Volume 12, Issue 23, July 14, 2020

CDC Science Clips: Volume 12, Issue 23, July 14, 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.
    • Communicable Diseases
      • Multisystem inflammatory syndrome in children in New York Stateexternal icon
        Dufort EM, Koumans EH, Chow EJ, Rosenthal EM, Muse A, Rowlands J, Barranco MA, Maxted AM, Rosenberg ES, Easton D, Udo T, Kumar J, Pulver W, Smith L, Hutton B, Blog D, Zucker H.
        N Engl J Med. 2020 Jun 29.
        BACKGROUND: A multisystem inflammatory syndrome in children (MIS-C) is associated with coronavirus disease 2019. The New York State Department of Health (NYSDOH) established active, statewide surveillance to describe hospitalized patients with the syndrome. METHODS: Hospitals in New York State reported cases of Kawasaki's disease, toxic shock syndrome, myocarditis, and potential MIS-C in hospitalized patients younger than 21 years of age and sent medical records to the NYSDOH. We carried out descriptive analyses that summarized the clinical presentation, complications, and outcomes of patients who met the NYSDOH case definition for MIS-C between March 1 and May 10, 2020. RESULTS: As of May 10, 2020, a total of 191 potential cases were reported to the NYSDOH. Of 95 patients with confirmed MIS-C (laboratory-confirmed acute or recent severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] infection) and 4 with suspected MIS-C (met clinical and epidemiologic criteria), 53 (54%) were male; 31 of 78 (40%) were black, and 31 of 85 (36%) were Hispanic. A total of 31 patients (31%) were 0 to 5 years of age, 42 (42%) were 6 to 12 years of age, and 26 (26%) were 13 to 20 years of age. All presented with subjective fever or chills; 97% had tachycardia, 80% had gastrointestinal symptoms, 60% had rash, 56% had conjunctival injection, and 27% had mucosal changes. Elevated levels of C-reactive protein, d-dimer, and troponin were found in 100%, 91%, and 71% of the patients, respectively; 62% received vasopressor support, 53% had evidence of myocarditis, 80% were admitted to an intensive care unit, and 2 died. The median length of hospital stay was 6 days. CONCLUSIONS: The emergence of multisystem inflammatory syndrome in children in New York State coincided with widespread SARS-CoV-2 transmission; this hyperinflammatory syndrome with dermatologic, mucocutaneous, and gastrointestinal manifestations was associated with cardiac dysfunction.

      • The COVID-19 Serology Studies Workshop: Recommendations and challengesexternal icon
        Lerner AM, Eisinger RW, Lowy DR, Petersen LR, Humes R, Hepburn M, Cassetti MC.
        Immunity. 2020 Jun 23.
        The development, validation, and appropriate application of serological assays to detect antibodies to SARS-CoV-2 are essential to determining seroprevalence of this virus in the United States and globally and in guiding government leadership and the private sector on back-to-work policies. An interagency working group of the US Department of Health and Human Services convened a virtual workshop to identify knowledge gaps and key outstanding scientific issues and to develop strategies to fill them. Key outcomes of the workshop included recommendations for (1) advancing serology assays as a tool to better understand SARS-CoV-2 infection and (2) conducting crucial serology field studies to advance an understanding of immunity to SARS-CoV-2, leading to protection and duration of protection, including the correlation between serological test results and risk of reinfection.

      • Pharyngeal gonococcal infections: A cross-sectional study in a network of sexually transmitted disease clinics; Sexually Transmitted Disease Surveillance Network-January 2016 to June 2018external icon
        Llata E, Braxton J, Asbel L, Huspeni D, Hsu K, Kerani RP, Nguyen TQ, Pathela P, Schumacher C, Toevs K, Torrone E.
        Sex Transm Dis. 2019 Dec;46(12):777-779.
        We conducted a cross-sectional analysis using sexually transmitted disease clinic data to determine test of cure rates among persons diagnosed with pharyngeal gonococcal infections who were treated with a nonceftriaxone, nonazithromycin therapy. Less than 10% returned for a test of cure, highlighting the need to understand factors that can lead to improved compliance.

      • Recent influenza activity in tropical Puerto Rico has become synchronized with mainland USexternal icon
        Paz-Bailey G, Quandelacy TM, Adams LE, Olsen SJ, Blanton L, Munoz-Jordan JL, Lozier M, Alvarado LI, Johansson MA.
        Influenza Other Respir Viruses. 2020 Jul 2.
        BACKGROUND: We used data from the Sentinel Enhanced Dengue Surveillance System (SEDSS) to describe influenza trends in southern Puerto Rico during 2012-2018 and compare them to trends in the United States. METHODS: Patients with fever onset </= 7 days presenting were enrolled. Nasal/oropharyngeal swabs were tested for influenza A and B viruses by PCR. Virologic data were obtained from the US World Health Organization (WHO) Collaborating Laboratories System and the National Respiratory and Enteric Virus Surveillance System (NREVSS). We compared influenza A and B infections identified from SEDSS and WHO/NREVSS laboratories reported by US Department of Health and Human Services (HHS) region using time series decomposition methods, and analysed coherence of climate and influenza trends by region. RESULTS: Among 23,124 participants, 9% were positive for influenza A and 5% for influenza B. Influenza A and B viruses were identified year-round, with no clear seasonal patterns from 2012 to 2015 and peaks in December-January in 2016-2017 and 2017-2018 seasons. Influenza seasons in HHS regions were relatively synchronized in recent years with the seasons in Puerto Rico. We observed high coherence between absolute humidity and influenza A and B virus in HHS regions. In Puerto Rico, coherence was much lower in the early years but increased to similar levels to HHS regions by 2017-2018. CONCLUSIONS: Influenza seasons in Puerto Rico have recently become synchronized with seasons in US HHS regions. Current US recommendations are for everyone 6 months and older to receive influenza vaccination by the end of October seem appropriate for Puerto Rico.

      • Establishing seasonal and alert influenza thresholds in Moroccoexternal icon
        Rguig A, Cherkaoui I, McCarron M, Oumzil H, Triki S, Elmbarki H, Bimouhen A, El Falaki F, Regragui Z, Ihazmad H, Nejjari C, Youbi M.
        BMC Public Health. 2020 Jun 29;20(1):1029.
        BACKGROUND: Several statistical methods of variable complexity have been developed to establish thresholds for influenza activity that may be used to inform public health guidance. We compared the results of two methods and explored how they worked to characterize the 2018 influenza season performance-2018 season. METHODS: Historical data from the 2005/2006 to 2016/2018 influenza season performance seasons were provided by a network of 412 primary health centers in charge of influenza like illness (ILI) sentinel surveillance. We used the WHO averages and the moving epidemic method (MEM) to evaluate the proportion of ILI visits among all outpatient consultations (ILI%) as a proxy for influenza activity. We also used the MEM method to evaluate three seasons of composite data (ILI% multiplied by percent of ILI with laboratory-confirmed influenza) as recommended by WHO. RESULTS: The WHO method estimated the seasonal ILI% threshold at 0.9%. The annual epidemic period began on average at week 46 and lasted an average of 18 weeks. The MEM model estimated the epidemic threshold (corresponding to the WHO seasonal threshold) at 1.5% of ILI visits among all outpatient consultations. The annual epidemic period began on week 49 and lasted on average 14 weeks. Intensity thresholds were similar using both methods. When using the composite measure, the MEM method showed a clearer estimate of the beginning of the influenza epidemic, which was coincident with a sharp increase in confirmed ILI cases. CONCLUSIONS: We found that the threshold methodology presented in the WHO manual is simple to implement and easy to adopt for use by the Moroccan influenza surveillance system. The MEM method is more statistically sophisticated and may allow a better detection of the start of seasonal epidemics. Incorporation of virologic data into the composite parameter as recommended by WHO has the potential to increase the accuracy of seasonal threshold estimation.

      • Epidemiology of invasive Haemophilus influenzae serotype a disease - United States, 2008-2017external icon
        Soeters HM, Oliver SE, Plumb ID, Blain AE, Zulz T, Simons BC, Barnes M, Farley MM, Harrison LH, Lynfield R, Massay S, McLaughlin J, Muse AG, Petit S, Schaffner W, Thomas A, Torres S, Watt J, Pondo T, Whaley MJ, Hu F, Wang X, Briere EC, Bruce MG.
        Clin Infect Dis. 2020 Jun 26.
        BACKGROUND: Haemophilus influenzae serotype a (Hia) can cause invasive disease similar to serotype b; no Hia vaccine is available. We describe the epidemiology of invasive Hia disease in the United States overall and specifically in Alaska during 2008-2017. METHODS: Active population- and laboratory-based surveillance for invasive Hia disease was conducted through Active Bacterial Core surveillance sites and from Alaska statewide invasive bacterial disease surveillance. Sterile-site isolates were serotyped via slide agglutination or real-time polymerase chain reaction. Incidences in cases per 100,000 were calculated. RESULTS: From 2008-2017, an estimated average of 306 invasive Hia disease cases occurred annually in the United States (estimated annual incidence: 0.10); incidence increased by an average of 11.1% annually. Overall, 42.7% of cases were in children aged <5 years (incidence: 0.64), with highest incidence among children aged <1 year (1.60). Case fatality was 7.8% overall and was highest among adults aged >/=65 years (15.1%). Among children aged <5 years, incidence was 17 times higher among American Indians and Alaska Native (AI/AN) children (8.29) than among children of all other races combined (0.49). In Alaska, incidences among all ages (0.68) and among children aged <1 year (24.73) were nearly 6 and 14 times higher, respectively, than corresponding U.S. incidences. Case fatality in Alaska was 10.2%, and the vast majority (93.9%) of cases occurred among AI/AN. CONCLUSIONS: Incidence of invasive Hia disease has increased since 2008, with the highest burden among AI/AN children. These data can inform prevention strategies, including Hia vaccine development.

    • Laboratory Sciences
      • Rapid diagnostic tests to address challenges for global measles surveillanceexternal icon
        Brown DW, Warrener L, Scobie HM, Donadel M, Waku-Kouomou D, Mulders MN, Rota PA.
        Curr Opin Virol. 2020 Jun 29;41:77-84.
        Recently, a lateral flow rapid diagnostic test (RDT) with good accuracy has been described. This test enables measles specific IgM antibody detection in serum, capillary blood and oral fluid. RDTs have the potential to transform measles surveillance by allowing real-time case confirmation outside of central/regional laboratories and by facilitating a timely public health response. Measles virus genes can also be amplified and sequenced consistently from dried IgM-positive RDTs stored outside of cold chain, which will enable more complete virologic surveillance. Critical questions remain regarding operational use of RDTs as part of global measles surveillance. Projects to evaluate RDT use as part of national surveillance programs and to commercialize the RDT are underway.

      • Persistence of bacteriophage Phi 6 on porous and non-porous surfaces; potential for use as Ebola or coronavirus surrogateexternal icon
        Whitworth C, Mu Y, Houston H, Martinez-Smith M, Noble-Wang J, Coulliette-Salmond A, Rose L.
        Appl Environ Microbiol. 2020 Jun 26.
        The infection of healthcare workers during the 2013 -2016 Ebola outbreak raised concerns about fomite transmission. In the wake of the Coronavirus Disease 2019 (COVID-19) pandemic, investigations are ongoing to determine the role of fomites in coronavirus transmission as well. The bacteriophage Phi 6 has a phospholipid envelope and is commonly used in environmental studies as a surrogate for human enveloped viruses. The persistence of Phi 6 was evaluated as a surrogate for EBOV and coronaviruses on porous and nonporous hospital surfaces. Phi 6 was suspended in a body fluid simulant and inoculated onto 1 cm(2) coupons of steel, plastic, and two fabric curtain types. The coupons were placed at two controlled absolute humidity (AH) levels; a low AH of 3.0 g/m(3) and a high AH of 14.4 g/m(3) Phi 6 declined at a slower rate on all materials under low AH conditions with a decay rate of 0.06 log10PFU/d to 0.11 log10PFU/d, as compared to the higher AH conditions with a decay rate of 0.65 log10PFU/h to 1.42 log10PFU/d. There was a significant difference in decay rates between porous and non-porous surfaces at both low AH (P < 0.0001) and high AH (P < 0.0001). Under these laboratory-simulated conditions, Phi 6 was found to be a conservative surrogate for EBOV under low AH conditions, in that it persisted longer than Ebola virus in similar AH conditions. Additionally, some coronaviruses persist longer than phi6 under similar conditions, therefore Phi6 may not be a suitable surrogate for coronaviruses.IMPORTANCE Understanding the persistence of enveloped viruses helps inform infection control practices and procedures in healthcare facilities and community settings. These data convey to public health investigators that enveloped viruses can persist and remain infective on surfaces, thus demonstrating a potential risk for transmission. Under these laboratory-simulated western indoor hospital conditions, Phi 6 was used to assess suitability as a surrogate for environmental persistence research related to enveloped viruses, including EBOV and coronaviruses.

    • Social and Behavioral Sciences
      • Peer companionship for mental health of older adults in primary care: A pragmatic, nonblinded, parallel-group, randomized controlled trialexternal icon
        Conwell Y, Van Orden KA, Stone DM, McIntosh WL, Messing S, Rowe J, Podgorski C, Kaukeinen KA, Tu X.
        Am J Geriatr Psychiatry. 2020 Jun 2.
        OBJECTIVES: To determine whether peer companionship delivered by an aging services agency to socially-disconnected older adult primary care patients was associated with improvement in suicidal ideation depression, anxiety, and psychological connectedness. DESIGN: Pragmatic, nonblinded, parallel-group, randomized controlled trial comparing peer companionship, The Senior Connection (TSC), to care-as-usual (CAU). SETTING: Lifespan, a nonmedical, community-based aging services agency. PARTICIPANTS: Adult primary care patients ages 60 years or older who endorsed feelings of loneliness or being a burden on others. INTERVENTION: TSC was delivered by Lifespan volunteers who provided supportive visits and phone calls in the subjects' homes. CAU involved no peer companion assignment. MEASUREMENTS: The primary outcome was suicidal ideation assessed by the Geriatric Suicide Ideation Scale; secondary outcomes were depression, anxiety, and feelings of belonging and being a burden on others. Data were collected at baseline, 3-, 6-, and 12-months. RESULTS: Subjects (55% female) had a mean age of 71 years. There was no difference between groups in change in suicidal ideation or belonging. Subjects randomized to TSC had greater reduction in depression (PHQ-9; 2.33 point reduction for TSC versus 1.32 for CAU, p = 0.05), anxiety (GAD-7; TSC 1.52 versus CAU 0.28, p = 0.03), and perceived burden on others (INQ; 0.46 TSC versus 0.09 CAU, p <0.01). CONCLUSIONS: TSC was superior to CAU for improving depression, anxiety, and perceived burden, but not suicidal ideation. Although effect sizes were small, the low-cost and nationwide availability of peer companionship justify further examination of its effectiveness and scalability in improving mental health outcomes of socially disconnected older adults.

