussion about out-of-pocket costs of cancer care. Multivariable multinomial logistic regression examined the correlates of discussions about out-of-pocket costs. Analyses were performed in 2019. RESULTS: Approximately one quarter of cancer survivors reported having discussed the out-of-pocket costs of cancer care. In multivariable analyses, respondents in the following categories were less likely to report no cost discussion than any cost discussion: black non-Hispanic/other race (RRR=0.67, 95% CI=0.45, 0.98; white non-Hispanic race as reference), no health insurance at diagnosis (RRR=0.51, 95% CI=0.27, 0.95; private health insurance as reference), and any experience of financial hardship (RRR=0.48, 95% CI=0.35, 0.66; no financial hardship as reference). CONCLUSIONS: Patient-reported discussions about out-of-pocket costs for cancer care are infrequent in the U.S. The findings highlight the needs to improve the understanding of the barriers and facilitators for effective discussions about out-of-pocket costs of cancer care.

    • Healthcare Associated Infections
      1. Handwashing sinks and their associated premise plumbing are an ideal environment for pathogen-harboring biofilms to grow and spread throughout facilities due to the connected system of wastewater plumbing. This study was designed to understand the distribution of pathogens and antibiotic resistant organisms (ARO) within and among handwashing sinks in healthcare settings, using culture-dependent methods to quantify Pseudomonas aeruginosa, opportunistic pathogens capable of growth on a cefotaxime-containing medium (OPP-C), and carbapenem-resistant Enterobacteriaceae (CRE). Isolates from each medium identified as P. aeruginosa or Enterobacteriaceae were tested for susceptibility to aztreonam, ceftazidime, and meropenem; Enterobacteriaceae were also tested against ertapenem and cefotaxime. Isolates exhibiting resistance or intermediate resistance were designated ARO. Pathogens were quantified at different locations within handwashing sinks and compared in quantity and distribution between healthcare personnel (HCP) and patient room (PR) sinks. ARO were compared between samples within a sink (biofilm vs planktonic samples) and between sink types (HCP vs. PR). The drain cover was identified as a reservoir within multiple sinks that was often colonized by pathogens despite daily sink cleaning. P. aeruginosa and OPP-C mean log10 CFU/cm(2) counts were higher in p-trap and tail pipe biofilm samples from HCP compared to PR sinks (2.77 +/- 2.39 vs. 1.23 +/- 1.62 and 5.27 +/- 1.10 vs. 4.74 +/- 1.06) for P. aeruginosa and OPP-C, respectively. P. aeruginosa and OPP-C mean log10 CFU/ml counts were also higher (p < 0.05) in HCP compared to PR sinks p-trap water (2.21 +/- 1.52 vs. 0.89 +/- 1.44 and 3.87 +/- 0.78 vs. 3.21 +/- 1.11) for P. aeruginosa and OPP-C, respectively. However, a greater percentage of ARO were recovered from PR sinks compared to HCP sinks (p < 0.05) for Enterobacteriaceae (76.4 vs. 32.9%) and P. aeruginosa (25.6 vs. 0.3%). This study supports previous work citing that handwashing sinks are reservoirs for pathogens and ARO and identifies differences in pathogen and ARO quantities between HCP and PR sinks, despite the interconnected premise plumbing.

      2. High burden of bloodstream infections associated with antimicrobial resistance and mortality in the neonatal intensive care unit in Pune, Indiaexternal icon
        Johnson J, Robinson ML, Rajput UC, Valvi C, Kinikar A, Parikh TB, Vaidya U, Malwade S, Agarkhedkar S, Randive B, Kadam A, Smith RM, Westercamp M, Mave V, Gupta A, Milstone AM, Manabe YC.
        Clin Infect Dis. 2020 May 18.
        BACKGROUND: Antimicrobial resistance (AMR) is a growing threat to newborns in low and middle income countries (LMIC). METHODS: We performed a prospective cohort study in three tertiary Neonatal Intensive Care Units (NICUs) in Pune, India, to describe the epidemiology of neonatal bloodstream infections (BSI). All neonates admitted to the NICU were enrolled. The primary outcome was BSI, defined as positive blood culture. Early onset BSI was defined as BSI on day of life (DOL) 0-2 and late onset BSI on DOL 3 or later. RESULTS: From May 1, 2017, until April 30, 2018, 4073 neonates were enrolled. Among at risk neonates, 55 (1.6%) developed early onset BSI and 176 (5.5%) developed late onset BSI. The majority of BSI were caused by Gram-negative bacteria (GNB) (58%); among GNB, 61 (45%) were resistant to carbapenems. Klebsiella spp. (n=53, 23%) were the most common cause of BSI. Compared with neonates without BSI, all-cause mortality was higher among neonates with early onset BSI (31% vs. 10%, p<0.001) and late onset BSI (24% vs. 7%, p<0.001). Non-low birth weight neonates with late onset BSI had the greatest excess in mortality, (22% vs. 3%, p<0.001). CONCLUSIONS: In our cohort, neonatal BSI were most commonly caused by GNB, with a high prevalence of AMR, and were associated with high mortality, even in term neonates. Effective interventions are urgently needed to reduce the burden of BSI and death due to AMR GNB in hospitalized neonates in LMIC.

    • Immunity and Immunization
      1. Objectives. To describe the ongoing collaboration of the Centers for Disease Control and Prevention's (CDC's) school vaccination assessment with state, local, and territorial immunization programs to provide data to monitor school entry vaccination.Methods. Departments of health and education partner to collect data from public school, private school, and homeschooled kindergartners in the 50 US states, the District of Columbia, 2 cities, and the US territories. Immunization programs submit vaccination coverage and exemption data to the CDC, and the CDC reports these data annually via multiple sources.Results. Among the 50 states and the District of Columbia, the number of programs using a census for vaccination coverage data increased from 39 to 41 during the school years 2012-2013 to 2017-2018 (which for most states was August or September through May or June), and the number using a census to collect exemption data increased from 40 to 46. The number of states that reported sharing their local-level vaccination coverage data online increased from 11 in 2012-2013 to 31 in 2017-2018.Conclusions. Coverage data can be used to address undervaccination among kindergartners to work with communities and schools that are susceptible to vaccine-preventable diseases. As more states publish local-level data online, access to improved data provides the public more valuable information. (Am J Public Health. Published online ahead of print May 21, 2020: e1-e6. doi:10.2105/AJPH.2020.305643).

