Volume 12, Issue 28, August 18, 2020

CDC Science Clips: Volume 12, Issue 28, August 18, 2020

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

This week, CDC Science Clips is pleased to feature items related to the August CDC Public Health Grand Rounds: Reducing Polysubstance Use in Pregnancy. The use of multiple substances, including tobacco, alcohol, and opioids, during pregnancy can have negative effects on a pregnant person and the developing baby. Research suggests that polysubstance use (using more than one substance at a time) during pregnancy is common. Recent evidence suggests that polysubstance use is highest during early pregnancy.

  1. CDC Public Health Grand Rounds
    • Reducing Polysubstance Use in Pregnancy
      1. Committee opinion no. 633: Alcohol abuse and other substance use disorders: ethical issues in obstetric and gynecologic practiceexternal icon
        American College of Obstetricians and Gynecologists, Committee on Ethics.
        Obstet Gynecol. 2015 Jun;125(6):1529-37.
        Alcohol abuse and other substance use disorders are major, often underdiagnosed health problems for women, regardless of age, race, ethnicity, and socioeconomic status, and have resulting high costs for individuals and society. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, defines substance use disorder as a pathologic pattern of behaviors related to the use of any of 10 separate classes of substances, including alcohol and licit and illicit substances. In order to optimize care of patients with substance use disorder, obstetrician-gynecologists are encouraged to learn and appropriately use routine screening techniques, clinical laboratory tests, brief interventions, and treatment referrals. The purpose of this Committee Opinion is to propose an ethical framework for incorporating such care into obstetric and gynecologic practice and for resolving common ethical dilemmas related to substance use disorder.

      2. Effect of maternal substance abuse on the fetus, neonate, and childexternal icon
        Bailey NA, Diaz-Barbosa M.
        Pediatr Rev. 2018 Nov;39(11):550-559.

      3. The public stigma of birth mothers of children with fetal alcohol spectrum disordersexternal icon
        Corrigan PW, Lara JL, Shah BB, Mitchell KT, Simmes D, Jones KL.
        Alcohol Clin Exp Res. 2017 Jun;41(6):1166-1173.
        BACKGROUND: Stigma affects not only the person with a stigmatizing condition such as fetal alcohol spectrum disorders (FASD), but also their family members. This study examined whether there are stigmatizing attitudes about biological mothers of children with FASD in a crowdsourced sample. METHODS: Three hundred and eighty-nine participants were asked to rate levels of difference, disdain, and responsibility on 4 conditions: serious mental illness (MI), substance use disorder (SUD), jail experience, and FASD. A budget allocation task was administered as a proxy of discrimination. Prior experience with each of the 4 conditions was noted to assess familiarity. RESULTS: Research participants viewed mothers of children with FASD as more different, disdained, and responsible than women with serious MI, SUD, and jail experience. Budget allocation toward FASD service programs was significantly lower than that toward all other human service programs. Familiarity with the 3 comparison conditions moderated most of the stigma ratings, but this effect was not seen in the FASD condition. CONCLUSIONS: Results supported the notion that mothers of children with FASD are highly stigmatized for their past behavior. The data also suggested that the public might discriminate against this population. Stigma reduction interventions should focus on contact-based strategies, rather than education-based strategies.

      4. Addressing the public health concerns of fetal alcohol spectrum disorder: Impact of stigma and health literacyexternal icon
        Corrigan PW, Shah BB, Lara JL, Mitchell KT, Simmes D, Jones KL.
        Drug Alcohol Depend. 2018 Apr 1;185:266-270.
        BACKGROUND: Fetal alcohol spectrum disorders (FASD) are a group of developmental disabilities that may result from the mother's consumption of alcohol during pregnancy. The present study examined the effects of health literacy and stigma on the public health agenda for preventing FASD. METHODS: Three hundred and forty-one participants were sampled to ascertain levels of endorsement of the public health priorities of FASD, and FASD health literacy. Stigma towards women who consume alcohol during pregnancy, and towards biological mothers of children with FASD were operationalized using ratings of difference and disdain. RESULTS: Public stigma towards women who consume alcohol during pregnancy was greater than stigma towards biological mothers of children with FASD. Research participants with higher FASD literacy were more likely to endorse the prevention priorities of FASD, but also more likely to endorse greater stigma towards biological mothers of children with FASD. Interestingly, those who endorsed greater stigma supported the public health priorities of FASD more strongly. Female research participants more strongly supported the prevention priorities of FASD than male participants. Male participants were more likely to endorse stigma than female participants. CONCLUSIONS: Stigma experienced by biological mothers of children with FASD generalizes to women who consume alcohol while pregnant. Some results were contrary to expectations: stigma was positively associated with health literacy and endorsement of prevention priorities of FASD. Reasons for these findings are speculated and should be tested in future research.

      5. Increase in prescription opioid use during pregnancy among Medicaid-enrolled womenexternal icon
        Desai RJ, Hernandez-Diaz S, Bateman BT, Huybrechts KF.
        Obstet Gynecol. 2014 May;123(5):997-1002.
        OBJECTIVE: To report the prevalence of prescription opioid use and evaluate the trends in a large cohort of Medicaid-enrolled pregnant women. METHODS: A cohort of pregnancies was identified using data from the Medicaid Analytical eXtract for the period of 2000-2007. Dispensing of opioids, as a class and separately for individual agents, was evaluated using claims from filled prescriptions. Variations in patterns of prescription opioid fills were examined by demographic characteristics, by geographic region, and over time. Median number of opioid prescriptions dispensed and cumulative days of availability for prescription opioids during pregnancy were reported. RESULTS: The study population consisted of more than 1.1 million women with completed pregnancies from 46 U.S. states and Washington, DC. One of five women from our cohort (21.6%) filled a prescription for an opioid during pregnancy; this proportion increased from 18.5% in 2000 to 22.8% in 2007. Substantial regional variation was seen with the proportion of women who filled a prescription during pregnancy, ranging between 9.5% and 41.6% across the states. Codeine and hydrocodone were the most commonly prescribed opioids. Among women filling at least one opioid prescription, the median (interquartile range) number of prescriptions filled was 1 (1-2) and the median (interquartile range) cumulative days of opioid availability during pregnancy were 5 (3-13) days. CONCLUSION: We observed high and increasing number of filled prescriptions for opioids during pregnancy among Medicaid-enrolled women. These findings call for further safety evaluations of these drugs and their effects on the developing fetus to inform clinical practice. LEVEL OF EVIDENCE: II.

      6. Alcohol use and co-use of other substances among pregnant females aged 12-44 years - United States, 2015-2018external icon
        England LJ, Bennett C, Denny CH, Honein MA, Gilboa SM, Kim SY, Guy GP, Tran EL, Rose CE, Bohm MK, Boyle CA.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 7;69(31):1009-1014.
        Drinking alcohol during pregnancy can cause fetal alcohol spectrum disorders, including birth defects, behavioral disorders, and impaired cognitive development (1). Little is known about the co-use of other substances by females who drink during pregnancy. CDC used 2015-2018 data from the National Survey on Drug Use and Health (NSDUH) to estimate the overall and trimester-specific prevalence of self-reported drinking in the past 12 months, current drinking, and binge drinking, overall and by trimester, and the co-use of other substances among pregnant females aged 12-44 years. Past drinking (12 months) was reported by 64.7% of pregnant respondents. Current drinking (at least one drink in the past 30 days) was reported by 19.6% of respondents who were in their first trimester of pregnancy and 4.7% of respondents who were in their second or third trimester. Binge drinking (consuming four or more drinks on at least one occasion in the past 30 days) was reported by 10.5% of first trimester respondents and 1.4% of second or third trimester respondents. Overall, 38.2% of pregnant respondents who reported current drinking also reported current use of one or more other substances. The substances used most with alcohol were tobacco and marijuana. Self-reported drinking prevalence was substantially lower among second or third trimester respondents than among first trimester respondents. The American College of Obstetricians and Gynecologists (ACOG) recommends alcohol use and substance use disorders screening for all females seeking obstetric-gynecologic care and counseling patients that there is no known safe level of alcohol use during pregnancy (2).

      7. Opioid use disorder documented at delivery hospitalization - United States, 1999-2014external icon
        Haight SC, Ko JY, Tong VT, Bohm MK, Callaghan WM.
        MMWR Morb Mortal Wkly Rep. 2018 Aug 10;67(31):845-849.
        Opioid use by pregnant women represents a significant public health concern given the association of opioid exposure and adverse maternal and neonatal outcomes, including preterm labor, stillbirth, neonatal abstinence syndrome, and maternal mortality (1,2). State-level actions are critical to curbing the opioid epidemic through programs and policies to reduce use of prescription opioids and illegal opioids including heroin and illicitly manufactured fentanyl, both of which contribute to the epidemic (3). Hospital discharge data from the 1999-2014 Healthcare Cost and Utilization Project (HCUP) were analyzed to describe U.S. national and state-specific trends in opioid use disorder documented at delivery hospitalization. Nationally, the prevalence of opioid use disorder more than quadrupled during 1999-2014 (from 1.5 per 1,000 delivery hospitalizations to 6.5; p<0.05). Increasing trends over time were observed in all 28 states with available data (p<0.05). In 2014, prevalence ranged from 0.7 in the District of Columbia (DC) to 48.6 in Vermont. Continued national, state, and provider efforts to prevent, monitor, and treat opioid use disorder among reproductive-aged and pregnant women are needed. Efforts might include improved access to data in Prescription Drug Monitoring Programs, increased substance abuse screening, use of medication-assisted therapy, and substance abuse treatment referrals.

      8. Polysubstance use among US women of reproductive age who use opioids for nonmedical reasonsexternal icon
        Jarlenski M, Barry CL, Gollust S, Graves AJ, Kennedy-Hendricks A, Kozhimannil K.
        Am J Public Health. 2017 Aug;107(8):1308-1310.
        OBJECTIVES: To determine the prevalence and patterns of polysubstance use among US reproductive-aged women who use opioids for nonmedical purposes. METHODS: We used the National Survey of Drug Use and Health (2005-2014) data on female respondents aged 18 to 44 years reporting nonmedical opioid use in the past 30 days (unweighted n = 4498). We categorized patterns of polysubstance use in the past 30 days, including cigarettes, binge drinking, and other legal and illicit substances and reported prevalence adjusted for age, race/ethnicity, and educational attainment. RESULTS: Of all women with nonmedical opioid use, 11% reported only opioid use. Polysubstance use was highest in non-Hispanic White women and women with lower educational attainment. The most frequently used other substances among women using opioids nonmedically were cigarettes (56.2% smoked > 5 cigarettes per day), binge drinking (49.7%), and marijuana (32.4%). Polysubstance use was similarly prevalent among pregnant women with nonmedical opioid use. CONCLUSIONS: Polysubstance use is highly prevalent among US reproductive-aged women reporting nonmedical opioid use. Public Health Implications. Interventions are needed that address concurrent use of multiple substances.