    • Veterinary Medicine
      • Linking longitudinal and cross-sectional biomarker data to understand host-pathogen dynamics: Leptospira in California sea lions (Zalophus californianus) as a case studyexternal icon
        Prager KC, Buhnerkempe MG, Greig DJ, Orr AJ, Jensen ED, Gomez F, Galloway RL, Wu Q, Gulland FM, Lloyd-Smith JO.
        PLoS Negl Trop Dis. 2020 Jun 29;14(6):e0008407.
        Confronted with the challenge of understanding population-level processes, disease ecologists and epidemiologists often simplify quantitative data into distinct physiological states (e.g. susceptible, exposed, infected, recovered). However, data defining these states often fall along a spectrum rather than into clear categories. Hence, the host-pathogen relationship is more accurately defined using quantitative data, often integrating multiple diagnostic measures, just as clinicians do to assess their patients. We use quantitative data on a major neglected tropical disease (Leptospira interrogans) in California sea lions (Zalophus californianus) to improve individual-level and population-level understanding of this Leptospira reservoir system. We create a "host-pathogen space" by mapping multiple biomarkers of infection (e.g. serum antibodies, pathogen DNA) and disease state (e.g. serum chemistry values) from 13 longitudinally sampled, severely ill individuals to characterize changes in these values through time. Data from these individuals describe a clear, unidirectional trajectory of disease and recovery within this host-pathogen space. Remarkably, this trajectory also captures the broad patterns in larger cross-sectional datasets of 1456 wild sea lions in all states of health but sampled only once. Our framework enables us to determine an individual's location in their time-course since initial infection, and to visualize the full range of clinical states and antibody responses induced by pathogen exposure. We identify predictive relationships between biomarkers and outcomes such as survival and pathogen shedding, and use these to impute values for missing data, thus increasing the size of the useable dataset. Mapping the host-pathogen space using quantitative biomarker data enables more nuanced understanding of an individual's time course of infection, duration of immunity, and probability of being infectious. Such maps also make efficient use of limited data for rare or poorly understood diseases, by providing a means to rapidly assess the range and extent of potential clinical and immunological profiles. These approaches yield benefits for clinicians needing to triage patients, prevent transmission, and assess immunity, and for disease ecologists or epidemiologists working to develop appropriate risk management strategies to reduce transmission risk on a population scale (e.g. model parameterization using more accurate estimates of duration of immunity and infectiousness) and to assess health impacts on a population scale.

  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. Costs and resources used by population-based cancer registries in the US-affiliated Pacific Islandsexternal icon
        Edwards P, Buenconsejo-Lum LE, Tangka FK, Jeong Y, Baksa J, Pordell P, Saraiya M, Subramanian S.
        Hawaii J Health Soc Welf. 2020 Jun 1;79(6 Suppl 2):89-98.
        Background: The costs of cancer registration have previously been estimated for registries in the continental United States and many international registries; however, to date, there has been no economic assessment of population-based registries in the US-Affiliated Pacific Islands. This study estimates the costs and factors affecting the operations of US-Affiliated Pacific Island population-based cancer registries. Methods: The web-based International Registry Costing Tool1 was used to collect costs, resources used, cancer cases processed, and other registry characteristics from the Pacific Regional Central Cancer Registry (PRCCR), Federated States of Micronesia National Cancer Registry, and nine satellite jurisdictional registries within the US Pacific Islands. The registries provided data on costs for June 30, 2016-June 29, 2017, and cases processed during 2014. Results: Local host institutions provided a vital source of support for US-Affiliated Pacific Islands registries, covering substantial fixed costs, such as management and overhead. The cost per cancer case processed had an almost tenfold variation across registries, with the average total cost per case of about $1,413. The average cost per inhabitant in the US-Affiliated Pacific Islands was about $1.77 per person. Discussion: The challenges of collecting data from dispersed populations spread across multiple islands of the US-Affiliated Pacific Islands are likely leading factors driving the magnitude of the registries' cost per case. The economic information from this study provides a valuable source of activity-based cost data that can both help guide cancer control initiatives and help registries improve operations and efficiency.

      2. PURPOSE: The purpose of this qualitative study was to examine perceived barriers to adoption of lifestyle changes for type 2 diabetes prevention among a diverse group of low-income women with a history of gestational diabetes mellitus (GDM). METHODS: A secondary data analysis of 10 semistructured focus group discussions was conducted. Participants were low-income African American, Hispanic, and Appalachian women ages 18 to 45 years who were diagnosed with GDM in the past 10 years. A qualitative content analysis was conducted to identify key themes that emerged within and between groups. RESULTS: Four key themes emerged on the role of knowledge, affordability, accessibility, and social support in type 2 diabetes prevention. Women discussed a lack of awareness of the benefits of breastfeeding and type 2 diabetes prevention, inaccessibility of resources in their local communities to help them engage in lifestyle change, and the desire for more culturally relevant education on healthful food options and proper portion sizes. DISCUSSION: Study findings suggests that to improve effectiveness of type 2 diabetes prevention efforts among low-income women with GDM history, health care providers and public health practitioners should avoid using "one-size-fits-all" approaches to lifestyle change and instead use tailored interventions that address the cultural and environmental factors that impact women's ability to engage in recommended behavior change.

      3. Building capacity for logic models and evaluation planning using canoe-building conceptsexternal icon
        Kuiper NM, Cash HL, Welton MT, Chung C.
        Hawaii J Health Soc Welf. 2020 Jun 1;79(6 Suppl 2):108-112.
        Non-communicable diseases (NCDs) are the leading causes of death in the United States Affiliated Pacific Islands (USAPIs); US Centers for Disease Control and Prevention funds programs for prevention and control of diabetes, tobacco use, and related chronic disease conditions. To build USAPI programs' capacity in evaluation and surveillance, we held in-person and virtual trainings on evaluation planning and logic models that were tailored with traditional canoe-building themes to be relatable and memorable. Evaluation results suggest the efforts were effective at translating concepts. Additional tools and technical assistance reinforced concepts and resulted in quality evaluation plans. Culturally tailored evaluation tools can be useful and should be developed with population representatives.

      4. BACKGROUND: Lifestyle change interventions (LCI) for prevention of type 2 diabetes are covered by Medicare, but rarely by US Medicaid programs that constitute the largest public payer system in the USA. We estimate the long-term health and economic implications of implementing LCIs in state Medicaid programs. METHODS: We compared LCIs modeled after the intervention of the Diabetes Prevention Program versus routine care advice using a decision analytic simulation model and best available data from representative surveys, cohort studies, Medicaid claims data, and the published literature. Target population were non-disability-based adult Medicaid beneficiaries aged 19-64 years at high risk for type 2 diabetes (BMI >/=25 kg/m(2) and HbA1c >/= 5.7% or fasting plasma glucose >/= 110 mg/dl) from eight study states (Alabama, California, Connecticut, Florida, Iowa, Illinois, New York, Oklahoma) that represent around 50% of the US Medicaid population. Incremental cost-effectiveness ratios (ICERs) measured in cost per quality-adjusted life years (QALYs) gained, and population cost and health impact were modeled from a healthcare system perspective and a narrow Medicaid perspective. RESULTS: In the eight selected study states, 1.9 million or 18% of non-disability-based adult Medicaid beneficiaries would belong to the eligible high-risk target population - 66% of them Hispanics or non-Hispanic black. In the base-case analysis, the aggregated 5- and 10-year ICERs are US$226 k/QALY and US$34 k/QALY; over 25 years, the intervention dominates routine care. The 5-, 10-, and 25-year probabilities that the ICERs are below US$50 k (US$100 k)/QALY are 6% (15%), 59% (82%) and 96% (100%). From a healthcare system perspective, initial program investments of US$800 per person would be offset after 13 years and translate to US$548 of savings after 25 years. With a 20% LCI uptake in eligible beneficiaries, this would translate to upfront costs of US$300 million, prevent 260 thousand years of diabetes and save US$205 million over a 25-year time horizon. Cost savings from a narrow Medicaid perspective would be much smaller. Minorities and low-income groups would over-proportionally benefit from LCIs in Medicaid, but the impact on population health and health equity would be marginal. CONCLUSIONS: In the long-term, investments in LCIs for Medicaid beneficiaries are likely to improve health and to decrease healthcare expenditures. However, population health and health equity impact would be low and healthcare expenditure savings from a narrow Medicaid perspective would be much smaller than from a healthcare system perspective.

      5. Cancer mortality in the US-affiliated Pacific Islands, 2008-2013external icon
        Van Dyne EA, Saraiya M, White A, Novinson D, Senkomago V, Buenconsejo-Lum L.
        Hawaii J Health Soc Welf. 2020 Jun 1;79(6 Suppl 2):99-107.
        Cancer-related mortality in the US-Affiliated Pacific Island (USAPI) jurisdictions is unknown. This is the first ever reporting of cancer-related mortality in the USAPI using cancer registry data. The individual USAPI jurisdictions collected incident cancer data and submitted it to the Pacific Regional Central Cancer Registry (PRCCR). All cases reported to PRCCR (n = 3,118) with vital status of dead (n = 1,323) during 2008-2013 were examined. Cause of death was coded based on clinical information provided in the cancer registry. Incidencebased mortality (IBM) rates were calculated using SEER*Stat software and age adjusted to the US standard population. Total cancer IBM rates among males were highest in Palau (151.5 per 100,000), Republic of the Marshall Islands (RMI, 142.0), and Guam (133.2); rates were lowest in American Samoa (21.7), the Commonwealth of the Northern Mariana Islands (CNMI, 22.7), and the Federated States of Micronesia (FSM, 28.9). Total cancer IBM rates among females were highest in RMI (120.3 per 100,000), Palau (107.7), and Guam (72.2); rates were lowest in CNMI (19.0), FSM (23.2), and American Samoa (42.8). The median time from cancer diagnosis to death was 8-28 days in the Freely Associated States and 102-128 days in the Flag Territories. IBM rates were higher among individuals in USAPI jurisdictions than among Asian/ Pacific Islanders in Hawai'i for many cancers preventable through vaccination, smoking cessation, overweight and obesity prevention, and cancer screening. Geographic remoteness, underreporting, delay in reporting, and challenges with accurate death registration and certification led to lower IBM rates for some jurisdictions. These mortality data can help prioritize evidence-based interventions to reduce cancer-related deaths through risk factor reduction, early detection, and improved quality of life after a cancer diagnosis through palliative care.

    • Communicable Diseases
      1. Hepatitis C management at federally qualified health centers during the opioid epidemic: A cost-effectiveness studyexternal icon
        Assoumou SA, Nolen S, Hagan L, Wang J, Eftekhari Yazdi G, Thompson WW, Mayer KH, Puro J, Zhu L, Salomon JA, Linas BP.
        Am J Med. 2020 Jun 27.
        BACKGROUND: The opioid epidemic has been associated with an increase in hepatitis C virus (HCV) infections. Federally qualified health centers (FQHCs) have a high burden of hepatitis C disease and could serve as venues to enhance testing and treatment. METHODS: We estimated clinical outcomes and the cost-effectiveness of hepatitis C testing and treatment at US FQHCs using individual-based simulation modeling. We used individual-level data from 57 FQHCs to model 9 strategies including permutations of HCV antibody testing modality, person initiating testing and testing approach. Outcomes included life expectancy, quality adjusted life years (QALY), hepatitis C cases identified, treated and cured, and incremental cost-effectiveness ratios (ICERs). RESULTS: Compared to current practice (risk-based with laboratory-based testing), routine rapid point-of-care testing initiated and performed by a counselor identified 68% more cases after (non-reflex) RNA testing in the first month of the intervention, led to a 17% reduction in cirrhosis cases, and a 22% reduction in liver deaths among those with cirrhosis over a lifetime. Routine rapid testing initiated by a counselor or a clinician provided better outcomes at either lower total cost or at lower cost per QALY gained, when compared to all other strategies. Findings were most influenced by the proportion of patients informed of their anti-HCV test results. CONCLUSIONS: Routine anti-HCV testing followed by prompt RNA testing for positives is recommended at FQHCs to identify infections. If using dedicated staff or point-of-care testing is not feasible, then measures to improve immediate patient knowledge of antibody status should be considered.

      2. Multisystem inflammatory syndrome in U.S. children and adolescentsexternal icon
        Feldstein LR, Rose EB, Horwitz SM, Collins JP, Newhams MM, Son MB, Newburger JW, Kleinman LC, Heidemann SM, Martin AA, Singh AR, Li S, Tarquinio KM, Jaggi P, Oster ME, Zackai SP, Gillen J, Ratner AJ, Walsh RF, Fitzgerald JC, Keenaghan MA, Alharash H, Doymaz S, Clouser KN, Giuliano JS, Gupta A, Parker RM, Maddux AB, Havalad V, Ramsingh S, Bukulmez H, Bradford TT, Smith LS, Tenforde MW, Carroll CL, Riggs BJ, Gertz SJ, Daube A, Lansell A, Coronado Munoz A, Hobbs CV, Marohn KL, Halasa NB, Patel MM, Randolph AG.
        N Engl J Med. 2020 Jun 29.
        BACKGROUND: Understanding the epidemiology and clinical course of multisystem inflammatory syndrome in children (MIS-C) and its temporal association with coronavirus disease 2019 (Covid-19) is important, given the clinical and public health implications of the syndrome. METHODS: We conducted targeted surveillance for MIS-C from March 15 to May 20, 2020, in pediatric health centers across the United States. The case definition included six criteria: serious illness leading to hospitalization, an age of less than 21 years, fever that lasted for at least 24 hours, laboratory evidence of inflammation, multisystem organ involvement, and evidence of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) based on reverse-transcriptase polymerase chain reaction (RT-PCR), antibody testing, or exposure to persons with Covid-19 in the past month. Clinicians abstracted the data onto standardized forms. RESULTS: We report on 186 patients with MIS-C in 26 states. The median age was 8.3 years, 115 patients (62%) were male, 135 (73%) had previously been healthy, 131 (70%) were positive for SARS-CoV-2 by RT-PCR or antibody testing, and 164 (88%) were hospitalized after April 16, 2020. Organ-system involvement included the gastrointestinal system in 171 patients (92%), cardiovascular in 149 (80%), hematologic in 142 (76%), mucocutaneous in 137 (74%), and respiratory in 131 (70%). The median duration of hospitalization was 7 days (interquartile range, 4 to 10); 148 patients (80%) received intensive care, 37 (20%) received mechanical ventilation, 90 (48%) received vasoactive support, and 4 (2%) died. Coronary-artery aneurysms (z scores >/=2.5) were documented in 15 patients (8%), and Kawasaki's disease-like features were documented in 74 (40%). Most patients (171 [92%]) had elevations in at least four biomarkers indicating inflammation. The use of immunomodulating therapies was common: intravenous immune globulin was used in 144 (77%), glucocorticoids in 91 (49%), and interleukin-6 or 1RA inhibitors in 38 (20%). CONCLUSIONS: Multisystem inflammatory syndrome in children associated with SARS-CoV-2 led to serious and life-threatening illness in previously healthy children and adolescents. (Funded by the Centers for Disease Control and Prevention.).

