Volume 12, Issue 18, June 9, 2020

CDC Science Clips: Volume 12, Issue 18, June 9, 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!

  1. Top Articles of the Week
    Selected weekly by a senior CDC scientist from the standard sections listed below.
    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions
      • Introduction: Chronic diseases in the United States are the leading drivers of disability, death, and health care costs. In women of reproductive age (WRA), chronic disease and related risk factors can also affect fertility and reproductive health outcomes. This analysis of trends from 2011 to 2017 adds additional indicators and updates an analysis covering 2001-2009. Methods: Data from the 2011-2017 Behavioral Risk Factor Surveillance System were analyzed for 265,544 WRA (18-44 years). To assess trends in 12 chronic conditions and related risk factors, we calculated annual prevalence estimates and adjusted prevalence ratios (APRs) with predicted marginals accounting for age, race, Hispanic ethnicity, education, and health care coverage. Results: From 2011 to 2017, prevalence decreased for current smoking (20.7%-15.9%; p < 0.001), gestational diabetes (3.1%-2.7%; p = 0.003), and high cholesterol (19.0%-16.7%; p < 0.001); prevalence increased for depression (20.4%-24.9%; p < 0.001) and obesity (24.6%-27.6%; p < 0.001). After adjustment, in 2017 WRA were more likely to report asthma (APR = 1.06; 95% confidence interval [CI] = 1.01-1.11), physical inactivity (APR = 1.08; 95% CI = 1.04-1.12), obesity (APR = 1.15; 95% CI = 1.11-1.19), and depression (APR = 1.29; 95% CI = 1.25-1.34) compared with 2011. They were less likely to report high cholesterol (APR = 0.89; 95% CI = 0.85-0.94) in 2015 compared with 2011, and current smoking (APR = 0.86; 95% CI = 0.82-0.89) and gestational diabetes (APR = 0.84; 95% CI = 0.75-0.94) in 2017 compared with 2011. Conclusions: Some chronic conditions and related risk factors improved, whereas others worsened over time. Research clarifying reasons for these trends may support the development of targeted interventions to promote improvements, potentially preventing adverse reproductive outcomes and promoting long-term health.

      • Outcomes among pediatric patients with cancer who are treated on trial versus off trial: A matched cohort studyexternal icon
        Schapira MM, Stevens EM, Sharpe JE, Hochman L, Reiter JG, Calhoun SR, Shah SA, Bailey LC, Bagatell R, Silber JH, Tai E, Barakat LP.
        Cancer. 2020 May 26.
        BACKGROUND: Approximately 50% of children with cancer in the United States who are aged <15 years receive primary treatment on a therapeutic clinical trial. To the authors' knowledge, it remains unknown whether trial enrollment has a clinical benefit compared with the best alternative standard therapy and/or off trial (ie, clinical trial effect). The authors conducted a retrospective matched cohort study to compare the morbidity and mortality of pediatric patients with cancer who are treated on a phase 3 clinical trial compared with those receiving standard therapy and/or off trial. METHODS: Subjects were aged birth to 19 years; were diagnosed between 2000 and 2010 with acute lymphocytic leukemia (ALL), acute myeloid leukemia (AML), rhabdomyosarcoma, or neuroblastoma; and had received initial treatment at the Children's Hospital of Philadelphia. On-trial and off-trial subjects were matched based on age, race, ethnicity, a diagnosis of Down syndrome (for patients with ALL or AML), prognostic risk level, date of diagnosis, and tumor type. RESULTS: A total of 428 participants were matched in 214 pairs (152 pairs for ALL, 24 pairs for AML, 32 pairs for rhabdomyosarcoma, and 6 pairs for neuroblastoma). The 5-year survival rate did not differ between those treated on trial versus those treated with standard therapy and/or off trial (86.9% vs 82.2%; P = .093). On-trial patients had a 32% lower odds of having worse (higher) mortality-morbidity composite scores, although this did not reach statistical significance (odds ratio, 0.68; 95% confidence interval, 0.45-1.03 [P = .070]). CONCLUSIONS: There was no statistically significant difference in outcomes noted between those patients treated on trial and those treated with standard therapy and/or off trial. However, in partial support of the clinical trial effect, the results of the current study indicate a trend toward more favorable outcomes in children treated on trial compared with those treated with standard therapy and/or off trial. These findings can support decision making regarding enrollment in pediatric phase 3 clinical trials.

    • Communicable Diseases
      • The HIV Outpatient Study - 25 years of HIV patient care and epidemiologic researchexternal icon
        Buchacz K, Armon C, Palella FJ, Novak RM, Fuhrer J, Tedaldi E, Ward D, Mayer C, Battalora L, Carlson K, Purinton S, Durham M, Li J.
        Open Forum Infect Dis. 2020 May;7(5):ofaa123.
        Background: The clinical epidemiology of treated HIV infection in the United States has dramatically changed in the past 25 years. Few sources of longitudinal data exist for people with HIV (PWH) spanning that period. Cohort data enable investigating new exposure and disease associations and monitoring progress along the HIV care continuum. Methods: We synthesized key published findings and conducted primary data analyses in the HIV Outpatient Study (HOPS), an open cohort of PWH seen at public and private HIV clinics since 1993. We assessed temporal trends in health outcomes (1993-2017) and mortality (1994-2017) for 10 566 HOPS participants. Results: The HOPS contributed to characterizing new conditions (eg, lipodystrophy), demonstrated reduced mortality with earlier HIV treatment, uncovered associations between select antiretroviral agents and cardiovascular disease, and documented remarkable shifts in morbidity from AIDS opportunistic infections to chronic noncommunicable diseases. The median CD4 cell count of participants increased from 244 cells/mm(3) to 640 cells/mm(3) from 1993 to 2017. Mortality fell from 121 to 16 per 1000 person-years from 1994 to 2017 (P < .001). In 2010, 83.7% of HOPS participants had a most recent HIV viral load <200 copies/mL, compared with 92.2% in 2017. Conclusions: Since 1993, the HOPS has been detecting emerging issues and challenges in HIV disease management. HOPS data can also be used for monitoring trends in infectious and chronic diseases, immunologic and viral suppression status, retention in care, and survival, thereby informing progress toward the Ending the HIV Epidemic initiative.

      • A neighbor-based approach to identify tuberculosis exposure, the Kopanyo Studyexternal icon
        Moonan PK, Zetola NM, Tobias JL, Basotli J, Boyd R, Click ES, Dima M, Fane O, Finlay AM, Ogopotse M, Wen XJ, Modongo C, Oeltmann JE.
        Emerg Infect Dis. 2020 May;26(5):1010-1013.
        Contact investigation is one public health measure used to prevent tuberculosis by identifying and treating persons exposed to Mycobacterium tuberculosis. Contact investigations are a major tenet of global tuberculosis elimination efforts, but for many reasons remain ineffective. We describe a novel neighbor-based approach to reframe contact investigations.

      • Knowledge of infectious disease specialists regarding aspergillosis complicating influenza, United Statesexternal icon
        Toda M, Beekmann SE, Polgreen PM, Chiller TM, Jackson BR, Beer KD.
        Emerg Infect Dis. 2020 Apr;26(4):809-811.
        In an online survey, we found that nearly one fifth of physicians in the United States who responded had seen or heard about a case of invasive pulmonary aspergillosis after severe influenza at their institution. However, <10% routinely used galactomannan testing to test for this fungus in patients with severe influenza.

    • Food Safety
    • Health Disparities
      • Association between racial discrimination and health-related quality of life and the impact of social relationshipsexternal icon
        Bergeron G, Lundy De La Cruz N, Gould LH, Liu SY, Levanon Seligson A.
        Qual Life Res. 2020 May 22.
        PURPOSE: Interpersonal racial discrimination is associated with poor health. Social relationships may moderate the impact of discrimination and represent modifiable behaviors that can be targeted by public health interventions. We described citywide associations between self-reported racial discrimination and health-related quality of life among the overall New York City (NYC) adult residential population and by four main race/ethnicity groups and explored whether social relationships moderated health effects of discrimination. METHODS: We analyzed cross-sectional survey data from 2335 adults weighted to be representative of the NYC population. We measured exposures to lifetime interpersonal racial discrimination in nine domains using a modified version of the Experiences of Discrimination scale. We performed unadjusted and adjusted regression analyses on four self-rated health-related quality of life outcomes including general health, physical health, mental health, and limitations from physical or mental health. RESULTS: Overall, 47% [95% CI 44.5, 50.3] of respondents reported having experienced racial discrimination in at least one domain. In the overall population, significant associations with racial discrimination were noted in adjusted models for poor physical health, poor mental health, and limitations by poor physical and mental health. Among those exposed to racial discrimination, the risk of experiencing poor mental health was lower among those who had contact with family or friends outside their household at least once a week, compared with those who had less frequent social contact. CONCLUSION: This study provides evidence that social relationships may moderate the impact of racial discrimination on mental health and should be integrated into health promotion efforts.

    • Immunity and Immunization
      • Influenza vaccine effectiveness in the inpatient setting: Evaluation of potential bias in the test-negative design by use of alternate control groupsexternal icon
        Segaloff HE, Cheng B, Miller AV, Petrie JG, Malosh RE, Cheng C, Lauring AS, Lamerato LE, Ferdinands JM, Monto AS, Martin ET.
        Am J Epidemiol. 2020 Mar 2;189(3):250-260.
        The test-negative design is validated in outpatient, but not inpatient, studies of influenza vaccine effectiveness. The prevalence of chronic pulmonary disease among inpatients can lead to nonrepresentative controls. Test-negative design estimates are biased if vaccine administration is associated with incidence of noninfluenza viruses. We evaluated whether control group selection and effects of vaccination on noninfluenza viruses biased vaccine effectiveness in our study. Subjects were enrolled at the University of Michigan and Henry Ford hospitals during the 2014-2015 and 2015-2016 influenza seasons. Patients presenting with acute respiratory infection were enrolled and tested for respiratory viruses. Vaccine effectiveness was estimated using 3 control groups: negative for influenza, positive for other respiratory virus, and pan-negative individuals; it was also estimated for other common respiratory viruses. In 2014-2015, vaccine effectiveness was 41.1% (95% CI: 1.7, 64.7) using influenza-negative controls, 24.5% (95% CI: -42.6, 60.1) using controls positive for other virus, and 45.8% (95% CI: 5.7, 68.9) using pan-negative controls. In 2015-2016, vaccine effectiveness was 68.7% (95% CI: 44.6, 82.5) using influenza-negative controls, 63.1% (95% CI: 25.0, 82.2) using controls positive for other virus, and 71.1% (95% CI: 46.2, 84.8) using pan-negative controls. Vaccination did not alter odds of other respiratory viruses. Results support use of the test-negative design among inpatients.

    • Laboratory Sciences
    • Maternal and Child Health
      • Symptom level associations between attention-deficit hyperactivity disorder and school performanceexternal icon
        Rigoni M, Blevins LZ, Rettew DC, Kasehagen L.
        Clin Pediatr (Phila). 2020 May 22:9922820924692.
        Attention-deficit hyperactivity disorder (ADHD) is associated with reduced school performance. To determine which ADHD symptoms and subtypes have the strongest association, we used type and frequency of symptoms on the 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome (NS-DATA) to create symptom scores for inattention and hyperactivity-impulsivity and define subtypes (ADHD-Inattentive [ADHD-I], ADHD-Hyperactive-Impulsive, ADHD-Combined [ADHD-C]). Regression methods were used to examine associations between symptoms and subtype and a composite measure of school performance. Children with ADHD-C and ADHD-I had higher adjusted odds of having reduced overall school performance (ADHD-C = 5.8, 95% confidence interval [CI] = 3.1-10.9; ADHD-I = 5.5, 95% CI = 3.1-10.1) compared with children without ADHD. All inattentive symptoms were significantly related to reduced school performance in reading, writing, and handwriting, while 6 of 9 symptoms were significantly associated in mathematics. Children with ADHD-I were significantly more likely than children with other ADHD subtypes to receive a school-based Individualized Education Program or 504 Plan. ADHD-I symptoms may be broadly linked to reduced school performance.