      2. Increasing non-susceptibility to antibiotics within carried pneumococcal serotypes - Alaska, 2008-2015external icon
        Plumb ID, Gounder PP, Bruden DJ, Bulkow LR, Rudolph KM, Singleton RJ, Hennessy TW, Bruce MG.
        Vaccine. 2020 Jun 2;38(27):4273-4280.
        BACKGROUND: In Alaska, while introduction of 13-valent pneumococcal conjugate vaccine led to declines in invasive pneumococcal disease, carriage prevalence remained stable because of replacement with non-vaccine serotypes. We assessed antibiotic non-susceptibility of carried pneumococci during serotype redistribution, determined the contributions of within-serotype shifts, and assessed factors that could explain changes in non-susceptibility. METHODS: Each year from 2008 to 2015, at multiple sites in Alaska, we collected nasopharyngeal swabs and completed surveys for a convenience sample of participants. Pneumococcal serotyping and antimicrobial susceptibility testing for penicillin and erythromycin were performed. We described changes in non-susceptibility of isolates from 2008-2011 to 2012-2015, and assessed the contributions of serotype redistribution and within-serotype changes in non-susceptibility by comparing observed data to modeled data removing either factor. We used weighted logistic regression to assess whether reported risk factors could explain changes over time in non-susceptibility within serotypes. RESULTS: From 2008-2011 to 2012-2015, the overall proportion of isolates non-susceptible to penicillin or erythromycin increased by 3%, from 23% (n = 1,183) to 26% (n = 1,589; P < 0.05). However, a decrease of 3% would be expected if serotype redistribution occurred without within-serotype changes in non-susceptibility. Standardization by either factor produced hypothetical data significantly different to observed data. Within serotypes, the average annual increase in odds of non-susceptibility to penicillin or erythromycin was 1.08 (95% CI 1.05-1.11). Recent antibiotic exposure, urban residence and increased household size of participants predicted isolate non-susceptibility but did not explain the increase over time. DISCUSSION: An overall increase in non-susceptibility of carried pneumococcal isolates to penicillin or erythromycin resulted from increases in non-susceptibility within serotypes, which outweighed a protective effect of serotype redistribution. Characterization of emerging resistant clones within carried non-vaccine serotypes, including risk factors for colonization and disease, would support disease prevention efforts and inform vaccine strategies.


      4. Human monkeypox - after 40 years, an unintended consequence of smallpox eradicationexternal icon
        Simpson K, Heymann D, Brown CS, Edmunds WJ, Elsgaard J, Fine P, Hochrein H, Hoff NA, Green A, Ihekweazu C, Jones TC, Lule S, Maclennan J, McCollum A, Muhlemann B, Nightingale E, Ogoina D, Ogunleye A, Petersen B, Powell J, Quantick O, Rimoin AW, Ulaeato D, Wapling A.
        Vaccine. 2020 May 13.
        Smallpox eradication, coordinated by the WHO and certified 40 years ago, led to the cessation of routine smallpox vaccination in most countries. It is estimated that over 70% of the world's population is no longer protected against smallpox, and through cross-immunity, to closely related orthopox viruses such as monkeypox. Monkeypox is now a re-emerging disease. Monkeypox is endemic in as yet unconfirmed animal reservoirs in sub-Saharan Africa, while its human epidemiology appears to be changing. Monkeypox in small animals imported from Ghana as exotic pets was at the origin of an outbreak of human monkeypox in the USA in 2003. Travellers infected in Nigeria were at the origin of monkeypox cases in the UK in 2018 and 2019, Israel in 2018 and Singapore in2019. Together with sporadic reports of human infections with other orthopox viruses, these facts invite speculation that emergent or re-emergent human monkeypox might fill the epidemiological niche vacated by smallpox. An ad-hoc and unofficial group of interested experts met to consider these issues at Chatham House, London in June 2019, in order to review available data and identify monkeypox-related research gaps. Gaps identified by the experts included:The experts further agreed on the need for a better understanding of the genomic evolution and changing epidemiology of orthopox viruses, the usefulness of in-field genomic diagnostics, and the best disease control strategies, including the possibility of vaccination with new generation non-replicating smallpox vaccines and treatment with recently developed antivirals.

    • Injury and Violence
      1. Use of sport-related concussion information sources among parents of United States middle school childrenexternal icon
        Kerr ZY, Chandran A, Nedimyer AK, Rothschild AE, Kay MC, Gildner P, Byrd KH, Haarbauer-Krupa JK, Register-Mihalik JK.
        J Sport Health Sci. 2020 May 14.
        OBJECTIVE: Parents may use various information sources to obtain information about sport-related concussions (SRC). This study examined SRC-related information sources used by parents of United States middle school (MS) children (aged approximately 10-15 years). METHODS: A panel of 1083 randomly selected U.S. residents, aged >/=18 years and identifying as parents of MS children, completed an online questionnaire capturing parental and child characteristics, and utilization and perceived trustworthiness of various sources of SRC-related information. Multivariable logistic regression models identified factors associated with utilizing each source. Adjusted odds ratios (OR) with 95% confidence intervals (CIs) excluding 1.00 were deemed significant. RESULTS: Doctors/healthcare providers (49.9%) and other healthcare-related resources (e.g., Centers for Disease Control and Prevention, WebMD) (37.8%) were common SRC-related information sources; 64.0% of parents utilized at least one of these sources. Both sources were considered "very" or "extremely" trustworthy for SRC-related information among parents using these sources (doctors/healthcare providers: 89.8%; other healthcare-related resources: 70.9%). A 10-year increase in parental age was associated with higher odds of utilizing doctors/healthcare providers (adjusted odd ratio (ORadjusted)=1.09, 95%CI: 1.02-1.16) and other healthcare-related resources (ORadjusted=1.11, 95%CI: 1.03-1.19). The odds of utilizing doctors/healthcare providers (ORadjusted=0.58, 95%CI: 0.40-0.84) and other healthcare-related resources (ORadjusted=0.64, 95%CI: 0.44-0.93) were lower among parents whose MS children had concussion histories versus the parents of children who did not have concussion histories. CONCLUSIONS: One-third of parents did not report using doctors/healthcare providers or other healthcare-related resources for SRC-related information. Factors associated with under-utilization of these sources may be targets for future intervention. Continuing education for healthcare providers and educational opportunities for parents should highlight accurate and up-to-date SRC-related information.

    • Laboratory Sciences
      1. Causes of fever in primary care in Southeast Asia and the performance of C-reactive protein in discriminating bacterial from viral pathogensexternal icon
        Althaus T, Thaipadungpanit J, Greer RC, Swe MM, Dittrich S, Peerawaranun P, Smit PW, Wangrangsimakul T, Blacksell S, Winchell JM, Diaz MH, Day NP, Smithuis F, Turner P, Lubell Y.
        Int J Infect Dis. 2020 May 10.
        OBJECTIVES: We investigated causes of fever in the primary levels of care in Southeast Asia, and evaluated whether C-reactive protein (CRP) could distinguish bacterial from viral pathogens. METHODS: Blood and nasopharyngeal swab specimens were taken from children and adults with fever (>37.5 C) or history of fever (<14 days) in Thailand and Myanmar. RESULTS: Of 773 patients with at least one blood or nasopharyngeal swab specimen collected, 227 (29.4%) had a target organism detected. Influenza virus type A was detected in 85/227 cases (37.5%), followed by dengue virus (30 cases, 13.2%), respiratory syncytial virus (24 cases, 10.6%) and Leptospira spp. (9 cases, 4.0%). Clinical outcome was similar between patients with a bacterial or a viral organism, regardless of antibiotic prescription. CRP was higher among patients with a bacterial organism compared to those with a viral organism (median 18mg/L, interquartile range [10-49] versus 10mg/L [</=8-22], p-value 0.003), with an area under the curve of 0.65, 95% confidence interval (0.55-0.75). CONCLUSIONS: Serious bacterial infections requiring antibiotics are exceptions rather than the rule in the first lines of care. CRP-testing could assist in ruling out such cases in settings where diagnostic uncertainty is high and routine antibiotic prescription is common. The original CRP randomised-controlled trial (RCT) was registered with ClinicalTrials.gov, number NCT02758821.