      3. During a pandemic, syndromic methods for monitoring illness outside of health care settings, such as tracking absenteeism trends in schools and workplaces, can be useful adjuncts to conventional disease reporting (1,2). Each month, CDC's National Institute for Occupational Safety and Health (NIOSH) monitors the prevalence of health-related workplace absenteeism among currently employed full-time workers in the United States, overall and by demographic and occupational subgroups, using data from the Current Population Survey (CPS).* This report describes trends in absenteeism during October 2019-April 2020, including March and April 2020, the period of rapidly accelerating transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). Overall, the prevalence of health-related workplace absenteeism in March and April 2020 were similar to their 5-year baselines. However, compared with occupation-specific baselines, absenteeism among workers in several occupational groups that define or contain essential critical infrastructure workforce(dagger) categories was significantly higher than expected in April. Significant increases in absenteeism were observed in personal care and service( section sign) (includes child care workers and personal care aides); healthcare support( paragraph sign); and production** (includes meat, poultry, and fish processing workers). Although health-related workplace absenteeism remained relatively unchanged or decreased in other groups, the increase in absenteeism among workers in occupational groups less able to avoid exposure to SARS-CoV-2 (3) highlights the potential impact of COVID-19 on the essential critical infrastructure workforce because of the risks and concerns of occupational transmission of SARS-CoV-2. More widespread and complete collection of occupational data in COVID-19 surveillance is required to fully understand workers' occupational risks and inform intervention strategies. Employers should follow available recommendations to protect workers' health.

      4. Addressing vulnerable population needs in the last mile to the elimination of mother to child transmission of HIV: (re)claiming the HIV response for female sex workers and their childrenexternal icon
        Hakim AJ, Callahan T, Benech I, Patel M, Adler M, Modi S, Bateganya M, Parris KA, Bingham T.
        BMC Public Health. 2020 Jun 26;20(1):1015.
        As countries strive to eliminate mother-to-child transmission of HIV, female sex workers (FSW) and their children still face barriers to accessing these essential services. Data on FSW uptake of HIV and reproductive health services before, during, and after pregnancy reveal inadequate service utilization. Stigma encountered by FSW in healthcare settings may contribute to low uptake of HIV testing, antiretroviral therapy (ART), and other prevention of mother-to-child HIV transmission (PMTCT) services. Coordination between community-based FSW and facility-based PMTCT programs can facilitate successful linkage of pregnant FSW to antenatal services to support PMTCT efforts. We offer a way forward to reach 90-90-90 targets for FSW and their families and eliminate mother-to-child transmission of HIV.

      5. Race/ethnicity, underlying medical conditions, homelessness, and hospitalization status of adult patients with COVID-19 at an urban safety-net medical center - Boston, Massachusetts, 2020external icon
        Hsu HE, Ashe EM, Silverstein M, Hofman M, Lange SJ, Razzaghi H, Mishuris RG, Davidoff R, Parker EM, Penman-Aguilar A, Clarke KE, Goldman A, James TL, Jacobson K, Lasser KE, Xuan Z, Peacock G, Dowling NF, Goodman AB.
        MMWR Morb Mortal Wkly Rep. 2020 Jul 10;69(27):864-869.
        As of July 5, 2020, approximately 2.8 million coronavirus disease 2019 (COVID-19) cases and 130,000 COVID-19-associated deaths had been reported in the United States (1). Populations historically affected by health disparities, including certain racial and ethnic minority populations, have been disproportionally affected by and hospitalized with COVID-19 (2-4). Data also suggest a higher prevalence of infection with SARS-CoV-2, the virus that causes COVID-19, among persons experiencing homelessness (5). Safety-net hospitals,(dagger) such as Boston Medical Center (BMC), which provide health care to persons regardless of their insurance status or ability to pay, treat higher proportions of these populations and might experience challenges during the COVID-19 pandemic. This report describes the characteristics and clinical outcomes of adult patients with laboratory-confirmed COVID-19 treated at BMC during March 1-May 18, 2020. During this time, 2,729 patients with SARS-CoV-2 infection were treated at BMC and categorized into one of the following mutually exclusive clinical severity designations: exclusive outpatient management (1,543; 56.5%), non-intensive care unit (ICU) hospitalization (900; 33.0%), ICU hospitalization without invasive mechanical ventilation (69; 2.5%), ICU hospitalization with mechanical ventilation (119; 4.4%), and death (98; 3.6%). The cohort comprised 44.6% non-Hispanic black (black) patients and 30.1% Hispanic or Latino (Hispanic) patients. Persons experiencing homelessness accounted for 16.4% of patients. Most patients who died were aged >/=60 years (81.6%). Clinical severity differed by age, race/ethnicity, underlying medical conditions, and homelessness. A higher proportion of Hispanic patients were hospitalized (46.5%) than were black (39.5%) or non-Hispanic white (white) (34.4%) patients, a finding most pronounced among those aged <60 years. A higher proportion of non-ICU inpatients were experiencing homelessness (24.3%), compared with homeless patients who were admitted to the ICU without mechanical ventilation (15.9%), with mechanical ventilation (15.1%), or who died (15.3%). Patient characteristics associated with illness and clinical severity, such as age, race/ethnicity, homelessness, and underlying medical conditions can inform tailored strategies that might improve outcomes and mitigate strain on the health care system from COVID-19.

      6. Using geographical data and rolling statistics for diagnostics of respondent-driven samplingexternal icon
        Kim B, Ogwal M, Sande E, Kiyingi H, Serwadda D, Hladik W.
        Social Networks. 2020 .
        Respondent-driven sampling (RDS) is commonly used to sample from key populations without a sampling frame since traditional methods are unable to efficiently survey them. Surveying these populations is often desirable to inform service delivery, assess effectiveness of programs, and determine prevalence of diseases. However, there are concerns about how RDS works in practice due to its many assumptions. To assess some of these assumptions, we develop diagnostics using geographical data and demonstrate their utility by identifying lack of convergence and characterizing RDS reach in surveys conducted among female sex workers and men who have sex with men in Kampala, Uganda.

      7. Presence of antibodies against Haemophilus influenzae serotype a in Alaska prior to and after the emergence of invasive infectionsexternal icon
        McClure M, Miernyk K, Bruden D, Rudolph K, Hennessy TW, Bruce MG, Nolen LD.
        J Infect Dis. 2020 Jun 28.
        BACKGROUND: Haemophilus influenzae bacteria can cause asymptomatic carriage and invasive disease. H. influenzae serotype a (Hia) is an emerging cause of invasive disease in Alaska, with greatest burden occurring among rural Alaska Native (AN) children. The first case of invasive Hia (iHia) in Alaska was reported in 2002; however, it is unclear how long the pathogen has been in Alaska. METHODS: We quantified IgG antibodies against Hia (anti-Hia) in 839 banked serum samples from Alaska residents, comparing antibody concentrations in samples drawn in the decades prior to (1980s and 1990s) and after (2000s) the emergence of iHia. We also assessed serum antibody concentration by age group, region of residence, and race. RESULTS: Anti-Hia was >0.1 microg/mL in 88.1% (348/395) and 91.0% (404/444) of samples from the decades prior and after the emergence of Hia, respectively (p=0.17). No significant differences in antibody levels were detected between people from rural and urban regions (1.55 microg/mL vs. 2.08 microg/mL, p=0.91 for age >/=5) or between AN and non-AN people (2.50 microg/mL vs 2.60 microg/mL, p=0.26). CONCLUSIONS: Our results are consistent with widespread Hia exposure in Alaska predating the first iHia case. No difference in Hia antibody prevalence was detected between populations with differing levels of invasive disease.

      8. Index and targeted community-based testing to optimize HIV case finding and ART linkage among men in Zambiaexternal icon
        Mwango LK, Stafford KA, Blanco NC, Lavoie MC, Mujansi M, Nyirongo N, Tembo K, Sakala H, Chipukuma J, Phiri B, Nzangwa C, Mwandila S, Nkwemu KC, Saadani A, Mwila A, Herce ME, Claassen CW.
        J Int AIDS Soc. 2020 Jun;23 Suppl 2(Suppl 2):e25520.
        INTRODUCTION: Current healthcare systems fail to provide adequate HIV services to men. In Zambia, 25% of adult men living with HIV were unaware of their HIV status in 2018, and 12% of those who were unaware of their HIV statu were not receiving antiretroviral therapy (ART) due to pervasive barriers to HIV testing services (HTS) and linkage to ART. To identify men and key and priority populations living with HIV in Zambia, and link them to care and treatment, we implemented the Community Impact to Reach Key and Underserved Individuals for Treatment and Support (CIRKUITS) project. We present HTS and ART linkage results from the first year of CIRKUITS. METHODS: CIRKUITS aimed to reach beneficiaries by training, mentoring, and deploying community health workers to provide index testing services and targeted community HTS. Community leaders and workplace supervisors were engaged to enable workplace HTS for men. To evaluate the effects of these interventions, we collected age- and sex-disaggregated routinely collected programme data for the first 12 months of the project (October 2018 to September 2019) across 37 CIRKUITS-supported facilities in three provinces. We performed descriptive statistics and estimated index cascades for indicators of interest, and used Chi square tests to compare indicators by age, sex, and district strata. RESULTS: Over 12 months, CIRKUITS tested 38,255 persons for HIV, identifying 10,974 (29%) new people living with HIV, of whom 10,239 (93%) were linked to ART. Among men, CIRKUITS tested 18,336 clients and identified 4458 (24%) as HIV positive, linked 4132 (93%) to ART. Men who tested HIV negative were referred to preventative services. Of the men found HIV positive, and 13.0% were aged 15 to 24 years, 60.3% were aged 25 to 39, 20.9% were aged 40 to 49 and 5.8% were ≥50 years old. Index testing services identified 2186 (49%) of HIV-positive men, with a positivity yield of 40% and linkage of 88%. Targeted community testing modalities accounted for 2272 (51%) of HIV-positive men identified, with positivity yield of 17% and linkage of 97%. CONCLUSIONS: Index testing and targeted community-based HTS are effective strategies to identify men living with HIV in Zambia. Index testing results in higher yield, but lower linkage and fewer absolute men identified compared to targeted community-based HTS.

      9. HIV prevalence among women who exchange sex for money or drugs - 4 U.S. citiesexternal icon
        Nerlander LM, Handanagic S, Hess KL, Lutnick A, Agnew-Brune CB, Hoots BE, Braunstein SL, Glick SN, Higgins E, Padgett P, Schuette SM, Broz D, Ivy W, Smith A, Thorson A, Paz-Bailey G.
        J Acquir Immune Defic Syndr. 2020 Aug 1;84(4):345-354.
        BACKGROUND: Limited data exist in the United States on the prevalence of HIV among women who exchange sex. SETTING: We estimate HIV prevalence of women who exchange sex from a 2016 survey in Chicago, Detroit, Houston, and Seattle and compare it with the prevalence of HIV among women of low socioeconomic status (SES), who did not exchange sex, and women in the general population. METHODS: Women who exchange sex were recruited via respondent-driven sampling among some cities participating in National HIV Behavioral Surveillance, interviewed, and offered HIV testing. We estimate HIV prevalence and, using prevalence ratios, compare it with the prevalence among women of low SES who did not exchange sex in the 2013 National HIV Behavioral Surveillance cycle, and to women in the general population estimated using 2015 National HIV Surveillance data. RESULTS: One thousand four hundred forty women reported exchange sex in 2016. Aggregated HIV prevalence was 4.9% [95% confidence interval (CI): 2.7 to 7.1] among women who exchanged sex, 1.6% (95% CI: 0.3 to 2.8) among women of low SES who did not exchange sex, and 0.6% (95% CI: 0.5% to 0.6%) among women in the general population. HIV prevalence among women who exchanged sex was 3.1 times (95% CI: 1.6 to 5.9) as high as among women of low SES who did not exchange sex, and 8.8 times (95% CI: 7.0 to 11.1) as high as among women in the general population. CONCLUSION: HIV prevalence was significantly higher among women who exchanged sex compared with women in the general population and women of low SES who did not exchange sex.

      10. PURPOSE: To identify and examine the correlates of multiple bacterial sexually transmitted infection (STI) hot spot counties in the United States. METHODS: We assembled and analyzed 5 years (2008-2012) of cross-sectional STI morbidity data to identify multiple bacterial STI (chlamydia, gonorrhea, and syphilis) hot spot counties using hot spot analysis. Then, we examined the association between the multi-STI hot spots and select multiyear (2008-2012) sociodemographic factors (data obtained from the American Community Survey) using ordered spatial logistic regression analyses. RESULTS: Of the 2935 counties, the results indicated that 85 counties were hot spots for all 3 STIs (3-STI hot spot counties), 177 were hot spots for 2 STIs (2-STI hot spot counties), and 145 were hot spots for only 1 STI (1-STI hot spot counties). Approximately 93% (79 of 85) of the counties determined to be 3-STI hot spots were found in 4 southern states--Mississippi (n = 25), Arkansas (n = 22), Louisiana (n = 19), and Alabama (n = 13). Counties determined to be 2 STI hot spots were found in 7 southern states--Arkansas, Louisiana, Mississippi, Alabama, Georgia, and North and South Carolina had at least ten 2-STI hot spot counties each. The multi-STI hot spot classes were significantly (P < 0.05) associated with percent black (non-Hispanic), percent Hispanics, percent American Indians, population density, male-female sex ratio, percent aged 25 to 44 years, and violent crime rate. CONCLUSIONS: This study provides information on multiple STI hot spot counties in the United States and the associated sociodemographic factors. Such information can be used to assist planning, designing, and implementing effective integrated bacterial STI prevention and control programs/interventions.