    • Nutritional Sciences
      • Dietary sodium intake and health indicators: A systematic review of published literature between January 2015 and December 2019external icon
        Overwyk KJ, Quader ZS, Maalouf J, Bates M, Webster J, George MG, Merritt RK, Cogswell ME.
        Adv Nutr. 2020 May 25.
        As the science surrounding population sodium reduction evolves, monitoring and evaluating new studies on intake and health can help increase our understanding of the associated benefits and risks. Here we describe a systematic review of recent studies on sodium intake and health, examine the risk of bias (ROB) of selected studies, and provide direction for future research. Seven online databases were searched monthly from January 2015 to December 2019. We selected human studies that met specified population, intervention, comparison, outcome, time, setting/study design (PICOTS) criteria and abstracted attributes related to the study population, design, intervention, exposure, and outcomes, and evaluated ROB for the subset of studies on sodium intake and cardiovascular disease risks or indicators. Of 41,601 abstracts reviewed, 231 studies were identified that met the PICOTS criteria and ROB was assessed for 54 studies. One hundred and fifty-seven (68%) studies were observational and 161 (70%) focused on the general population. Five types of sodium interventions and a variety of urinary and dietary measurement methods were used to establish and quantify sodium intake. Five observational studies used multiple 24-h urine collections to assess sodium intake. Evidence mainly focused on cardiovascular-related indicators (48%) but encompassed an assortment of outcomes. Studies varied in ROB domains and 87% of studies evaluated were missing information on >/=1 domains. Two or more studies on each of 12 outcomes (e.g., cognition) not previously included in systematic reviews and 9 new studies at low ROB suggest the need for ongoing or updated systematic reviews of evidence on sodium intake and health. Summarizing evidence from assessments on sodium and health outcomes was limited by the various methods used to measure sodium intake and outcomes, as well as lack of details related to study design and conduct. In line with research recommendations identified by the National Academies of Science, future research is needed to identify and standardize methods for measuring sodium intake.

    • Zoonotic and Vectorborne Diseases

  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. Asian Americans are one of the fastest growing races in the US. The objectives of this report were to assess self-reported hypertension prevalence and treatment among Asian Americans. Merging 2013, 2015, and 2017 Behavioral Risk Factor Surveillance System data, we estimated self-reported hypertension and antihypertensive medication use among non-Hispanic Asian Americans (NHA) and compared estimates between NHA and non-Hispanic whites (NHW), and by NHA subgroup (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese/other). The prevalence of hypertension was 20.8% and 33.5%, respectively, for NHAs and NHWs (p < 0.001). Among those with hypertension, the prevalence of antihypertensive medication use was 71.6% and 78.2%, respectively, for NHAs and NHWs (p < 0.001). Among NHA subgroups, a wide range of hypertension prevalence and medication use was found. Overall NHA had a lower reported prevalence of hypertension and use of antihypertensive medication than NHW. Certain NHA subgroups had a burden comparable to high-risk disparate populations.

      2. CDC-supported epilepsy surveillance and epidemiologic studies: A review of progress since 1994external icon
        Tian N, Croft JB, Kobau R, Zack MM, Greenlund KJ.
        Epilepsy Behav. 2020 May 22:107123.
        To report progress, to identify gaps, and to plan epilepsy surveillance and research activities more effectively, the Centers for Disease Control and Prevention (CDC) Epilepsy Program has summarized findings from selected CDC-supported surveillance and epidemiologic studies about epilepsy from 1994 through 2019. We identified publications supported by CDC funding and publications conducted by the CDC Epilepsy Program alone or with partners. We included only epilepsy surveillance and epidemiologic studies focusing on epilepsy burden, epilepsy-related outcomes, and healthcare utilization. We describe the findings of these studies in the following order: 1)prevalence; 2)incidence; 3)epilepsy-related outcomes by selected demographic characteristics; 4)cysticercosis or neurocysticercosis (NCC); 5)traumatic brain injury (TBI); 6)comorbidity; 7)mortality; 8)access to care; 9)quality of care; and 10) cost. We have characterized these findings in relation to the scope of the first three domains of the 2012 Institute of Medicine report on epilepsy and its relevant first four recommendations. From 1994 through 2019, 76 publications on epilepsy-related epidemiologic and surveillance studies were identified. Over the past 25years, CDC has expanded community, state, and national surveillance on epilepsy and supported epidemiologic studies by using multiple assessment methods and validated case-ascertainment criteria to identify epilepsy burden, epilepsy-related outcomes, and healthcare utilization in the general population or in population subgroups. Among identified research opportunities, studies on epilepsy incidence and risk factors, mortality, and cost are considered as important surveillance gaps. Other remaining gaps and suggested surveillance strategies are also proposed. Findings from this review may help epilepsy researchers and other stakeholders reference and prioritize future activities for epidemiologic and surveillance studies in epilepsy.

    • Communicable Diseases
      1. Possible transmission mechanisms of mixed Mycobacterium tuberculosis infection in high HIV prevalence country, Botswanaexternal icon
        Baik Y, Modongo C, Moonan PK, Click ES, Tobias JL, Boyd R, Finlay A, Oeltmann JE, Shin SS, Zetola NM.
        Emerg Infect Dis. 2020 May;26(5):953-960.
        Tuberculosis caused by concurrent infection with multiple Mycobacterium tuberculosis strains (i.e., mixed infection) challenges clinical and epidemiologic paradigms. We explored possible transmission mechanisms of mixed infection in a population-based, molecular epidemiology study in Botswana during 2012-2016. We defined mixed infection as multiple repeats of alleles at >2 loci within a discrete mycobacterial interspersed repetitive unit-variable-number tandem-repeat (MIRU-VNTR) result. We compared mixed infection MIRU-VNTR results with all study MIRU-VNTR results by considering all permutations at each multiple allele locus; matched MIRU-VNTR results were considered evidence of recently acquired strains and nonmatched to any other results were considered evidence of remotely acquired strains. Among 2,051 patients, 34 (1.7%) had mixed infection, of which 23 (68%) had recently and remotely acquired strains. This finding might support the mixed infection mechanism of recent transmission and simultaneous remote reactivation. Further exploration is needed to determine proportions of transmission mechanisms in settings where mixed infections are prevalent.

      2. Using nonpolio enterovirus detection to assess the integrity of stool specimens collected from acute flaccid paralysis cases in Somalia during 2014-2017external icon
        Ben Hamida A, Mohamed Ali K, Mdodo R, Mohamed A, Mengistu K, Nzunza RM, Farag NH, Ehrhardt DT, Elfakki E, Mbaeyi C.
        Open Forum Infect Dis. 2020 May;7(5):ofaa135.
        Background: Despite insecurity challenges in Somalia, key indicators for acute flaccid paralysis (AFP) surveillance have met recommended targets. However, recent outbreaks of vaccine-derived polioviruses have raised concerns about possible gaps. We analyzed nonpolio enterovirus (NPEV) and Sabin poliovirus isolation rates to investigate whether comparing these rates can inform about the integrity of stool specimens from inaccessible areas and the likelihood of detecting circulating polioviruses. Methods: Using logistic regression, we analyzed case-based AFP surveillance data for 1348 cases with onset during 2014-2017. We assessed the adjusted impacts of variables including age, accessibility, and Sabin-like virus isolation on NPEV detection. Results: NPEVs were more likely to be isolated from AFP case patients reported from inaccessible areas than accessible areas (23% vs 15%; P = .01). In a multivariable model, inaccessibility and detection of Sabin-like virus were positively associated with NPEV detection (adjusted odds ratio [AOR], 1.75; 95% confidence interval [CI], 1.14-2.65; and AOR, 1.79; 95% CI, 1.07-2.90; respectively), while being aged >/=5 years was negatively associated (AOR, 0.42; 95% CI, 0.20-0.85). Conclusions: Rates of NPEV and Sabin poliovirus detection in inaccessible areas suggest that the integrity of fecal specimens tested for AFP surveillance in Somalia can generate useful AFP data, but uncertainties remain about surveillance system quality.

      3. Evidence for limited early spread of COVID-19 within the United States, January-February 2020external icon
        CDC COVID-19 Response Team , Jorden MA, Rudman SL, Villarino E, Hoferka S, Patel MT, Bemis K, Simmons CR, Jespersen M, Iberg Johnson J, Mytty E, Arends KD, Henderson JJ, Mathes RW, Weng CX, Duchin J, Lenahan J, Close N, Bedford T, Boeckh M, Chu HY, Englund JA, Famulare M, Nickerson DA, Rieder MJ, Shendure J, Starita LM.
        MMWR Morb Mortal Wkly Rep. 2020 Jun 5;69(22):680-684.
        From January 21 through February 23, 2020, public health agencies detected 14 U.S. cases of coronavirus disease 2019 (COVID-19), all related to travel from China (1,2). The first nontravel-related U.S. case was confirmed on February 26 in a California resident who had become ill on February 13 (3). Two days later, on February 28, a second nontravel-related case was confirmed in the state of Washington (4,5). Examination of four lines of evidence provides insight into the timing of introduction and early transmission of SARS-CoV-2, the virus that causes COVID-19, into the United States before the detection of these two cases. First, syndromic surveillance based on emergency department records from counties affected early by the pandemic did not show an increase in visits for COVID-19-like illness before February 28. Second, retrospective SARS-CoV-2 testing of approximately 11,000 respiratory specimens from several U.S. locations beginning January 1 identified no positive results before February 20. Third, analysis of viral RNA sequences from early cases suggested that a single lineage of virus imported directly or indirectly from China began circulating in the United States between January 18 and February 9, followed by several SARS-CoV-2 importations from Europe. Finally, the occurrence of three cases, one in a California resident who died on February 6, a second in another resident of the same county who died February 17, and a third in an unidentified passenger or crew member aboard a Pacific cruise ship that left San Francisco on February 11, confirms cryptic circulation of the virus by early February. These data indicate that sustained, community transmission had begun before detection of the first two nontravel-related U.S. cases, likely resulting from the importation of a single lineage of virus from China in late January or early February, followed by several importations from Europe. The widespread emergence of COVID-19 throughout the United States after February highlights the importance of robust public health systems to respond rapidly to emerging infectious threats.

      4. Multistate mumps outbreak originating from asymptomatic transmission at a Nebraska wedding - six states, August-October 2019external icon
        Donahue M, Hendrickson B, Julian D, Hill N, Rother J, Koirala S, Clayton JL, Safranek T, Buss B.
        MMWR Morb Mortal Wkly Rep. 2020 Jun 5;69(22):666-669.
        In August 2019, 30 attendees at a Nebraska wedding developed mumps after being exposed to one asymptomatic index patient who was fully vaccinated according to Advisory Committee on Immunization Practices (ACIP) recommendations (1), resulting in a multistate outbreak. A public health investigation and response revealed epidemiologic links that extended from the index patient through secondary, tertiary, and quaternary patients and culminated in a measles-mumps-rubella (MMR) booster vaccination campaign in the local community where approximately half of the patients resided.