      9. A randomized controlled trial of screening and brief interventions for substance misuse in reproductive healthexternal icon
        Martino S, Ondersma SJ, Forray A, Olmstead TA, Gilstad-Hayden K, Howell HB, Kershaw T, Yonkers KA.
        Am J Obstet Gynecol. 2018 Mar;218(3):322.e1-322.e12.
        BACKGROUND: Screening, brief intervention, and referral to treatment may reduce substance misuse but has received minimal study among women who are treated in reproductive health settings. OBJECTIVE: The purpose of this study was to determine whether "screening, brief intervention and referral to treatment" that is delivered either electronically or by clinician are more effective than enhanced usual care in decreasing days of primary substance use. STUDY DESIGN: Women from 2 reproductive centers who smoked cigarettes or misused alcohol, illicit drugs, or prescription medication were allocated randomly to "screening, brief intervention and referral to treatment" delivered electronically or by clinician or to enhanced usual care. Assessments were completed at baseline and at 1-, 3-, and 6-months after a baseline has been established. Coprimary outcomes were days/months of primary substance use and postintervention treatment use. A sample size of 660 women was planned; randomization was stratified by primary substance use and pregnancy status. "Screening, brief intervention and referral to treatment" groups were compared with enhanced usual care groups with the use of generalized estimation equations, and effect sizes were calculated with the use of Cohen's d. RESULTS: Between September 2011 and January 2015, women were assigned randomly to a group: 143 women (16.8% pregnant) in the electronic-delivered "screening, brief intervention and referral to treatment" group, 145 women (18.6% pregnant) in the clinician-delivered "screening, brief intervention and referral to treatment" group, and 151 women (19.2% pregnant) in the enhanced usual care group; the retention was >84%. Based on the generalized estimating equations model, predicted mean days per month of use at baseline for primary substance were 23.9 days (95% confidence interval, 22.4-25.5) for the electronic-delivered group, 22.8 days (95% confidence interval, 21.4-24.3) for the clinician-delivered group, and 23.5 days (95% confidence interval, 22.2, 24.9) for enhanced usual care, which respectively declined to 20.5 days (95% confidence interval, 19.0-22.2), 19.8 days (95% confidence interval,18.5-21.3), and 21.9 days (95% confidence interval, 20.7-23.1) at 1 month; 16.9 days (95% confidence interval, 15.0-19.0), 16.6 days (95% confidence interval, 14.8-18.6), and 19.5 days (95% confidence interval, 18.1-21.1) at 3 months; and 16.3 days (95% confidence interval, 14.3-18.7), 16.3 days (95% confidence interval, 14.4-18.5), and 17.9 days (95% confidence interval, 16.1-19.9) at 6 months. Estimated declines were greater in the electronic-delivered group (β [standard error]=-0.090[0.034]; P=.008; Cohen's d, 0.19 at 1 month, 0.30 at 3 months, and 0.17 at 6 months) and the clinician-delivered group (β [standard error]=-0.078[0.037]; P=.038; Cohen's d, 0.17 at 1 month, 0.22 at 3 months, and 0.06 at 6 months) compared with enhanced usual care. Treatment use did not differ between groups. CONCLUSION: "Screening, brief intervention and referral to treatment" significantly decreased days of primary substance use among women in reproductive healthcare centers; neither resulted in more treatment use than enhanced usual care.

      10. Screening for alcohol use and brief counseling of adults - 13 states and the District of Columbia, 2017external icon
        McKnight-Eily LR, Okoro CA, Turay K, Acero C, Hungerford D.
        MMWR Morb Mortal Wkly Rep. 2020 Mar 13;69(10):265-270.
        Binge drinking* is a leading preventable public health problem. From 2006 to 2010, binge drinking contributed to approximately 49,000 annual deaths resulting from acute conditions (e.g., injuries and violence) (1). Binge drinking also increases the risk for adverse health conditions, including some chronic diseases (e.g., breast cancer) and fetal alcohol spectrum disorders (2). In 2004, 2013, and again in 2018, for all U.S. adults aged ≥18 years in primary care, the U.S. Preventive Services Task Force (USPSTF) recommended alcohol screening and brief intervention (alcohol SBI) or counseling for persons whose screening indicated drinking in excess of recommended limits or in ways that increase risk for poor health outcomes (3-5). However, previous CDC surveillance data indicate that patients report rarely talking to their provider about alcohol use,(†) and alcohol SBI is traditionally delivered through conversation. CDC recently analyzed 2017 data from the Behavioral Risk Factor Surveillance System (BRFSS) survey's five-question module, which asked adults in 13 states(§) and the District of Columbia (DC) about the delivery of alcohol SBI during their most recent checkup in the past 2 years. Overall, 81.4% of adults (age-standardized estimate) reported being asked about alcohol use by a health professional in person or on a form during a checkup in the past 2 years, but only 37.8% reported being asked a question about binge-level alcohol consumption, which is included on USPSTF recommended instruments (3). Among module respondents who were asked about alcohol use at a checkup in the past 2 years and reported current binge drinking (past 30 days) at time of survey, only 41.7% were advised about the harms of drinking too much at a checkup in the past 2 years, and only 20.1% were advised to reduce or quit drinking at a checkup in the past 2 years. These findings suggest that missed opportunities remain for health care providers to intervene with patients who report binge drinking. Working to implement alcohol SBI at a systems level, including the provision of the new Healthcare Effectiveness Data Information Set (HEDIS) measure, Unhealthy Alcohol Use Screening and Follow-Up, can improve alcohol SBI's use and benefit in primary care.

      11. The Health Consequences of Smoking - 50 Years of Progress: A Report of the Surgeon Generalexternal icon
        National Center for Chronic Disease Prevention and Health Promotion , Office on Smoking and Health .
        Reports of the Surgeon General. 2014 .
        Fifty years have passed since publication of the landmark report of the Surgeon General’s Advisory Committee on smoking and health. This report highlights both the dramatic progress our nation has made reducing tobacco use and the continuing burden of disease and death caused by smoking.

      12. A public health response to opioid use in pregnancyexternal icon
        Patrick SW, Schiff DM.
        Pediatrics. 2017 Mar;139(3).
        The use of opioids during pregnancy has grown rapidly in the past decade. As opioid use during pregnancy increased, so did complications from their use, including neonatal abstinence syndrome. Several state governments responded to this increase by prosecuting and incarcerating pregnant women with substance use disorders; however, this approach has no proven benefits for maternal or infant health and may lead to avoidance of prenatal care and a decreased willingness to engage in substance use disorder treatment programs. A public health response, rather than a punitive approach to the opioid epidemic and substance use during pregnancy, is critical, including the following: a focus on preventing unintended pregnancies and improving access to contraception; universal screening for alcohol and other drug use in women of childbearing age; knowledge and informed consent of maternal drug testing and reporting practices; improved access to comprehensive obstetric care, including opioid-replacement therapy; gender-specific substance use treatment programs; and improved funding for social services and child welfare systems. The American College of Obstetricians and Gynecologists supports the value of this clinical document as an educational tool (December 2016).

      13. Marijuana is one of the most widely used substances during pregnancy in the United States. Emerging data on the ability of cannabinoids to cross the placenta and affect the development of the fetus raise concerns about both pregnancy outcomes and long-term consequences for the infant or child. Social media is used to tout the use of marijuana for severe nausea associated with pregnancy. Concerns have also been raised about marijuana use by breastfeeding mothers. With this clinical report, we provide data on the current rates of marijuana use among pregnant and lactating women, discuss what is known about the effects of marijuana on fetal development and later neurodevelopmental and behavioral outcomes, and address implications for education and policy.

      14. Computerized versus in-person brief intervention for drug misuse: a randomized clinical trialexternal icon
        Schwartz RP, Gryczynski J, Mitchell SG, Gonzales A, Moseley A, Peterson TR, Ondersma SJ, O'Grady KE.
        Addiction. 2014 Jul;109(7):1091-8.
        BACKGROUND AND AIMS: Several studies have found that brief interventions (BIs) for drug misuse have superior effectiveness to no-treatment controls. However, many health centers do not provide BIs for drug use consistently due to insufficient behavioral health staff capacity. Computerized BIs for drug use are a promising approach, but their effectiveness compared with in-person BIs has not been established. This study compared the effectiveness of a computerized brief intervention (CBI) to an in-person brief intervention (IBI) delivered by a behavioral health counselor. METHODS: Two-arm randomized clinical trial, conducted in two health centers in New Mexico, United States. Participants were 360 adult primary care patients with moderate-risk drug scores on the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) who were randomly assigned on a 1 : 1 basis to a computerized brief intervention (CBI) or to an in-person brief intervention (IBI) delivered by a behavioral health counselor. Assessments were conducted at baseline and 3-month follow-up, and included the ASSIST and drug testing on hair samples. RESULTS: The IBI and CBI conditions did not differ at 3 months on global ASSIST drug scores [b = -1.79; 95% confidence interval (CI) = -4.37, 0.80] or drug-positive hair tests [odds ratio (OR) = 0.97; 95% CI = 0.47, 2.02]. There was a statistically significant advantage of CBI over IBI in substance-specific ASSIST scores for marijuana (b = -1.73; 95% CI = -2.91, -0.55; Cohen's d = 0.26; P = 0.004) and cocaine (b = -4.48; 95% CI = -8.26, -0.71; Cohen's d = 0.50; P = 0.021) at 3 months. CONCLUSIONS: Computerized brief intervention can be an effective alternative to in-person brief intervention for addressing moderate drug use in primary care.

  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. Major depression and adverse patient-reported outcomes in systemic lupus erythematosus: Results from the California Lupus Epidemiology Studyexternal icon
        Dietz B, Katz P, Dall'Era M, Murphy LB, Lanata C, Trupin L, Criswell LA, Yazdany J.
        Arthritis Care Res (Hoboken). 2020 Aug 2.
        OBJECTIVE: Health-related quality of life (HRQoL) is reduced in SLE, partly driven by comorbid depression. The association between major depression among those with SLE and HRQoL measured using the National Institutes of Health's Patient-Reported Outcomes Measurement Information System (PROMIS) is not well characterized. METHODS: Cross-sectional data were obtained from the California Lupus Epidemiology Study (CLUES), a cohort of adults in the San Francisco Bay Area with SLE. We studied the association between major depression (score ≥ 10 on Patient Health Questionnaire [PHQ-8] depression scale) and T-scores (scaled to population mean of 50, SD of 10) on 12 PROMIS domains representing physical, mental, and social health. Mean T-scores in depressed and non-depressed individuals were compared using multiple linear regression models, adjusting for age, sex, race/ethnicity, disease activity, damage, body mass index (BMI), and household income. RESULTS: Mean age of the 326 participants was 45 years; approximately 89% were women, 29% white, 23% Hispanic, 10% black, and 36% Asian. One-quarter met criteria for major depression. In multivariable analyses, major depression was independently associated with worse T-scores on all 12 PROMIS domains (p<0.001); compared with those without major depression, depressed individuals scored more than 10 points (1 SD) worse on Fatigue, Sleep Impairment, Negative Psychosocial Impact of Illness, Satisfaction in Discretionary Social Activities, and Satisfaction in Social Roles. CONCLUSION: In individuals with SLE, major depression is associated with markedly worse PROMIS scores in physical, mental, and social domains. Diagnosing and treating depression may help improve HRQoL in individuals with SLE.