      2. A new pneumococcal capsule type, 10D, is the 100th serotype and has a large cps fragment from an oral streptococcusexternal icon
        Ganaie F, Saad JS, McGee L, van Tonder AJ, Bentley SD, Lo SW, Gladstone RA, Turner P, Keenan JD, Breiman RF, Nahm MH.
        mBio. 2020 May 19;11(3).
        Streptococcus pneumoniae (pneumococcus) is a major human pathogen producing structurally diverse capsular polysaccharides. Widespread use of highly successful pneumococcal conjugate vaccines (PCVs) targeting pneumococcal capsules has greatly reduced infections by the vaccine types but increased infections by nonvaccine serotypes. Herein, we report a new and the 100th capsule type, named serotype 10D, by determining its unique chemical structure and biosynthetic roles of all capsule synthesis locus (cps) genes. The name 10D reflects its serologic cross-reaction with serotype 10A and appearance of cross-opsonic antibodies in response to immunization with 10A polysaccharide in a 23-valent pneumococcal vaccine. Genetic analysis showed that 10D cps has three large regions syntenic to and highly homologous with cps loci from serotype 6C, serotype 39, and an oral streptococcus strain (S. mitis SK145). The 10D cps region syntenic to SK145 is about 6 kb and has a short gene fragment of wciNalpha at the 5' end. The presence of this nonfunctional wciNalpha fragment provides compelling evidence for a recent interspecies genetic transfer from oral streptococcus to pneumococcus. Since oral streptococci have a large repertoire of cps loci, widespread PCV usage could facilitate the appearance of novel serotypes through interspecies recombination.IMPORTANCE The polysaccharide capsule is essential for the pathogenicity of pneumococcus, which is responsible for millions of deaths worldwide each year. Currently available pneumococcal vaccines are designed to elicit antibodies to the capsule polysaccharides of the pneumococcal isolates commonly causing diseases, and the antibodies provide protection only against the pneumococcus expressing the vaccine-targeted capsules. Since pneumococci can produce different capsule polysaccharides and therefore reduce vaccine effectiveness, it is important to track the appearance of novel pneumococcal capsule types and how these new capsules are created. Herein, we describe a new and the 100th pneumococcal capsule type with unique chemical and serological properties. The capsule type was named 10D for its serologic similarity to 10A. Genetic studies provide strong evidence that pneumococcus created 10D capsule polysaccharide by capturing a large genetic fragment from an oral streptococcus. Such interspecies genetic exchanges could greatly increase diversity of pneumococcal capsules and complicate serotype shifts.

      3. Draft genome sequences of two extensively drug-resistant strains of Acinetobacter baumannii isolated from clinical samples in Pakistanexternal icon
        Lomonaco S, Crawford MA, Lascols C, Fisher DJ, Anderson K, Hodge DR, Pillai SP, Morse SA, Khan E, Hughes MA, Allard MW, Sharma SK.
        Microbiol Resour Announc. 2020 May 14;9(20).
        Infections in immunocompromised patients that are caused by extensively drug-resistant (XDR) Acinetobacter baumannii strains have been increasingly reported worldwide. In particular, carbapenem-resistant A. baumannii strains are a prominent cause of health care-associated infections. Here, we report draft genome assemblies for two clinical XDR A. baumannii isolates obtained from hospitalized patients in Pakistan.

      4. A DNA polymerization-independent role for mitochondrial DNA polymerase I-like protein C in African trypanosomesexternal icon
        Miller JC, Delzell SB, Concepcion-Acevedo J, Boucher MJ, Klingbeil MM.
        J Cell Sci. 2020 May 7;133(9).
        Mitochondrial DNA of Trypanosoma brucei and related parasites is a catenated network containing thousands of minicircles and tens of maxicircles, called kinetoplast DNA (kDNA). Replication of a single nucleoid requires at least three DNA polymerase I-like proteins (i.e. POLIB, POLIC and POLID), each showing discrete localizations near the kDNA during S phase. POLIB and POLID have roles in minicircle replication but the specific role of POLIC in kDNA maintenance is less clear. Here, we use an RNA interference (RNAi)-complementation system to dissect the functions of two distinct POLIC regions, i.e. the conserved family A DNA polymerase (POLA) domain and the uncharacterized N-terminal region (UCR). While RNAi complementation with wild-type POLIC restored kDNA content and cell cycle localization of kDNA, active site point mutations in the POLA domain impaired minicircle replication similar to that of POLIB and POLID depletions. Complementation with POLA domain alone abolished the formation of POLIC foci and partially rescued the RNAi phenotype. Furthermore, we provide evidence that the UCR is crucial in cell cycle-dependent protein localization and facilitates proper distribution of progeny networks. This is the first report of a DNA polymerase that impacts on mitochondrial nucleoid distribution.This article has an associated First Person interview with the first author of the paper.

      5. Amino acid and acylcarnitine first-tier newborn screening typically employs derivatized or non-derivatized sample preparation methods followed by FIA coupled to triple quadrupole (TQ) MS/MS. The low resolving power of TQ instruments results in difficulties distinguishing nominal isobaric metabolites, especially those with identical quantifying product ions such as malonylcarnitine (C3DC) and 4-hydroxybutylcarnitine (C4OH). Twenty-eight amino acids and acylcarnitines extracted from dried blood spots (DBS) were analyzed by direct injection (DI)-HRMS on a Q-Exactive Plus across available mass resolving powers in SIM, in PRM at 17,000 full width at half maximum (FWHM), and a developed SIM/PRM hybrid MS method. Most notably, quantitation of C3DC and C4OH was successful by HRMS in non-derivatized samples, thus, potentially eliminating sample derivatization requirements. Quantitation differed between SIM and PRM acquired data for several metabolites, and it was determined these quantitative differences were due to collision energy differences or kinetic isotope effects between the unlabeled metabolites and the corresponding labeled isotopologue internal standards. Overall quantitative data acquired by HRMS were similar to data acquired on TQ MS/MS platform. A proof-of-concept hybrid DI-HRMS and SIM/PRM/FullScan method was developed demonstrating the ability to hybridize targeted newborn screening with metabolomic screening.

      6. Structure-guided optimization of inhibitors of acetyltransferase Eis from Mycobacterium tuberculosisexternal icon
        Punetha A, Ngo HX, Holbrook SY, Green KD, Willby MJ, Bonnett SA, Krieger K, Dennis EK, Posey JE, Parish T, Tsodikov OV, Garneau-Tsodikova S.
        ACS Chem Biol. 2020 May 18.
        The enhanced intracellular survival (Eis) protein of Mycobacterium tuberculosis (Mtb) is a versatile acetyltransferase that multiacetylates aminoglycoside antibiotics abolishing their binding to the bacterial ribosome. When overexpressed as a result of promoter mutations, Eis causes drug resistance. In an attempt to overcome the Eis-mediated kanamycin resistance of Mtb, we designed and optimized structurally unique thieno[2,3-d]pyrimidine Eis inhibitors toward effective kanamycin adjuvant combination therapy. We obtained 12 crystal structures of enzyme-inhibitor complexes, which guided our rational structure-based design of 72 thieno[2,3-d]pyrimidine analogues divided into three families. We evaluated the potency of these inhibitors in vitro as well as their ability to restore the activity of kanamycin in a resistant strain of Mtb, in which Eis was upregulated. Furthermore, we evaluated the metabolic stability of 11 compounds in vitro. This study showcases how structural information can guide Eis inhibitor design.