      11. HIV-exposed uninfected infant morbidity and mortality within a nationally representative prospective cohort of mother-infant pairs in Zimbabweexternal icon
        Patel MR, Mushavi A, Balachandra S, Shambira G, Nyakura J, Mugurungi O, Kilmarx PH, Rivadeneira E, Dinh TH.
        Aids. 2020 Jul 15;34(9):1339-1346.
        OBJECTIVE: To examine morbidity and mortality risk among HIV-exposed uninfected (HEU) infants. DESIGN: Secondary data analysis of HEU infants in a prospective cohort study of mother-infant pairs. METHODS: Infants were recruited from immunization clinics (n = 151) in Zimbabwe from February to August 2013, enrolled at 4-12 weeks age, and followed every 3 months until incident HIV-infection, death, or 18-month follow-up. We estimated cumulative mortality probability and hazard ratios with 95% confidence intervals (CIs) using Kaplan-Meier curves and Cox regression, respectively. We also described reported reasons for infant hospitalization and symptoms preceding death. Median weight-for-age z-scores (WAZ) and median age were calculated and analyzed across study visits. RESULTS: Of 1188 HIV-exposed infants, 73 (6.1%) contracted HIV; we analyzed the remaining 1115 HEU infants. In total, 54 (4.8%) infants died, with median time to death of 5.5 months since birth (interquartile range: 3.6-9.8 months). Diarrhea, difficulty breathing, not eating, fever, and cough were commonly reported (range: 7.4-22.2%) as symptoms preceding infant death. Low birth weight was associated with higher mortality (adjusted hazard ratio 2.66, CI: 1.35-5.25), whereas maternal antiretroviral therapy predelivery (adjusted hazard ratio 0.34, CI: 0.18-0.64) and exclusive breastfeeding (adjusted hazard ratio 0.50, CI: 0.28-0.91) were associated with lower mortality. Overall, 9.6% of infants were hospitalized. Infant median WAZ declined after 3 months of age, reaching a minimum at 14.5 months of age, at which 50% of infants were underweight (WAZ below -2.0). CONCLUSION: Clinical interventions including maternal antiretroviral therapy; breastfeeding and infant feeding counseling and support; and early prevention, identification, and management of childhood illness; are needed to reduce HEU infant morbidity and mortality.

      12. Probabilistic reconstruction of measles transmission clusters from routinely collected surveillance dataexternal icon
        Robert A, Kucharski AJ, Gastanaduy PA, Paul P, Funk S.
        J R Soc Interface. 2020 Jul;17(168):20200084.
        Pockets of susceptibility resulting from spatial or social heterogeneity in vaccine coverage can drive measles outbreaks, as cases imported into such pockets are likely to cause further transmission and lead to large transmission clusters. Characterizing the dynamics of transmission is essential for identifying which individuals and regions might be most at risk. As data from detailed contact-tracing investigations are not available in many settings, we developed an R package called o2geosocial to reconstruct the transmission clusters and the importation status of the cases from their age, location, genotype and onset date. We compared our inferred cluster size distributions to 737 transmission clusters identified through detailed contact-tracing in the USA between 2001 and 2016. We were able to reconstruct the importation status of the cases and found good agreement between the inferred and reference clusters. The results were improved when the contact-tracing investigations were used to set the importation status before running the model. Spatial heterogeneity in vaccine coverage is difficult to measure directly. Our approach was able to highlight areas with potential for local transmission using a minimal number of variables and could be applied to assess the intensity of ongoing transmission in a region.

      13. Initial and repeated point prevalence surveys to inform SARS-CoV-2 infection prevention in 26 skilled nursing facilities - Detroit, Michigan, March-May 2020external icon
        Sanchez GV, Biedron C, Fink LR, Hatfield KM, Polistico JM, Meyer MP, Noe RS, Copen CE, Lyons AK, Gonzalez G, Kiama K, Lebednick M, Czander BK, Agbonze A, Surma AR, Sandhu A, Mika VH, Prentiss T, Zervos J, Dalal DA, Vasquez AM, Reddy SC, Jernigan J, Kilgore PE, Zervos MJ, Chopra T, Bezold CP, Rehman NK.
        MMWR Morb Mortal Wkly Rep. 2020 Jul 10;69(27):882-886.
        Skilled nursing facilities (SNFs) are focal points of the coronavirus disease 2019 (COVID-19) pandemic, and asymptomatic infections with SARS-CoV-2, the virus that causes COVID-19, among SNF residents and health care personnel have been described (1-3). Repeated point prevalence surveys (serial testing of all residents and health care personnel at a health care facility irrespective of symptoms) have been used to identify asymptomatic infections and have reduced SARS-CoV-2 transmission during SNF outbreaks (1,3). During March 2020, the Detroit Health Department and area hospitals detected a sharp increase in COVID-19 diagnoses, hospitalizations, and associated deaths among SNF residents. The Detroit Health Department collaborated with local government, academic, and health care system partners and a CDC field team to rapidly expand SARS-CoV-2 testing and implement infection prevention and control (IPC) activities in all Detroit-area SNFs. During March 7-May 8, among 2,773 residents of 26 Detroit SNFs, 1,207 laboratory-confirmed cases of COVID-19 were identified during three periods: before (March 7-April 7) and after two point prevalence surveys (April 8-25 and April 30-May 8): the overall attack rate was 44%. Within 21 days of receiving their first positive test results, 446 (37%) of 1,207 COVID-19 patients were hospitalized, and 287 (24%) died. Among facilities participating in both surveys (n = 12), the percentage of positive test results declined from 35% to 18%. Repeated point prevalence surveys in SNFs identified asymptomatic COVID-19 cases, informed cohorting and IPC practices aimed at reducing transmission, and guided prioritization of health department resources for facilities experiencing high levels of SARS-CoV-2 transmission. With the increased availability of SARS-CoV-2 testing, repeated point prevalence surveys and enhanced and expanded IPC support should be standard tools for interrupting and preventing COVID-19 outbreaks in SNFs.

      14. Upper airways colonisation of Streptococcus pneumoniae in adults aged 60 years and older: A systematic review of prevalence and individual participant data meta-analysis of risk factorsexternal icon
        Smith EL, Wheeler I, Adler H, Ferreira DM, Sá-Leão R, Abdullahi O, Adetifa I, Becker-Dreps S, Esposito S, Farida H, Kandasamy R, Mackenzie GA, Nuorti JP, Nzenze S, Madhi SA, Ortega O, Roca A, Safari D, Schaumburg F, Usuf E, Sanders EA, Grant LR, Hammitt LL, O'Brien KL, Gounder P, Bruden DJ, Stanton MC, Rylance J.
        J Infect. 2020 Jun 17.
        BACKGROUND: Colonisation with Streptococcus pneumoniae can lead to invasive pneumococcal disease and pneumonia. Pneumococcal acquisition and prevalence of colonisation are high in children. In older adults, a population susceptible to pneumococcal disease, colonisation prevalence is reported to be lower, but studies are heterogeneous. METHODS: This is a systematic review and meta-analysis of prevalence of, and risk factors for, pneumococcal colonisation in adults ≥ 60 years of age (PROSPERO #42016036891). We identified peer-reviewed studies reporting the prevalence of S. pneumoniae colonisation using MEDLINE and EMBASE (until April 2016), excluding studies of acute disease. Participant-level data on risk factors were sought from each study. FINDINGS: Of 2202 studies screened, 29 were analysable: 18 provided participant-level data (representing 6290 participants). Prevalence of detected pneumococcal colonisation was 0-39% by conventional culture methods and 3-23% by molecular methods. In a multivariate analysis, colonisation was higher in persons from nursing facilities compared with the community (odds ratio (OR) 2•30, 95% CI 1•26-4•21 and OR 7•72, 95% CI 1•15-51•85, respectively), in those who were currently smoking (OR 1•69, 95% CI 1•12-2•53) or those who had regular contact with children (OR 1•93, 95%CI 1•27-2•93). Persons living in urban areas had significantly lower carriage prevalence (OR 0•43, 95%CI 0•27-0•70). INTERPRETATION: Overall prevalence of pneumococcal colonisation in older adults was higher than expected but varied by risk factors. Future studies should further explore risk factors for colonisation, to highlight targets for focussed intervention such as pneumococcal vaccination of high-risk groups. FUNDING: No funding was required.

      15. Evaluation of pneumococcal meningitis clusters in Burkina Faso and implications for potential reactive vaccinationexternal icon
        Soeters HM, Kambire D, Sawadogo G, Ouedraogo-Traore R, Bicaba B, Medah I, Sangare L, Ouedraogo AS, Ouangraoua S, Yameogo I, Congo-Ouedraogo M, Ky Ba A, Ake F, Velusamy S, McGee L, Van Beneden C, Whitney CG.
        Vaccine. 2020 Jun 23.
        BACKGROUND: To better understand how to prevent and respond to pneumococcal meningitis outbreaks in the meningitis belt, we retrospectively examined Burkina Faso's case-based meningitis surveillance data for pneumococcal meningitis clusters and assessed potential usefulness of response strategies. METHODS: Demographic and clinical information, and cerebrospinal fluid laboratory results for meningitis cases were collected through nationwide surveillance. Pneumococcal cases were confirmed by culture, polymerase chain reaction (PCR), or latex agglutination; strains were serotyped using PCR. We reviewed data from 2011 to 2017 to identify and describe clusters of >/= 5 confirmed pneumococcal meningitis cases per week in a single district. We assessed whether identified clusters met the 2016 WHO provisional pneumococcal meningitis outbreak definition: a district with a weekly incidence of >5 suspected meningitis cases/100,000 persons, >60% of confirmed meningitis cases caused by Streptococcus pneumoniae, and >10 confirmed pneumococcal meningitis cases. RESULTS: Twenty pneumococcal meningitis clusters were identified, with a maximum weekly incidence of 7 cases and a maximum duration of 4 weeks. Most identified clusters (15/20; 75%) occurred before nationwide introduction of 13-valent pneumococcal conjugate vaccine (PCV13) in October 2013. Most cases were due to serotype 1 (74%), 10% were due to PCV13 serotypes besides serotype 1, and 8 clusters had >1 serotype. While 6 identified clusters had a weekly incidence of >5 suspected cases/100,000 and all 20 clusters had >60% of confirmed meningitis cases due to S. pneumoniae, no cluster had >10 confirmed pneumococcal meningitis cases in a single week. CONCLUSIONS: Following PCV13 introduction, pneumococcal meningitis clusters were rarely detected, and none met the WHO provisional pneumococcal outbreak definition. Due to the limited cluster size and duration, there were no clear instances where reactive vaccination could have been useful. More data are needed to inform potential response strategies.

      16. Outcomes of reflex cryptococcal antigen (CrAg) screening in HIV-positive patients with CD4 counts of 100-200 cells/microL in Botswanaexternal icon
        Tenforde MW, Milton T, Rulaganyang I, Muthoga C, Tawe L, Chiller T, Greene G, Jordan A, Williams CG, Owen L, Leeme TB, Boose A, Ngidi J, Mine M, Jarvis JN.
        Clin Infect Dis. 2020 Jun 30.
        Increasing the CD4-count threshold for cryptococcal antigen (CrAg) screening from </=100 to </=200 cells/microL resulted in a 3-fold increase in numbers screened. CrAg-prevalence was 3.5% at CD4 101-200 and 6.2% </=100 cells/microL. Six-month mortality was 21.4% (9/42) in CrAg-positive CD4 </=100 cells/microL and 3.2% (1/31) in CrAg-positive CD4 101-200 cells/microL.

      17. Update: COVID-19 among workers in meat and poultry processing facilities - United States, April-May 2020external icon
        Waltenburg MA, Victoroff T, Rose CE, Butterfield M, Jervis RH, Fedak KM, Gabel JA, Feldpausch A, Dunne EM, Austin C, Ahmed FS, Tubach S, Rhea C, Krueger A, Crum DA, Vostok J, Moore MJ, Turabelidze G, Stover D, Donahue M, Edge K, Gutierrez B, Kline KE, Martz N, Rajotte JC, Julian E, Diedhiou A, Radcliffe R, Clayton JL, Ortbahn D, Cummins J, Barbeau B, Murphy J, Darby B, Graff NR, Dostal TK, Pray IW, Tillman C, Dittrich MM, Burns-Grant G, Lee S, Spieckerman A, Iqbal K, Griffing SM, Lawson A, Mainzer HM, Bealle AE, Edding E, Arnold KE, Rodriguez T, Merkle S, Pettrone K, Schlanger K, LaBar K, Hendricks K, Lasry A, Krishnasamy V, Walke HT, Rose DA, Honein MA.
        MMWR Morb Mortal Wkly Rep. 2020 Jul 10;69(27):887-892.
        Meat and poultry processing facilities face distinctive challenges in the control of infectious diseases, including coronavirus disease 2019 (COVID-19) (1). COVID-19 outbreaks among meat and poultry processing facility workers can rapidly affect large numbers of persons. Assessment of COVID-19 cases among workers in 115 meat and poultry processing facilities through April 27, 2020, documented 4,913 cases and 20 deaths reported by 19 states (1). This report provides updated aggregate data from states regarding the number of meat and poultry processing facilities affected by COVID-19, the number and demographic characteristics of affected workers, and the number of COVID-19-associated deaths among workers, as well as descriptions of interventions and prevention efforts at these facilities. Aggregate data on confirmed COVID-19 cases and deaths among workers identified and reported through May 31, 2020, were obtained from 239 affected facilities (those with a laboratory-confirmed COVID-19 case in one or more workers) in 23 states.* COVID-19 was confirmed in 16,233 workers, including 86 COVID-19-related deaths. Among 14 states reporting the total number of workers in affected meat and poultry processing facilities (112,616), COVID-19 was diagnosed in 9.1% of workers. Among 9,919 (61%) cases in 21 states with reported race/ethnicity, 87% occurred among racial and ethnic minority workers. Commonly reported interventions and prevention efforts at facilities included implementing worker temperature or symptom screening and COVID-19 education, mandating face coverings, adding hand hygiene stations, and adding physical barriers between workers. Targeted workplace interventions and prevention efforts that are appropriately tailored to the groups most affected by COVID-19 are critical to reducing both COVID-19-associated occupational risk and health disparities among vulnerable populations. Implementation of these interventions and prevention efforts(dagger) across meat and poultry processing facilities nationally could help protect workers in this critical infrastructure industry.

      18. Active surveillance for acute respiratory infections among pediatric long-term care facility staffexternal icon
        Wilmont S, Neu N, Hill-Ricciuti A, Alba L, Prill MM, Whitaker B, Garg S, Stone ND, Lu X, Kim L, Gerber SI, Larson E, Saiman L.
        Am J Infect Control. 2020 Jun 25.
        BACKGROUND: Transmission of respiratory viruses between staff and residents of pediatric long-term care facilities (pLTCFs) can occur. We assessed the feasibility of using text or email messages to perform surveillance for acute respiratory infections (ARIs) among staff. METHODS: From December 7, 2016 to May 7, 2017, 50 staff participants from two pLTCFs received weekly text or email requests to report the presence or absence of ARI symptoms. Those who fulfilled the ARI case definition (>/=2 symptoms) had respiratory specimens collected to detect viruses by reverse transcriptase polymerase chain reaction assays. Pre- and post-surveillance respiratory specimens were collected to assess subclinical viral shedding. RESULTS: The response rate to weekly electronic messages was 93%. Twenty-one ARIs reported from 20 (40%) participants fulfilled the case definition. Respiratory viruses were detected in 29% (5/17) of specimens collected at symptom onset (influenza B, respiratory syncytial virus, coronavirus [CoV] 229E, rhinovirus [RV], and dual detection of CoV OC43 and bocavirus). Four participants had positive pre-surveillance (4 RV), and six had positive post-surveillance specimens (3 RV, 2 CoV NL63 and 1 adenovirus). CONCLUSIONS: Electronic messaging to conduct ARI surveillance among pLTCF staff was feasible.