      5. Loss to follow-up and opportunities for reengagement in HIV care in rural Mozambique: A prospective cohort studyexternal icon
        Fuente-Soro L, Lopez-Varela E, Augusto O, Bernardo EL, Sacoor C, Nhacolo A, Ruiz-Castillo P, Alfredo C, Karajeanes E, Vaz P, Naniche D.
        Medicine (Baltimore). 2020 May;99(20):e20236.
        Patients lost to follow-up (LTFU) over the human immunodeficiency virus (HIV) cascade have poor clinical outcomes and contribute to onward HIV transmission. We assessed true care outcomes and factors associated with successful reengagement in patients LTFU in southern Mozambique.Newly diagnosed HIV-positive adults were consecutively recruited in the Manhica District. Patients LTFU within 12 months after HIV diagnosis were visited at home from June 2015 to July 2016 and interviewed for ascertainment of outcomes and reasons for LTFU. Factors associated with reengagement in care within 90 days after the home visit were analyzed by Cox proportional hazards model.Among 1122 newly HIV-diagnosed adults, 691 (61.6%) were identified as LTFU. Of those, 557 (80.6%) were approached at their homes and 321 (57.6%) found at home. Over 50% had died or migrated, 10% had been misclassified as LTFU, and 252 (78.5%) were interviewed. Following the visit, 79 (31.3%) reengaged in care. Having registered in care and a shorter time between LTFU and visit were associated with reengagement in multivariate analyses: adjusted hazards ratio of 3.54 [95% confidence interval (CI): 1.81-6.92; P < .001] and 0.93 (95% CI: 0.87-1.00; P = .045), respectively. The most frequently reported barriers were the lack of trust in the HIV-diagnosis, the perception of being in good health, and fear of being badly treated by health personnel and differed by type of LTFU.Estimates of LTFU in rural areas of sub-Saharan Africa are likely to be overestimated in the absence of active tracing strategies. Home visits are resource-intensive but useful strategies for reengagement for at least one-third of LTFU patients when applied in the context of differentiated care for those LTFU individuals who had already enrolled in HIV care at some point.

      6. Missed opportunities for prevention of congenital syphilis - United States, 2018external icon
        Kimball A, Torrone E, Miele K, Bachmann L, Thorpe P, Weinstock H, Bowen V.
        MMWR Morb Mortal Wkly Rep. 2020 Jun 5;69(22):661-665.
        Congenital syphilis is an infection with Treponema pallidum in an infant or fetus, acquired during pregnancy from a mother with untreated or inadequately treated syphilis. Congenital syphilis can cause miscarriage, stillbirth, or early infant death, and infected infants can experience lifelong physical and neurologic problems. Although timely identification and treatment of maternal syphilis during pregnancy can prevent congenital syphilis (1,2), the number of reported congenital syphilis cases in the United States increased 261% during 2013-2018, from 362 to 1,306. Among reported congenital syphilis cases during 2018, a total of 94 resulted in stillbirths or early infant deaths (3). Using 2018 national congenital syphilis surveillance data and a previously developed framework (4), CDC identified missed opportunities for congenital syphilis prevention. Nationally, the most commonly missed prevention opportunities were a lack of adequate maternal treatment despite the timely diagnosis of syphilis (30.7%) and a lack of timely prenatal care (28.2%), with variation by geographic region. Congenital syphilis prevention involves syphilis prevention for women and their partners and timely identification and treatment of pregnant women with syphilis. Preventing continued increases in congenital syphilis requires reducing barriers to family planning and prenatal care, ensuring syphilis screening at the first prenatal visit with rescreening at 28 weeks' gestation and at delivery, as indicated, and adequately treating pregnant women with syphilis (2). Congenital syphilis prevention strategies that implement tailored public health and health care interventions to address missed opportunities can have substantial public health impact.

      7. Partner notification approaches for sex partners and children of HIV index cases in Cote d'Ivoireexternal icon
        Kingbo MK, Isaakidis P, Lasry A, Takarinda KC, Manzi M, Pringle J, Konan FA, N'Draman J, Krou Danho N, Abokon AK, Doumatey NI.
        Sex Transm Dis. 2020 May 20.
        BACKGROUND: Four partner notification approaches were introduced in health facilities in Cote d'Ivoire to increase HIV testing uptake amongst the type of contacts (sex partners and biological children under 15). The study assessed the four approaches: client referral (index cases refer the contacts for HIV testing), provider referral (healthcare providers refer the contacts), contract referral (index case-provider hybrid approach), and dual referral (both the index and their partner are tested simultaneously). METHODS: Program data were collected at four facilities from October 2018 to March 2019 from index case files and HIV-testing register. We compared uptake of the approaches, uptake of HIV testing, and HIV positivity percentages, stratified by contact type and gender. RESULTS: There were 1,089 sex partners and 469 children from 1,089 newly diagnosed index cases. About 90% of children were contacted through client referral: 85.2% of those were tested and 1.4% was positive. 90% of children came from female index cases. The provider referral brought in 56.3% of sex partners, of whom 97.2% were HIV-tested. The client referral brought in 30% of sex partners, of whom only 81.5% were HIV-tested. HIV positivity percentages were 75.5% and 72.7% respectively for the two approaches. Male index cases helped to reach twice as many HIV positive sexual contacts outside the household (115) than female index cases (53). The contract and dual referrals were not preferred by index cases. CONCLUSION: Provider referral is a successful and acceptable strategy for bringing in sex partners for testing. Client referral is preferred for children.

      8. Tuberculosis in pregnancyexternal icon
        Miele K, Bamrah Morris S, Tepper NK.
        Obstet Gynecol. 2020 Jun;135(6):1444-1453.
        Tuberculosis (TB) in pregnancy poses a substantial risk of morbidity to both the pregnant woman and the fetus if not diagnosed and treated in a timely manner. Assessing the risk of having Mycobacterium tuberculosis infection is essential to determining when further evaluation should occur. Obstetrician-gynecologists are in a unique position to identify individuals with infection and facilitate further evaluation and follow up as needed. A TB evaluation consists of a TB risk assessment, medical history, physical examination, and a symptom screen; a TB test should be performed if indicated by the TB evaluation. If a pregnant woman has signs or symptoms of TB or if the test result for TB infection is positive, active TB disease must be ruled out before delivery, with a chest radiograph and other diagnostics as indicated. If active TB disease is diagnosed, it should be treated; providers must decide when treatment of latent TB infection is most beneficial. Most women will not require latent TB infection treatment while pregnant, but all require close follow up and monitoring. Treatment should be coordinated with the TB control program within the respective jurisdiction and initiated based on the woman's risk factors including social history, comorbidities (particularly human immunodeficiency virus [HIV] infection), and concomitant medications.

      9. Risk factors for epidemic cholera in Lusaka, Zambia-2017external icon
        Nanzaluka FH, Davis WW, Mutale L, Kapaya F, Sakubita P, Langa N, Gama A, N'Cho H S, Malambo W, Murphy J, Blackstock A, Mintz E, Riggs M, Mukonka V, Sinyange N, Yard E, Brunkard J.
        Am J Trop Med Hyg. 2020 May 26.
        On October 6, 2017, the Zambia Ministry of Health declared a cholera outbreak in Lusaka. By December, 1,462 cases and 38 deaths had occurred (case fatality rate, 2.6%). We conducted a case-control study to identify risk factors and inform interventions. A case was any person with acute watery diarrhea (>/= 3 loose stools in 24 hours) admitted to a cholera treatment center in Lusaka from December 16 to 21, 2017. Controls were neighbors without diarrhea during the same time period. Up to two controls were matched to each case by age-group (1-4, 5-17, and >/= 18 years) and neighborhood. Surveyors interviewed cases and controls, tested free chlorine residual (FCR) in stored water, and observed the presence of soap in the home. Conditional logistic regression was used to generate matched odds ratios (mORs) based on subdistricts and age-groups with 95% CIs. We enrolled 82 cases and 132 controls. Stored water in 71% of case homes had an FCR > 0.2 mg/L. In multivariable analyses, those who drank borehole water (mOR = 2.4, CI: 1.1-5.6), had close contact with a cholera case (mOR = 6.2, CI: 2.5-15), and were male (mOR = 2.5, CI: 1.4-5.0) had higher odds of being a cholera case than their matched controls. The use of groundwater for drinking, contact with a cholera case, and male gender were associated with cholera. Based on these findings, we recommended health education about household water chlorination and hygiene in the home. Emergency responses included providing chlorinated water through emergency tanks and maintaining adequate FCR levels through close monitoring of water sources.

      10. Estimating the impact of HIV combination prevention in men who have sex with men, the Bangkok MSM Cohort Study, Thailandexternal icon
        Pattanasin S, Cadwell BL, Smith DK, Sukwicha W, Mock PA, Wimonsate W, Ungsedhapand C, Sirivongrangson P, Dunne EF, Thigpen MC.
        Int J STD AIDS. 2020 May 23.
        In Thailand, pre-exposure prophylaxis (PrEP) is recommended for human immunodeficiency virus (HIV) prevention among at-risk men who have sex with men (MSM). We modeled the impact of PrEP and condom use as independent and combined interventions on the estimated number of HIV infections among a hypothetical population of 10,000 MSM in Bangkok, Thailand. Our model demonstrated a 92% (95% confidence interval 89.7, 94.2) reduction in HIV infections among Thai MSM who took daily PrEP and self-reported using condoms correctly and consistently (100% condom use). Increased use of PrEP and condoms likely would have a substantial impact on the HIV epidemic in Thailand.

      11. Toward universal HIV treatment in Haiti: Time trends in ART retention after expanded ART eligibility in a national cohort from 2011 to 2017external icon
        Puttkammer N, Parrish C, Desir Y, Hyppolite N, Wagenaar BH, Joseph N, Hall L, Honore JG, Robin E, Perrin G, Francois K.
        J Acquir Immune Defic Syndr. 2020 Jun 1;84(2):153-161.
        BACKGROUND: The World Health Organization (WHO) recommends universal antiretroviral therapy (ART) for persons living with HIV (PLWH), but evidence about effects of expanded ART access on ART retention in low-resource settings is limited. SETTING: Haiti's Ministry of Health endorsed universal ART for pregnant women in March 2013 (Option B+) and for all PLWH in July 2016. This study included 51,579 ART patients from 2011 to 2017 at 94 hospitals and clinics in Haiti. METHODS: This observational, retrospective cohort study described time trends in 6-month ART retention using secondary data, and compared results during 3 periods using an interrupted time series model: pre-Option B+ (period 1: 1/11-2/13), Option B+ (period 2: 3/13-6/16), and Test and Start (T&S, period 3: 7/16-9/17). RESULTS: From the pre-Option B+ to the T&S period, the monthly count of new ART patients increased from 366/month to 877/month, and the proportion with same-day ART increased from 6.3% to 42.1% (P < 0.001). The proportion retained on ART after 6 months declined from 78.4% to 75.0% (P < 0.001). In the interrupted time series model, ART retention improved by a rate of 1.4% per quarter during the T&S period after adjusting for patient characteristics (adjusted incidence rate ratio = 1.014; 95% confidence interval: 1.002 to 1.026, P < 0.001). However, patients with same-day ART were 14% less likely to be retained compared to those starting ART >30 days after HIV diagnosis (adjusted incidence rate ratio = 0.86; 95% confidence interval: 0.84-0.89, P < 0.001). CONCLUSIONS: Achieving targets for HIV epidemic control will require increasing ART retention and reducing the disparity in retention for those with same-day ART.