      2. The impact of limited health literacy on patient-reported outcomes in systemic lupus erythematosusexternal icon
        Katz P, Dall'Era M, Trupin L, Rush S, Murphy LB, Lanata C, Criswell LA, Yazdany J.
        Arthritis Care Res (Hoboken). 2020 Aug 2.
        OBJECTIVE: Health disparities in patient-reported outcomes (PROs) by income and education are well documented; the impact of health literacy on PROs has received less attention. We examined independent effects of income, education, and health literacy on PROs in SLE. METHODS: Data from the California Lupus Epidemiology Study (CLUES, n=323) were used. Health literacy was assessed with a validated 3-item measure (ability to understand written information, reliance on others to understand written information, confidence in completing written forms). PROs were administered by interview in English, Spanish, Cantonese, or Mandarin. Generic and disease-specific PROs were examined: ten PROMIS short forms, the eight SF-36 subscales, and three patient-reported SLE disease activity and damage measures. We conducted two sets of multivariable analyses: the first examined education, income, or health literacy individually; the second included all three simultaneously. All multivariable models included age, sex, race/ethnicity, language, disease duration, and physician-assessed disease activity and damage. RESULTS: Over one-third (38%) had limited health literacy (LHL), including >25% with greater than high school education. In multivariable analyses simultaneously considering education, income, and health literacy, LHL was associated with significantly worse scores on all PROs except disease damage. In contrast, disparities by income were seen in only three PROMIS scales, three SF-36 subscales, and one disease activity measure. No disparities by education level were noted. CONCLUSIONS: We found significantly worse PRO scores among individuals with LHL, even after controlling for disease activity and damage. Whether disparities are due to actual differences in health or measurement issues requires further study.

      3. Gastric cancer among American Indian and Alaska Native populations in the United States, 2005-2016external icon
        Melkonian SC, Pete D, Jim MA, Haverkamp D, Wiggins CL, Bruce MG, White MC.
        Am J Gastroenterol. 2020 Jul 27.
        INTRODUCTION: American Indian and Alaska Native (AI/AN) populations have higher gastric cancer rates than the general US population. This study provides a comprehensive overview of incidence rates among AI/AN persons during 2005-2016 compared with non-Hispanic whites (whites). METHODS: Population-based cancer registry data for 2005-2016 were linked with the Indian Health Service patient registration databases to address racial misclassification. Age-adjusted gastric cancer incidence rates were expressed per 100,000 per year. Incidence and trend analyses were restricted to purchased/referred care delivery area counties in 6 geographic regions, comparing gastric cancer incidence rates for AI/AN vs white populations in the United States. RESULTS: Gastric cancer rates were higher in the AI/AN compared with white populations in nearly every US region. Incidence rates for central/distal portions of the stomach were higher in AI/AN individuals compared with whites. Rates of later stage gastric cancer were higher in AI/AN populations overall and in every region except the Pacific Coast and East. Incidence rates decreased significantly over time in both populations. Declining rates in the AI/AN populations were driven by changes in the Pacific Coast and Northern Plains regions. DISCUSSION: AI/AN populations have a disproportionately high incidence of gastric cancer, especially in Alaska. High incidence in the central/distal portions of the stomach among AI/AN populations likely reflects a high prevalence of Helicobacter pylori infection in these populations. These data can be used to develop interventions to reduce risk factors and improve access to health services among AI/AN people at high risk for gastric cancer.

      4. A comparison of general, genitourinary, bowel, and sexual quality of life among long term survivors of prostate, bladder, colorectal, and lung cancerexternal icon
        Ramsey SD, Hall IJ, Smith JL, Ekwueme DU, Fedorenko CR, Kreizenbeck K, Bansal A, Thompson IM, Penson DF.
        J Geriatr Oncol. 2020 Jul 29.
        OBJECTIVES: Studies of local stage prostate cancer survivors suggest that treatments carry risk of persistent impotence, incontinence, and bowel dysfunction. To examine impacts of cancer type and side effects on health-related quality of life (HRQoL) in long-term cancer survivorship, we evaluated 5-year follow-up of patients with prostate cancer and compared results with a matched group of male long-term survivors of other local-stage cancers. MATERIALS AND METHODS: We examined genitourinary, bowel and sexual symptoms, and general quality of life. Matched survivors of colorectal, lung, and bladder cancers were recruited via registries in 3 different regions in the United States. Patients were surveyed 3-5 years after diagnosis with the SF-12 and EPIC to evaluate general mental and physical health-related quality of life (HRQoL) and patient function and bother. RESULTS: We analyzed responses from long-term prostate (n = 77) and bladder, colorectal, and lung cancer (n = 124) patients. In multivariate analysis, long-term local stage prostate cancer survivors had significantly higher SF-12 physical component scores but did not differ from long-term survivors of other cancers in terms of their SF-12 mental summary scores. Prostate survivors had similar mental, urinary, bowel, and sexual HRQoL compared to long-term survivors of other local stage cancers. CONCLUSION: Long-term general and prostate-specific HRQoL was similar between local stage prostate and bladder, colorectal, and lung patients with cancer. Future research focusing on factors other than initial treatment and the cancer type per se may provide more meaningful information regarding factors that predict disparities on HRQoL among longer-term survivors of early stage male cancers.

      5. Association between fear of hypoglycemia and physical activity in youth with type 1 diabetes: the SEARCH for Diabetes in Youth Studyexternal icon
        Roberts AJ, Taplin CE, Isom S, Divers J, Saydah S, Jensen ET, Mayer-Davis EJ, Reid LA, Liese AD, Dolan LM, Dabelea D, Lawrence JM, Pihoker C.
        Pediatr Diabetes. 2020 Aug 1.
        BACKGROUND: Youth with type 1 diabetes (T1D) are encouraged to participate in physical activity (PA). Studies have identified fear of hypoglycemia (FOH) as a barrier to participating in PA. OBJECTIVES: To examine 1) PA patterns in youth with T1D by age group and 2) the relationship between both parental and youth FOH and youth PA. METHODS: A cross-sectional analysis from the SEARCH cohort study visit of youth ages 10-17 years with T1D (n=1,129) was conducted. Linear regression models estimated the association between self-reported number of days of vigorous PA (VPA) and moderate PA (MPA) and both youth- and parent-reported FOH. Multivariable models were adjusted for age, sex, race, duration of T1D, HbA1c, use of continuous glucose monitoring (CGM), recent severe hypoglycemia, primary insulin regimen, and BMI. RESULTS: Participants were 52% female, had mean (sd) age 14.4 (4.2) years, diabetes duration 7.5 years (1.8), HbA1c 9.2% (1.7). Older youth were less likely to engage in VPA (p=0.003), or sports teams (p=0.0001), but more likely to engage in MPA (p=0.001). Higher youth FOH (behavior subscale) was associated with increased levels of VPA (β (se) 0.30 (0.11), p=0.005) but not significantly associated with MPA (p=0.06). There was no statistically significant association between parental FOH and youth PA. CONCLUSIONS: In SEARCH participants with T1D, VPA and team sports participation declined with age, while MPA increased. We observed that higher scores on the youth FOH behavioral subscale were associated with increased VPA levels, suggesting that FOH may be less of a barrier to PA than previously thought. This article is protected by copyright. All rights reserved.

      6. Dietary strategies to manage diabetes and glycemic control in youth and young adults with youth-onset type 1 and type 2 diabetes: The SEARCH for Diabetes in Youth Studyexternal icon
        Sauder KA, Stafford JM, The NS, Mayer-Davis EJ, Thomas J, Lawrence JM, Kim G, Siegel KR, Jensen ET, Shah A, D'Agostino RB, Dabelea D.
        Pediatr Diabetes. 2020 Jul 31.
        AIMS: Examine associations of dietary strategies used to manage diabetes over time with hemoglobin A1c in youth-onset type 1 or type 2 diabetes. METHODS: The SEARCH for Diabetes in Youth observational study assessed dietary strategies used by 1,814 participants with diabetes (n=1,558 type 1, n=256 type 2) at 2-3 research visits over 5.5 years (range 1.7-12.2). Participants reported often, sometimes, or never using 10 different dietary strategies, and use over time was categorized into 5 mutually exclusive groups: often using across visits; started using at later visits; sometimes using across visits; stopped using at later visits; or never using across visits. General multivariable linear models evaluated most recent A1c by use category for each strategy. RESULTS: In type 1 diabetes, A1c was lower among those who starting tracking calories (-0.4%, Tukey p<0.05), often counted carbs (-0.8%, Tukey p<0.001), or sometimes chose low glycemic index foods (-0.5%, Tukey p=0.02) versus those with less use, while participants who never drank more milk had the lowest A1c (-0.5%, Tukey p=0.04). In type 2 diabetes, A1c was lower among those who often limited high fat foods (-2.0%, Tukey p=0.02) or started counting carbohydrates (-1.7%, Tukey p=0.07) than those who did so less. CONCLUSIONS: For several dietary strategies, more frequent use over time was related to lower A1c in youth-onset type 1 and type 2 diabetes, suggesting these strategies can likely support diabetes management for this population. Investigation into factors predicting receipt of advice for specific strategies and corresponding impact on intake might be considered. This article is protected by copyright. All rights reserved.

    • Communicable Diseases
      1. Transmission of SARS-CoV-2 involving residents receiving dialysis in a nursing home - Maryland, April 2020external icon
        Bigelow BF, Tang O, Toci GR, Stracker N, Sheikh F, Jacobs Slifka KM, Novosad SA, Jernigan JA, Reddy SC, Katz MJ.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 14;69(32):1089-1094.
        SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), can spread rapidly in nursing homes once it is introduced (1,2). To prevent outbreaks, more data are needed to identify sources of introduction and means of transmission within nursing homes. Nursing home residents who receive hemodialysis (dialysis) might be at higher risk for SARS-CoV-2 infections because of their frequent exposures outside the nursing home to both community dialysis patients and staff members at dialysis centers (3). Investigation of a COVID-19 outbreak in a Maryland nursing home (facility A) identified a higher prevalence of infection among residents undergoing dialysis (47%; 15 of 32) than among those not receiving dialysis (16%; 22 of 138) (p<0.001). Among residents with COVID-19, the 30-day hospitalization rate among those receiving dialysis (53%) was higher than that among residents not receiving dialysis (18%) (p = 0.03); the proportion of dialysis patients who died was 40% compared with those who did not receive dialysis (27%) (p = 0.42).Careful consideration of infection control practices throughout the dialysis process (e.g., transportation, time spent in waiting areas, spacing of machines, and cohorting), clear communication between nursing homes and dialysis centers, and coordination of testing practices between these sites are critical to preventing COVID-19 outbreaks in this medically vulnerable population.

      2. Geographic distribution of HIV transmission networks in the United Statesexternal icon
        Board AR, Oster AM, Song R, Gant Z, Linley L, Watson M, Zhang T, France AM.
        J Acquir Immune Defic Syndr. 2020 Jul 27.
        BACKGROUND: Understanding geographic patterns of HIV transmission is critical to designing effective interventions. We characterized geographic proximity by transmission risk and urban-rural characteristics among people with closely related HIV strains suggestive of potential transmission relationships. METHODS: We analyzed U.S. National HIV Surveillance System data for people diagnosed 2010-2016 with a reported HIV-1 partial polymerase nucleotide sequence. We used HIV-TRACE (HIV TRAnsmission Cluster Engine) to identify sequences linked at a genetic distance ≤ 0.5%. For each linked person, we assessed median distances between counties of residence at diagnosis by transmission category and urban-rural classification, weighting observations to account for persons with multiple linked sequences. RESULTS: There were 24,743 persons with viral sequence linkages to at least one other person included in this analysis. Overall, half (50.9%) of persons with linked viral sequences resided in different counties, and the median distance from persons with linked viruses was 11 km/7 miles (IQR 0-145 km/90 mi). Median distances were highest for men who have sex with men (MSM: 14 km/9 mi, IQR 0-179 km/111 mi) and MSM who inject drugs, and median distances increased with increasing rurality (large central metro: 0 km/mi, IQR 0-83 km/52 mi; nonmetro: 103 km/64 mi, IQR 40 km/25 mi-316 km/196 mi). CONCLUSION: Transmission networks in the U.S. involving MSM, MSM who inject drugs, or persons living in small metro and nonmetro counties may be more geographically dispersed, highlighting the importance of coordinated health department efforts for comprehensive follow-up and linkage to care.