    • Maternal and Child Health
      1. Epidemiology of sudden death in a population-based study of infants and childrenexternal icon
        Burns KM, Cottengim C, Dykstra H, Faulkner M, Erck Lambert AB, MacLeod H, Novak A, Parks SE, Russell MW, Shapiro-Mendoza CK, Shaw E, Tian N, Whittemore V, Kaltman JR.
        Journal of Pediatrics: X. 2020 ;2.
        Objective: To describe epidemiologic data from the Sudden Death in the Young (SDY) Case Registry. Understanding the scope of SDY may optimize prevention efforts. Study design: We analyzed sudden, unexpected deaths of infants (<365 days) and children (1-17 years) from a population-based registry of 8 states/jurisdictions in 2015 and 9 in 2016. Natural deaths and injury deaths from drowning, motor vehicle accident drivers, and infant suffocation were included; other injury deaths, homicide, suicide, intentional overdose, and terminal illness were excluded. Cases were categorized using a standardized algorithm. Descriptive statistics were used to characterize deaths, and mortality rates were calculated. Results: Of 1319 cases identified, 92% had an autopsy. We removed incomplete cases, leaving 1132 analyzable deaths (889 infants, 243 children). The SDY rate for infants was 120/100 000 live births and for children was 1.9/100 000 children. Explained Cardiac rates were greater for infants (2.7/100 000 live births) than children (0.3/100 000 children). The pediatric Sudden Unexpected Death in Epilepsy (SUDEP) mortality rate was 0.2/100 000 live births and children. Blacks comprised 42% of infant and 43% of child deaths but only 23% of the population. In all ages, myocarditis/endocarditis was the most common Explained Cardiac cause; respiratory illness was the most common Explained Other cause. SDY occurred during activity in 13% of childhood cases. Conclusions: Prevention strategies include optimizing identification and treatment of respiratory and cardiac diseases.

      2. OBJECTIVES: To measure the rates of thyroid gland imaging and levothyroxine (L-T4) discontinuation and to assess whether discontinuation was monitored with thyroid stimulating hormone (TSH) testing in subjects with congenital hypothyroidism. STUDY DESIGN: This is a retrospective analysis of claims data from the IBM MarketScan Databases for children born during 2010-2016 and continuously enrolled in a non-capitated employer-sponsored private health insurance plan or in Medicaid for >/=36 months from the date of the first filled L-T4 prescription. RESULTS: 263 privately-insured and 241 Medicaid-enrolled children met the inclusion criteria. More privately-insured than Medicaid-enrolled children had imaging between the first filled prescription and 180 days after the last filled prescription (24.3% vs. 12.9%; P = .001). By 36 months, 35.7% discontinued L-T4, with no difference by insurance status (P=0.48). Among those who discontinued, 29.1% of privately-insured children and 47.7% of Medicaid-enrolled children had no claims for TSH testing within the next 180 days (P=0.01). CONCLUSIONS: Nearly one-third of children with suspected CH discontinued L-T4 by 3 years and fewer Medicaid-enrolled than privately-insured children received timely follow-up TSH testing. Future studies are indicated to understand the quality of care and developmental outcomes for children with CH and barriers to guideline adherence in evaluating for transient CH.

      3. Congenital CMV-coded diagnosis among American Indian and Alaska Native infants in the United States, 2000-2017external icon
        Leung J, Kennedy JL, Haberling DL, Apostolou A, Lanzieri TM.
        J Immigr Minor Health. 2020 May 18.
        To assess prevalence of congenital cytomegalovirus (CMV)-coded diagnosis among American Indian/Alaska Native (AI/AN) infants who received Indian Health Service (IHS)-funded care during 2000-2017. Using data from the Indian Health Service National Data Warehouse, we identified AI/AN infants with congenital CMV-coded diagnosis, defined as presence of a diagnostic code for congenital CMV disease or CMV infection (International Classification of Diseases, Ninth Revision or Tenth Revision, Clinical Modification 771.1, 078.5, P35.1, B25.xx) within 90 days of life. We calculated prevalence of congenital CMV-coded diagnosis overall, by age at first CMV-coded diagnosis, and by geographical region. During 2000-2017, 54 (1.5/10,000) of 354,923 AI/AN infants had a congenital CMV-coded diagnosis; 32 (0.9/10,000) had their first CMV-coded diagnosis within 45 days of life, and 22 (0.6/10,000) between 46 and 90 days of life. Prevalence of congenital CMV-coded diagnosis varied by region (range 0.9/10,000 in Southern Plains to 3.7/10,000 in Alaska, P = 0.0038). Among the 54 infants with a congenital CMV-coded diagnosis, 48% had clinical signs such as jaundice, petechiae, or microcephaly, compared to 25% of 354,869 infants without a CMV-coded diagnosis (P < 0.01); and 1 (2%) vs. 277 (0.1%), respectively, died (P < 0.05). The prevalence of congenital CMV-coded diagnosis among AI/AN infants who received care at IHS facilities was slightly lower than in other studies based on health claims data and varied by geographical region.

      4. Etiology of prelingual hearing loss in the universal newborn hearing screening era: A scoping reviewexternal icon
        Satterfield-Nash A, Umrigar A, Lanzieri TM.
        Otolaryngol Head Neck Surg. 2020 May 19.
        OBJECTIVE: To conduct a scoping review on etiologic investigation of prelingual hearing loss among children <2 years of age in the era of universal newborn hearing screening (UNHS). DATA SOURCES: PubMed, Embase, PsycInfo, CINAHL, and Cochrane Library databases. REVIEW METHODS: We searched for articles published from January 1, 1998, to February 19, 2020. We reviewed studies that (1) included children identified with either congenital or delayed-onset hearing loss before 2 years of age among cohorts who had undergone UNHS and (2) investigated >/=1 etiologies of hearing loss. We defined hearing loss as congenital when confirmed after UNHS failure and as delayed onset when diagnosed after >/=1 assessments with normal hearing. RESULTS: Among 2069 unique citations, 115 studies met criteria for full-text assessment, and 20 met our inclusion criteria. Six studies tested children diagnosed with hearing loss for genetic etiology, 9 for congenital cytomegalovirus (CMV) infection, and 5 for both. Among 1787 children with congenital hearing loss and etiologic investigation, 933 (52.2%) were tested for genetic mutations and 1021 (57.1%) for congenital CMV infection. The proportion of congenital hearing loss cases attributable to genetic etiology ranged between 7.7% and 83.3% and to congenital CMV infection between 0.0% and 32.0%. CONCLUSION: Data are lacking on the identification and etiology of delayed-onset hearing loss in children <2 years of age in the UNHS era. The proportion of congenital hearing loss cases attributable to genetic etiologies and congenital CMV infection appears to vary widely.

    • Nutritional Sciences
      1. PURPOSE: Examine association of health literacy (HL) and menu-labeling (ML) usage with sugar-sweetened beverage (SSB) intake among adults in Mississippi. DESIGN: Quantitative, cross-sectional study. SETTING: 2016 Mississippi Behavioral Risk Factor Surveillance System data. PARTICIPANTS: Adults living in Mississippi (n = 4549). MEASURES: Outcome variable was SSB intake (regular soda, fruit drinks, sweet tea, and sports/energy drinks). Exposure variables were 3 HL questions (find information, understand oral information, and understand written information) and ML usage among adults who eat at fast-food/chain restaurants (user, nonuser, and do not notice ML). ANALYSIS: Multinomial logistic regressions were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for SSB intake >/=1 time/d (reference: 0 times/d) associated with HL and ML. RESULTS: In Mississippi, 46.8% of adults consumed SSB >/=1 time/d, and 26.9% consumed >/=2 times/d. The odds of consuming SSBs >/=1 time/d were higher among adults with lower HL (aOR = 1.7; 95% CI = 1.3-2.2) than those with higher HL. Among adults who ate at fast-food/chain restaurants, the odds of consuming SSBs >/=1 time/d were higher among nonusers of ML (aOR = 2.3; 95% CI = 1.7-3.1) and adults who did not notice ML (aOR = 1.8; 95% CI = 1.3-2.6) than ML users. CONCLUSION: Adults with lower HL and adults who do not use or notice ML consumed more SSBs in Mississippi. Understanding why lower HL and no ML usage are linked to SSB intake could guide the design of interventions to reduce SSB intake in this population.