      12. Transactional sex and incident chlamydia and gonorrhea among black men who have sex with men in Atlanta, Georgiaexternal icon
        Rucinski KB, Eaton LA, Learner ER, Watson RJ, Maksut JL, Earnshaw VA.
        Sex Transm Dis. 2020 Jun;47(6):355-360.
        BACKGROUND: Black men who have sex with men (BMSM) are disproportionately affected by sexually transmitted infections (STI), including chlamydia and gonorrhea. Transactional sex is an hypothesized risk factor for STI acquisition in BMSM. METHODS: We estimated the association of transactional sex with incident chlamydia/gonococcal infection among BMSM using longitudinal data from a randomized trial in Atlanta (2012-2015). BMSM were eligible for inclusion if they tested human immunodeficiency virus (HIV)-antibody-negative and reported both ≥2 male sex partners and any condomless anal sex in the last year. We defined chlamydia/gonorrhea incidence as the first occurrence of either rectal or urogenital chlamydia or gonococcal infections after a negative result at enrollment. We used Poisson regression to estimate the incidence rate (IR) for chlamydia/gonorrhea over 12 months. Incidence rate ratios (IRR) compared estimates by reported experience of transactional sex. Subgroup analyses assessed potential heterogeneity by age and sexual identity. RESULTS: This analysis included 416 BMSM, of whom 191 (46%) were gay-identified, 146 (42%) reported a history of transactional sex, and 57 (14%) had prevalent chlamydia/gonococcal infection at baseline. Over a median of 1 year of follow-up, an additional 55 men tested laboratory-positive for chlamydia/gonorrhea (IR, 17.3 per 100 person-years). Transactional sex was not associated with chlamydia/gonorrhea incidence overall. However, among gay-identified BMSM, transactional sex was associated with incident chlamydia/gonorrhea (IRR, 2.9; 95% confidence interval, 1.2-6.8). CONCLUSIONS: Economic and social vulnerabilities may motivate engagement in high-risk sexual behaviors through commodified sex, potentially increasing the burden of STIs among BMSM. In this investigation, the relationship between transactional sex and chlamydia/gonorrhea was not homogenous across BMSM with diverse sexual identities in Atlanta, suggesting that within select sexual networks, transactional sex may drive STI risks. Delivering accessible and targeted STI screening for marginalized BMSM should be prioritized for STI and HIV prevention.

      13. Birth testing for infant HIV diagnosis in Eswatini: Implementation experience and uptake among women living with HIV in Manzini Regionexternal icon
        Teasdale CA, Tsiouris F, Mafukidze A, Shongwe S, Choy M, Nhlengetfwa H, Simelane S, Mthethwa S, Ao T, Ryan C, Dale H, Rivadeneira E, Abrams EJ.
        Pediatr Infect Dis J. 2020 May 21.
        INTRODUCTION: HIV testing at birth of HIV-exposed infants (HEIs) may improve the identification of infants infected with HIV in utero and accelerate antiretroviral treatment (ART) initiation. METHODS: ICAP at Columbia University supported implementation of a national pilot of HIV testing at birth (0-7 days) in Eswatini at 2 maternity facilities. Dried blood spot (DBS) samples from neonates of women living with HIV (WLHIV) were collected and processed at the National Molecular Reference Laboratory using polymerase chain reaction (PCR). Mothers received birth test results at community health clinics. We report data on HIV birth testing uptake and outcomes for HIV-positive infants from the initial intensive phase (October 2017-March 2018) and routine support phase (April-December 2018). RESULTS: During the initial intensive pilot phase, 1669 WLHIV delivered 1697 live-born HEI at 2 health facilities and 1480 (90.3%) HEI received birth testing. During the routine support phase, 2546 WLHIV delivered and 2277 (93.5%) HEI received birth testing. Overall October 2017-December 2018, 22 (0.6%) infants of 3757 receiving birth testing had a positive PCR test, 15 (68.2%) of whom were successfully traced and linked for confirmatory testing (2 infants were reported by caregivers to have negative follow-up HIV tests). Median time from birth test to receipt of results by the caregiver was 13 days (range: 8-23). Twelve (60.0%) of 20 infants confirmed to be HIV-positive started ART at median age of 17.5 days (12-43). One mother of an HIV-positive infant who was successfully traced refused ART following linkage to care and another child died after ART initiation. Three infants (15.0%) had died by the time their mothers were reached and 4 (15.0%) infants were never located. CONCLUSION: This pilot of universal birth testing in Eswatini demonstrates the feasibility of using a standard of care approach in a low resource and high burden setting. We document high uptake of testing for newborns among HIV-positive mothers and very few infants were found to be infected through birth testing.

    • Disaster Control and Emergency Services
      1. The Centers for Disease Control and Prevention (CDC), Division of State and Local Readiness (DSLR), Public Health Emergency Preparedness(PHEP) program funds 62 recipients to strengthen capability standards to prepare for and respond to public health emergencies. Recipients use these PHEP resources in addition to CDC's administrative and scientific guidance to support preparedness and response program planning and requirements. It is expected that public health agencies develop and maintain comprehensive emergency preparedness and response plans in preparation for disasters such as hurricanes. The 2017 historic hurricane season highlighted how emergency planning and collaborative operational execution is important for public health agencies to effectively prepare for and respond to both the immediate and long-term population health consequences of these disasters. In 2017, the southeastern United States (US) and US Caribbean territories experienced 3 Category 4 or higher Atlantic hurricanes (Harvey, Irma, and Maria) within a 5-week period. This paper highlights selected case studies that illustrate the contributions and impact of jurisdictional emergency management planning and operational capacity supported by capability standards during the 2017 hurricane season. Although the magnitude of the 2017 hurricanes required public health officials to seek additional assistance, the following case studies describe the use of public health preparedness systems and recovery resources supported by the PHEP program.

    • Disease Reservoirs and Vectors
      1. Mammalian pathogenicity and transmissibility of low pathogenic avian influenza H7N1 and H7N3 viruses isolated from North America in 2018external icon
        Belser JA, Sun X, Brock N, Pulit-Penaloza JA, Jones J, Zanders N, Davis CT, Tumpey TM, Maines TR.
        Emerg Microbes Infect. 2020 Dec;9(1):1037-1045.
        ABSTRACTLow pathogenic avian influenza (LPAI) H7 subtype viruses are infrequently, but persistently, associated with outbreaks in poultry in North America. These LPAI outbreaks provide opportunities for the virus to develop enhanced virulence and transmissibility in mammals and have previously resulted in both occasional acquisition of a highly pathogenic avian influenza (HPAI) phenotype in birds and sporadic cases of human infection. Two notable LPAI H7 subtype viruses caused outbreaks in 2018 in North America: LPAI H7N1 virus in chickens and turkeys, representing the first confirmed H7N1 infection in poultry farms in the United States, and LPAI H7N3 virus in turkeys, a virus subtype often associated with LPAI-to-HPAI phenotypes. Here, we investigated the replication capacity of representative viruses from these outbreaks in human respiratory tract cells and mammalian pathogenicity and transmissibility in the mouse and ferret models. We found that the LPAI H7 viruses replicated to high titre in human cells, reaching mean peak titres generally comparable to HPAI H7 viruses. Replication was efficient in both mammalian species, causing mild infection, with virus primarily limited to respiratory tract tissues. The H7 viruses demonstrated a capacity to transmit to naive ferrets in a direct contact setting. These data support the need to perform routine risk assessments of LPAI H7 subtype viruses, even in the absence of confirmed human infection.

      2. In recent decades, tickborne disease (TBD) cases and established populations of medically important ticks have been reported over expanding geographic areas, and an increasing number of tickborne bacteria, viruses, and protozoans have been recognized as human pathogens, collectively contributing to an increasing burden of TBDs in the United States. The prevention and diagnosis of TBDs depend greatly on an accurate understanding by the public and healthcare providers of when and where persons are at risk for exposure to human-biting ticks and to the pathogens these ticks transmit. However, national maps showing the distributions of medically important ticks and the presence or prevalence of tickborne pathogens are often incomplete, outdated, or lacking entirely. Similar deficiencies exist regarding geographic variability in host-seeking tick abundance. Efforts to accurately depict acarological risk are hampered by lack of systematic and routine surveillance for medically important ticks and their associated human pathogens. In this review, we: 1) outline the public health importance of tick surveillance; 2) identify gaps in knowledge regarding the distributions and abundance of medically important ticks in the United States and the presence and prevalence of their associated pathogens; 3) describe key objectives for tick surveillance and review methods appropriate for addressing those goals; and 4) assess current capacity and barriers to implementation and sustainability of tick surveillance programs.

      3. Novel PCR exclusion assay to detect spotted fever group rickettsiae in the lone star tick (Amblyomma americanum)external icon
        Lydy SL, Williams-Newkirk AJ, Dugan EJ, Hensley JR, Dasch GA.
        Ticks Tick Borne Dis. 2020 Apr 28:101453.
        The lone star tick (Amblyomma americanum) is the most common and abundant human-biting tick in the southeastern United States where spotted fever rickettsioses frequently occur. However, the role of this tick in transmitting and maintaining pathogenic and non-pathogenic spotted fever group rickettsiae (SFGR) remains poorly defined. This is partially due to the high prevalence and abundance of Rickettsia amblyommatis in most populations of A. americanum. Many molecular assays commonly employed to detect rickettsiae use PCR primers that target highly conserved regions in the SFGR so low abundance rickettsia may not be detected when R. amblyommatis is present. It is costly and inefficient to test for low abundance rickettsial agents with multiple individual specific assays even when they are multiplexed, as most samples will be negative. Real time PCR assays may also be hampered by inadequate limits of detection (LODs) for low abundance agents. We exploited the absence of an otherwise relatively SFGR-conserved genome region in R. amblyommatis to design a hemi-nested PCR-assay which has a sensitivity of 10 copies in detecting the presence of most SFGR, but not R. amblyommatis in DNA of infected lone star ticks. This deletion is conserved in 21 isolates of R. amblyommatis obtained from multiple states. We demonstrated the assay's utility by detecting a pathogenic SFGR, Rickettsia parkeri, in 15/50 (30 %) of field collected A. americanum ticks that were previously screened with conventional assays and found to be positive for R. amblyommatis. These co-infected ticks included 1 questing female, 6 questing nymphs, and 8 attached males. The high prevalence of R. parkeri among host-attached ticks may be due to several variables and does not necessarily reflect the risk of disease transmission from attached ticks to vertebrate hosts. This novel assay can provide accurate estimates of the prevalence of less common SFGR in A. americanum and thus improve our understanding of the role of this tick in the maintenance and transmission of the SFGR commonly responsible for human rickettsioses.

      4. Mosquito control activities during local transmission of Zika virus, Miami-Dade County, Florida, USA, 2016external icon
        McAllister JC, Porcelli M, Medina JM, Delorey MJ, Connelly CR, Godsey MS, Panella NA, Dzuris N, Boegler KA, Kenney JL, Kothera L, Vizcaino L, Lenhart AE, Mutebi JP, Vasquez C.
        Emerg Infect Dis. 2020 May;26(5):881-890.
        In 2016, four clusters of local mosquitoborne Zika virus transmission were identified in Miami-Dade County, Florida, USA, generating "red zones" (areas into which pregnant women were advised against traveling). The Miami-Dade County Mosquito Control Division initiated intensive control activities, including property inspections, community education, and handheld sprayer applications of larvicides and adulticides. For the first time, the Mosquito Control Division used a combination of areawide ultralow-volume adulticide and low-volume larvicide spraying to effectively control Aedes aegypti mosquitoes, the primary Zika virus vector within the county. The number of mosquitoes rapidly decreased, and Zika virus transmission was interrupted within the red zones immediately after the combination of adulticide and larvicide spraying.