      3. Policy and public health: Reducing the burden of infectious diseasesexternal icon
        Burton DC, Burris S, Mermin JH, Purcell DW, Zeigler SC, Bull-Otterson L, Dean HD.
        Public Health Rep. 2020 Jul/Aug;135(1_suppl):5s-9s.

      4. Integration of hepatitis C treatment at harm reduction centers in Georgia - findings from a patient satisfaction surveyexternal icon
        Butsashvili M, Kamkamidze G, Kajaia M, Gvinjilia L, Kuchuloria T, Khonelidze I, Gogia M, Dolmazashvili E, Kerashvili V, Zakalashvili M, Shadaker S, Nasrullah M, Sonjelle S, Japaridze M, Averhoff F.
        Int J Drug Policy. 2020 Jul 30;84:102893.
        BACKGROUND: Georgia launched national HCV elimination program in 2015. PWID may experience barriers to accessing HCV care. To improve linkage to care among PWID, pilot program to integrate HCV treatment with HR services at opiate substitution therapy (OST) centers and needle syringe program (NSP) sites was initiated. Our study aimed to assess satisfaction of patients with integrated HCV treatment services at HR centers. METHODS: Survey was conducted among convenience sample of patients receiving HCV treatment at 5 integrated care sites and 4 specialized clinics not providing HR services. Simplified pre-treatment diagnostic algorithm and treatment monitoring procedure was introduced for HCV treatment programs at OST/NSP centers which includes fewer pre-treatment and monitoring tests compared to standard algorithm. RESULTS: In total, 358 patients participated in the survey - 48.6% receiving HCV treatment at the specialized clinics while 51.4% at HR site with integrated treatment. Similar proportions of surveyed patients at HR sites (88.0%) and clinics (84.5%) stated that they did not face any barriers to enrollment in the elimination program. Most patients from HR pilot sites and specialized clinics stated that they received comprehensive information about the treatment (98.4% vs 94.3%; p<0.010). 95% of respondents at both sites were confident that confidentiality was completely protected during treatment. Higher proportion of patients at pilot sites thought that HCV treatment services provided at facility were good compared to those from the specialized clinics (85.3% vs 81.0%). We found significant difference in the time to treatment, measured as average time from viremia testing to administration of first dose of HCV medication: 42.9% of patients at pilot sites vs 4.6% at specialized clinics received the first dose of medication within two weeks. CONCLUSION: Quality of services and perceived satisfaction of patients receiving treatment, suggests that integration of HCV treatment with HR services is feasible.

      5. High prevalence of hepatitis C virus infection among people who use crack cocaine in an important international drug trafficking route in Central-West Region Brazilexternal icon
        Castro VO, Kamili S, Forbi JC, Stabile AC, da Silva EF, do Valle Leone de Oliveira SM, de Carvalho PR, Puga MA, Tanaka TS, do Lago BV, Ibanhes ML, Araujo A, Tejada-Strop A, Lin Y, Xia GL, Sue A, Teles SA, Motta-Castro AR.
        Infect Genet Evol. 2020 Jul 31:104488.
        In this study, the prevalence rate, associated risk factors and genetic diversity of hepatitis C virus (HCV) infection were determined among people who use crack from an international drug trafficking route in Central-West, Brazil. Blood samples were collected from 700 users of crack from Campo Grande and two border cities of Mato Grosso do Sul State and tested for HCV infection using serological and molecular testing methodologies. Anti-HCV was detected in 31/700 (4.5%, 95% CI: 2.9-6.0%) and HCV RNA in 26/31 (83.9%) of anti-HCV positive samples. Phylogenetic analysis of three HCV sub-genomic regions (5'UTR, NS5B and HVR-1) revealed the circulation of 1a (73.9%), 1b (8.7%) and 3a (17.4%) genotypes. Next-generation sequencing and phylogenetic analysis of intra-host viral populations of HCV HVR-1 showed a significant variation in intra-host genetic diversity among infected individuals, with 58.8% composed of more than one sub-population. Bayesian analysis estimated that the most recent common HCV ancestor for strains identified here was introduced to this region after 1975 following expansion of intravenous drug use in Brazil. Multivariate analyses showed that only 'ever having injected drugs' was independently associated with HCV infection. These results indicate an increasing spread of multiple HCV strains requiring public health intervention, such as harm reduction, testing services and treatment among crack users in this important border region of Central Brazil.

      6. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020external icon
        Czeisler ME, Lane RI, Petrosky E, Wiley JF, Christensen A, Njai R, Weaver MD, Robbins R, Facer-Childs ER, Barger LK, Czeisler CA, Howard ME, Rajaratnam SM.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 14;69(32):1049-1057.
        The coronavirus disease 2019 (COVID-19) pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease and to mitigation activities, including the impact of physical distancing and stay-at-home orders.* Symptoms of anxiety disorder and depressive disorder increased considerably in the United States during April-June of 2020, compared with the same period in 2019 (1,2). To assess mental health, substance use, and suicidal ideation during the pandemic, representative panel surveys were conducted among adults aged ≥18 years across the United States during June 24-30, 2020. Overall, 40.9% of respondents reported at least one adverse mental or behavioral health condition, including symptoms of anxiety disorder or depressive disorder (30.9%), symptoms of a trauma- and stressor-related disorder (TSRD) related to the pandemic(†) (26.3%), and having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%). The percentage of respondents who reported having seriously considered suicide in the 30 days before completing the survey (10.7%) was significantly higher among respondents aged 18-24 years (25.5%), minority racial/ethnic groups (Hispanic respondents [18.6%], non-Hispanic black [black] respondents [15.1%]), self-reported unpaid caregivers for adults(§) (30.7%), and essential workers(¶) (21.7%). Community-level intervention and prevention efforts, including health communication strategies, designed to reach these groups could help address various mental health conditions associated with the COVID-19 pandemic.

      7. Observations of the global epidemiology of COVID-19 from the prepandemic period using web-based surveillance: a cross-sectional analysisexternal icon
        Dawood FS, Ricks P, Njie GJ, Daugherty M, Davis W, Fuller JA, Winstead A, McCarron M, Scott LC, Chen D, Blain AE, Moolenaar R, Li C, Popoola A, Jones C, Anantharam P, Olson N, Marston BJ, Bennett SD.
        Lancet Infect Dis. 2020 Jul 29.
        Background Scant data are available about global patterns of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spread and global epidemiology of early confirmed cases of COVID-19 outside mainland China. We describe the global spread of SARS-CoV-2 and characteristics of COVID-19 cases and clusters before the characterisation of COVID-19 as a pandemic. METHODS: Cases of COVID-19 reported between Dec 31, 2019, and March 10, 2020 (ie, the prepandemic period), were identified daily from official websites, press releases, press conference transcripts, and social media feeds of national ministries of health or other government agencies. Case characteristics, travel history, and exposures to other cases were abstracted. Countries with at least one case were classified as affected. Early cases were defined as those among the first 100 cases reported from each country. Later cases were defined as those after the first 100 cases. We analysed reported travel to affected countries among the first case reported from each country outside mainland China, demographic and exposure characteristics among cases with age or sex information, and cluster frequencies and sizes by transmission settings. FINDINGS: Among the first case reported from each of 99 affected countries outside of mainland China, 75 (76%) had recent travel to affected countries; 60 (61%) had travelled to China, Italy, or Iran. Among 1200 cases with age or sex information, 874 (73%) were early cases. Among 762 early cases with age information, the median age was 51 years (IQR 35-63); 25 (3%) of 762 early cases occurred in children younger than 18 years. Overall, 21 (2%) of 1200 cases were in health-care workers and none were in pregnant women. 101 clusters were identified, of which the most commonly identified transmission setting was households (76 [75%]; mean 2·6 cases per cluster [range 2-7]), followed by non-health-care occupational settings (14 [14%]; mean 4·3 cases per cluster [2-14]), and community gatherings (11 [11%]; mean 14·2 cases per cluster [4-36]). INTERPRETATION: Cases with travel links to China, Italy, or Iran accounted for almost two-thirds of the first reported COVID-19 cases from affected countries. Among cases with age information available, most were among adults aged 18 years and older. Although there were many clusters of household transmission among early cases, clusters in occupational or community settings tended to be larger, supporting a possible role for physical distancing to slow the progression of SARS-CoV-2 spread. FUNDING: None.

      8. Missed opportunities for human immunodeficiency virus (HIV) testing during injection drug use-related healthcare encounters among a cohort of persons who inject drugs with HIV diagnosed during an outbreak-Cincinnati/Northern Kentucky, 2017-2018external icon
        Furukawa NW, Blau EF, Reau Z, Carlson D, Raney ZD, Johnson TK, Deputy NP, Sami S, McClung RP, Neblett-Fanfair R, de Fijter S, Ingram T, Thoroughman D, Vogel S, Lyss SB.
        Clin Infect Dis. 2020 May 4.
        BACKGROUND: Persons who inject drugs (PWID) have frequent healthcare encounters related to their injection drug use (IDU) but are often not tested for human immunodeficiency virus (HIV). We sought to quantify missed opportunities for HIV testing during an HIV outbreak among PWID. METHODS: PWID with HIV diagnosed in 5 Cincinnati/Northern Kentucky counties during January 2017-September 2018 who had ≥1 encounter 12 months prior to HIV diagnosis in 1 of 2 Cincinnati/Northern Kentucky area healthcare systems were included in the analysis. HIV testing and encounter data were abstracted from electronic health records. A missed opportunity for HIV testing was defined as an encounter for an IDU-related condition where an HIV test was not performed and had not been performed in the prior 12 months. RESULTS: Among 109 PWID with HIV diagnosed who had ≥1 healthcare encounter, 75 (68.8%) had ≥1 IDU-related encounters in the 12 months before HIV diagnosis. These 75 PWID had 169 IDU-related encounters of which 86 (50.9%) were missed opportunities for HIV testing and occurred among 46 (42.2%) PWID. Most IDU-related encounters occurred in the emergency department (118/169; 69.8%). Using multivariable generalized estimating equations, HIV testing was more likely in inpatient compared with emergency department encounters (adjusted relative risk [RR], 2.72; 95% confidence interval [CI], 1.70-4.33) and at the healthcare system receiving funding for emergency department HIV testing (adjusted RR, 1.76; 95% CI, 1.10-2.82). CONCLUSIONS: PWID have frequent IDU-related encounters in emergency departments. Enhanced HIV screening of PWID in these settings can facilitate earlier diagnosis and improve outbreak response.

      9. Recent epidemiologic, virologic, and modeling reports support the possibility of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission from persons who are presymptomatic (SARS-CoV-2 detected before symptom onset) or asymptomatic (SARS-CoV-2 detected but symptoms never develop). SARS-CoV-2 transmission in the absence of symptoms reinforces the value of measures that prevent the spread of SARS-CoV-2 by infected persons who may not exhibit illness despite being infectious. Critical knowledge gaps include the relative incidence of asymptomatic and symptomatic SARS-CoV-2 infection, the public health interventions that prevent asymptomatic transmission, and the question of whether asymptomatic SARS-CoV-2 infection confers protective immunity.