    • Occupational Safety and Health
      1. Challenges and recommendations on the conduct of systematic reviews of observational epidemiologic studies in environmental and occupational healthexternal icon
        Arroyave WD, Mehta SS, Guha N, Schwingl P, Taylor KW, Glenn B, Radke EG, Vilahur N, Carreon T, Nachman RM, Lunn RM.
        J Expo Sci Environ Epidemiol. 2020 May 15.
        Systematic reviews are powerful tools for drawing causal inference for evidence-based decision-making. Published systematic reviews and meta-analyses of environmental and occupational epidemiology studies have increased dramatically in recent years; however, the quality and utility of published reviews are variable. Most methodologies were adapted from clinical epidemiology and have not been adequately modified to evaluate and integrate evidence from observational epidemiology studies assessing environmental and occupational hazards, especially in evaluating the quality of exposure assessments. Although many reviews conduct a systematic and transparent assessment for the potential for bias, they are often deficient in subsequently integrating across a body of evidence. A cohesive review considers the impact of the direction and magnitude of potential biases on the results, systematically evaluates important scientific issues such as study sensitivity and effect modifiers, identifies how different studies complement each other, and assesses other potential sources of heterogeneity. Given these challenges of conducting informative systematic reviews of observational studies, we provide a series of specific recommendations based on practical examples for cohesive evidence integration to reach an overall conclusion on a body of evidence to better support policy making in public health.

      2. The effect of blood glucose on quiet standing balance in young healthy individualsexternal icon
        Breloff SP, Bachman JL, Lugade VA, Stuka AD.
        Biomed Eng (Singapore). 2020 ;32(2).
        Falling is one of the leading causes of accidental injury and death among elderly adults and construction workers, with costs exceeding US31 billion each year. Having good balance reduces the likelihood of falling - therefore it is important to determine which possible factors might influence balance. The purpose of this study was to determine if consuming three different types of breakfast altered blood glucose levels in such a way that young healthy individual's balance control was compromised. Balance was then measured while the subjects completed single- and dual-task standing trials with eyes open and closed. Although changing blood glucose did alter quiet standing balance - as measured by the separation distance between the COG and COP, the velocity of the COM, and the total distance traveled by the COG and COP along the anterior-posterior (AP) and medial-lateral (ML) axes - the results were contradictory to what was hypothesized. Subjects with lower blood glucose swayed less than those with higher blood glucose. This could potentially be due to the habitual skipping of breakfast in young adults. Though the changing of blood glucose did influence quiet standing balance of young healthy adults, it was not in a way which increased the risk of falling.

      3. Recent studies have shown that high concentrations of ultrafine particles can be emitted during the 3D printing process. This study characterized the emissions from different filaments using common fused deposition modeling printers. It also assessed the effectiveness of a novel engineering control designed to capture emissions directly at the extruder head. Airborne particle and volatile organic compound concentrations were measured, and particle emission rates were calculated for several different 3D printer and filament combinations. Each printer and filament combination was tested inside a test chamber to measure overall emissions using the same print design for approximately 2 h. Emission rates ranged from 0.71 × 107 to 1400 × 107 particles/min, with particle geometric mean diameters ranging from 45.6 to 62.3 nm. To assess the effectiveness of a custom-designed engineering control, a 1-h print program using a MakerBot Replicator+ with Slate Gray Tough polylactic acid filament was employed. Emission rates and particle counts were evaluated both with and without the extruder head emission control installed. Use of the control showed a 98% reduction in ultrafine particle concentrations from an individual 3D printer evaluated in a test chamber. An assessment of the control in a simulated makerspace with 20 printers operating showed particle counts approached or exceeded 20,000 particles/cm3 without the engineering controls but remained at or below background levels (&lt; 1000 particles/cm3) with the engineering controls in place. This study showed that a low-cost control could be added to existing 3D printers to significantly reduce emissions to the work environment.

      4. Effects of working posture and roof slope on activation of lower limb muscles during shingle installationexternal icon
        Dutta A, Breloff SP, Dai F, Sinsel EW, Warren CM, Carey RE, Wu JZ.
        Ergonomics. 2020 May 21:1-17.
        Awkward and extreme kneeling during roofing generates high muscular tension which can lead to knee musculoskeletal disorders (MSDs) among roofers. However, the combined impact of roof slope and kneeling posture on the activation of the knee postural muscles and their association to potential knee MSD risks among roofers have not been studied. The current study evaluated the effects of kneeling posture and roof slope on the activation of major knee postural muscles during shingle installation via a laboratory assessment. Maximum normalized electromyography (EMG) data were collected from knee flexor and extensor muscles of seven subjects, who mimicked the shingle installation process on a slope-configurable wooden platform. The results revealed a significant increase in knee muscle activation during simulated shingle installation on sloped rooftops. Given the fact that increased muscle activation of knee postural muscles has been associated with knee MSDs, roof slope and awkward kneeling posture can be considered as potential knee MSD risk factors.Practitioner Summary: This study demonstrated significant effects of roof slope and kneeling posture on the peak activation of knee postural muscles. The findings of this study suggested that residential roofers could be exposed to a greater risk of developing knee MSDs with the increase of roof slope during shingle installation due to increased muscle loading.

      5. Nurse health: The influence of chronotype and shift timingexternal icon
        Hittle BM, Caruso CC, Jones HJ, Bhattacharya A, Lambert J, Gillespie GL.
        West J Nurs Res. 2020 May 17.
        Extreme chronotype and circadian disrupting work hours may increase nurse disease risks. This national, cross-sectional study of nurses (N = 527) had three hypotheses. When chronotype and shift times are incongruent, nurses will experience increased likelihood of (1) obesity, (2) cardiovascular disease/risk factors, and (3) obesity or cardiovascular disease/risk factors when theoretically linked variables exist. Chronotype mismatched nurses' (n = 206) average sleep (6.1 hours, SD = 1.2) fell below 7-9 hours/24-hours sleep recommendations. Proportion of male nurses was significantly higher chronotype mismatched (12.3%) than matched (6.3%). Analyses found no direct relationship between chronotype match/mismatch with outcome variables. Exploratory interaction analysis demonstrated nurses with mismatched chronotype and above average sleep quality had an estimated 3.51 times the adjusted odds (95% CI 1.52,8.17; p = .003) of being obese. Although mechanism is unclear, this suggests sleep quality may be intricately associated with obesity. Further research is needed to inform nurses on health risks from disrupted sleep, chronotypes, and shift work.

    • Parasitic Diseases

      2. Notes from the field: Impact of a mass drug administration campaign using a novel three-drug regimen on lymphatic filariasis antigenemia - American Samoa, 2019external icon
        Hast MA, Tufa A, Brant TA, Suiaunoa-Scanlan L, Camacho J, Vaifanua-Leo J, Robinson K, Dodd E, Sili B, Lees LS, Won KY, Utu F.
        MMWR Morb Mortal Wkly Rep. 2020 May 29;69(21):656-657.