    • Food Safety
      1. Restaurant characteristics associated with the use of specific food-cooling methodsexternal icon
        Ree K, Brown L, Ripley D, Hedeen N, Nicholas D, Faw B, Bushnell L, Nair P, Wickam T.
        J Environ Health. 2020 ;82(10):8-13.
        Pathogen growth caused by improper or slow cooling of hot foods was a contributing factor in 504 of restaurant- and deli-related outbreaks in the U.S. from 1998-2008. Little is known, however, about restaurant cooling practices. To fill this gap, the Centers for Disease Control and Prevention's Environmental Health Specialists Network (EHS-Net) conducted an observational study to identify and understand factors that might determine which methods restaurants follow to rapidly cool food. These methods include refrigerating food at <=41 degreesF, at shallow depths, and in containers that are ventilated, unstacked, and have space around them. EHS-Net personnel collected data through manager interviews and observation of cooling processes in 420 randomly selected restaurants. Regression analyses revealed characteristics of restaurants most likely to use the cooling methods assessed. These characteristics included ownership by restaurant chains, manager food safety training and certification, few foods cooled at a time, many meals served daily, and a high ratio of workers to managers. These findings suggest that regulatory food safety programs and the retail industry might improve cooling methods-and reduce outbreaks-by providing and encouraging manager food safety training and certification, and by focusing intervention efforts on independent and smaller restaurants.

    • Health Economics
      1. INTRODUCTION: The cost of the Social Security Disability Insurance (DI) program has increased over time though recent reports showed that disability incidence and prevalence rates have started declining. We explored whether occupation was one of the risk factors for the rising number of disabled workers who received DI benefits during 1992-2016. METHODS: We used a cohort of 16 196 Health and Retirement Survey respondents between the age of 51 and 64 years who were followed from their date of entry until they received DI benefits, died, reached full retirement age, or reached the end of the follow-up period (2016). We used the extended stratified Cox proportional hazard model. Because one-third of the respondents in our cohort did not report their longest-held occupation, we used a multiple-imputation method. RESULTS: The hazard of receiving DI benefits was 51%, 78%, 81%, and 85% higher among workers with longest-held occupations in sales, mechanics and repair, protective services, and personal services, respectively than among workers with longest-held occupations in the reference managerial occupation. The hazard of receiving DI benefits was more than double among workers with longest-held occupations in the construction trade and extractors, transportation operation, machine operators, handlers, and food preparation than among workers with the longest-held occupation in the reference managerial occupation. CONCLUSION: Improving the overall working conditions in these occupations would help reduce worker suffering and the number of applicants for DI benefits, thereby reducing the burden of workplace injury and illness on the DI program.

      2. Epidemiology and cost of Lyme disease-related hospitalizations among patients with employer-sponsored health insurance-United States, 2005-2014external icon
        Schwartz AM, Shankar MB, Kugeler KJ, Max RJ, Hinckley AF, Meltzer MI, Nelson CA.
        Zoonoses Public Health. 2020 Jun;67(4):407-415.
        An estimated 300,000 cases of Lyme disease occur in the United States annually. Disseminated Lyme disease may result in carditis, arthritis, facial palsy or meningitis, sometimes requiring hospitalization. We describe the epidemiology and cost of Lyme disease-related hospitalizations. We analysed 2005-2014 data from the Truven Health Analytics MarketScan Commercial Claims and Encounters Databases to identify inpatient records associated with Lyme disease based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. We estimated the annual number and median cost of Lyme disease-related hospitalizations in the United States in persons under 65 years of age. Costs were adjusted to reflect 2016 dollars. Of 20,983,165 admission records contained in the inpatient databases during the study period, 2,823 (0.01%) met inclusion criteria for Lyme disease-related hospitalizations. Over half of the identified records contained an ICD-9-CM code for meningitis (n = 614), carditis (n = 429), facial palsy (n = 400) or arthritis (n = 377). Nearly 60% of hospitalized patients were male. The median cost per Lyme disease-related hospitalization was $11,688 (range: $140-$323,613). The manifestation with the highest median cost per stay was carditis ($17,461), followed by meningitis ($15,177), arthritis ($13,012) and facial palsy ($10,491). Median cost was highest among the 15- to 19-year-old age group ($12,991). Admissions occurring in January had the highest median cost ($13,777) for all study years. Based on extrapolation to the U.S. population, we estimate that 2,196 Lyme disease-related hospitalizations in persons under 65 years of age occur annually with an estimated annual cost of $25,826,237. Lyme disease is usually treated in an outpatient setting; however, some patients with Lyme disease require hospitalization, underscoring the need for effective prevention methods to mitigate these serious cases. Information from this analysis can aid economic evaluations of interventions that prevent infection and advances in disease detection.

    • Immunity and Immunization
      1. Physicians' use of evidence-based strategies to increase adult vaccination uptakeexternal icon
        Hurley LP, Lindley MC, Allison MA, O'Leary ST, Crane LA, Brtnikova M, Beaty BL, Kempe A.
        Am J Prev Med. 2020 May 21.
        INTRODUCTION: This study assesses the following among primary care physicians: (1) the use of evidence-based strategies to improve adult vaccination rates, (2) the number of strategies employed simultaneously, and (3) characteristics associated with assessing adult vaccinations at each visit. METHODS: An internet and mail survey was administered between December 2015 and January 2016 on primary care physicians designed to be representative of the American College of Physicians and American Academy of Family Physicians memberships. Data analysis was conducted in 2019. RESULTS: The response rate was 66% (617 of 935); 94% reported using electronic health records. Standing orders (84%) and electronic provider reminders at a visit (61%) were the most common strategies reported for influenza vaccine. Electronic provider reminders at a visit (53%) and recording a vaccination in an immunization registry (32%) were the most common strategies reported for all noninfluenza vaccines. Most physicians reported using 2 or more strategies, although this was more common for influenza (74%) than for noninfluenza (62%) vaccines. In multivariable analysis, physicians who reported assessing adult vaccinations at every patient visit were more likely to work in practices where decisions about purchasing and handling vaccines were made at a larger system level (RR=1.20, 95% CI=1.04,1.40), and they reported using electronic provider reminders (RR=1.38, 95% CI=1.15, 1.69) and standing orders (RR=1.45, 95% CI=1.21, 1.75) for all noninfluenza adult vaccines. CONCLUSIONS: Several strategies are being used to increase adult vaccination, particularly for the influenza vaccine. Investment in implementing standing orders and electronic clinical decision support for all routine adult vaccinations could help facilitate assessment of adult vaccinations at each visit and potentially improve adult vaccination rates.

      2. A call to action: Strengthening vaccine confidence in the United Statesexternal icon
        Mbaeyi S, Cohn A, Messonnier N.
        Pediatrics. 2020 May 27.

      3. Feasibility of direct venous inoculation of the radiation-attenuated Plasmodium falciparum whole sporozoite vaccine in children and infants in Siaya, western Kenyaexternal icon
        Oneko M, Cherop YR, Sang T, Gutman JR, Wiegand R, Nyang'au EM, Odila AD, Akach D, Hamel MJ, Samuels AM, Kariuki S, Abebe Y, Nzuu EL, Wijayalath W, James ER, Sim BK, Billingsley PF, Richie TL, Hoffman SL, Seder RA, Steinhardt LC.
        Vaccine. 2020 May 19.
        PfSPZ Vaccine, composed of radiation-attenuated, aseptic, purified, cryopreserved Plasmodium falciparum sporozoites, is administered by direct venous inoculation (DVI) for maximal efficacy against malaria. A critical issue for advancing vaccines that are administered intravenously is the ability to efficiently administer them across multiple age groups. As part of a pediatric safety, immunogenicity, and efficacy trial in western Kenya, we evaluated the feasibility and tolerability of DVI, including ease of venous access, injection time, and crying during the procedure across age groups. Part 1 was an age de-escalation, dose escalation trial in children aged 13 months-5 years and infants aged 5-12 months; part 2 was a vaccine efficacy trial including only infants, using the most skilled injectors from part 1. Injectors could use a vein viewer, if needed. A total of 1222 injections (target 0.5 mL) were initiated by DVI in 511 participants (36 were 5-9-year-olds, 65 were 13-59-month-olds, and 410 infants). The complete volume was injected in 1185/1222 (97.0%) vaccinations, 1083/1185 (91.4%) achieved with the first DVI. 474/511 (92.8%) participants received only complete injections, 27/511 (5.3%) received at least one partial injection (<0.5 mL), and in 10/511 (2.0%) venous access was not obtained. The rate of complete injections by single DVI for infants improved from 77.1% in part 1 to 92.8% in part 2. No crying occurred in 51/59 (86.4%) vaccinations in 5-9-year-olds, 25/86 (29.1%) vaccinations in 13-59-month-olds and 172/1067 (16.1%) vaccinations in infants. Mean administration time ranged from 2.6 to 4.6 minutes and was longer for younger age groups. These data show that vaccination by DVI was feasible and well tolerated in infants and children in this rural hospital in western Kenya, when performed by skilled injectors. We also report that shipping and storage in liquid nitrogen vapor phase was simple and efficient. ( NCT02687373).

      4. Immunity and field efficacy of type 2-containing polio vaccines after cessation of trivalent oral polio vaccine: A population-based serological study in Pakistanexternal icon
        Voorman A, Habib MA, Hussain I, Muhammad Safdar R, Ahmed JA, Weldon WC, Ahmed I, Umer M, Partridge J, Soofi SB.
        Vaccine X. 2020 Aug 7;5:100067.
        Background: In Pakistan and other countries using oral polio vaccine (OPV), immunity to type 2 poliovirus is now maintained by a single dose of inactivated polio vaccine (IPV) in routine immunization, supplemented in outbreak settings by monovalent OPV type 2 (mOPV2) and IPV. While well-studied in clinical trials, population protection against poliovirus type 2 achieved in routine and outbreak settings is generally unknown. Methods: We conducted two phases of a population-based serological survey of 7940 children aged 6-11 months old, between November 2016 and October 2017 from 13 polio high-risk locations in Pakistan. Results: Type 2 seroprevalence was 50% among children born after trivalent OPV (tOPV) withdrawal (April 2016), with heterogeneity across survey areas. Supplementary immunization activities (SIAs) with mOPV2 followed by IPV improved population immunity, varying from 89% in Pishin to 64% in Killa Abdullah, with little observed marginal benefit of subsequent campaigns. In the other high-risk districts surveyed, a single SIA with IPV was conducted and appeared to improve immunity to 57% in Karachi to 84% in Khyber. Conclusions: Our study documents declining population immunity following trivalent OPV withdrawal in Pakistan, and wide heterogeneity in the population impact of supplementary immunization campaigns. Differences between areas, attributable to vaccination campaign coverage, were far more important for type 2 humoral immunity than the number of vaccination campaigns or vaccines used. This emphasizes the importance of immunization campaign coverage for type 2 outbreak response in the final stages of polio eradication. Given the declining type 2 immunity in new birth cohorts it is also recommended that 2 or more doses of IPV should be introduced in the routine immunization program of Pakistan.

      5. Incidence of herpes zoster among varicella-vaccinated children, by number of vaccine doses and simultaneous administration of measles, mumps, and rubella vaccineexternal icon
        Weinmann S, Irving SA, Koppolu P, Naleway AL, Belongia EA, Hambidge SJ, Jackson ML, Klein NP, Lewin B, Liles E, Marin M, Smith N, Weintraub E, Chun C.
        Vaccine. 2020 May 19.
        INTRODUCTION: Children may receive measles-mumps-rubella (MMR) and varicella (VAR) vaccines separately or as measles-mumps-rubella-varicella (MMRV). We examined whether pediatric herpes zoster (HZ) incidence varied by pattern of varicella vaccine administration. METHODS: In six integrated health systems, we examined HZ incidence among children turning 12 months old during 2003-2008. All received varicella and MMR vaccines on recommended schedules. Cases were identified through 2014 using ICD-9 codes. Incidence was examined by number of varicella vaccine doses and same-day MMR. RESULTS: Among 199,797 children, overall HZ incidence was 18.6/100,000 person-years in the first-dose MMR + VAR group, 17.9/100,000 person-years in the MMRV group, and 7.5/100,000 person-years in the VAR-alone group. HZ incidence was lower following the second dose than before the second dose in all first-dose groups. CONCLUSIONS: HZ incidence was not meaningfully different between the MMRV and MMR + VAR first-dose groups. Overall and within first-dose groups, HZ incidence was lower among children receiving two varicella vaccine doses.