      10. COVID-19-associated multisystem inflammatory syndrome in children - United States, March-July 2020external icon
        Godfred-Cato S, Bryant B, Leung J, Oster ME, Conklin L, Abrams J, Roguski K, Wallace B, Prezzato E, Koumans EH, Lee EH, Geevarughese A, Lash MK, Reilly KH, Pulver WP, Thomas D, Feder KA, Hsu KK, Plipat N, Richardson G, Reid H, Lim S, Schmitz A, Pierce T, Hrapcak S, Datta D, Morris SB, Clarke K, Belay E.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 14;69(32):1074-1080.
        In April 2020, during the peak of the coronavirus disease 2019 (COVID-19) pandemic in Europe, a cluster of children with hyperinflammatory shock with features similar to Kawasaki disease and toxic shock syndrome was reported in England* (1). The patients' signs and symptoms were temporally associated with COVID-19 but presumed to have developed 2-4 weeks after acute COVID-19; all children had serologic evidence of infection with SARS-CoV-2, the virus that causes COVID-19 (1). The clinical signs and symptoms present in this first cluster included fever, rash, conjunctivitis, peripheral edema, gastrointestinal symptoms, shock, and elevated markers of inflammation and cardiac damage (1). On May 14, 2020, CDC published an online Health Advisory that summarized the manifestations of reported multisystem inflammatory syndrome in children (MIS-C), outlined a case definition,(†) and asked clinicians to report suspected U.S. cases to local and state health departments. As of July 29, a total of 570 U.S. MIS-C patients who met the case definition had been reported to CDC. A total of 203 (35.6%) of the patients had a clinical course consistent with previously published MIS-C reports, characterized predominantly by shock, cardiac dysfunction, abdominal pain, and markedly elevated inflammatory markers, and almost all had positive SARS-CoV-2 test results. The remaining 367 (64.4%) of MIS-C patients had manifestations that appeared to overlap with acute COVID-19 (2-4), had a less severe clinical course, or had features of Kawasaki disease.(§) Median duration of hospitalization was 6 days; 364 patients (63.9%) required care in an intensive care unit (ICU), and 10 patients (1.8%) died. As the COVID-19 pandemic continues to expand in many jurisdictions, clinicians should be aware of the signs and symptoms of MIS-C and report suspected cases to their state or local health departments; analysis of reported cases can enhance understanding of MIS-C and improve characterization of the illness for early detection and treatment.

      11. Drug resistance mutations among South African children living with HIV on WHO-recommended ART regimensexternal icon
        Hackett S, Teasdale CA, Pals S, Muttiti A, Mogashoa M, Chang J, Zeh C, Ramos A, Rivadeneira ED, DeVos J, Sleeman K, Abrams EJ.
        Clin Infect Dis. 2020 Jul 30.
        BACKGROUND: Children living with HIV (CLHIV) receiving antiretroviral treatment (ART) in resource limited settings are susceptible to high rates of acquired HIV drug resistance (HIVDR), but few studies include children initiating age-appropriate WHO-recommended first-line regimens. We report data from a cohort of ART-naïve South African children who initiated first-line ART. METHODS: ART-eligible CLHIV aged 0-12 years were enrolled from 2012 to 2014 at five public South African facilities and followed for up to 24 months. Enrolled CLHIV received standard of care WHO-recommended first-line ART. At the final study visit, a dried blood spot sample was obtained for viral load and genotypic resistance testing. RESULTS: Among 72 successfully genotyped CLHIV, 49 (68.1%) received ABC/3TC/LPV/r, and 23 (31.9%) received ABC/3TC/EFV. All but 2 children on ABC/3TC/LPV/r were <3 years and all CLHIV on ABC/3TC/EFV were ≥3 years. Overall, 80.6% (58/72) had at least one drug resistance mutation (DRM). DRMs to NNRTIs and NRTIs were found among 65% and 51% of all CLHIV, respectively, with no statistical difference by ART regimen. More CLHIV on ABC/3TC/EFV, 47.8% (11/23), were found to have 0 or only 1 effective antiretroviral drug remaining in their current regimen compared to 8.2% (4/49) on ABC/3TC/LPV/r. CONCLUSIONS: High levels of NNRTI and NRTI DRMs among CLHIV receiving ABC/3TC/LPV/r suggests a lasting impact of failed PMTCT interventions on DRMs. However, drug susceptibility analysis, reveals that CLHIV with detectable viremia on ABC/3TC/LPV/r are more likely to have maintained at least two effective agents on their current HIV regimen than those on ABC/3TC/EFV.

      12. Facility-wide testing for SARS-CoV-2 in nursing homes - seven U.S. jurisdictions, March-June 2020external icon
        Hatfield KM, Reddy SC, Forsberg K, Korhonen L, Garner K, Gulley T, James A, Patil N, Bezold C, Rehman N, Sievers M, Schram B, Miller TK, Howell M, Youngblood C, Ruegner H, Radcliffe R, Nakashima A, Torre M, Donohue K, Meddaugh P, Staskus M, Attell B, Biedron C, Boersma P, Epstein L, Hughes D, Lyman M, Preston LE, Sanchez GV, Tanwar S, Thompson ND, Vallabhaneni S, Vasquez A, Jernigan JA.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 11;69(32):1095-1099.
        Undetected infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) contributes to transmission in nursing homes, settings where large outbreaks with high resident mortality have occurred (1,2). Facility-wide testing of residents and health care personnel (HCP) can identify asymptomatic and presymptomatic infections and facilitate infection prevention and control interventions (3-5). Seven state or local health departments conducted initial facility-wide testing of residents and staff members in 288 nursing homes during March 24-June 14, 2020. Two of the seven health departments conducted testing in 195 nursing homes as part of facility-wide testing all nursing homes in their state, which were in low-incidence areas (i.e., the median preceding 14-day cumulative incidence in the surrounding county for each jurisdiction was 19 and 38 cases per 100,000 persons); 125 of the 195 nursing homes had not reported any COVID-19 cases before the testing. Ninety-five of 22,977 (0.4%) persons tested in 29 (23%) of these 125 facilities had positive SARS-CoV-2 test results. The other five health departments targeted facility-wide testing to 93 nursing homes, where 13,443 persons were tested, and 1,619 (12%) had positive SARS-CoV-2 test results. In regression analyses among 88 of these nursing homes with a documented case before facility-wide testing occurred, each additional day between identification of the first case and completion of facility-wide testing was associated with identification of 1.3 additional cases. Among 62 facilities that could differentiate results by resident and HCP status, an estimated 1.3 HCP cases were identified for every three resident cases. Performing facility-wide testing immediately after identification of a case commonly identifies additional unrecognized cases and, therefore, might maximize the benefits of infection prevention and control interventions. In contrast, facility-wide testing in low-incidence areas without a case has a lower proportion of test positivity; strategies are needed to further optimize testing in these settings.

      13. Validation of ICD-10-CM codes for identifying cases of chlamydia and gonorrheaexternal icon
        Ho YA, Rahurkar S, Tao G, Patel CG, Arno JN, Wang J, Broyles AA, Dixon BE.
        Sex Transm Dis. 2020 Jul 31.
        BACKGROUND: While researchers seek to use administrative health data to examine outcomes for individuals with sexually transmitted infections, the ICD-CM-10 codes used to identify persons with chlamydia and gonorrhea have not been validated. Objectives were to determine the validity of using ICD-10-CM codes to identify individuals with chlamydia and gonorrhea. METHODS: We utilized data from electronic health records gathered from public and private health systems from October 1, 2015 to December 31, 2016. Patients were included if they were aged 13-44 years and received either 1) laboratory testing for chlamydia or gonorrhea or 2) an ICD-10-CM diagnosis of chlamydia, gonorrhea, or an unspecified STI. To validate ICD-10-CM codes, we calculated positive and negative predictive values, sensitivity, and specificity based on the presence of a laboratory test result. We further examined the timing of clinical diagnosis relative to laboratory testing. RESULTS: The positive predictive values for chlamydia, gonorrhea, and unspecified STI ICD-10-CM codes were 87.6%, 85.0%, and 32.0%, respectively. Negative predictive values were high (>92%). Sensitivity for chlamydia diagnostic codes was 10.6% and gonorrhea was 9.7%. Specificity was 99.9% for both chlamydia and gonorrhea. The date of diagnosis occurred on or after the date of the laboratory result for 84.8% of persons with chlamydia, 91.9% for gonorrhea, and 23.5% for unspecified STI. CONCLUSIONS: Disease specific ICD-10-CM codes accurately identify persons with chlamydia and gonorrhea. However, low sensitivities suggest that most individuals could not be identified in administrative data alone without laboratory test results.

      14. Estimating the incubation period of Salmonella urinary tract infections using foodborne outbreak dataexternal icon
        Jacobs Slifka KM, Blackstock A, Nguyen V, Schwensohn C, Gieraltowski L, Mahon BE.
        Foodborne Pathog Dis. 2020 Jul 28.
        Urinary tract infections (UTIs) are common and may occur in foodborne Salmonella outbreaks. Using data from PulseNet, the U.S. national molecular subtyping network for foodborne disease surveillance, we analyzed the 9781 Salmonella isolates associated with the 110 outbreaks from 2004 to 2013 that included at least one urine isolate. Within each outbreak, we calculated standardized isolation dates, using these dates in a linear mixed model to estimate the difference in incubation period for infections yielding stool versus urine isolates. We estimate that the incubation period for Salmonella UTIs is on average 10.6 (95% confidence interval 6.0-15.2) days longer than for gastrointestinal illness, suggesting that outbreak investigators should interview UTI patients about a longer time period before illness onset to identify sources of infection.

      15. The burden and epidemiology of hepatitis B and hepatitis D in Georgia: findings from the national seroprevalence surveyexternal icon
        Kasradze A, Shadaker S, Kuchuloria T, Gamkrelidze A, Nasrullah M, Gvinjilia L, Baliashvili D, Chitadze N, Kodani M, Tejada-Strop A, Drobeniuc J, Hagan L, Morgan J, Imnadze P, Averhoff F.
        Public Health. 2020 Jul 29;185:341-347.
        OBJECTIVES: The burden of hepatitis B virus (HBV) and hepatitis D virus (HDV) infections is unknown in Georgia. This analysis describes the prevalence of hepatitis B and coinfection with HDV and the demographic characteristics and risk factors for persons with HBV infection in Georgia. STUDY DESIGN: This is a cross-sectional seroprevalence study. METHODS: A cross-sectional, nationwide survey to assess hepatitis B prevalence among the general adult Georgian population (age ≥18 years) was conducted in 2015. Demographic and risk behavior data were collected. Blood specimens were screened for anti-hepatitis B core total antibody (anti-HBc). Anti-HBc-positive specimens were tested for hepatitis B surface antigen (HBsAg). HBsAg-positive specimens were tested for HBV and HDV nucleic acid. Nationally weighted prevalence estimates and adjusted odds ratios (aORs) for potential risk factors were determined for anti-HBc and HBsAg positivity. RESULTS: The national prevalence of anti-HBc and HBsAg positivity among adults were 25.9% and 2.9%, respectively. Persons aged ≥70 years had the highest anti-HBc positivity (32.7%), but the lowest HBsAg positivity prevalence (1.3%). Anti-HBc positivity was associated with injection drug use (aOR = 2.34; 95% confidence interval [CI] = 1.46-3.74), receipt of a blood transfusion (aOR = 1.68; 95% CI = 1.32-2.15), and sex with a commercial sex worker (aOR = 1.46; 95% CI = 1.06-2.01). HBsAg positivity was associated with receipt of a blood transfusion (aOR = 2.72; 95% CI = 1.54-4.80) and past incarceration (aOR = 2.72; 95% CI = 1.25-5.93). Among HBsAg-positive persons, 0.9% (95% CI = 0.0-2.0) were HDV coinfected. CONCLUSIONS: Georgia has an intermediate to high burden of hepatitis B, and the prevalence of HDV coinfection among HBV-infected persons is low. Existing infrastructure for hepatitis C elimination could be leveraged to promote hepatitis B elimination.