      3. Malaria in the pregnant travelerexternal icon
        McKinney KL, Wu HM, Tan KR, Gutman JR.
        J Travel Med. 2020 May 18.
        Pregnant travelers face numerous risks, notably increased susceptibility to or severity of multiple infections, including malaria. Because pregnant women residing in areas non-endemic for malaria are unlikely to have protective immunity, travel to endemic areas poses risk of severe illness and pregnancy complications, such as low birthweight and fetal loss. If travel to malaria endemic areas cannot be avoided, preventive measures are critical. However, malaria chemoprophylaxis in pregnancy can be challenging, since commonly used regimens have varying levels of safety data, and national guidelines differ. Furthermore, although chloroquine and mefloquine have wide acceptance for use in pregnancy, regional malaria resistance and non-pregnancy contraindications limit their use. Mosquito repellents, including DEET and permethrin treatment of clothing, are considered safe in pregnancy and important to prevent malaria as well as other arthropod-borne infections such as Zika virus infection. Pregnant travelers at risk for malaria exposure should be advised to seek medical attention immediately if any symptoms of illness, particularly fever, develop.

    • Substance Use and Abuse
      1. Demographics, substance use behaviors, and clinical characteristics of adolescents with e-cigarette, or vaping, product use-associated lung injury (EVALI) in the United States in 2019external icon
        Adkins SH, Anderson KN, Goodman AB, Twentyman E, Danielson ML, Kimball A, Click ES, Ko JY, Evans ME, Weissman DN, Melstrom P, Kiernan E, Krishnasamy V, Rose DA, Jones CM, King BA, Ellington SR, Pollack LA, Wiltz JL.
        JAMA Pediatr. 2020 May 18:e200756.
        Importance: To date, limited information is available on the characteristics of adolescents with e-cigarette, or vaping, product use-associated lung injury (EVALI). Objective: To inform public health and clinical practice by describing differences in demographics, substance use behaviors, and clinical characteristics of EVALI among adolescents compared with adults. Design, Setting, and Participants: Surveillance data reported to the Centers for Disease Control and Prevention during the 2019 EVALI outbreak were used to calculate adjusted prevalence ratios (aPRs) with 95% CIs and to test differences between 360 hospitalized or deceased adolescents vs 859 young adults and 936 adults with EVALI (N = 2155). Main Outcomes and Measures: Demographics, substance use behaviors, and clinical characteristics. Results: Included in this cross-sectional study were 360 hospitalized or deceased adolescents (age range, 13-17 years; 67.9% male) vs 859 young adults (age range, 18-24 years; 72.4% male) and 936 adults (age range, 25-49 years; 65.6% male) with EVALI. Adolescents diagnosed as having EVALI reported using any nicotine-containing (62.4%), any tetrahydrocannabinol (THC)-containing (81.7%), and both (50.8%) types of e-cigarette or vaping products. Informal sources for obtaining nicotine-containing and THC-containing e-cigarette or vaping products were more commonly reported by adolescents (50.5% for nicotine and 96.5% for THC) than young adults (19.8% for nicotine [aPR, 2.49; 95% CI, 1.78-3.46] and 86.9% for THC [aPR, 1.11; 95% CI, 1.05-1.18]) or adults (24.3% for nicotine [aPR, 2.06; 95% CI, 1.49-2.84] and 75.1% for THC [aPR, 1.29; 95% CI, 1.19-1.40]). Mental, emotional, or behavioral disorders were commonly reported; a history of attention-deficit/hyperactivity disorder was almost 4 times more likely among adolescents (18.1%) than adults (4.9%) (aPR, 3.74; 95% CI, 1.92-7.26). A history of asthma was more likely to be reported among adolescents (43.6%) than adults (28.3%) (aPR, 1.53; 95% CI, 1.14-2.05). Gastrointestinal and constitutional symptoms were more common in adolescents (90.9% and 97.3%, respectively) than adults (75.3% and 94.5%, respectively) (aPR, 1.20; 95% CI, 1.13-1.28 and aPR, 1.03; 95% CI, 1.00-1.06, respectively). Because of missing data, percentages may not be able to be calculated from data provided. Conclusions and Relevance: Public health and clinical professionals should continue to provide information to adolescents about the association between EVALI and THC-containing e-cigarette or vaping product use, especially those products obtained through informal sources, and that the use of any e-cigarette or vaping product is unsafe. Compared with adults, it appears that adolescents with EVALI more frequently have a history of asthma and mental, emotional, or behavioral disorders, such as attention-deficit/hyperactivity disorder, and report nonspecific problems, including gastrointestinal and constitutional symptoms; therefore, obtaining a confidential substance use history that includes e-cigarette or vaping product use is recommended.

      2. Opioid prescribing history prior to heroin overdose among commercially insured adultsexternal icon
        Lagisetty P, Zhang K, Haffajee RL, Lin LA, Goldstick J, Brownlee R, Bohnert A, Larochelle MR.
        Drug Alcohol Depend. 2020 May 12;212:108061.
        BACKGROUND: Since 2010, heroin-related overdoses have risen sharply, coinciding with policies to restrict access to prescription opioids. It is unknown if patients tapered or discontinued off prescription opioids transitioned to riskier heroin use. This study examined opioid prescribing, including long-term opioid therapy (LTOT) and discontinuation, prior to heroin overdose. METHODS: We used retrospective longitudinal data from a national claims database to identify adults with an emergency or inpatient claim for heroin overdose between January 2010 and June 2017. Receipt of opioid prescription, LTOT episodes, and discontinuation of LTOT were measured for the period of one year prior to heroin overdose. RESULTS: We identified 3183 individuals (53.2% age 18-25; 70.0% male) with a heroin overdose (incidence rate 4.20 per 100k person years). Nearly half (42.3%) received an opioid prescription in the prior 12 months, and 10.9% had an active opioid prescription in the week prior to overdose. LTOT at any time in the 12 months prior to overdose was uncommon (12.8%) among those with heroin overdoses, especially among individuals 18-25 years old (3.5%, P < 0.001). LTOT discontinuation prior to overdose was also relatively uncommon, experienced by 6.7% of individuals aged 46 and over and 2.5% of individuals aged 18-25 years (P < 0.001). CONCLUSIONS: Prior to heroin overdose, prescription opioid use was common, but LTOT discontinuation was uncommon and observed primarily in older individuals with the lowest heroin overdose rates. Further study is needed to determine if these prescribing patterns are associated with increased heroin overdose.

      3. Tobacco use by pregnant Medicaid beneficiaries: Validating a claims-based measure in Oregonexternal icon
        Luck J, Larson AE, Tong VT, Yoon J, Oakley LP, Harvey SM.
        Prev Med Rep. 2020 Sep;19:101039.
        In Oregon, more than 4 in 5 pregnant women who smoke are covered by Medicaid. Although birth certificate data for smoking during pregnancy are not accessible in a timely manner, Medicaid claims data are available monthly and provide person-level data. This study utilized an individually linked database of Medicaid claims and birth certificate data to compare the prevalence of tobacco use diagnosis codes in Medicaid claims data to self-reported smoking during pregnancy reported on birth certificates. We computed the sensitivity and specificity of Medicaid claims data to ascertain tobacco use during pregnancy compared to self-report on linked birth certificates. Using logistic regression models, we also examined demographic, prenatal care, and behavioral health factors that predicted agreement between claims and birth certificates. From 2008 to 2013, 17.9% of women with Medicaid births reported smoking during pregnancy on birth certificates compared to 3.8% of non-Medicaid births. Tobacco-related claims during pregnancy were present for 12.6% of Medicaid births. Overall agreement between claims and birth certificates rose from 87.0% in 2008 to 90.2% in 2013; sensitivity rose from 43.0% to 62.2%. Sensitivity was lowest for Hispanic women and highest for White women, and declined as maternal education increased. Sensitivity was 33.9 percentage points higher for women with any mental illness diagnosis and 27.3 percentage points higher for women with any substance use disorder diagnosis. Specificity was greater than 95% in all years. Medicaid claims data may help in surveillance of maternal smoking rates and assessment of smoking cessation programs for female Medicaid beneficiaries of reproductive age.