    • Injury and Violence
      1. Emotional violence in childhood and health conditions, risk-taking behaviors, and violence perpetration among young adults in Nigeriaexternal icon
        Annor FB, Gilbert LK, Davila EP, Massetti GM, Kress H, Onotu D, Ogbanufe O.
        Child Abuse Negl. 2020 May 21;106:104510.
        BACKGROUND: Globally, over 1 billion children are victims of violence against children annually. Studies examining the health consequences of childhood violence have mostly focused on childhood physical violence (PV) and sexual violence (SV). Recent evidence suggests that childhood emotional violence (EV) may also be deleterious to the health and wellbeing of victims. OBJECTIVE: This study examines the independent association between EV and some health conditions, risk taking behaviors, and violence perpetration among Nigerian young adults ages 18-24 years. PARTICIPANTS AND SETTING: Data from 2014 Nigeria Violence Against Children Survey (n = 4,203), a nationally representative cross-sectional survey of individuals ages 13-24 were used. METHODS: Childhood EV was defined as EV victimization before age 18 perpetrated by a parent, adult caregiver or other adult relative. Logistic regression analyses assessed the association between EV in childhood and mental distress in the past 30 days, ever self-harm behaviors and history of sexually transmitted infections; risk behaviors such as having multiple sex partners in the past 12 months; and ever violence perpetration. RESULTS: After controlling for study covariates, EV in childhood was associated with mental distress in both males and females, and self-harm behaviors in females; excessive alcohol use and infrequent condom use in males, and multiple sexual partners in females; and PV perpetration in males and SV perpetration in females. CONCLUSION: EV in childhood is associated with some health conditions, risk taking behaviors, and violence perpetration. Implementing programs that address all forms of violence in childhood, including EV may benefit children.

      2. Mortality secondary to unintentional poisoning after inpatient rehabilitation among individuals with moderate to severe traumatic brain injuryexternal icon
        Hammond F, Ketchum J, Dams-O'Connor K, Corrigan JD, Miller AC, Haarbauer-Krupa J, Faul M, Trexler LE, Harrison-Felix CL.
        J Neurotrauma. 2020 May 22.
        Studies have shown reduced life expectancy following moderate-severe traumatic brain injury (TBI) with death due to unintentional poisoning (UP) 11x higher following TBI than in the general population. The characteristics of those who die of unintentional poisoning are compared to those who die of other causes (OC) in a retrospective cohort who received inpatient rehabilitation following traumatic brain injury (TBI) and enrolled in the TBI Model Systems National Database between 1989 and 2017 (n = 15,835 cases with 2,238 deaths recorded). Seventy-eight cases (3.5%) of deaths were due to UP, 76% were due to OC, and 20.5% died of unknown cause. Among the UP deaths, 90% involved drugs (of these 67% involved narcotic drugs and 14% psychostimulants) and 8% involved alcohol. Age- adjusted risk for UP death was associated with: White/Non-Hispanic race/ethnicity, living alone, non-institutionalization, pre- and post-injury illicit drug use and alcohol/drug problem use, any alcohol use at last follow up, better Functional Independence Measure TM (FIM) scores, history of arrest, moderate disability (vs severe disability or good recovery), less supervision needed, and greater anxiety. Adults who receive inpatient rehabilitation for TBI who die due to UP are distinguishable from those who die of OC. Factors such as pre-injury substance use in the context of functional independence may be regarded as targets for prevention and/or intervention to reduce substance use and substance-related mortality among survivors of moderate-severe TBI. The current findings may have implications for medical care, surveillance, prevention, and health promotion.

    • Laboratory Sciences
      1. Immunodiagnostic assays for the investigation of fungal outbreaksexternal icon
        Caceres DH, Chiller T, Lindsley MD.
        Mycopathologia. 2020 May 26.
        Fungal pathogens can affect humans, animals, and plants, and they can be found in the environment or as part of the host microbiome. Fungal diseases present a broad clinical spectrum, ranging from superficial to invasive infections, and can cause outbreaks. During an outbreak investigation, the laboratory plays an essential role in verifying the diagnosis and helping to confirm the source of the outbreak. Immunodiagnostic assays are important tools and often relied upon for the diagnosis of fungal infections, since the gold standard assays of culture and histopathology are time-consuming and often require invasive procedures. Immunodiagnostic assays range from complement fixation and immunodiffusion to enzyme immunoassays and, most recently, to point-of-care lateral flow devices. In general, these assays provide results faster and offer good analytical performance. These characteristics make immunodiagnostic assays good laboratory tools for outbreak investigations. The aim of this review is to describe the principles, advantages, limitations, and availability of immunodiagnostics assays in outbreak investigations, based on the experience of a reference laboratory.

      2. Tissue specific fate of nanomaterials by advanced analytical imaging techniques - a reviewexternal icon
        Graham UM, Dozier AK, Oberdörster G, Yokel RA, Molina R, Brain JD, Pinto JM, Weuve J, Bennett DA.
        Chem Res Toxicol. 2020 May 18;33(5):1145-1162.
        A variety of imaging and analytical methods have been developed to study nanoparticles in cells. Each has its benefits, limitations, and varying degrees of expense and difficulties in implementation. High-resolution analytical scanning transmission electron microscopy (HRSTEM) has the unique ability to image local cellular environments adjacent to a nanoparticle at near atomic resolution and apply analytical tools to these environments such as energy dispersive spectroscopy and electron energy loss spectroscopy. These tools can be used to analyze particle location, translocation and potential reformation, ion dispersion, and in vivo synthesis of second-generation nanoparticles. Such analyses can provide in depth understanding of tissue-particle interactions and effects that are caused by the environmental "invader" nanoparticles. Analytical imaging can also distinguish phases that form due to the transformation of "invader" nanoparticles in contrast to those that are triggered by a response mechanism, including the commonly observed iron biomineralization in the form of ferritin nanoparticles. The analyses can distinguish ion species, crystal phases, and valence of parent nanoparticles and reformed or in vivo synthesized phases throughout the tissue. This article will briefly review the plethora of methods that have been developed over the last 20 years with an emphasis on the state-of-the-art techniques used to image and analyze nanoparticles in cells and highlight the sample preparation necessary for biological thin section observation in a HRSTEM. Specific applications that provide visual and chemical mapping of the local cellular environments surrounding parent nanoparticles and second-generation phases are demonstrated, which will help to identify novel nanoparticle-produced adverse effects and their associated mechanisms.

      3. Oxidative stress (OS) plays a major role in the pathogenesis of various diseases in humans. OS is a result of an imbalance between reactive oxygen species (ROS) and the biologically available antioxidants that prevent or repair damage that ROS inflict on the host cells. ROS are naturally generated during normal mitochondrial respiration and by oxidative burst during the immune response. Many factors may influence OS, including genetics, diet, exercise, and exposure to environmental toxicants (e.g., tobacco smoke). A nonenzymatic peroxidation product of arachidonic acid (AA), 8-iso-PGF2alpha (8-isoprostane), is a validated biomarker of OS that is present in urine as both glucuronide conjugate and free acid. Previous studies report that the conjugated forms of 8-isoprostane can vary between 30 and 80% of the total 8-isoprostane levels. By hydrolyzing the conjugated forms, it is possible to obtain a total (free + conjugated) measurement of 8-isoprostane in urine samples. Here, we describe a robust, automated, and high-throughput method for measuring total urinary 8-isoprostane using a polymeric weak anion-exchange solid-phase extraction (SPE) and isotope-dilution ultrahigh performance liquid chromatography electrospray ionization-tandem mass spectrometry (UHPLC-MS/MS). This method, using a 96-well plate platform, showed good sensitivity (8.8 pg/mL LOD) and used only 400 muL of the sample volume with a cycle time of 11 min. The inter- and intraday precision, calculated from 20 repeated measurements of two quality control pools, varied from 4 to 10%. Accuracy, calculated from the recovery percentage at three spiking levels, ranged from 92.7 to 106.7%. We modified this method to allow for the exclusive measurement of free 8-isoprostane by removing the hydrolysis step. We measured both free and total 8-isoprostane in urine collected from 30 cigarette smokers (free: 460 +/- 78.8 pg/mL; total: 704 +/- 108 pg/mL) and 30 nonusers of tobacco products (free: 110 +/- 24.2 pg/mL; total: 161 +/- 38.7 pg/mL). This method is robust, accurate, and easily adaptable for large population studies.

      4. The effects of gamma irradiation on chemical biomarker recovery from mixed chemical/biological threat exposure specimensexternal icon
        Isenberg SL, Carter MD, Moon JL, Laughlin S, Petway M, Mojica MA, Rood JE, Gursky AK, Sheppard CI, Bagarozzi DA, Pirkle JL, Johnson RC.
        J Appl Lab Med. 2020 Mar 1;5(2):273-280.
        BACKGROUND: Irradiative sterilization of clinical specimens prior to chemical laboratory testing provides a way to not only sterilize pathogens and ensure laboratorian safety but also preserve sample volume and maintain compatibility with quantitative chemical diagnostic protocols. Since the compatibility of clinical biomarkers with gamma irradiation is not well characterized, a subset of diagnostic biomarkers ranging in molecular size, concentration, and clinical matrix was analyzed to determine recovery following gamma irradiation. METHODS: Sample irradiation of previously characterized quality control materials (QCs) at 5 Mrad was carried out at the Gamma Cell Irradiation Facility at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. Following irradiation, the QCs were analyzed alongside non-irradiated QCs to determine analyte recovery between dosed and control samples. RESULTS: Biomarkers for exposure to abrin, ricin, and organophosphorus nerve agents (OPNAs) were analyzed for their stability following gamma irradiation. The diagnostic biomarkers included adducts to butyrylcholinesterase, abrine, and ricinine, respectively, and were recovered at over 90% of their initial concentration. CONCLUSIONS: The results from this pilot study support the implementation of an irradiative sterilization protocol for possible mixed-exposure samples containing both chemical and biological threat agents (mixed CBTs). Furthermore, irradiative sterilization significantly reduces a laboratorian's risk of infection from exposure to an infectious agent without compromising chemical diagnostic testing integrity, particularly for diagnostic assays in which the chemical analyte has been shown to be fully conserved following a 5 Mrad irradiative dose.

      5. Whole-genome sequencing for characterization of capsule locus and prediction of serogroup of invasive meningococcal isolatesexternal icon
        Marjuki H, Topaz N, Rodriguez-Rivera LD, Ramos E, Potts CC, Chen A, Retchless AC, Doho GH, Wang X.
        J Clin Microbiol. 2019 Mar;57(3).
        Invasive meningococcal disease is mainly caused by Neisseria meningitidis serogroups A, B, C, X, W, and Y. The serogroup is typically determined by slide agglutination serogrouping (SASG) and real-time PCR (RT-PCR). We describe a whole-genome sequencing (WGS)-based method to characterize the capsule polysaccharide synthesis (cps) locus, classify N. meningitidis serogroups, and identify mechanisms for nongroupability using 453 isolates from a global strain collection. We identified novel genomic organizations within functional cps loci, consisting of insertion sequence (IS) elements in unique positions that did not disrupt the coding sequence. Genetic mutations (partial gene deletion, missing genes, IS insertion, internal stop, and phase-variable off) that led to nongroupability were identified. The results of WGS and SASG were in 91% to 100% agreement for all serogroups, while the results of WGS and RT-PCR showed 99% to 100% agreement. Among isolates determined to be nongroupable by WGS (31 of 453), the results of all three methods agreed 100% for those without a capsule polymerase gene. However, 61% (WGS versus SASG) and 36% (WGS versus RT-PCR) agreements were observed for the isolates, particularly those with phase variations or internal stops in cps loci, which warrant further characterization by additional tests. Our WGS-based serogrouping method provides comprehensive characterization of the N. meningitidis capsule, which is critical for meningococcal surveillance and outbreak investigations.