      19. We used the 1-month pilot implementation of Positive Health Check, a brief web-based video counseling intervention that supports patients with HIV attending HIV primary care clinics, to exemplify how studying implementation strategies earlier in the evidence-generation process can improve implementation outcomes in later pragmatic trials. We identified how implementation strategies were operationalized and the barriers and facilitators these strategies addressed using multiple data sources, including adapted implementation procedures and weekly structured interviews conducted with 9 key stakeholders in 4 HIV primary care clinics. Nineteen of 73 discrete implementation strategies for clinical innovations were used in the pilot implementation of Positive Health Check. Clinic staff reported 17 barriers and facilitators related to the clinic environment, patient population, intervention characteristics, and training and technical assistance. Identifying the link between strategies, barriers, and facilitators helped plan for a subsequent larger multisite pragmatic trial.

    • Disease Reservoirs and Vectors
      1. Abortive vampire bat rabies infections in Peruvian peridomestic livestockexternal icon
        Benavides JA, Velasco-Villa A, Godino LC, Satheshkumar PS, Ruby N, Rojas-Paniagua E, Shiva C, Falcon N, Streicker DG.
        PLoS Negl Trop Dis. 2020 Jun 29;14(6):e0008194.
        Rabies virus infections normally cause universally lethal encephalitis across mammals. However, 'abortive infections' which are resolved prior to the onset of lethal disease have been described in bats and a variety of non-reservoir species. Here, we surveyed rabies virus neutralizing antibody titers in 332 unvaccinated livestock of 5 species from a vampire bat rabies endemic region of southern Peru where livestock are the main food source for bats. We detected rabies virus neutralizing antibody titers in 11, 5 and 3.6% of cows, goats and sheep respectively and seropositive animals did not die from rabies within two years after sampling. Seroprevalence was correlated with the number of local livestock rabies mortalities reported one year prior but also one year after sample collection. This suggests that serological status of livestock can indicate the past and future levels of rabies risk to non-reservoir hosts. To our knowledge, this is the first report of anti-rabies antibodies among goats and sheep, suggesting widespread abortive infections among livestock in vampire bat rabies endemic areas. Future research should resolve the within-host biology underlying clearance of rabies infections. Cost-effectiveness analyses are also needed to evaluate whether serological monitoring of livestock can be a viable complement to current monitoring of vampire bat rabies risk based on animal mortalities alone.

    • Environmental Health
      1. BACKGROUND/OBJECTIVE: Human exposure to per- and polyfluoroalkyl substances (PFAS) has changed since the early 2000s, in part, because of the phase-out and replacement of some long-chain PFAS. Studies of PFAS exposure and its temporal changes have been limited to date mostly to adults and pregnant women. We examined temporal trends and determinants of PFAS serum concentrations among mothers with a young child who participated in the CHARGE (CHildhood Autism Risk from Genetics and Environment) case-control study. METHODS: We quantified nine PFAS in serum samples collected from 2009 to 2016 in 450 Northern California mothers when their child was 2-5 years old. With five compounds that were detected in more than 50% of the samples, we performed multiple regression to estimate least square geometric means (LSGMs) of PFAS concentrations with adjustment for sampling year and other characteristics that may affect maternal concentrations (e.g., breastfeeding duration). We also used time-related regression coefficients to calculate percent changes over the study period. RESULTS: LSGM concentrations of perfluorooctanoate (PFOA), perfluorooctane sulfonate (PFOS), and perfluorohexane sulfonate (PFHxS) decreased over the study period [percent change (95% confidence interval): -10.7% (-12.7%, -8.7%); -10.8% (-12.9%, -8.5%); -8.0% (-10.5%, -5.5%), respectively]. On the other hand, perfluorononanoate (PFNA) and perfluorodecanoate (PFDA) showed mixed time trends. Among the selected covariates, longer breastfeeding duration was associated with decreased maternal serum concentrations of PFOA, PFOS, PFHxS, PFNA and PFDA. CONCLUSIONS: Our study demonstrated that body burden of some common long-chain PFAS among California mothers with a young child decreased over the study period and that breastfeeding appears to contribute to the elimination of PFAS in lactating mothers.

      2. Maternal occupational exposure to polycyclic aromatic hydrocarbons and the risk of isolated congenital heart defects among offspringexternal icon
        Patel J, Nembhard WN, Politis MD, Rocheleau CM, Langlois PH, Shaw GM, Romitti PA, Gilboa SM, Desrosiers TA, Insaf T, Lupo PJ.
        Environ Res. 2020 Apr 18;186:109550.
        BACKGROUND: Although there is evidence in experimental model systems that exposure to polycyclic aromatic hydrocarbons (PAHs) is linked with congenital heart defects (CHDs), few studies have examined the association in humans. We conducted a case-control study to examine the association between maternal exposure to PAHs and CHDs in offspring using data from the National Birth Defects Prevention Study (NBDPS) (1997-2011). METHODS: We obtained detailed information on maternal occupation during the month before to three months after conception. Expert raters, masked to case-control status, assessed job descriptions to assign categorical levels of exposure. Categories were quantitatively mapped to estimate cumulative exposure to PAHs, incorporating exposure intensity, frequency, work duration, and work hours. Quartiles were generated for cumulative maternal exposure to PAHs. Crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using unconditional logistic regression for quartiles of PAH exposure and six CHD groupings (e.g. conotruncal) and specific subtypes (e.g. tetralogy of Fallot [ToF]). Final models were adjusted for maternal age, race/ethnicity, education, smoking, anticonvulsant use, folic acid supplementation, and study center. RESULTS: There were 4,775 case and 7,734 control infants eligible for the study. The prevalence of occupational exposure to PAHs was 10.2% among both case and control mothers. In adjusted analysis, compared to mothers with no occupational PAH exposure, those in the highest quartile of exposure were more likely to have offspring in the conotruncal heart defects group (OR 1.41; 95% CI 1.00-2.00), and with ToF (OR 1.83; 95% CI 1.21-2.78). CONCLUSIONS: Women in the highest quartile of estimated cumulative occupational PAH exposure during early pregnancy were more likely to have offspring with conotruncal heart defects, specifically ToF, compared to women with no occupational PAH exposure. Other comparisons between PAHs and other CHDs subgroups did not show any statistically precise associations.

      3. Perfluoroalkyl acids, hyperuricemia and gout in adults: Analyses of NHANES 2009-2014external icon
        Scinicariello F, Buser MC, Balluz L, Gehle K, Murray HE, Abadin HG, Attanasio R.
        Chemosphere. 2020 Jun 20;259:127446.
        BACKGROUND: Previous studies have reported a positive association of perfluoralkyl acids (PFAAs), including perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS), with hyperuricemia. The objective of the study is to investigate whether there is an association between concurrent serum levels of several PFAAs and gout, serum uric acid (SUA) or hyperuricemia in the U.S. adult population as represented by the National Health and Nutrition Examination Survey (NHANES) 2009-2014 sample (n = 4917). The PFAAs investigated include PFOA, perfluorononanoic acid (PFNA), perfluorodecanoic acid (PFDA), perfluorohexane sulfonic acid (PFHxS) and PFOS. METHODS: This cross-sectional study used multivariate logistic regressions to analyze the association of single PFAAs with hyperuricemia and self-reported gout; the association with SUA was analyzed by multivariate linear regression. Analyses were adjusted for race/ethnicity, age, sex, education, alcohol consumption, smoking, serum cotinine, BMI, diabetes, hypertension, chronic kidney disease, and SUA (for gout only). RESULTS: Higher quartile values of serum PFOA and PFHxS were associated with increased odds of self-reported gout. There was a positive association of SUA with increased levels of PFOA, PFNA, PFOS, PFHxS and PFDA. Higher quartile values of PFOA, PFNA, and PFHxS were associated with higher odds of hyperuricemia. CONCLUSIONS: In this population-based cross-sectional analysis, we found an association between selected PFAAs and self-reported gout. We also confirmed previous reports of an association between several PFAAs and hyperuricemia. Our study suggests that exposure to PFAAs may be a risk factor for hyperuricemia and gout.

    • Genetics and Genomics
      1. The Global Meningitis Genome Partnershipexternal icon
        Rodgers E, Bentley SD, Borrow R, Bratcher HB, Brisse S, Brueggemann AB, Caugant DA, Findlow J, Fox L, Glennie L, Harrison LH, Harrison OB, Heyderman RS, van Rensburg MJ, Jolley KA, Kwambana-Adams B, Ladhani S, LaForce M, Levin M, Lucidarme J, MacAlasdair N, Maclennan J, Maiden MC, Maynard-Smith L, Muzzi A, Oster P, Rodrigues CM, Serino OR, Smith V, van der Ende A, Vazquez J, Wang X, Yezli S, Stuart JM.
        J Infect. 2020 Jun 29.
        Genomic surveillance of bacterial meningitis pathogens is essential for effective disease control globally, enabling identification of emerging and expanding strains and consequent public health interventions. While there has been a rise in the use of whole genome sequencing, this has been driven predominately by a subset of countries with adequate capacity and resources. Global capacity to participate in surveillance needs to be expanded, particularly in low and middle-income countries with high disease burdens. In light of this, the WHO-led collaboration, Defeating Meningitis by 2030 Global Roadmap, has called for the establishment of a Global Meningitis Genome Partnership that links resources for: N. meningitidis (Nm), S. pneumoniae (Sp), H. influenzae (Hi) and S. agalactiae (Sa) to improve worldwide co-ordination of strain identification and tracking. Existing platforms containing relevant genomes include: PubMLST: Nm (31,622), Sp (15,132), Hi (1,935), Sa (9,026); The Wellcome Sanger Institute: Nm (13,711), Sp (>24,000), Sa (6,200), Hi (1738); and BMGAP: Nm (8,785), Hi (2,030). A steering group is being established to coordinate the initiative and encourage high-quality data curation. Next steps include: developing guidelines on open-access sharing of genomic data; defining a core set of metadata; and facilitating development of user-friendly interfaces that represent publicly available data.

    • Health Communication and Education
      1. Applying lessons learned from CDC's health literacy initiativesexternal icon
        Martinez LM.
        Stud Health Technol Inform. 2020 Jun 25;269:341-347.
        This report describes health literacy initiatives at the Centers for Disease Control and Prevention (CDC) and the lessons learned from more than 20 years of commitment to health literacy. Efforts described include CDC's training and tools, the Science Ambassador Fellowship program, and an action plan and report card. The report concludes with recommendations on how to meet the needs of communities and systems.

    • Health Disparities
      1. This analysis develops indices of (1) modifiable social determinants of health and (2) social determinant inequity and applies the indices to the black population in US states. It uses state data available between 2013 and 2018 stratified by black and white race on six social determinants covering a range of topics (high school non-completion, incarceration, non-home ownership, poverty, unemployment, and voter non-registration). Determinants are ranked by state on (1) limited determinant access by blacks and (2) on black-white determinant differences, i.e., inequity. For each state, ranks are summed for each determinant and determinant differences. Greater determinant access and greater equity are found in southern states. More limited access is found in northeastern and western states; lowest ranked of access is found in some midwestern states. Greatest equity is found in southern states; greatest inequity is found in midwestern states. Indices are associated with state rates of black self-reported health. Indices of social determinant access and inequity can be developed and applied to states for US minority populations. The indices promote attention to the differential distribution of social determinants, suggest the consequences of structural racism, and indicate targets for the redress of inequity.

      2. The goal of this study was to analyze trends in black age-adjusted mortality rates (AADR) from 1900 through 2010 and to propose explanations. Analyses included a descriptive study of trends in AADR from major causes for blacks and age-specific all-cause mortality at each decade. In 1900, all-cause AADRs were higher for blacks than whites. Over the century, differences decreased substantially. Reductions mortality were greatest among young people, lowest among older adults. Deaths from infectious diseases showed the greatest decrease. Heart disease mortality among blacks increased from 1920 to 1950, then decreased by 2010. For men and women, AADRs for cancer rose to a peak in 1990, then declined. Stroke mortality decreased steadily for males and females. AADRs from unintentional injuries (not including motor vehicle injury) decreased gradually. Despite widespread societal resistance, blacks have made substantial gains in a wide range of social determinants of health, such as civil rights, education, employment, income, and housing. Substantial gains remain to be made.

      3. Why a right to health makes no sense, and what doesexternal icon
        Hahn RA, Muntaner C.
        Health Equity. 2020 ;4(1):249-254.
        There is a widely held belief in a universal right to the highest attainable standard of health. This essay shows how this right is conceptually unclear, unattainable, and a distraction from a more concrete and attainable right: a right to equitable access to available resources for health (RARH), including equitable access to the social determinants of health. It clarifies conceptual and theoretical issues in the RARH: its underlying theory rooted in historical, economic, and axiological rationales; its concept of component resources and their availability, equity, sustainability; and the redistribution of wealth and power, metrics, and ethics. The advancement of global health equity requires explicit theorizing of what underlies a right to health. The right to the highest attainable standard of health fails in this regard. The RARH provides a desirable, actionable, and measurable foundation for global health equity.

      4. This is the first nationally representative study to identify differences between adult day services centers, a unique home- and community-based service, by racial/ethnic case-mix: Centers were classified as having a majority of participants who were Hispanic, non-Hispanic Black, or non-Hispanic other race/ethnicities and non-Hispanic White. The associations between racial/ethnic case-mix and geographic and operational characteristics of centers and health and functioning needs of participants were assessed using multivariate regression analyses, using the 2014 National Study of Long-term Care Providers' survey of 2,432 centers. Half of all adult day centers predominantly served racial/ethnic minorities, which were more likely to be for-profit, had lower percentages of self-pay revenue, more commonly provided transportation services, and had higher percentages of participants with diabetes, compared with predominantly non-Hispanic White centers. Findings show differences by racial/ethnic case-mix, which are important when considering the long-term care needs of a diverse population of older adults.

      5. Does racial disparity in kidney transplant waitlisting persist after accounting for social determinants of health?external icon
        Ng YH, Pankratz VS, Leyva Y, Ford CG, Pleis JR, Kendall K, Croswell E, Dew MA, Shapiro R, Switzer GE, Unruh ML, Myaskovsky L.
        Transplantation. 2020 Jul;104(7):1445-1455.
        BACKGROUND: African Americans (AA) have lower rates of kidney transplantation (KT) compared with Whites (WH), even after adjusting for demographic and medical factors. In this study, we examined whether the racial disparity in KT waitlisting persists after adjusting for social determinants of health (eg, cultural, psychosocial, and knowledge). METHODS: We prospectively followed a cohort of 1055 patients who were evaluated for KT between 3 of 10 to 10 of 12 and followed through 8 of 18. Participants completed a semistructured telephone interview shortly after their first KT evaluation appointment. We used the Wilcoxon rank-sum and Pearson chi-square tests to examine race differences in the baseline characteristics. We then assessed racial differences in the probability of waitlisting while accounting for all predictors using cumulative incidence curves and Fine and Gray proportional subdistribution hazards models. RESULTS: There were significant differences in the baseline characteristics between non-Hispanic AA and non-Hispanic WH. AA were 25% less likely (95% confidence interval, 0.60-0.96) to be waitlisted than WH even after adjusting for medical factors and social determinants of health. In addition, being older, having lower income, public insurance, more comorbidities, and being on dialysis decreased the probability of waitlisting while having more social support and transplant knowledge increased the probability of waitlisting. CONCLUSIONS: Racial disparity in kidney transplant waitlisting persisted even after adjusting for medical factors and social determinants of health, suggesting the need to identify novel factors that impact racial disparity in transplant waitlisting. Developing interventions targeting cultural and psychosocial factors may enhance equity in access to transplantation.