      4. Adolescent opioid misuse attributable to adverse childhood experiencesexternal icon
        Swedo EA, Sumner SA, de Fijter S, Werhan L, Norris K, Beauregard JL, Montgomery MP, Rose EB, Hillis SD, Massetti GM.
        J Pediatr. 2020 May 10.
        OBJECTIVES: To estimate the proportion of opioid misuse attributable to adverse childhood experiences (ACEs) among adolescents. STUDY DESIGN: A cross-sectional survey was administered to 10,546 7th12th grade students in northeastern Ohio in Spring 2018. Study measures included self-reported lifetime exposure to 10 ACEs and past 30 day use of nonmedical prescription opioid or heroin. Using generalized estimating equations, we evaluated associations between recent opioid misuse, individual ACEs, and cumulative number of ACEs. We calculated population attributable fractions (PAF) to determine the proportion of adolescents' recent opioid misuse attributable to ACEs. RESULTS: Nearly one in 50 adolescents reported opioid misuse within 30 days (1.9%); approximately 60% of youth experienced >/=1 ACE; 10.2% experienced >/=5 ACEs. Cumulative ACE exposure demonstrated a significant graded relationship with opioid misuse. Compared with youth with zero ACEs, youth with 1 ACE (adjusted odds ratio [AOR]: 1.9, 95% confidence interval [CI]: 0.93.9), 2 ACEs (AOR: 3.8, CI: 1.97.9), 3 ACEs (AOR: 3.7, CI: 2.26.5), 4 ACEs (AOR: 5.8, CI: 3.111.2), and >/=5 ACEs (AOR: 15.3, CI: 8.826.6) had higher odds of recent opioid misuse. The population attributable fraction of recent opioid misuse associated with experiencing >/=1 ACE was 71.6% (CI: 59.8-83.5). CONCLUSIONS: There was a significant graded relationship between number of ACEs and recent opioid misuse among adolescents. Over 70% of recent adolescent opioid misuse in our study population was attributable to ACEs. Efforts to decrease opioid misuse could include programmatic, policy, and clinical practice interventions to prevent and mitigate the negative effects of ACEs.

    • Zoonotic and Vectorborne Diseases
      1. Barriers to attendance of canine rabies vaccination campaigns in Haiti, 2017external icon
        Barbosa Costa G, Ludder F, Monroe B, Dilius P, Crowdis K, Blanton JD, Pieracci EG, Head JR, Gibson AD, Wallace RM.
        Transbound Emerg Dis. 2020 May 21.
        We conducted a cross-sectional survey to better understand the barriers to attendance at canine rabies vaccination campaigns in Haiti. A structured community-based questionnaire was conducted over a 15-day period during May-June 2017, focused on socio-economic status correlated with participation at canine rabies vaccination campaigns. Questions phrased as a bidding game were asked to determine individuals' willingness to pay (WTP) for dog rabies vaccination and willingness to walk (WTW) to fixed-point vaccination campaigns. The Kaplan-Meier estimator was applied to determine relationships between survey variables. Logistic regression was used to examine factors associated with participants' WTP and WTW. A total of 748 households from eight communities were surveyed. Respondents were predominantly female (54.4%) and had a median age of 45 years. The total number of owned dogs reported from households was 926, yielding a human-to-dog ratio in dog-owning households of 5.2:1. The majority of dogs (87.2%) were acquired for security, and 49% were allowed to roam freely; 42.0% of dog owners reported that they were unable to manage (or restrain) their dogs using a leash. Seventy per cent of dog owners were willing to pay up to 15.9 gourdes (0.25 USD) and/or walk up to 75 m to vaccinate their dogs. Households that owned free-roaming dogs, owned dogs for the purpose of companionship and owned dogs that they were unable to walk on a leash were associated with a higher WTP for vaccination. Living in Artibonite Department, having a middle or higher household income, and owning a dog for security purpose were associated with a higher WTW for vaccination. Low leash use and propensity for dogs to roam freely are barriers to successful fixed-point vaccination methods in Haiti, and alternative methods such as door to door (DD), capture-vaccinate-release (CVR) or oral vaccination should be explored. There may be some prospect for fee-for-service vaccination in Haiti; however, this programme should be introduced as a supplement, rather than a replacement for free rabies vaccination programmes so that mass dog vaccination is not discouraged.

      2. Brucellosis knowledge, attitudes and practices of a South African communal cattle keeper groupexternal icon
        Cloete A, Gerstenberg C, Mayet N, Tempia S.
        Onderstepoort J Vet Res. 2019 Feb 18;86(1):e1-e10.
        Brucellosis remains an animal and public health concern in South Africa, given the intensity and widespread distribution of outbreaks in cattle. We conducted a cross-sectional survey among cattle keepers in the Whittlesea community of the Eastern Cape Province of South Africa, which utilises communal grazing. Individual cattle keepers (N = 227) who attended prearranged meetings in selected villages were interviewed using a structured questionnaire to assess their knowledge, attitude and practices (KAP) regarding bovine brucellosis. We compared KAP scores between previous brucellosis-affected villages and unaffected villages. We compared attitude and practices scores between those who had heard of brucellosis and those who had not and between those above the 75th percentile knowledge score and those below. The KAP for the study population were described using frequency tables. Scores of different groups were compared using the Welch t-test or the Wilcoxon rank-sum test. Knowledge scores of those who had heard of brucellosis (60%) showed a bimodal distribution with a 0/18 primary peak and 5-6/18 secondary peak. Attitude scores showed a median of 7/14 (interquartile range [IQR] 6-9), with 98% requesting more information on brucellosis. Practices scores showed a median of 6/18 (IQR 3-8), with high-risk practices identified that could facilitate brucellosis transmission. There were significant differences in attitude and practices scores between the groups above and below the 75th percentile knowledge score. The community showed poor knowledge, poor to average practices and average to good attitude. Identified high-risk practices highlight the risk of potential introduction and transmission of brucellosis between cattle and zoonotic transmission to humans.

      3. Etiology of microcephaly and central nervous system defects during the Zika epidemic in Colombiaexternal icon
        Galang RR, Avila GA, Valencia D, Daza M, Tong VT, Bermudez AJ, Gilboa SM, Rico A, Cates J, Pacheco O, Winfield CM, Prieto F, Honein MA, Cortes LJ, Moore CA, Ospina ML.
        J Pediatr. 2020 May 13.
        OBJECTIVE: To estimate the prevalence of microcephaly and central nervous system (CNS) defects during the Zika virus (ZIKV) epidemic in Colombia and proportion attributable to congenital ZIKV infection. STUDY DESIGN: Clinical and laboratory data for cases of microcephaly and/or CNS defects reported to national surveillance between 2015 and 2017 were reviewed and classified by a panel of clinical subject matter experts. Maternal and fetal/infant biologic specimens were tested for congenital infection and chromosomal abnormalities. Infants/fetuses with microcephaly and/or CNS defects (cases) were classified into broad etiologic categories (teratogenic, genetic, multifactorial, and unknown). Cases classified as potentially attributable to congenital ZIKV infection were stratified by strength of evidence for ZIKV etiology (strong, moderate, or limited) using a novel strategy considering birth defects unique or specific to ZIKV or other infections and laboratory evidence. RESULTS: Among 858 reported cases with sufficient information supporting a diagnosis of microcephaly or CNS defects, 503 were classified as potentially attributable to congenital ZIKV infection. Of these, the strength of evidence was considered strong in 124 (24.7%) cases; moderate in 232 (46.1%) cases; and limited in 147 (29.2%). Of the remaining, 355 (41.4%) were attributed to etiologies other than ZIKV infection (syphilis, toxoplasmosis, rubella, cytomegalovirus, herpes 1 and herpes 2 viruses only, n = 32 [3.7%]; genetic, n = 16 [1.9%]; multifactorial, n = 42 [4.9%]; unknown, n = 265 [30.9%]). CONCLUSIONS: Fifty-eight percent of cases of microcephaly and/or CNS defects were potentially attributable to congenital ZIKV infection; however, the strength of evidence varied considerably. This surveillance protocol might serve as a model approach for investigation and etiologic classification of complex congenital conditions.