      16. OBJECTIVES: Tuberculosis (TB) outbreaks disproportionately affect persons experiencing homelessness (PEH) in the United States. During 2014-2016, a resurgent TB outbreak occurred among PEH in Atlanta, Georgia. To control the outbreak, citywide policies and educational interventions were implemented in January 2015. Policy changes standardized and enforced TB screening requirements for PEH in homeless shelters. Educational campaigns informed PEH of the outbreak and encouraged TB screening. We evaluated factors associated with, and the effect policy changes and educational interventions had on, TB screening and awareness among PEH in Atlanta. METHODS: Questions related to TB screening and awareness of the outbreak were added to an annual US Department of Housing and Urban Development survey of PEH in Atlanta in 2015 (n = 296 respondents) and 2016 (n = 1325 respondents). We analyzed the 2016 survey data to determine characteristics associated with outcomes. RESULTS: From 2015 to 2016, reported TB screening increased from 81% to 86%, and awareness of the TB outbreak increased from 68% to 75%. In 2016, sheltered PEH were significantly more likely than unsheltered PEH to report being evaluated for TB in the previous 6 months (prevalence odds ratio [pOR] = 3.18; 95% confidence interval [CI], 2.28-4.47) and to report being aware of the TB outbreak (pOR = 4.00; 95% CI, 2.89-5.55). CONCLUSIONS: Implementation of required TB screening and educational interventions may reduce the incidence and severity of TB outbreaks among PEH in other communities. Furthermore, the annual survey of PEH offers an opportunity to collect data to better inform practices and policies.

      17. Hospitalization rates and characteristics of children aged <18 years hospitalized with laboratory-confirmed COVID-19 - COVID-NET, 14 States, March 1-July 25, 2020external icon
        Kim L, Whitaker M, O'Halloran A, Kambhampati A, Chai SJ, Reingold A, Armistead I, Kawasaki B, Meek J, Yousey-Hindes K, Anderson EJ, Openo KP, Weigel A, Ryan P, Monroe ML, Fox K, Kim S, Lynfield R, Bye E, Shrum Davis S, Smelser C, Barney G, Spina NL, Bennett NM, Felsen CB, Billing LM, Shiltz J, Sutton M, West N, Talbot HK, Schaffner W, Risk I, Price A, Brammer L, Fry AM, Hall AJ, Langley GE, Garg S.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 14;69(32):1081-1088.
        Most reported cases of coronavirus disease 2019 (COVID-19) in children aged <18 years appear to be asymptomatic or mild (1). Less is known about severe COVID-19 illness requiring hospitalization in children. During March 1-July 25, 2020, 576 pediatric COVID-19 cases were reported to the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET), a population-based surveillance system that collects data on laboratory-confirmed COVID-19-associated hospitalizations in 14 states (2,3). Based on these data, the cumulative COVID-19-associated hospitalization rate among children aged <18 years during March 1-July 25, 2020, was 8.0 per 100,000 population, with the highest rate among children aged <2 years (24.8). During March 21-July 25, weekly hospitalization rates steadily increased among children (from 0.1 to 0.4 per 100,000, with a weekly high of 0.7 per 100,000). Overall, Hispanic or Latino (Hispanic) and non-Hispanic black (black) children had higher cumulative rates of COVID-19-associated hospitalizations (16.4 and 10.5 per 100,000, respectively) than did non-Hispanic white (white) children (2.1). Among 208 (36.1%) hospitalized children with complete medical chart reviews, 69 (33.2%) were admitted to an intensive care unit (ICU); 12 of 207 (5.8%) required invasive mechanical ventilation, and one patient died during hospitalization. Although the cumulative rate of pediatric COVID-19-associated hospitalization remains low (8.0 per 100,000 population) compared with that among adults (164.5),* weekly rates increased during the surveillance period, and one in three hospitalized children were admitted to the ICU, similar to the proportion among adults. Continued tracking of SARS-CoV-2 infections among children is important to characterize morbidity and mortality. Reinforcement of prevention efforts is essential in congregate settings that serve children, including childcare centers and schools.

      18. Advanced notification calls prior to mailed fecal immunochemical test in previously screened patients: A randomized controlled trialexternal icon
        Lee B, Patel S, Rachocki C, Issaka R, Vittinghoff E, Shapiro JA, Ladabaum U, Somsouk M.
        J Gen Intern Med. 2020 Aug 3.
        BACKGROUND: Phone calls as part of multimodal fecal immunochemical test (FIT) outreach are effective but resource-intensive. Previous studies of advanced notification calls before FIT mailing have not differentiated patients' prior screening status. OBJECTIVE: To determine the effectiveness of a phone call preceding mailing of a FIT kit on test completion rate for patients who have completed a prior FIT. DESIGN: Randomized controlled trial nested within a larger study. All patients were assigned to receive organized mailed FIT outreach in the larger study. PARTICIPANTS: Patients in a safety-net health setting ages 50-75 years old with a previously negative FIT. INTERVENTIONS: Patients were assigned to either receive an advanced notification phone call or no phone call preceding a mailed FIT kit. Both groups received an informational postcard prior to the mailed FIT. MAIN MEASURES: The primary outcome was FIT completion rate at 1 year. The secondary outcomes were FIT completion rates at 60, 90, and 180 days, rates stratified by demographic subgroups, and rates according to outcome of the phone call. KEY RESULTS: A total of 1645 patients were assigned to advanced notification calls and 1595 were assigned to no call preceding the FIT mailing. Although FIT completion rate was higher at day 60 (55.5% vs. 50.8%, p < 0.01), an advanced notification call did not significantly improve FIT completion at 1 year (70.9% vs. 69.9%, p = 0.52). Of the patients assigned to receive an advanced notification call, 90.5% were spoken with or left a voicemail; patients who were spoken with were more likely to complete a FIT at 1 year compared with patients who were only left a voicemail or could not be left a voicemail (79.9% vs. 69.2% vs. 49.6%, p < 0.01). CONCLUSIONS: Advanced notification phone calls prior to FIT mailing did not improve rates at 1 year for patients with a previously negative FIT.

      19. Guillain-Barre syndrome in times of pandemicsexternal icon
        Leonhard SE, Cornblath DR, Endtz HP, Sejvar JJ, Jacobs BC.
        J Neurol Neurosurg Psychiatry. 2020 Jul 30.

      20. Positive health check evaluation: A type 1 hybrid design randomized trial to decrease HIV viral loads in patients seen in HIV primary careexternal icon
        Lewis MA, Harshbarger C, Bann C, Burrus O, Peinado S, Garner B, Khavjou O, Shrestha R, Karns S, Borkowf CB, Zulkiewicz B, Ortiz A, Galindo C, Piazza MD, Holm P, Marconi VC, Somboonwit C, Swaminathan S.
        Contemp Clin Trials. 2020 Jul 29:106097.
        For people with HIV, important transmission prevention strategies include early initiation and adherence to antiretroviral therapy and retention in clinical care with the goal of reducing viral loads as quickly as possible. Consequently, at this point in the HIV epidemic, innovative and effective strategies are urgently needed to engage and retain people in health care to support medication adherence. To address this gap, the Positive Health Check Evaluation Trial uses a type 1 hybrid randomized trial design to test whether the use of a highly tailored video doctor intervention will reduce HIV viral load and retain people with HIV in health care. Eligible and consenting patients from four HIV primary care clinical sites are randomly assigned to receive either the Positive Health Check intervention in addition to the standard of care or the standard of care only. The primary aim is to determine the effectiveness of the intervention. A second aim is to understand the implementation potential of the intervention in clinic workflows, and a third aim is to assess the costs of intervention implementation. The trial findings will have important real-world applicability for understanding how digital interventions that take the form of video doctors can be used to decrease viral load and to support retention in care among diverse patients attending HIV primary care clinics.

      21. Effect of policy change to require laboratory reporting with pregnancy indicated for syphilis and hepatitis B virus infection, New York City, January 2013-June 2018external icon
        Liao TS, Hashmi A, Lazaroff J, Hennessy RR, Sanders Kim A, Evans Lloyd P, Rosen JB.
        Public Health Rep. 2020 Jul/Aug;135(1_suppl):182s-188s.
        OBJECTIVES: We evaluated the impact of a 2014 New York City health code change requiring laboratories to indicate if a patient is pregnant or probably pregnant in the electronic laboratory report (ELR) when reporting syphilis and hepatitis B virus (HBV) cases to the New York City Department of Health and Mental Hygiene (DOHMH). METHODS: We calculated the number of pregnant persons with syphilis or HBV infection reported to DOHMH from January 1, 2013, through June 30, 2018. We compared the proportion in which the first report to DOHMH was an ELR with pregnancy indicated before and after the policy change. We calculated time between first ELR with pregnancy indicated and subsequent reporting by a method other than ELR and the proportion of cases in which ELR with pregnancy indicated was the only report source. RESULTS: A total of 552 new syphilis and 8414 HBV-infected cases were reported to DOHMH. From January 2013-June 2014 (pre-change) to January 2017-June 2018 (post-change), the proportion of cases in which ELR with pregnancy indicated was the first report to DOHMH increased significantly (14.7% [23/156] to 46.2% [80/173] for syphilis; 8.0% [200/2498] to 45.3% [851/1879] for HBV infection [P < .001]). Median time between first ELR with pregnancy indicated and subsequent reporting by a method other than ELR was 9.0 days for syphilis and 51.0 days for HBV infection. ELR with pregnancy indicated was the only report for 43.1% (238/552) of syphilis cases and 23.4% (1452/6200) of HBV cases during the study period. CONCLUSION: Including pregnancy status with ELR can increase the ability of public health departments to conduct timely interventions to prevent mother-to-child transmission.

      22. Policy implications of mathematical modeling of latent tuberculosis infection testing and treatment strategies to accelerate tuberculosis eliminationexternal icon
        Marks SM, Dowdy DW, Menzies NA, Shete PB, Salomon JA, Parriott A, Shrestha S, Flood J, Hill AN.
        Public Health Rep. 2020 Jul/Aug;135(1_suppl):38s-43s.

      23. BACKGROUND: We aimed to examine how the classification of gonorrhea cases by race and Hispanic ethnicity (HE) affects the measurement of racial/HE disparities in the rates of reported gonorrhea. METHODS: We examined gonorrhea cases reported through the National Notifiable Diseases Surveillance System during January 1, 2010-December 31, 2017 and assigned race and HE using 1) "Current classification", where cases with HE are classified as Hispanic regardless of race (e.g., Hispanic, non-Hispanic White, non-Hispanic Black), and 2) "Alternate classification", which separates each race category by HE (e.g., Hispanic White, non-Hispanic White). We estimated annual gonorrhea rates during 2010-2017 by race/HE category and calculated disparity measures (index of disparity, population attributable proportion, and Gini coefficient) for gonorrhea rates under each classification strategy. RESULTS: All disparity measures revealed decreases in racial/HE disparities in the rates of reported gonorrhea during 2010-2017, regardless of classification strategy; however, the magnitude of the disparity and the percent change in the disparity over time varied across disparity measures. CONCLUSIONS: Understanding how classification of race/HE affects observed disparities is critical when monitoring interventions to reduce disparities and improve health equity.