      6. Live oral rotavirus vaccines have been developed by serial passaging in cell culture and found safe in infants. However, mechanisms for the adaptation and attenuation of rotavirus vaccines are not fully understood. We have prepared a human rotavirus vaccine strain CDC-9 (G1P[8]) which when grown in MA104 cells to passages 11 or 12 (P11/P12), had no nucleotide and amino acid sequence changes from the original virus in stool. Upon adaptation and passages in Vero cells, the strain underwent five amino acid changes at passage 28 (P28) and one additional change at P44/P45 in VP4 gene. We performed virologic, immunological and pathogenic characterization of wild-type CDC-9 virus P11/P12 and its two mutants at P28 or P44/P45 using in vitro- and in vivo-model systems. We found that mutants CDC-9 P28 and P44 induced upregulated expression of immunomodulatory cytokines. On the other hand, the two mutant viruses induced lower STAT-1 phosphorylation and grew to two logs higher titers than wild-type virus in human CaCo-2 cells and simian Vero cells. In neonatal rats, CDC-9 P45 showed reduced rotavirus shedding in fecal specimens and did not induce diarrhea compared to wild-type virus, and modulated cytokine responses comparable to Rotarix infection. These findings indicate that mutant CDC-9 is attenuated and safe. Our study is the first to provide insight into the possible mechanisms of human rotavirus adaptation and attenuation and supports ongoing efforts to develop CDC-9 as a new generation of rotavirus vaccine for live oral or parenteral administration.IMPORTANCE Mechanisms for in vitro adaptation and in vivo attenuation of human rotavirus vaccines are not known. The present study is the first to comprehensively compare the in vitro growth characteristics, virulence, and host response of a wild-type and an attenuated human rotavirus CDC-9 strain in CaCo-2 cells and neonatal rats. Our study identifies critical sequence changes in the genome that render human rotavirus adapted to high growth in Vero cells and attenuated and safe in neonatal rats thus supports clinical development of CDC-9 for oral or parenteral vaccination in children.

      7. The Crimean-Congo hemorrhagic fever virus NSm protein is dispensable for growth in vitro and disease in Ifnar(-/-) miceexternal icon
        Welch SR, Scholte FE, Spengler JR, Ritter JM, Coleman-McCray JD, Harmon JR, Nichol ST, Zaki SR, Spiropoulou CF, Bergeron E.
        Microorganisms. 2020 May 21;8(5).
        Crimean-Congo hemorrhagic fever virus (CCHFV) is a tri-segmented, tick-borne nairovirus that causes disease of ranging severity in humans. The CCHFV M segment encodes a complex glycoprotein precursor (GPC) that undergoes extensive endoproteolytic cleavage, giving rise to two structural proteins (Gn and Gc) required for virus attachment and entry, and to multiple non-structural proteins (NSm, GP160, GP85, and GP38). The functions of these non-structural proteins remain largely unclear. Here, we investigate the role of NSm during infection by generating a recombinant CCHFV lacking the complete NSm domain (10200NSm) and observing CCHFV NSm replication in cell lines and pathogenicity in Ifnar(-/-) mice. Our data demonstrate that the NSm domain is dispensable for viral replication in vitro, and, despite the delayed onset of clinical signs, CCHFV lacking this domain caused severe or lethal disease in infected mice.

    • Occupational Safety and Health
      1. Potential classification of chemical immunologic response based on gene expression profilesexternal icon
        Anderson SE, Baur R, Kashon M, Lukomska E, Weatherly L, Shane HL.
        J Immunotoxicol. 2020 Dec;17(1):122-134.
        Occupational immune diseases are a serious public health burden and are often a result of exposure to low molecular weight (LMW) chemicals. The complete immunological mechanisms driving these responses are not fully understood which has made the classification of chemical allergens difficult. Antimicrobials are a large group of immunologically-diverse LMW agents. In these studies, mice were dermally exposed to representative antimicrobial chemicals (sensitizers: didecyldimethylammonium chloride (DDAC), ortho-phthalaldehyde (OPA), irritants: benzal-konium chloride (BAC), and adjuvant: triclosan (TCS)) and the mRNA expression of cytokines and cellular mediators was evaluated using real-time qPCR in various tissues over a 7-days period. All antimicrobials caused increases in the mRNA expression of the danger signals Tslp (skin), and S100a8 (skin, blood, lung). Expression of the TH2 cytokine Il4 peaked at different timepoints for the chemicals based on exposure duration. Unique expression profiles were identified for OPA (Il10 in lymph node, Il4 and Il13 in lung) and TCS (Tlr4 in skin). Additionally, all chemicals except OPA induced decreased expression of the cellular adhesion molecule Ecad. Overall, the results from these studies suggest that unique gene expression profiles are implicated following dermal exposure to various antimicrobial agents, warranting the need for additional studies. In order to advance the development of preventative and therapeutic strategies to combat immunological disease, underlying mechanisms of antimicrobial-induced immunomodulation must be fully understood. This understanding will aid in the development of more effective methods to screen for chemical toxicity, and may potentially lead to more effective treatment strategies for those suffering from immune diseases.

      2. Patients with asthma typically have chronic airway inflammation, variable airflow limitation, and intermittent respiratory symptoms; patients with chronic obstructive pulmonary disease (COPD) often have fixed airflow limitation and persistent respiratory symptoms. Some patients exhibit features suggesting that they have both conditions, which is termed asthma-COPD overlap. These patients have been reported to have worse health outcomes than do those with asthma or COPD alone (1). To describe mortality among persons aged >/=25 years with asthma-COPD overlap, CDC analyzed 1999-2016 National Vital Statistics multiple-cause-of-death mortality data* extracted from the National Occupational Mortality System (NOMS), which included industry and occupation(dagger) information collected from 26 states( section sign) for the years 1999, 2003, 2004, and 2007-2014. Age-adjusted death rates per one million persons( paragraph sign) and proportionate mortality ratios (PMRs)** were calculated. During 1999-2016, 6,738 male decedents (age-adjusted rate per million = 4.30) and 12,028 female decedents (5.59) had both asthma and COPD assigned on their death certificate as the underlying or contributing cause of death. The annual age-adjusted death rate per million among decedents with asthma-COPD overlap declined from 6.70 in 1999 to 3.01 in 2016 (p<0.05) for men and from 7.71 in 1999 to 4.01 in 2016 (p<0.05) for women. Among adults aged 25-64 years, asthma-COPD overlap PMRs, by industry, were significantly elevated among nonpaid workers, nonworkers, and persons working at home for both men (1.72) and women (1.40) and among male food, beverage, and tobacco products workers (2.64). By occupation, asthma-COPD overlap PMRs were significantly elevated among both men (1.98) and women (1.79) who were unemployed, had never worked, or were disabled workers and among women bartenders (3.28) and homemakers (1.34). The association between asthma-COPD overlap mortality and nonworking status among adults aged 25-64 years suggests that asthma-COPD overlap might be associated with substantial morbidity. Increased risk for asthma-COPD overlap mortality among adults in certain industries and occupations suggests targets for public health interventions (e.g., elimination of or removal from exposures, engineering controls, and workplace smoke-free policies) to prevent asthma and COPD in and out of the workplace.

      3. Introduction: Even though the majority of youth in the U.S. work, and workers under the age of 18 are seriously injured on the job at higher rates when compared to adults, most adolescents lack instruction on workplace safety and health. Method: This qualitative study examines the extent to which selected U.S. school districts provide workplace safety and health instruction to students and explores the factors that influence districts’ decision to adopt a free, foundational occupational safety and health (OSH) curriculum. Results: Results from key informant interviews conducted with a purposive sample of 34 school administrators revealed that only a third of the districts have at least 75% of their students receive some instruction on workplace safety and health, while 15% indicated they provide no instruction on this topic. District staff who indicated that they provide OSH instruction stated that it is most often taught through career and technical education (CTE; 65%) and/or health classes (26%). They believed the benefits of providing this instruction include assisting students to get jobs (38%) and helping students learn about safety (32%), while competing demands (44%) and time constraints (41%) were identified as barriers to providing OSH education to students. Conclusions: Given the importance of work to teens and their increased risk of work injury, interested stakeholders—including parents, teachers, employers, and the public health community—should promote the inclusion of workplace safety and health instruction in U.S. secondary schools. Practical Applications: This research fills a gap in current knowledge about the extent to which OSH is currently taught within U.S. secondary schools, enumerates barriers and facilitators to the inclusion of workplace safety and health instruction in schools, presents a free, foundational curriculum in workplace safety and health, and provides directions for future research on the vital role schools can play in preparing the future workforce for safe and healthy employment.

      4. Surgical team exposure to cautery smoke and its mitigation during tonsillectomyexternal icon
        O'Brien DC, Lee EG, Soo JC, Friend S, Callaham S, Carr MM.
        Otolaryngol Head Neck Surg. 2020 May 26:194599820917394.
        OBJECTIVES: To assess the exposure of surgical personnel to known carcinogens during pediatric tonsillectomy and adenoidectomy (T&A) and compare the efficacy of surgical smoke evacuation systems during T&A. STUDY DESIGN: Prospective, case series. SETTING: Tertiary children's hospital. SUBJECTS AND METHODS: The present study assessed operating room workers' exposure to chemical compounds and aerosolized particulates generated during T&A. We also investigated the effect of 3 different smoke-controlling methods: smoke-evacuator pencil cautery (SE), cautery with suction held by an assistant (SA), and cautery without suction (NS). RESULTS: Thirty cases were included: 12 in the SE group, 9 in SA, and 9 in NS. The chemical exposure levels were lower than or similar to baseline background concentrations, with the exception of methylene chloride and acetaldehyde. Within the surgical plume, none of the chemical compounds exceeded the corresponding occupational exposure limit (OEL). The mean particulate number concentration in the breathing zone during tonsillectomy was 508 particles/cm(3) for SE compared to 1661 particles/cm(3) for SA and 8208 particles/cm(3) for NS cases. NS was significantly different compared to the other two methods (P = .0009). CONCLUSIONS: Although the exposure levels to chemicals were considerably lower than the OELs, continuous exposures to these chemicals could cause adverse health effects to surgical personnel. These findings suggest that the use of a smoke-evacuator pencil cautery or an attentive assistant with handheld suction would reduce exposure levels to the aerosolized particles during routine T&A, compared to the use of cautery without suction.

      5. Demographic considerations in analyzing decedents by usual occupationexternal icon
        Peterson C, Schumacher PK, Steege AL.
        Am J Ind Med. 2020 May 23.
        BACKGROUND: Public health research uses decedents' usual industry and occupation (I&O) from US death certificates to assess mortality incidence and risk factors. Of necessity, such research may exclude decedents with insufficient I&O information, and assume death certificates reflect current (at time of death) I&O. This study explored the demographic implications of such research conditions by describing usual occupation and current employment status among decedents by demographic characteristics in a large multistate data set. METHODS: Death certificate occupations classified by Standard Occupational Classification (SOC) (ie, compensated occupation) and other categories (eg, student) for 36 507 decedents (suicide, homicide, other, undetermined intent) age 22+ years from the 2016 National Violent Death Reporting System's (NVDRS) 32 US states were analyzed. Decedents not employed at the time of death (eg, laid off) were identified through nondeath certificate NVDRS data sources (eg, law enforcement reports). RESULTS: Female decedents, younger (age < 30 years) male decedents, some non-White racial group decedents, less educated decedents, and undetermined intent death decedents were statistically less likely to be classified by SOC based on death certificates-primarily due to insufficient information. Decedents classified by SOC from death certificates but whose non-death certificate data indicated no employment at the time of death were more often 30+ years old, White, less educated, died by suicide, or had nonmanagement occupations. CONCLUSIONS: Whether decedents have classifiable occupations from death certificates may vary by demographic characteristics. Research studies that assess decedents by usual I&O can identify and describe how any such demographic trends may affect research results on particular public health topics.