      4. Evidence of behaviour change during an Ebola virus disease outbreak, Sierra Leonepdf iconexternal icon
        Jalloh MF, Sengeh P, Bunnell RE, Jalloh MB, Monasch R, Li W, Mermin J, Deluca N, Brown V, Nur SA, August EM, Ransom RL, Namageyo-Funa A, Clements SA, Dyson M, Hageman K, Pratt SA, Nuriddin A, Carroll DD, Hawk N, Manning C, Hersey S, Marston BJ, Kilmarx PH, Conteh L, Ekström AM, Zeebari Z, Redd JT, Nordenstedt H, Morgan O.
        Bull World Health Organ. 2020 ;98(5):330-340B.
        Objective To evaluate changes in Ebola-related knowledge, attitudes and prevention practices during the Sierra Leone outbreak between 2014 and 2015. Methods Four cluster surveys were conducted: two before the outbreak peak (3499 participants) and two after (7104 participants). We assessed the effect of temporal and geographical factors on 16 knowledge, attitude and practice outcomes. Findings Fourteen of 16 knowledge, attitude and prevention practice outcomes improved across all regions from before to after the outbreak peak. The proportion of respondents willing to: (i) welcome Ebola survivors back into the community increased from 60.0% to 89.4% (adjusted odds ratio, aOR: 6.0; 95% confidence interval, CI: 3.9–9.1); and (ii) wait for a burial team following a relative’s death increased from 86.0% to 95.9% (aOR: 4.4; 95% CI: 3.2–6.0). The proportion avoiding unsafe traditional burials increased from 27.3% to 48.2% (aOR: 3.1; 95% CI: 2.4–4.2) and the proportion believing spiritual healers can treat Ebola decreased from 15.9% to 5.0% (aOR: 0.2; 95% CI: 0.1–0.3). The likelihood respondents would wait for burial teams increased more in high-transmission (aOR: 6.2; 95% CI: 4.2–9.1) than low-transmission (aOR: 2.3; 95% CI: 1.4–3.8) regions. Self-reported avoidance of physical contact with corpses increased in high but not low-transmission regions, aOR: 1.9 (95% CI: 1.4–2.5) and aOR: 0.8 (95% CI: 0.6–1.2), respectively. Conclusion Ebola knowledge, attitudes and prevention practices improved during the Sierra Leone outbreak, especially in high-transmission regions. Behaviourally-targeted community engagement should be prioritized early during outbreaks.

      5. A framework for coordination between obstetric and pediatric providers in public health emergencies: Lessons learned from the Zika outbreak in the United States, 2015 to 2017external icon
        Leeb RT, Cree RA, Aird L, DeBiasi RL, Driggers RW, Garbarczyk E, Mofenson LM, Needle S, Rodriguez J, Curry C, Garcia F, Godfred-Cato S, Hawks D, Rosenblum E, Dziuban E, Hudak M.
        Am J Perinatol. 2020 May 21.
        Emergency response to emerging threats with the potential for vertical transmission, such as the 2015 to 2017 response to Zika virus, presents unique clinical challenges that underscore the need for better communication and care coordination between obstetric and pediatric providers to promote optimal health for women and infants. Published guidelines for routine maternal-infant care during the perinatal period, and models for transitions of care in various health care settings are available, but no broad framework has addressed coordinated multidisciplinary care of the maternal-infant dyad during emergency response. We present a novel framework and strategies to improve care coordination and communication during an emergency response. The proposed framework includes (1) identification and collection of critical information to inform care, (2) key health care touchpoints for the maternal-infant dyad, and (3) primary pathways of communication and modes of transfer across touchpoints, as well as practical strategies. This framework and associated strategies can be modified to address the care coordination needs of pregnant women and their infants with possible exposure to other emerging infectious and noninfectious congenital threats that may require long-term, multidisciplinary management. KEY POINTS: . Emerging congential threats present unique coordination challenges for obstetric and pediatric clinicians during emergency response.. . We present a framework to help coodinate care of pregnant women/infants exposed to congenital threats.. . The framework identifies critical information to inform care, health care touchpoints, and communication/information transfer pathways..

      6. Immunologic timeline of Ebola virus disease and recovery in humansexternal icon
        McElroy AK, Akondy RS, McLlwain DR, Chen H, Bjornson-Hooper Z, Mukherjee N, Mehta AK, Nolan G, Nichol ST, Spiropoulou CF.
        JCI Insight. 2020 May 21;5(10).
        A complete understanding of human immune responses to Ebola virus infection is limited by the availability of specimens and the requirement for biosafety level 4 (BSL-4) containment. In an effort to bridge this gap, we evaluated cryopreserved PBMCs from 4 patients who survived Ebola virus disease (EVD) using an established mass cytometry antibody panel to characterize various cell populations during both the acute and convalescent phases. Acute loss of nonclassical monocytes and myeloid DCs, especially CD1c+ DCs, was noted. Classical monocyte proliferation and CD38 upregulation on plasmacytoid DCs coincided with declining viral load. Unsupervised analysis of cell abundance demonstrated acute declines in monocytic, NK, and T cell populations, but some populations, many of myeloid origin, increased in abundance during the acute phase, suggesting emergency hematopoiesis. Despite cell losses during the acute phase, upregulation of Ki-67 correlated with recovery of cell populations over time. These data provide insights into the human immune response during EVD.

      7. As the number of human infections with avian and swine influenza viruses continues to rise, the pandemic risk posed by zoonotic influenza viruses cannot be underestimated. Implementation of global pandemic preparedness efforts has largely focused on H5 and H7 avian influenza viruses; however, the pandemic threat posed by other subtypes of avian influenza viruses, especially the H9 subtype, should not be overlooked. In this review, we summarize the literature pertaining to the emergence, prevalence and risk assessment of H9N2 viruses, and add new molecular analyses of key mammalian adaptation markers in the hemagglutinin and polymerase proteins. Available evidence has demonstrated that H9N2 viruses within the Eurasian lineage continue to evolve, leading to the emergence of viruses with an enhanced receptor binding preference for human-like receptors and heightened polymerase activity in mammalian cells. Furthermore, the increased prevalence of certain mammalian adaptation markers and the enhanced transmissibility of selected viruses in mammalian animal models add to the pandemic risk posed by this virus subtype. Continued surveillance of zoonotic H9N2 influenza viruses, inclusive of close genetic monitoring and phenotypic characterization in animal models, should be included in our pandemic preparedness efforts.


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