      24. Predictive value of TNF-alpha, IFN-gamma, and IL-10 for tuberculosis among recently exposed contacts in the United States and Canadaexternal icon
        Reichler MR, Hirsch C, Yuan Y, Khan A, Dorman SE, Schluger N, Sterling TR.
        BMC Infect Dis. 2020 Jul 31;20(1):553.
        BACKGROUND: We examined cytokine immune response profiles among contacts to tuberculosis patients to identify immunologic and epidemiologic correlates of tuberculosis. METHODS: We prospectively enrolled 1272 contacts of culture-confirmed pulmonary tuberculosis patients at 9 United States and Canadian sites. Epidemiologic characteristics were recorded. Blood was collected and stimulated with Mycobacterium tuberculosis culture filtrate protein, and tumor necrosis factor (TNF-α), interferon gamma (IFN-γ), and interleukin 10 (IL-10) concentrations were determined using immunoassays. RESULTS: Of 1272 contacts, 41 (3.2%) were diagnosed with tuberculosis before or < 30 days after blood collection (co-prevalent tuberculosis) and 19 (1.5%) during subsequent four-year follow-up (incident tuberculosis). Compared with contacts without tuberculosis, those with co-prevalent tuberculosis had higher median baseline TNF-α and IFN-γ concentrations (in pg/mL, TNF-α 129 versus 71, P < .01; IFN-γ 231 versus 27, P < .001), and those who subsequently developed incident tuberculosis had higher median baseline TNF-α concentrations (in pg/mL, 257 vs. 71, P < .05). In multivariate analysis, contact age < 15 years, US/Canadian birth, and IFN or TNF concentrations > the median were associated with co-prevalent tuberculosis (P < .01 for each); female sex (P = .03) and smoking (P < .01) were associated with incident tuberculosis. In algorithms combining young age, positive skin test results, and elevated CFPS TNF-α, IFN-γ, and IL-10 responses, the positive predictive values for co-prevalent and incident tuberculosis were 40 and 25%, respectively. CONCLUSIONS: Cytokine concentrations and epidemiologic factors at the time of contact investigation may predict co-prevalent and incident tuberculosis.

      25. Notes from the field: Multidrug-resistant tuberculosis among workers at two food processing facilities - Ohio, 2018-2019external icon
        Talwar A, Stewart R, Althomsons SP, Rinsky J, Jackson DA, Galvis ME, Graham P, Huaman MA, Karrer J, Kondapally K, Mitchell S, Wortham J, de Fijter S.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 14;69(32):1104-1105.

      26. Beta-lactamase-producing, ciprofloxacin-resistant Neisseria meningitidis isolated from a 5-month-old boy in the United Statesexternal icon
        Taormina G, Campos J, Sweitzer J, Retchless AC, Lunquest K, McNamara LA, Reese N, Karlsson M, Hanisch B.
        J Pediatric Infect Dis Soc. 2020 Aug 3.
        Worldwide, there have been few reports of beta-lactamases causing penicillin resistance in Neisseria meningitidis. The first known case of disease in the United States due to a beta-lactamase-producing, ciprofloxacin-resistant N. meningitidis was recently identified. This has potential implications on standard laboratory testing and empiric management of meningococcal disease.

      27. Exposures in adult outpatients with COVID-19 infection during early community transmission, Tennesseeexternal icon
        Tenforde MW, Feldstein LR, Lindsell CJ, Patel MM, Self WH.
        Influenza Other Respir Viruses. 2020 Aug 4.

      28. Using mixed methods and multidisciplinary research to strengthen policy assessments focusing on populations at high risk for sexually transmitted diseasesexternal icon
        Thompson K, Cramer R, LaPollo AB, Hubbard SH, Chesson HW, Leichliter JS.
        Public Health Rep. 2020 Jul/Aug;135(1_suppl):32s-37s.

      29. Serious adverse health events, including death, associated with ingesting alcohol-based hand sanitizers containing methanol - Arizona and New Mexico, May-June 2020external icon
        Yip L, Bixler D, Brooks DE, Clarke KR, Datta SD, Dudley S, Komatsu KK, Lind JN, Mayette A, Melgar M, Pindyck T, Schmit KM, Seifert SA, Shirazi FM, Smolinske SC, Warrick BJ, Chang A.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 14;69(32):1070-1073.
        Alcohol-based hand sanitizer is a liquid, gel, or foam that contains ethanol or isopropanol used to disinfect hands. Hand hygiene is an important component of the U.S. response to the emergence of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). If soap and water are not readily available, CDC recommends the use of alcohol-based hand sanitizer products that contain at least 60% ethyl alcohol (ethanol) or 70% isopropyl alcohol (isopropanol) in community settings (1); in health care settings, CDC recommendations specify that alcohol-based hand sanitizer products should contain 60%-95% alcohol (≥60% ethanol or ≥70% isopropanol) (2). According to the Food and Drug Administration (FDA), which regulates alcohol-based hand sanitizers as an over-the-counter drug, methanol (methyl alcohol) is not an acceptable ingredient. Cases of ethanol toxicity following ingestion of alcohol-based hand sanitizer products have been reported in persons with alcohol use disorder (3,4). On June 30, 2020, CDC received notification from public health partners in Arizona and New Mexico of cases of methanol poisoning associated with ingestion of alcohol-based hand sanitizers. The case reports followed an FDA consumer alert issued on June 19, 2020, warning about specific hand sanitizers that contain methanol. Whereas early clinical effects of methanol and ethanol poisoning are similar (e.g., headache, blurred vision, nausea, vomiting, abdominal pain, loss of coordination, and decreased level of consciousness), persons with methanol poisoning might develop severe anion-gap metabolic acidosis, seizures, and blindness. If left untreated methanol poisoning can be fatal (5). Survivors of methanol poisoning might have permanent visual impairment, including complete vision loss; data suggest that vision loss results from the direct toxic effect of formate, a toxic anion metabolite of methanol, on the optic nerve (6). CDC and state partners established a case definition of alcohol-based hand sanitizer-associated methanol poisoning and reviewed 62 poison center call records from May 1 through June 30, 2020, to characterize reported cases. Medical records were reviewed to abstract details missing from poison center call records. During this period, 15 adult patients met the case definition, including persons who were American Indian/Alaska Native (AI/AN). All had ingested an alcohol-based hand sanitizer and were subsequently admitted to a hospital. Four patients died and three were discharged with vision impairment. Persons should never ingest alcohol-based hand sanitizer, avoid use of specific imported products found to contain methanol, and continue to monitor FDA guidance (7). Clinicians should maintain a high index of suspicion for methanol poisoning when evaluating adult or pediatric patients with reported swallowing of an alcohol-based hand sanitizer product or with symptoms, signs, and laboratory findings (e.g., elevated anion-gap metabolic acidosis) compatible with methanol poisoning. Treatment of methanol poisoning includes supportive care, correction of acidosis, administration of an alcohol dehydrogenase inhibitor (e.g., fomepizole), and frequently, hemodialysis.

    • Disaster Control and Emergency Services
      1. Factors affecting implementation of evidence-based practices in public health preparedness and responseexternal icon
        Kennedy M, Carbone EG, Siegfried AL, Backman D, Henson JD, Sheridan J, Meit MB, Thomas EV.
        J Public Health Manag Pract. 2020 Sep/Oct;26(5):434-442.
        CONTEXT: There is limited research on what factors are most salient to implementation of evidence-based practices (EBPs) among public health agencies in public health emergency preparedness and response (PHPR) and under what conditions EBP implementation will occur. OBJECTIVE: This study assessed the conditions, barriers, and enablers affecting EBP implementation among the PHPR practice community and identified opportunities to support EBP implementation. DESIGN: A Web-based survey gathered information from public health agencies. Data obtained from 228 participating agencies were analyzed. SETTING: State, local, and territorial public health agencies across the United States. PARTICIPANTS: Preparedness program officials from 228 public health agencies in the United States, including Public Health Emergency Preparedness (PHEP) cooperative agreement awardees (PHEP awardees) and a random sample of local health departments (LHDs). RESULTS: Respondents indicated that EBP is necessary and improves PHPR functions and tasks and that staff are interested in improving skills for EBP implementation. Top system-level barriers to EBP implementation were insufficient funding, lack of EBP, and lack of clarity regarding which practices are evidence based. PHEP awardees were significantly more likely to report a lack of EBP in the field, whereas LHDs were significantly more likely to report a lack of incentives. The top organizational-level barrier was insufficient staff. Most respondents indicated their agency culture supports EBP; however, LHDs were significantly more likely to report a lack of support from supervisors and leadership. Few respondents reported individual barriers to EBP implementation. CONCLUSIONS: Findings indicate an opportunity to improve dissemination strategies, communication efforts, and incentives to support EBP implementation in PHPR. Potential strategies include improving awareness of and accessibility to EBPs through targeted dissemination efforts; building organizational capacity to support EBP implementation, particularly staff capacity, knowledge, and skills; and identifying funding and incentives to promote EBP uptake and sustainment.

      2. Applying an innovative model of disaster resilience at the neighborhood level: The COPEWELL New York City Experienceexternal icon
        Slemp CC, Sisco S, Jean MC, Ahmed MS, Kanarek NF, Eros-Sarnyai M, Gonzalez IA, Igusa T, Lane K, Tirado FP, Tria M, Lin S, Martins VN, Ravi S, Kendra JM, Carbone EG, Links JM.
        Public Health Rep. 2020 Jul 31.
        Community resilience is a community's ability to maintain functioning (ie, delivery of services) during and after a disaster event. The Composite of Post-Event Well-Being (COPEWELL) is a system dynamics model of community resilience that predicts a community's disaster-specific functioning over time. We explored COPEWELL's usefulness as a practice-based tool for understanding community resilience and to engage partners in identifying resilience-strengthening strategies. In 2014, along with academic partners, the New York City Department of Health and Mental Hygiene organized an interdisciplinary work group that used COPEWELL to advance cross-sector engagement, design approaches to understand and strengthen community resilience, and identify local data to explore COPEWELL implementation at neighborhood levels. The authors conducted participant interviews and collected shared experiences to capture information on lessons learned. The COPEWELL model led to an improved understanding of community resilience among agency members and community partners. Integration and enhanced alignment of efforts among preparedness, disaster resilience, and community development emerged. The work group identified strategies to strengthen resilience. Searches of neighborhood-level data sets and mapping helped prioritize communities that are vulnerable to disasters (eg, medically vulnerable, socially isolated, low income). These actions increased understanding of available data, identified data gaps, and generated ideas for future data collection. The COPEWELL model can be used to drive an understanding of resilience, identify key geographic areas at risk during and after a disaster, spur efforts to build on local metrics, and result in innovative interventions that integrate and align efforts among emergency preparedness, community development, and broader public health initiatives.