    • Parasitic Diseases
      1. Risk factors for malaria infection and seropositivity in the elimination area of Grand'Anse, Haiti: A case-control study among febrile individuals seeking treatment at public health facilitiesexternal icon
        Ashton RA, Joseph V, van den Hoogen LL, Tetteh KK, Stresman G, Worges M, Druetz T, Chang MA, Rogier E, Lemoine JF, Drakeley C, Eisele TP.
        Am J Trop Med Hyg. 2020 May 26.
        The island of Hispaniola aims to eliminate malaria by 2025; however, there are limited data to describe epidemiologic risk factors for malaria in this setting. A prospective case-control study was conducted at four health facilities in southwest Haiti, aiming to describe factors influencing the risk of current and past malaria infection. Cases were defined as individuals attending facilities with current or recent fever and positive malaria rapid diagnostic test (RDT), whereas controls were those with current or recent fever and RDT negative. Serological markers of recent and cumulative exposure to Plasmodium were assessed using the multiplex bead assay from dried blood spots and used for alternate case definitions. Kuldorff's spatial scan statistic was used to identify local clusters of infection or exposure. Logistic regression models were used to assess potential risk factors for RDT positivity and recent exposure markers, including age-group, gender, and recruiting health facility as group-matching variables. A total of 192 cases (RDT positive) and 915 controls (RDT negative) were recruited. Consistent spatial clusters were identified for all three infection and exposure metrics, indicating temporal stability of malaria transmission at these sites. Risk factors included remoteness from health facilities and household construction, whereas insecticide-treated net ownership or use was associated with reduced odds of RDT positivity. These findings indicate the malaria risk in Grand'Anse is driven primarily by location. Travel, occupation, and other behavioral factors were not associated with malaria. These data can support the National Malaria Program to refine and target their intervention approaches, and to move toward elimination.

      2. Guinea worm in domestic dogs in Chad: A description and analysis of surveillance dataexternal icon
        Guagliardo SA, Roy SL, Ruiz-Tiben E, Zirimwabagabo H, Romero M, Chop E, Ouakou PT, Hopkins DR, Weiss AJ.
        PLoS Negl Trop Dis. 2020 May;14(5):e0008207.
        After a ten-year absence of reported Guinea worm disease in Chad, human cases were rediscovered in 2010, and canine cases were first recorded in 2012. In response, active surveillance for Guinea worm in both humans and animals was re-initiated in 2012. As of 2018, the Chad Guinea Worm Eradication Program (CGWEP) maintains an extensive surveillance system that operates in 1,895 villages, and collects information about worms, hosts (animals and humans), and animal owners. This report describes in detail the CGWEP surveillance system and explores epidemiological trends in canine Guinea worm cases during 2015-2018. Our results showed an increased in the number of canine cases detected by the system during the period of interest. The proportion of worms that were contained (i.e., water contamination was prevented) improved significantly over time, from 72.8% in 2015 to 85.7% in 2018 (Mantel-Haenszel chi-square = 253.3, P < 0.0001). Additionally, approximately 5% of owners of infected dogs reported that the dog had a Guinea worm-like infection earlier that year; 12.6% had a similar worm in a previous year. The proportion of dogs with a history of infection in a previous year increased over time (Mantel-Haenszel chi-square = 18.8, P < 0.0001). Canine cases were clustered in space and time: most infected dogs (80%) were from the Chari Baguirmi (38.1%) and Moyen Chari Regions (41.9%), and for each year the peak month of identified canine cases was June, with 78.5% occurring during March through August. Findings from this report evoke additional questions about why some dogs are repeatedly infected. Our results may help to target interventions and surveillance efforts in terms of space, time, and dogs susceptible to recurrent infection, with the ultimate goal of Guinea worm eradication.

      3. Comparing the durability of the long-lasting insecticidal nets DawaPlus((R)) 2.0 and DuraNet(c) in northwest Democratic Republic of Congoexternal icon
        Mansiangi P, Umesumbu S, Etewa I, Zandibeni J, Bafwa N, Blaufuss S, Olapeju B, Ntoya F, Sadou A, Irish S, Mukomena E, Kalindula L, Watsenga F, Akogbeto M, Babalola S, Koenker H, Kilian A.
        Malar J. 2020 May 24;19(1):189.
        BACKGROUND: Anecdotal reports from DRC suggest that long-lasting insecticidal nets (LLIN) distributed through mass campaigns in DRC may not last the expected average three years. To provide the National Malaria Control Programme with evidence on physical and insecticidal durability of nets distributed during the 2016 mass campaign, two brands of LLIN, DawaPlus((R)) 2.0 and DuraNet(c), were monitored in neighbouring and similar health zones in Sud Ubangi and Mongala Provinces. METHODS: This was a prospective cohort study of representative samples of households from two health zones recruited at baseline, 2 months after the mass campaign. All campaign nets in these households were labelled, and followed up over a period of 31 months. Primary outcome was the "proportion of nets surviving in serviceable condition" based on attrition and integrity measures and the median survival in years. The outcome for insecticidal durability was determined by bio-assay from subsamples of campaign nets. RESULTS: A total of 754 campaign nets (109% of target) from 240 households were included in the study. Definite outcomes could be determined for 67% of the cohort nets in Sud Ubangi and 74% in Mongala. After 31 months all-cause attrition was 57% in Sud Ubangi and 76% in Mongala (p = 0.005) and attrition due to wear and tear was 26% in Sud Ubangi and 48% in Mongala (p = 0.0009). Survival in serviceable condition at the last survey was 37% in Sud Ubangi and 17% in Mongala (p = 0.003). Estimated median survival was 1.6 years for the DawaPlus((R)) 2.0 in Mongala (95% CI 1.3-1.9) and 2.2 years for the DuraNet in Sud Ubangi (95% CI 2.0-2.4). Multivariable Cox proportionate hazard models suggest that the difference between sites was mainly attributable to the LLIN brand. Insecticidal effectiveness was optimal for DuraNet(c), but significantly dropped after 24 months for DawaPlus((R)) 2.0. CONCLUSIONS: In the environment of northwest DRC the polyethylene LLIN DuraNet(c) performed significantly better than the polyester LLIN DawaPlus((R)) 2.0, but both were below a three-year median survival. Improvement of net care behaviours should be able to improve physical durability.

      4. Combination of serological, antigen detection, and DNA data for Plasmodium falciparum provides robust geospatial estimates for malaria transmission in Haitiexternal icon
        Oviedo A, Knipes A, Worrell C, Fox LM, Desir L, Fayette C, Javel A, Monestime F, Mace K, Chang MA, Udhayakumar V, Lemoine JF, Won K, Lammie PJ, Rogier E.
        Sci Rep. 2020 May 21;10(1):8443.
        Microscopy is the gold standard for malaria epidemiology, but laboratory and point-of-care (POC) tests detecting parasite antigen, DNA, and human antibodies against malaria have expanded this capacity. The island nation of Haiti is endemic for Plasmodium falciparum (Pf) malaria, though at a low national prevalence and heterogenous geospatial distribution. In 2015 and 2016, serosurveys were performed of children (ages 6-7 years) sampled in schools in Saut d'Eau commune (n = 1,230) and Grand Anse department (n = 1,664) of Haiti. Children received malaria antigen rapid diagnostic test and provided a filter paper blood sample for further laboratory analysis of the Pf histidine-rich protein 2 (HRP2) antigen, Pf DNA, and anti-Pf IgG antibodies. Prevalence of Pf infection ranged from 0.0-16.7% in 53 Saut d'Eau schools, and 0.0-23.8% in 56 Grand Anse schools. Anti-Pf antibody carriage exceeded 80% of students in some schools from both study sites. Geospatial prediction ellipses were created to indicate clustering of positive tests within the survey areas and overlay of all prediction ellipses for the different types of data revealed regions with high likelihood of active and ongoing Pf malaria transmission. The geospatial utilization of different types of Pf data can provide high confidence for spatial epidemiology of the parasite.

      5. Community-based participatory research in travel medicine to identify barriers to preventing malaria in VFR travellersexternal icon
        Walz EJ, Wanduragala D, Adedimeji AA, Volkman HR, Gaines J, Angelo KM, Boumi AE, Coyle C, Dunlop SJ, Stauffer WM.
        J Travel Med. 2019 Jan 1;26(1).

    • Social and Behavioral Sciences
      1. Early adolescent gender diversity and mental health in the Adolescent Brain Cognitive Development studyexternal icon
        Potter A, Dube S, Allgaier N, Loso H, Ivanova M, Barrios LC, Bookheimer S, Chaarani B, Dumas J, Feldstein-Ewing S, Freedman EG, Garavan H, Hoffman E, McGlade E, Robin L, Johns MM.
        J Child Psychol Psychiatry. 2020 May 28.
        BACKGROUND: There are known associations between mental health symptoms and transgender identity among adults. Whether this relationship extends to early adolescents and to gender domains other than identity is unclear. This study measured dimensions of gender in a large, diverse, sample of youth, and examined associations between diverse gender experiences and mental health. METHODS: The ABCD study is an ongoing, longitudinal, US cohort study. Baseline data (release 2.0) include 11,873 youth age 9/10 (48% female); and the 4,951 1-year follow-up visits (age 10/11; 48% female) completed prior to data release. A novel gender survey at the 1-year visit assessed felt-gender, gender noncontentedness, and gender nonconformity using a 5-point scale. Mental health measures included youth- and parent-reports. RESULTS: Roughly half a percent of 9/10-year-olds (n = 58) responded 'yes' or 'maybe' when asked, 'Are you transgender' at baseline. Recurrent thoughts of death were more prevalent among these youth compared to the rest of the cohort (19.6% vs. 6.4%, chi(2) = 16.0, p < .001). At the 1-year visit, when asked about the three dimensions of gender on a 5-point scale, 33.2% (n = 1,605) provided responses that were not exclusively and totally aligned with one gender. Significant relationships were observed between mental health symptoms and gender diversity for all dimensions assessed. CONCLUSIONS: Similar to adult studies, early adolescents identifying as transgender reported increased mental health symptoms. Results also point to considerable diversity in other dimensions of gender (felt-gender, gender noncontentedness, gender nonconformity) among 10/11-year-olds, and find this diversity to be related to critical mental health symptoms. These findings add to our limited understanding of the relationship between dimensions of gender and wellness for youth.

    • Zoonotic and Vectorborne Diseases
      1. Zika inquiries made to the CDC-INFO System, December 2015-September 2017external icon
        Sell TK, Watson C, Meyer D, Snyder MR, Ravi SJ, McGinty EE, Pechta LE, Rose DA, Podgornik MN, Lubell KM.
        Emerg Infect Dis. 2020 May;26(5):1022-1024.
        We examined Zika-related inquiries to CDC-INFO, the national contact center for the Centers for Disease Control and Prevention, to identify potential communication gaps. The most frequently asked questions related to travel or geographic location of Zika (42% of all inquiries), information about laboratory testing (13%), or acquiring a Zika test (11%).

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

Page last reviewed: June 16, 2020, 12:00 AM