      6. Racial differences in sleep duration intersect with sex, socioeconomic status, and U.S. geographic region: The REGARDS studyexternal icon
        Petrov ME, Long DL, Grandner MA, MacDonald LA, Cribbet MR, Robbins R, Cundiff JM, Molano JR, Hoffmann CM, Wang X, Howard G, Howard VJ.
        Sleep Health. 2020 Jun 26.
        OBJECTIVES: Short and long sleep duration are associated with poor health outcomes and are most prevalent among racial/ethnic minorities. Few studies have investigated the intersection of other sociodemographic characteristics with race/ethnicity on sleep duration prevalence. DESIGN: Longitudinal retrospective analysis of continental U.S. cohort, the REasons for Geographic And Racial Differences in Stroke (REGARDS) PARTICIPANTS: Black (n = 7,547) and white (n = 12,341) adults, 56% women, >/=45 years MEASUREMENTS: At baseline (2003-07), participants reported age, sex, race, education, income, marital status, U.S. region, and employment status. The weighted average of reported sleep duration on weekdays and weekends, assessed at follow-up (2008-10), was categorized as <6, 6.0-6.99, 7.0-7.99 [reference], 8.0-8.99, and >/=9 h. Multinomial logistic regression models examined the independent and multivariable associations of sociodemographic factors with sleep duration. Interactions terms between race with education, income, region, and sex were examined. RESULTS: Average sleep duration was 7.0 h (SD=1.3). Prevalence of short (<6 h) and long (>/=9 h) sleep duration was 11.4% (n = 2,260) and 7.0% (n = 1,395), respectively. In the multivariable model, interactions terms race*income, race*sex, and race*region were significant (P < .05). Relative to white adults, black adults, were most likely to have short sleep duration. The magnitude of that likelihood increased across greater levels of household income, but with greatest odds among black adults living outside of the Southeast and Appalachian United States, particularly for men (>/=$75k; black men OR = 5.47, 95%CI: 3.94,7.54; black women OR = 4.28, 95%CI: 3.08, 5.96). CONCLUSIONS: Race in the context of socioeconomic, sex, and regional factors should be examined as key modifiers of sleep duration.

    • Healthcare Associated Infections
      1. Understanding the emergence of multidrug-resistant Candida: Using whole-genome sequencing to describe the population structure of Candida haemulonii species complexexternal icon
        Gade L, Munoz JF, Sheth M, Wagner D, Berkow EL, Forsberg K, Jackson BR, Ramos-Castro R, Escandon P, Dolande M, Ben-Ami R, Espinosa-Bode A, Caceres DH, Lockhart SR, Cuomo CA, Litvintseva AP.
        Front Genet. 2020 ;11:554.
        The recent emergence of a multidrug-resistant yeast, Candida auris, has drawn attention to the closely related species from the Candida haemulonii complex that include C. haemulonii, Candida duobushaemulonii, Candida pseudohaemulonii, and the recently identified Candida vulturna. Here, we used antifungal susceptibility testing and whole-genome sequencing (WGS) to investigate drug resistance and genetic diversity among isolates of C. haemulonii complex from different geographic areas in order to assess population structure and the extent of clonality among strains. Although most isolates of all four species were genetically distinct, we detected evidence of the in-hospital transmission of C. haemulonii and C. duobushaemulonii in one hospital in Panama, indicating that these species are also capable of causing outbreaks in healthcare settings. We also detected evidence of the rising azole resistance among isolates of C. haemulonii and C. duobushaemulonii in Colombia, Panama, and Venezuela linked to substitutions in ERG11 gene as well as amplification of this gene in C. haemulonii in isolates in Colombia suggesting the presence of evolutionary pressure for developing azole resistance in this region. Our results demonstrate that these species need to be monitored as possible causes of outbreaks of invasive infection.

      2. Transmission of novel Klebsiella pneumoniae carbapenemase-producing Escherichia coli sequence type 1193 among residents and caregivers in a community-based, residential care setting - Nevada, 2018external icon
        Gomes DJ, Bardossy AC, Chen L, Forero A, Gorzalski A, Holmstadt H, Causey K, Njoku C, Stone ND, Ogundimu A, Moulton-Meissner H, McAllister G, Halpin AL, Gable P, Vlachos N, Larson S, Walters MS, Epstein L.
        Infect Control Hosp Epidemiol. 2020 Jun 29:1-3.
        We describe transmission of Klebsiella pneumoniae carbapenemase-producing Escherichia coli sequence type (ST) 1193 in a group home. E. coli ST1193 is an emerging multidrug-resistant clone not previously shown to carry carbapenemases in the United States. Our investigation illustrates the potential of residential group homes to amplify rare combinations of pathogens and resistance mechanisms.

      3. Evaluation of nine surface disinfectants against Candida auris using a quantitative disk carrier method: EPA SOP-MB-35external icon
        Sexton DJ, Welsh RM, Bentz ML, Forsberg K, Jackson B, Berkow EL, Litvintseva AP.
        Infect Control Hosp Epidemiol. 2020 Jun 30:1-3.
        We tested 9 disinfectants against Candida auris using the quantitative disk carrier method EPA-MB-35-00: 5 products with hydrogen peroxide or alcohol-based chemistries were effective and 4 quaternary ammonium compound-based products were not. This work supported a FIFRA Section 18 emergency exemption granted by the US Environmental Protection Agency to expand disinfectant guidance for C. auris.

      4. Review of influenza-associated pulmonary aspergillosis in ICU patients and proposal for a case definition: an expert opinionexternal icon
        Verweij PE, Rijnders BJ, Bruggemann RJ, Azoulay E, Bassetti M, Blot S, Calandra T, Clancy CJ, Cornely OA, Chiller T, Depuydt P, Giacobbe DR, Janssen NA, Kullberg BJ, Lagrou K, Lass-Flörl C, Lewis RE, Liu PW, Lortholary O, Maertens J, Martin-Loeches I, Nguyen MH, Patterson TF, Rogers TR, Schouten JA, Spriet I, Vanderbeke L, Wauters J, van de Veerdonk FL.
        Intensive Care Med. 2020 Jun 22:1-12.
        PURPOSE: Invasive pulmonary aspergillosis is increasingly reported in patients with influenza admitted to the intensive care unit (ICU). Classification of patients with influenza-associated pulmonary aspergillosis (IAPA) using the current definitions for invasive fungal diseases has proven difficult, and our aim was to develop case definitions for IAPA that can facilitate clinical studies. METHODS: A group of 29 international experts reviewed current insights into the epidemiology, diagnosis and management of IAPA and proposed a case definition of IAPA through a process of informal consensus. RESULTS: Since IAPA may develop in a wide range of hosts, an entry criterion was proposed and not host factors. The entry criterion was defined as a patient requiring ICU admission for respiratory distress with a positive influenza test temporally related to ICU admission. In addition, proven IAPA required histological evidence of invasive septate hyphae and mycological evidence for Aspergillus. Probable IAPA required the detection of galactomannan or positive Aspergillus culture in bronchoalveolar lavage (BAL) or serum with pulmonary infiltrates or a positive culture in upper respiratory samples with bronchoscopic evidence for tracheobronchitis or cavitating pulmonary infiltrates of recent onset. The IAPA case definitions may be useful to classify patients with COVID-19-associated pulmonary aspergillosis (CAPA), while awaiting further studies that provide more insight into the interaction between Aspergillus and the SARS-CoV-2-infected lung. CONCLUSION: A consensus case definition of IAPA is proposed, which will facilitate research into the epidemiology, diagnosis and management of this emerging acute and severe Aspergillus disease, and may be of use to study CAPA.

    • Immunity and Immunization
      1. Persistence of varicella-zoster virus-specific plasma cells in adult human bone marrow following childhood vaccinationexternal icon
        Eberhardt CS, Wieland A, Nasti TH, Grifoni A, Wilson E, Schmid DS, Pulendran B, Sette A, Waller EK, Rouphael N, Ahmed R.
        J Virol. 2020 Jun 16;94(13).
        Childhood immunization with the live-attenuated varicella-zoster virus (VZV) vaccine induces protective immune responses. Routine VZV vaccination started only 2 decades ago, and thus, there are few studies examining the longevity of vaccine-induced immunity. Here, we analyzed the quantity of VZV-specific plasma cells (PCs) and CD4 T cells in the bone marrow (BM) of healthy young adults (n = 15) following childhood VZV immunization. Long-lived BM resident plasma cells constitutively secrete antibodies, and we detected VZV-specific PCs in the BM of all subjects. Anti-VZV plasma antibody titers correlated positively with the number of VZV-specific BM PCs. Furthermore, we quantified the number of interferon gamma (IFN-γ)-producing CD4 T cells specific for VZV glycoprotein E and all other structural and nonstructural VZV proteins in both BM and blood (peripheral blood mononuclear cells [PBMCs]). The frequency of VZV-specific IFN-γ-producing CD4 T cells was significantly higher in PBMCs than BM. Our study shows that VZV-specific PCs and VZV-specific CD4 memory T cells persist up to 20 years after vaccination. These findings indicate that childhood VZV vaccination can elicit long-lived immune memory responses in the bone marrow.IMPORTANCE Childhood varicella-zoster virus (VZV) immunization induces immune memory responses that protect against primary VZV infection, chicken pox. In the United States, routine childhood VZV vaccination was introduced only 2 decades ago. Hence, there is limited information on the longevity of B and CD4 T cell memory, which are both important for protection. Here, we showed in 15 healthy young adults that VZV-specific B and CD4 T cell responses are detectable in bone marrow (BM) and blood up to 20 years after vaccination. Specifically, we measured antibody-secreting plasma cells in the BM and VZV-specific CD4 T cells in BM and blood. These findings suggest that childhood VZV vaccination induces long-lived immunity.

      2. Implementation of the Standards for Adult Immunization Practice: A survey of U.S. health care providersexternal icon
        Granade CJ, Parker Fiebelkorn A, Black CL, Lutz CS, Srivastav A, Bridges CB, Ball SW, Devlin RG, Cloud AJ, Kim DK.
        Vaccine. 2020 Jul 14;38(33):5305-5312.
        The revised Standards for Adult Immunization Practice ("Standards"), published in 2014, recommend routine vaccination assessment, strong provider recommendation, vaccine administration or referral, and documentation of vaccines administered into immunization information systems (IIS). We assessed clinician and pharmacist implementation of the Standards in the United States from 2016 to 2018. Participating clinicians (family and internal medicine physicians, obstetricians-gynecologists, specialty physicians, physician assistants, and nurse practitioners) and pharmacists responded using an internet panel survey. Weighted proportion of clinicians and pharmacists reporting full implementation of each component of the Standards were calculated. Adjusted prevalence ratio (APR) estimates of practice characteristics associated with self-reported implementation of the Standards are also presented. Across all medical specialties, the percentages of clinicians and pharmacists implementing the vaccine assessment and recommendation components of the Standards were >80.0%. However, due to low IIS documentation, full implementation of the Standards was low overall, ranging from 30.4% for specialty medicine to 45.8% in family medicine clinicians. The presence of an immunization champion (APR, 1.40 [95% confidence interval {CI}, 1.26 to 1.54]), use of standing orders (APR, 1.41 [95% CI, 1.27 to 1.57]), and use of a patient reminder-recall system (APR, 1.39 [95% CI, 1.26 to 1.54]) were positively associated with adherence to the Standards by clinicians. Similar results were observed for pharmacists. Nonetheless, vaccination improvement strategies, i.e., having standing orders in place, empowering an immunization champion, and using patient recall-reminder systems were underutilized in clinical settings; full implementation of the Standards was inconsistent across all health care provider practices.

      3. Recent reports suggest that routine childhood immunization coverage might have decreased during the coronavirus disease 2019 (COVID-19) pandemic (1,2). To assess the capacity of pediatric health care practices to provide immunization services to children during the pandemic, a survey of practices participating in the Vaccines for Children (VFC) program was conducted during May 12-20, 2020. Data were weighted to account for the sampling design; thus, all percentages reported are weighted. Among 1,933 responding practices, 1,727 (89.8%) were currently open; 1,397 (81.1%) of these reported offering immunization services to all of their patients. When asked whether the practice would likely be able to accommodate new patients to assist with provision of immunization services through August, 1,135 (59.1%) respondents answered affirmatively. These results suggest that health care providers appear to have the capacity to deliver routinely recommended childhood vaccines, allowing children to catch up on vaccines that might have been delayed as a result of COVID-19-related effects on the provision of or demand for routine well child care. Health care providers and immunization programs should educate parents on the need to return for well-child and immunization visits or refer patients to other practices, if they are unable to provide services (3).

      4. Determining which of several simultaneously administered vaccines increase risk of an adverse eventexternal icon
        Wang SV, Stefanini K, Lewis E, Newcomer SR, Fireman B, Daley MF, Glanz JM, Duffy J, Weintraub E, Kulldorff M.
        Drug Saf. 2020 Jul 1.
        INTRODUCTION: Childhood immunization schedules often involve multiple vaccinations per visit. When increased risk of an adverse event is observed after simultaneous (same-day) vaccinations, it can be difficult to ascertain which triggered the adverse event. This methods paper discusses a systematic process to determine which of the simultaneously administered vaccine(s) are most likely to have caused an observed increase in risk of an adverse event. METHODS: We use an example from the literature where excess risk of seizure was observed 1 day after vaccination, but same-day vaccination patterns made it difficult to discern which vaccine(s) may trigger the adverse event. We illustrate the systematic identification process using a simulation that retained the observed pattern of simultaneous vaccination in an empirical cohort of vaccinated children. We simulated "true" effects for diphtheria-tetanus-acellular pertussis (DTaP) and pneumococcal conjugate (PCV) on risk of seizure the day after vaccination. We varied the independent and interactive effects of vaccines (on the multiplicative scale). After applying the process to simulated data, we evaluated risk of seizure 1 day after vaccination in the empirical cohort. RESULTS: In all simulations, we were able to determine which vaccines contributed to excess risk. In the empirical data, we narrowed the association with seizure from all vaccines in the schedule to three likely candidates, DTaP, PCV, and/or Haemophilus influenzae type B (HiB) (p < 0.01, attributable risk when all three were administered together: five per 100,000). Disentangling their associations with seizure would require a larger sample or more variation in the combinations administered. When none of these three were administered, no excess risk was observed. CONCLUSION: The process outlined could provide valuable information on the magnitude of potential risk from individual and simultaneousvaccinations. Associations should be further investigated with independent data as well as biologically based, statistically independent hypotheses.

    • Injury and Violence
      1. Trends in nonfatal falls and fall-related injuries among adults aged >/=65 years - United States, 2012-2018external icon
        Moreland B, Kakara R, Henry A.
        MMWR Morb Mortal Wkly Rep. 2020 Jul 10;69(27):875-881.
        Falls are the leading cause of injury among adults aged >/=65 years (older adults) in the United States. In 2018, an estimated 3 million emergency department visits, more than 950,000 hospitalizations or transfers to another facility (e.g., trauma center), and approximately 32,000 deaths resulted from fall-related injuries among older adults.* Deaths from falls are increasing, with the largest increases occurring among persons aged >/=85 years (1). To describe the percentages and rates of nonfatal falls by age group and demographic characteristics and trends in falls and fall-related injuries over time, data were analyzed from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) and were compared with data from 2012, 2014, and 2016. In 2018, 27.5% of older adults reported falling at least once in the past year, and 10.2% reported an injury from a fall in the past year. The percentages of older adults reporting a fall increased between 2012 and 2016 and decreased slightly between 2016 and 2018. Falls are preventable, and health care providers can help their older patients reduce their risk for falls. Screening older patients for fall risk, assessing modifiable risk factors (e.g., use of psychoactive medications or poor gait and balance), and recommending interventions to reduce this risk (e.g., medication management or referral to physical therapy) can prevent older adult falls (

      2. Trends in emergency department visits for contact sports-related traumatic brain injuries among children - United States, 2001-2018external icon
        Waltzman D, Womack LS, Thomas KE, Sarmiento K.
        MMWR Morb Mortal Wkly Rep. 2020 Jul 10;69(27):870-874.
        During 2010-2016, there were an average of 283,000 U.S. emergency department (ED) visits each year among children for sports and recreation-related traumatic brain injuries (SRR-TBIs); approximately 45% of these SRR-TBIs were associated with contact sports (1). Although most children with an SRR-TBI are asymptomatic within 4 weeks, there is growing concern about potential long-term effects on a child's developing brain (2). This has led to calls to reduce the risk for traumatic brain injuries (TBIs) among child athletes, resulting in the introduction of state policies and the institution of safety rules (e.g., age and contact restrictions) for some sports programs. To assess changes in the incidence of ED-related SRR-TBI among children, CDC analyzed data from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) for the period 2001-2018. After more than a decade of increasing rates, the rate of contact sports-related TBI ED visits declined 32% from 2012 to 2018. This reduction was primarily the result of a decline in football-related SRR-TBI ED visits during 2013-2018. Decreased participation in tackle football (3) and implementation of contact limitations (4) were likely contributing factors to this decline. Public health professionals should continue to expand efforts to address SRR-TBIs in football, which is the sport with the highest incidence of TBI, and identify effective prevention strategies for all sports to reduce TBIs among children.

    • Laboratory Sciences
      1. Genetically and antigenically divergent influenza A(H9N2) viruses exhibit differential replication and transmission phenotypes in mammalian modelsexternal icon
        Belser JA, Sun X, Brock N, Pappas C, Pulit-Penaloza JA, Zeng H, Jang Y, Jones J, Carney PJ, Chang J, Van Long N, Diep NT, Thor S, Di H, Yang G, Cook PW, Creager HM, Wang D, McFarland J, Van Dong P, Wentworth DE, Tumpey TM, Barnes JR, Stevens J, Davis CT, Maines TR.
        J Virol. 2020 Jul 1.
        Low pathogenicity avian influenza A(H9N2) viruses, enzootic in poultry populations in Asia, are associated with fewer confirmed human infections but higher rates of seropositivity compared to A(H5) or A(H7) subtype viruses. Co-circulation of A(H5) and A(H7) viruses leads to the generation of reassortant viruses bearing A(H9N2) internal genes with markers of mammalian adaptation, warranting continued surveillance in both avian and human populations. Here, we describe active surveillance efforts in live poultry markets in Vietnam in 2018 and compare representative viruses to G1 and Y280 lineage viruses that have infected humans. Receptor binding properties, pH thresholds for HA activation, in vitro replication in human respiratory tract cells, and in vivo mammalian pathogenicity and transmissibility were investigated. While A(H9N2) viruses from both poultry and humans exhibited features associated with mammalian adaptation, one human isolate from 2018, A/Anhui-Lujiang/39/2018, exhibited increased capacity for replication and transmission, demonstrating the pandemic potential of A(H9N2) viruses.IMPORTANCE A(H9N2) influenza viruses are widespread in poultry in many parts of the world, and for over twenty years, have sporadically jumped species barriers to cause human infection. As these viruses continue to diversify genetically and antigenically, it is critical to closely monitor viruses responsible for human infections, to ascertain if A(H9N2) viruses are acquiring properties that make them better suited to infect and spread among humans. In this study, we describe an active poultry surveillance system established in Vietnam to identify the scope of influenza viruses present in live bird markets and the threat they pose to human health. Assessment of a recent A(H9N2) virus isolated from an individual in China in 2018 is also reported and was found to exhibit properties of adaptation to humans and, importantly, show similarities to strains isolated from the live bird markets of Vietnam.

      2. Using liquid chromatography mass spectrometry (LC-MS) to assess the effect of age, high-fat diet, and rat strain on the liver metabolomeexternal icon
        Boyce G, Shoeb M, Kodali V, Meighan T, Roberts JR, Erdely A, Kashon M, Antonini JM.
        PLoS One. 2020 ;15(7):e0235338.
        The goal of this study was to use liquid chromatography mass spectrometry to assess metabolic changes of two different diets in three distinct rat strains. Sprague-Dawley, Fischer 344, and Brown-Norway male rats were maintained on a high-fat, or regular diet for 24 weeks. Liver tissue was collected at 4, 12, and 24 weeks to assess global small molecule metabolite changes using high resolution accurate mass spectrometry coupled to ultra-high-performance liquid chromatography. The results of the global metabolomics analysis revealed significant changes based on both age and diet within all three strains. Principal component analysis revealed that the influence of diet caused a greater variation in significantly changing metabolites than that of age for the Brown Norway and Fisher 344 strains, whereas diet had the greatest influence in the Sprague Dawley strain only at the 4-week time point. As expected, metabolites involved in lipid metabolism were changed in the animals maintained on a high fat diet compared to the regular diet. There were also significant changes observed in the concentration of Tri carboxylic acid cycle intermediates that were extracted from the liver of all three strains based on diet. The results of this study showed that a high fat diet caused significant liver and metabolic changes compared to a regular diet in multiple rat strains. The inbred Fisher 344 and Brown Norway rats were more metabolically sensitive to the diet changes than outbred Sprague Dawley strain. The study also showed that age, as was the case for Sprague Dawley, is an important variable to consider when assessing metabolic changes.

      3. PCR-based method for Shigella flexneri serotyping: International multicenter validationexternal icon
        Brengi SP, Sun Q, Bolanos H, Duarte F, Jenkins C, Pichel M, Shahnaij M, Sowers EG, Strockbine N, Talukder KA, Derado G, Vinas MR, Kam KM, Xu J.
        J Clin Microbiol. 2019 Apr;57(4).
        Shigella spp. are a leading cause of human diarrheal disease worldwide, with Shigella flexneri being the most frequently isolated species in developing countries. This serogroup is presently classified into 19 serotypes worldwide. We report here a multicenter validation of a multiplex-PCR-based strategy previously developed by Q. Sun, R. Lan, Y. Wang, A. Zhao, et al. (J Clin Microbiol 49:3766-3770, 2011) for molecular serotyping of S. flexneri This study was performed by seven international laboratories, with a panel of 71 strains (researchers were blind to their identity) as well as 279 strains collected from each laboratory's own local culture collections. This collaborative work found a high extent of agreement among laboratories, calculated through interrater reliability (IRR) measures for the PCR test that proved its robustness. Agreement with the traditional method (serology) was also observed in all laboratories for 14 serotypes studied, while specific genetic events could be responsible for the discrepancies among methodologies in the other 5 serotypes, as determined by PCR product sequencing in most of the cases. This work provided an empirical framework that allowed the use of this molecular method to serotype S. flexneri and showed several advantages over the traditional method of serological typing. These advantages included overcoming the problem of availability of suitable antisera in testing laboratories as well as facilitating the analysis of multiple samples at the same time. The method is also less time-consuming for completion and easier to implement in routine laboratories. We recommend that this PCR be adopted, as it is a reliable diagnostic and characterization methodology that can be used globally for laboratory-based shigella surveillance.

      4. Resolution of pulmonary inflammation induced by carbon nanotubes and fullerenes in mice: Role of macrophage polarizationexternal icon
        Lim CS, Porter DW, Orandle MS, Green BJ, Barnes MA, Croston TL, Wolfarth MG, Battelli LA, Andrew ME, Beezhold DH, Siegel PD, Ma Q.
        Front Immunol. 2020 ;11:1186.
        Pulmonary exposure to certain engineered nanomaterials (ENMs) causes chronic lesions like fibrosis and cancer in animal models as a result of unresolved inflammation. Resolution of inflammation involves the time-dependent biosynthesis of lipid mediators (LMs)-in particular, specialized pro-resolving mediators (SPMs). To understand how ENM-induced pulmonary inflammation is resolved, we analyzed the inflammatory and pro-resolving responses to fibrogenic multi-walled carbon nanotubes (MWCNTs, Mitsui-7) and low-toxicity fullerenes (fullerene C60, C60F). Pharyngeal aspiration of MWCNTs at 40 mug/mouse or C60F at a dose above 640 mug/mouse elicited pulmonary effects in B6C3F1 mice. Both ENMs stimulated acute inflammation, predominated by neutrophils, in the lung at day 1, which transitioned to histiocytic inflammation by day 7. By day 28, the lesion in MWCNT-exposed mice progressed to fibrotic granulomas, whereas it remained as alveolar histiocytosis in C60F-exposed mice. Flow cytometric profiling of whole lung lavage (WLL) cells revealed that neutrophil recruitment was the greatest at day 1 and declined to 36.6% of that level in MWCNT- and 16.8% in C60F-treated mice by day 7, and to basal levels by day 28, suggesting a rapid initiation phase and an extended resolution phase. Both ENMs induced high levels of proinflammatory leukotriene B4 (LTB4) and prostaglandin E2 (PGE2) with peaks at day 1, and high levels of SPMs resolvin D1 (RvD1) and E1 (RvE1) with peaks at day 7. MWCNTs and C60F induced time-dependent polarization of M1 macrophages with a peak at day 1 and subsequently of M2 macrophages with a peak at day 7 in the lung, accompanied by elevated levels of type 1 or type 2 cytokines, respectively. M1 macrophages exhibited preferential induction of arachidonate 5-lipoxygenase activating protein (ALOX5AP), whereas M2 macrophages had a high level expression of arachidonate 15-lipoxygenase (ALOX15). Polarization of macrophages in vitro differentially induced ALOX5AP in M1 macrophages or ALOX15 in M2 macrophages resulting in increased preferential biosynthesis of proinflammatory LMs or SPMs. MWCNTs increased the M1- or M2-specific production of LMs accordingly. These findings support a mechanism by which persistent ENM-induced neutrophilic inflammation is actively resolved through time-dependent polarization of macrophages and enhanced biosynthesis of specialized LMs via distinct ALOX pathways.

      5. BACKGROUND: Dual human immunodeficiency virus (HIV)/syphilis rapid, point-of-care testing may enhance syphilis screening among high-risk populations, increase case finding, reduce time to treatment, and prevent complications. We assessed the laboratory-based performance of a rapid dual HIV/syphilis test using serum collected from patients enrolled in the Zimbabwe Sexually Transmitted Infections (STI) Etiology study. METHODS: Blood specimens were collected from patients presenting with STI syndromes in 6, predominantly urban STI clinics in different regions of Zimbabwe. All specimens were tested at a central research laboratory using the Standard Diagnostics Bioline HIV/Syphilis Duo test. The treponemal syphilis component of the dual rapid test was compared with the Treponema pallidum hemagglutination assay (TPHA) as a gold standard comparator, both alone or in combination with a nontreponemal test, the rapid plasma reagin test. The HIV component of the dual test was compared with a combination of HIV rapid tests conducted at the research laboratory following the Zimbabwe national HIV testing algorithm. RESULTS: Of 600 men and women enrolled in the study, 436 consented to serological syphilis and HIV testing and had specimens successfully tested by all assays. The treponemal component of the dual test had a sensitivity of 66.2% (95% confidence interval [CI], 55.2%-77.2%) and a specificity of 96.4% (95% CI, 94.5%-98.3%) when compared with TPHA; the sensitivity increased to 91.7% (95% CI, 82.6%-99.9%) when both TPHA and rapid plasma reagin were positive. The HIV component of the dual test had a sensitivity of 99.4% (95% CI, 98.4%-99.9%) and a specificity of 100% (95% CI, 99.9%-100%) when compared with the HIV testing algorithm. CONCLUSIONS: Laboratory performance of the SD Bioline HIV/Syphilis Duo test was high for the HIV component of the test. Sensitivity of the treponemal component was lower than reported from most laboratory-based evaluations in the literature. However, sensitivity of the test increased substantially among patients more likely to have active syphilis for which results of both standard treponemal and nontreponemal tests were positive.

    • Maternal and Child Health
      1. Using an online, modified Delphi approach to engage patients and caregivers in determining the patient-centeredness of duchenne muscular dystrophy care considerationsexternal icon
        Khodyakov D, Grant S, Denger B, Kinnett K, Martin A, Booth M, Armstrong C, Dao E, Chen C, Coulter I, Peay H, Hazlewood G, Street N.
        Med Decis Making. 2019 Nov;39(8):1019-1031.
        Purpose. To determine the patient-centeredness of endocrine and bone health Duchenne muscular dystrophy (DMD) care considerations using the RAND/PPMD Patient-Centeredness Method (RPM), which is a novel, online, modified-Delphi approach to engaging patients and caregivers in clinical guideline development. Methods. We solicited input on the patient-centeredness of care considerations from 28 individuals with DMD and 94 caregivers, randomly assigned to 1 of 2 mixed panels. During a 3-round online modified-Delphi process, participants rated the importance and acceptability of 19 DMD care considerations (round 1), reviewed and discussed the initial results (round 2), and revised their original ratings (round 3). Patient-centeredness was operationalized as importance and acceptability of recommendations. We considered a care consideration to be patient-centered if both panels deemed it important and acceptable. Results. Ninety-five panelists (78%) participated in this study. Of these, 88 (93%) participated in round 1, 74 (78%) in round 2, and 56 (59%) in round 3. Panelists deemed 12 care considerations to be patient-centered: 3 weight management, 3 bone health, 4 vertical growth, and 2 puberty recommendations. Seven care considerations did not meet patient-centeredness criteria. Common reasons were lack of evidence specific to DMD and concerns about insurance coverage, access to treatment, and patient safety. Conclusions. Using the RPM, Duchenne families considered most care considerations to be patient-centered. Besides being clinically appropriate, these considerations are likely to be consistent with the preferences, needs, and values of Duchenne families. While all relevant care considerations should be discussed during patient-provider encounters, those that did not meet patient-centeredness criteria in particular should be carefully considered as part of joint decision making between Duchenne families and their providers. Study Registration: HSRProj 20163126.

    • Mining
      1. The relaxation test on sandstone specimens showed typical behavior in pre-failure region and stepwise behavior in the post-failure region. Overall, more significant stress relaxation occurred within the failed specimens than the intact ones. Numerical simulations were conducted with pre-defined failure plane and with Voronoi tessellation to visualize the relaxation behavior. The model with pre-defined failure plane showed the key role of failure plane and asperity in simulating the step-wise post-failure relaxation behavior. The inhomogeneous stress distribution within failed specimen and the viscous deformation of intact rocks induced high stress concentration at the asperities. The observed step-wise relaxation initiated from the failure of asperity. Furthermore, the simulations with Voronoi tessellation showed time-dependent fracture development during relaxation in post-failure region. The presence of fractures completely changed the stress distribution. Stress concentration occurred at the front area of fractures and at the interacting areas between fractures. During relaxation, fractures still developed with time and the sudden significant increase in the “damage” coincided with the acceleration of stress relaxation leading to step-wise relaxation. Finally, the results showed the possibility of using residual strength as the long-term strength of failed rock.

    • Occupational Safety and Health
      1. The association of airflow obstruction with occupational exposures in a sample of rural adults in Iowaexternal icon
        Henneberger PK, Humann MJ, Liang X, Doney BC, Kelly KM, Cox-Ganser JM.
        COPD. 2020 Jun 25:1-9.
        A recent article reported that occupational exposure to vapor-gas, dust, and fumes (VGDF) was more common in a sample of rural adults than in a sample of adults in urban settings. In another study of the same urban adults, airflow obstruction (AO) was associated with occupational VGDF and the combination of smoking and occupational exposure. The goal of the current study was to determine if similar associations were evident in the sample of rural adults. We analyzed enrollment data from the Keokuk County Rural Health Study (KCRHS), which investigated the health of rural residents in Iowa. We used the same methods as the study of urban adults. A job-exposure matrix (JEM) assigned an occupational VGDF exposure level based on each participants' last reported job. The health outcome was AO, defined as both the forced expiratory volume in one second (FEV1) and the FEV1/forced vital capacity (FVC) ratio < lower limit of normal. Of the 1699 KCRHS participants, 436 (25.7%) had high total VGDF occupational exposure, 661 (38.9%) had ever smoked cigarettes, and 110 (6.5%) had AO. The crude frequency of AO increased across the joint categories of smoking (never, ever) and high exposure (no, yes) (p < 0.05 for linear trend). After adjusting for potential confounders, AO was associated with high total occupational VGDF exposure only among smokers (OR = 1.81, 95% CI 1.002 to 3.26). In conclusion, the association of AO with occupational exposure in the current study of rural adults was similar to what was previously observed among urban adults.

      2. Objective: The purpose of this study is to estimate the prevalence of hearing loss among noise-exposed U.S. workers within the Services sector.Methods: Audiograms for 1.9 million workers (158,436 within Services) from 2006 to 2015 were examined. Prevalence and adjusted risk for hearing loss as compared with a reference industry were estimated for the Services sector/sub-sectors, and all industries combined.Results: The prevalence of hearing loss within Services was 17 compared to 16% for all industries combined. However, many sub-sectors greatly exceeded the overall prevalence (10-33% higher) and/or had adjusted risks significantly higher than the reference industry. Workers in Administration of Urban Planning and Community and Rural Development had the highest prevalence (50%), and workers in Solid Waste Combustors and Incinerators had more than double the risk, the highest of any sub-sector. Some sub-sectors traditionally viewed as 'low-risk' also had high prevalences and risks.Conclusions: Large numbers of workers within Services have an elevated risk of hearing loss and need immediate hearing conservation efforts. Additional research and surveillance are needed for sub-sectors for which there is low awareness of hearing hazards or a lack of hearing data.

    • Occupational Safety and Health - Mining
      1. In May 1994, the National Institute for Occupational Safety and Health (NIOSH) considered crystalline silica to be a potential occupational carcinogen as defined by the Occupational Safety and Health Administration's (OSHA) carcinogen policy [29 CFR 1990], and this information was used in establishing the NIOSH Recommended Exposure Limit (REL) at 50 micro g/m3. NIOSH has long realized that occupational overexposure to respirable crystalline silica (RCS) dust can lead to the development of silicosis, an incurable and often fatal lung disease, but it can also result in health problems that include chronic obstructive pulmonary disease, tuberculosis, chronic bronchitis, emphysema and chronic renal disease. Probably the most significant occupational travesty that brought focus to the effects of silicosis was the Hawk's Nest Tunnel Disaster in southern West Virginia where a 4.83-km (3-mile) tunnel was driven through the Gauley Mountain. The material being removed during the mining of this tunnel for the development of a hydroelectric power plant was a sandstone and limestone ore containing very high levels of crystalline silica. Within months of the completion of this work, 476 of the workers died from acute silicosis. This acute silicosis was caused by extremely high respirable dust concentrations while driving this tunnel and was attributed to inconsistent dust-control methods, including poor ventilation and minimal use of water, not allowing the dust to settle after blasting occurred before workers returned back inside the tunnel and no use of respiratory protection.

      2. Nonfatal injuries from slips, trips, and falls (STF) that occur at surface mines can result from inadequate lighting. Mobile equipment operators are among the occupations associated with the nonfatal incidents reported to the U.S. Mine Safety and Health Administration (MSHA). In addition, getting on/off the equipment (ingress/egress) frequently adds to the highest proportion of nonfatal incidents. Accordingly, researchers at the Pittsburgh Mining Research Division (PMRD), National Institute for Occupational Safety and Health (NIOSH) conducted a field study to investigate lighting on haul trucks and wheel loaders with regard to glare and illuminance levels recommended by the Illuminating Engineering Society (IES). The objective was to determine whether two light-emitting diode (LED) area luminaires—a Mr. Beams® (model MB390 Ultrabright) (area luminaire-1) and a NIOSH-developed Saturn (custom-designed for a mine roof bolter study) (area luminaire-2)—could complement a headlamp luminaire. Measured levels of visual tasks, with the headlamp alone and the area luminaires plus the headlamp, demonstrated that illuminance met or exceeded IES-recommended levels. Nevertheless, the area luminaires illuminated a much broader area, which is key to increasing hazard awareness. Discomfort and disability glare were lower with area luminaire-1 than with area luminaire-2. Differences in glare were more noticeable for newer models of haul trucks and loaders featuring updated ingress/egress system designs. This study demonstrates that commercially available luminaires, such as area luminaire-1, are capable of complementing headlamp lighting, and can thus improve a miner’s ability to detect and avoid STF hazards.

    • Parasitic Diseases
      1. Parasitic infection surveillance in Mississippi Delta childrenexternal icon
        Bradbury RS, Arguello I, Lane M, Cooley G, Handali S, Dimitrova SD, Nascimento FS, Jameson S, Hellmann K, Tharp M, Byers P, Montgomery SP, Haynie L, Kirmse B, Pilotte N, Williams SA, Hobbs CV.
        Am J Trop Med Hyg. 2020 Jun 22.
        Some recent studies suggest ongoing transmission of parasitic diseases in the American South; however, surveys in Mississippi children are lacking. We enrolled 166 children (median age 8 years, range 4-13 years) from the Mississippi Delta region and carried out multi-parallel real-time polymerase chain reaction (PCR) for Necator americanus, Ascaris lumbricoides, and Strongyloides stercoralis on their stool samples. Dried blood spots were obtained for multiplex serology antibody detection. Of 166 children, all reported having flushable toilets, 11% had soil exposure, and 34% had a pet dog or cat. None had prior diagnosis or treatment of parasitic disease. Multi-parallel real-time PCRs were negative on the 89 stool DNA extracts available for testing. Dried blood spot testing of all 166 children determined the seroprevalence of IgG antibodies to Toxocara spp. (3.6%), Cryptosporidium (2.4%), S. stercoralis, Fasciola hepatica, and Giardia duodenalis (all 0%). In conclusion, parasitic infections and exposure were scarce in this population. Larger studies of at-risk populations are needed.

      2. Leveraging risk maps of malaria vector abundance to guide control efforts reduces malaria incidence in Eastern Province, Zambiaexternal icon
        Larsen DA, Martin A, Pollard D, Nielsen CF, Hamainza B, Burns M, Stevenson J, Winters A.
        Sci Rep. 2020 Jun 25;10(1):10307.
        Although transmission of malaria and other mosquito-borne diseases is geographically heterogeneous, in sub-Saharan Africa risk maps are rarely used to determine which communities receive vector control interventions. We compared outcomes in areas receiving different indoor residual spray (IRS) strategies in Eastern Province, Zambia: (1) concentrating IRS interventions within a geographical area, (2) prioritizing communities to receive IRS based on predicted probabilities of Anopheles funestus, and (3) prioritizing communities to receive IRS based on observed malaria incidence at nearby health centers. Here we show that the use of predicted probabilities of An. funestus to guide IRS implementation saw the largest decrease in malaria incidence at health centers, a 13% reduction (95% confidence interval = 5-21%) compared to concentrating IRS geographically and a 37% reduction (95% confidence interval = 30-44%) compared to targeting IRS based on health facility incidence. These results suggest that vector control programs could produce better outcomes by prioritizing IRS according to malaria-vector risk maps.

      3. Ecology of domestic dogs (Canis familiaris) as a host for Guinea worm (Dracunculus medinensis) infection in Ethiopiaexternal icon
        Wilson-Aggarwal JK, Goodwin CE, Swan GJ, Fielding H, Tadesse Z, Getahun D, Odiel A, Adam A, Marshall HH, Bryant J, Zingeser JA, McDonald RA.
        Transbound Emerg Dis. 2020 Jul 2.
        The global programme for the eradication of Guinea worm disease, caused by the parasitic nematode Dracunculus medinensis, has been successful in driving down human cases, but infections in non-human animals, particularly domestic dogs (Canis familiaris), now present a major obstacle to further progress. Dog infections have mainly been found in Chad and, to a lesser extent in Mali and Ethiopia. While humans classically acquire infection by drinking water containing infected copepods, it has been hypothesised that dogs might additionally or alternatively acquire infection via a novel pathway, such as consumption of fish or frogs as possible transport or paratenic hosts. We characterised the ecology of free-ranging dogs living in three villages in Gog woreda, Gambella region, Ethiopia in April-May 2018. We analysed their exposure to potential sources of Guinea worm infection, and investigated risk factors associated with infection histories. The home ranges of 125 dogs and their activity around water sources were described using GPS tracking, and the diets of 119 dogs were described using stable isotope analysis. Unlike in Chad, where Guinea worm infection is most frequent, we found no ecological or behavioural correlates of infection history in dogs in Ethiopia. Unlike in Chad, there was no effect of variation among dogs in their consumption of aquatic vertebrates (fish or frogs) on their infection history, and we found no evidence to support hypotheses for this novel transmission pathway in Ethiopia. Dog owners had apparently increased the frequency of clean water provision to dogs in response to previous infections. Variations in dog ranging behaviour, owner behaviour and the characteristics of natural water bodies all influenced the exposure of dogs to potential sources of infection. This initial study suggests that the classical transmission pathway should be a focus of attention for Guinea worm control in non-human animals in Ethiopia.

    • Public Health Leadership and Management
      1. Scientific conferences provide attendees opportunities to network, share research, learn new skills and ideas, and initiate collaborations. Conference attendance is especially important for students and early career researchers who are establishing their research careers or looking for jobs. However, attending conferences can be expensive, and the high cost of conference attendance may hit students and early career researchers the hardest. According to a new member survey from the Society for Epidemiologic Research, early career members are more racially and ethnically diverse than senior members, meaning that reducing financial barriers to conference participation may be an important consideration for increasing diversity among conference attendees. In this commentary, we discuss how choice of conference location-choosing less expensive cities nearer to more Society for Epidemiologic Research members-could reduce financial and other barriers to conference attendance for all members and improve diversity and inclusion in the Society.

    • Substance Use and Abuse
      1. Addressing alcohol use in pregnancyexternal icon
        Mitchell AM, Porter RR, Pierce-Bulger M, McKnight-Eily LR.
        Am J Nurs. 2020 Jul;120(7):22-24.
        Screening and brief counseling interventions are evidence-based approaches.

    • Zoonotic and Vectorborne Diseases
      1. Clinical characteristics, histopathology, and tissue immunolocalization of chikungunya virus antigen in fatal casesexternal icon
        Sharp TM, Keating MK, Shieh WJ, Bhatnagar J, Bollweg BC, Levine R, Blau DM, Torres JV, Rivera A, Perez-Padilla J, Munoz-Jordan J, Sanabria D, Fischer M, Garcia BR, Tomashek KM, Zaki SR.
        Clin Infect Dis. 2020 Jul 2.
        BACKGROUND: Death in patients with chikungunya is rare, and has been associated with encephalitis, hemorrhage, and septic shock. We describe clinical, histologic and immunohistochemical findings in individuals who died following chikungunya virus (CHIKV) infection. METHODS: We identified individuals who died in Puerto Rico during 2014 following an acute illness, and had CHIKV RNA detected by RT-PCR in a pre- or post-mortem blood or tissue specimen. We performed histopathology and immunohistochemistry (IHC) for CHIKV antigen on tissue specimens and collected medical data via record review and family interviews. RESULTS: Thirty CHIKV-infected fatal cases were identified (0.8 per 100,000 population). Median age was 61 years (range: 6 days-86 years), and 19 (63%) were male. Death occurred a median of four days (range: 1-29) after illness onset. Nearly all (93%) had at least one co-morbidity, most frequently hypertension, diabetes, or obesity. Nine had severe co-morbidities (e.g., chronic heart or kidney disease, sickle cell anemia) or co-infection (e.g., leptospirosis). Among 24 fatal cases with tissue specimens, 11 (46%) were positive by IHC. CHIKV antigen was most frequently detected in mesenchymal tissues and mononuclear cells including tissue macrophages, blood mononuclear cells, splenic follicular dendritic cells, and Kupffer cells. Common histopathologic findings were intra-alveolar hemorrhage and edema in the lung, chronic or acute tenosynovitis, and increased immunoblasts in the spleen. CHIKV infection likely caused fatal septic shock in two patients. CONCLUSIONS: Evaluation of tissue specimens provided insights into the pathogenesis of CHIKV, which may rarely result in septic shock and other severe manifestations.

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

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