    • Disease Reservoirs and Vectors
      1. Vector competence of Rhipicephalus sanguineus sensu stricto for Anaplasma platysexternal icon
        Snellgrove AN, Krapiunaya I, Ford SL, Stanley HM, Wickson AG, Hartzer KL, Levin ML.
        Ticks and Tick-borne Diseases. 2020 ;11(6).
        Anaplasma platys is a Gram-negative, obligate intracellular bacteria that causes canine infectious cyclic thrombocytopenia in dogs. The brown dog tick Rhipicephalus sanguineus sensu lato is presumed to be the vector of A. platys based on the overlap in distribution of R. sanguineus and A. platys infections, detection of A. platys DNA in both flat and engorged field-collected R. sanguineus, and the fact that dogs are primary hosts of both brown dog ticks and A. platys. However, the only study evaluating the vector competence of R. sanguineus for A. platys under controlled laboratory conditions reported an apparent inability of ticks to acquire or maintain the pathogen. In 2016, engorged female Rhipicephalus sanguineus sensu stricto ticks were collected off dogs to start a laboratory tick colony. After one generation of colony maintenance on tick-naive and pathogen-free New Zealand White rabbits, a rabbit used to feed F1 adults seroconverted to Anaplasma phagocytophilum antigen. PCR and subsequent DNA sequencing identified the presence of A. platys in both the adult ticks fed on this rabbit and their resulting F2 progenies. Retrospective testing of all previous (P and F1) life stages of this colony demonstrated that the infection originated from one field-collected A. platys-infected female whose progeny was propagated in the laboratory and produced the PCR-positive F1 adults. Over the following (F2-F4) generations, the prevalence of A. platys in this colony reached 90-100 % indicating highly efficient transovarial and horizontal transmission, as well as transstadial maintenance, of this pathogen by R. sanguineus s.s.

      2. Proliferation of Aedes aegypti in urban environments mediated by the availability of key aquatic habitatsexternal icon
        Wilke AB, Vasquez C, Carvajal A, Medina J, Chase C, Cardenas G, Mutebi JP, Petrie WD, Beier JC.
        Sci Rep. 2020 Jul 31;10(1):12925.
        Aedes aegypti is the main vector of dengue, Zika, chikungunya, and yellow fever viruses. Controlling populations of vector mosquito species in urban environments is a major challenge and being able to determine what aquatic habitats should be prioritized for controlling Ae. aegypti populations is key to the development of more effective mosquito control strategies. Therefore, our objective was to leverage on the Miami-Dade County, Florida immature mosquito surveillance system based on requested by citizen complaints through 311 calls to determine what are the most important aquatic habitats in the proliferation of Ae. aegypti in Miami. We used a tobit model for Ae. aegypti larvae and pupae count data, type and count of aquatic habitats, and daily rainfall. Our results revealed that storm drains had 45% lower percentage of Ae. aegypti larvae over the total of larvae and pupae adjusted for daily rainfall when compared to tires, followed by bromeliads with 33% and garbage cans with 17%. These results are indicating that storm drains, bromeliads and garbage cans had significantly more pupae in relation to larvae when compared to tires, traditionally know as productive aquatic habitats for Ae. aegypti. Ultimately, the methodology and results from this study can be used by mosquito control agencies to identify habitats that should be prioritized in mosquito management and control actions, as well as to guide and improve policies and increase community awareness and engagement. Moreover, by targeting the most productive aquatic habitats this approach will allow the development of critical emergency outbreak responses by directing the control response efforts to the most productive aquatic habitats.

    • Environmental Health
      1. Urinary biomarkers of exposure to volatile organic compounds from the Population Assessment of Tobacco and Health Study Wave 1 (2013-2014)external icon
        De Jesus VR, Bhandari D, Zhang L, Reese C, Capella K, Tevis D, Zhu W, Del Valle-Pinero AY, Lagaud G, Chang JT, van Bemmel D, Kimmel HL, Sharma E, Goniewicz ML, Hyland A, Blount BC.
        Int J Environ Res Public Health. 2020 Jul 28;17(15).
        Volatile organic compounds (VOCs) are ubiquitous in the environment. In the United States (U.S.), tobacco smoke is the major non-occupational source of exposure to many harmful VOCs. Exposure to VOCs can be assessed by measuring their urinary metabolites (VOCMs). The Population Assessment of Tobacco and Health (PATH) Study is a U.S. national longitudinal study of tobacco use in the adult and youth civilian non-institutionalized population. We measured 20 VOCMs in urine specimens from a subsample of adults in Wave 1 (W1) (2013-2014) to characterize VOC exposures among tobacco product users and non-users. We calculated weighted geometric means (GMs) and percentiles of each VOCM for exclusive combustible product users (smokers), exclusive electronic cigarette (e-cigarette) users, exclusive smokeless product users, and tobacco product never users. We produced linear regression models for six VOCMs with sex, age, race, and tobacco user group as predictor variables. Creatinine-ratioed levels of VOCMs from exposure to acrolein, crotonaldehyde, isoprene, acrylonitrile, and 1,3-butadiene were significantly higher in smokers than in never users. Small differences of VOCM levels among exclusive e-cigarette users and smokeless users were observed when compared to never users. Smokers showed higher VOCM concentrations than e-cigarette, smokeless, and never users. Urinary VOC metabolites are useful biomarkers of exposure to harmful VOCs.

      2. Exposure to uranium and co-occurring metals among pregnant Navajo womenexternal icon
        Hoover JH, Erdei E, Begay D, Gonzales M, Jarrett JM, Cheng PY, Lewis J.
        Environ Res. 2020 Jul 17;190:109943.
        Navajo Nation residents are at risk for exposure to uranium and other co-occurring metals found in abandoned mine waste. The Navajo Birth Cohort Study (NBCS) was initiated in 2010 to address community concerns regarding the impact of chronic environmental exposure to metals on pregnancy and birth outcomes. The objectives of this paper were to 1) evaluate maternal urine concentrations of key metals at enrollment and delivery from a pregnancy cohort; and 2) compare the NBCS to the US general population by comparing representative summary statistical values. Pregnant Navajo women (N = 783, age range 14-45 years) were recruited from hospital facilities on the Navajo Nation during prenatal visits and urine samples were collected by trained staff in pre-screened containers. The U.S. Centers for Disease Control and Prevention (CDC), National Center for Environmental Health's (NCEH) Division of Laboratory Sciences (DLS) analyzed urine samples for metals. Creatinine-corrected urine concentrations of cadmium decreased between enrollment (1st or 2nd trimester) and delivery (3rd trimester) while urine uranium concentrations were not observed to change. Median and 95th percentile values of maternal NBCS urine concentrations of uranium, manganese, cadmium, and lead exceeded respective percentiles for National Health and Nutrition Evaluation Survey (NHANES) percentiles for women (ages 14-45 either pregnant or not pregnant.) Median NBCS maternal urine uranium concentrations were 2.67 (enrollment) and 2.8 (delivery) times greater than the NHANES median concentration, indicating that pregnant Navajo women are exposed to metal mixtures and have higher uranium exposure compared to NHANES data for women. This demonstrates support for community concerns about uranium exposure and suggests a need for additional analyses to evaluate the impact of maternal metal mixtures exposure on birth outcomes.

      3. Exposure to bisphenols and asthma morbidity among low-income urban children with asthmaexternal icon
        Quiros-Alcala L, Hansel NN, McCormack M, Calafat AM, Ye X, Peng RD, Matsui EC.
        J Allergy Clin Immunol. 2020 Jul 21.
        BACKGROUND: Bisphenol A (BPA) has been linked with pediatric asthma development and allergic airway inflammation in animal models. Whether exposure to BPA or its structural analogs bisphenol S (BPS) and bisphenol F (BPF) is associated with asthma morbidity remains unknown. OBJECTIVE: We examined associations between bisphenols and morbidity due to pediatric asthma. METHODS: We quantified concentrations of BPA, BPS, and BPF in 660 urine samples from 148 predominantly low-income, African American children (aged 5-17 years) with established asthma. We used biobanked biospecimens and data on symptoms, health care utilization, and pulmonary function and inflammation that were collected every 3 months over the course of a year. We used generalized estimating equations to examine associations between concentrations or detection of urinary bisphenols and morbidity outcomes and assessed heterogeneity of associations by sex. RESULTS: We observed consistent positive associations between BPA exposure and measures of asthma morbidity. For example, we observed increased odds of general symptom days (adjusted odds ratio [aOR] = 1.40 [95% C = 1.02-1.92]), maximal symptom days (aOR = 1.36 [95% CI = 1.00-1.83]), and emergency department visits (aOR = 2.12 [95% CI =1.28-3.51]) per 10-fold increase in BPA concentration. We also observed evidence of sexually dimorphic effects; BPA concentrations were associated with increased odds of symptom days and health care utilization only among boys. Findings regarding BPS and BPF did not consistently point to associations with asthma symptoms or health care utilization. CONCLUSION: We found evidence to suggest that BPA exposure in a predominantly low-income, minority pediatric cohort is associated with asthma morbidity and that associations may differ by sex. Our findings support additional studies, given the high pediatric asthma burden and widespread exposure to BPA in the United States.

    • Health Disparities
      1. Racial/ethnic disparities among US children and adolescents in use of dental careexternal icon
        Robison V, Wei L, Hsia J.
        Prev Chronic Dis. 2020 Jul 30;17:E71.
        INTRODUCTION: Dental care among children has increased over the past decade, and racial/ethnic disparities have narrowed for some groups. We measured changes in racial/ethnic disparities in annual dental care for children and adolescents aged 2 to 17 years and conducted multivariate analysis to study factors associated with changes in disparities over time. METHODS: We used Medical Expenditure Panel Survey data to obtain crude prevalence estimates of dental care use and calculated absolute disparities and changes in disparities for 3 racial/ethnic groups of children and adolescents compared with non-Hispanic white children and adolescents relative to fixed points in time (2001 and 2016). We pooled all single years of data into 3 data cycles (2001-2005, 2006-2010, and 2011-2016) and used multivariate regression to assess the relationship between dental care use and race/ethnicity, controlling for the covariates of age, sex, parents' education, household income, insurance status, and data cycle (time). RESULTS: Use increased by 18% only in low-income children and adolescents. Low-income Hispanic (adjusted prevalence ratio [aPR] = 0.98; 95% CI, 0.94-1.02) and Asian (aPR = 0.92; 95% CI, 0.83-1.02) participants showed no difference in dental care use relative to non-Hispanic white participants, but non-Hispanic black participants had significantly lower use (aPR = 0.84; 95% CI, 0.81-0.88). Public and private insurance were associated with a doubling of use among low-income children. CONCLUSION: We saw a modest increase in dental care use and a narrowing of disparities for some low-income children and adolescents. Use among low-income Hispanic and Asian participants "caught up" with use among Hispanic white participants but remained well below that of children and adolescents in families with middle and high incomes. Disparities persisted for non-Hispanic black participants at all income levels.

    • Health Economics
      1. Objective: To examine Medicaid expansion (ME) effects on health insurance coverage (HIC) and cost barriers to medical care among people with asthma.Method: We analyzed 2012-2013 and 2015-2016 data from low-income adults with current asthma aged 18-64 years in the Behavioral Risk Factor Surveillance System Asthma Call-Back Survey (state-level telephone survey). We calculated weighted percentages and 95% confidence intervals from ME and non-ME jurisdictions (according to 2014 ME status). Outcomes were HIC and cost barriers to buying asthma medication (MED), seeing a health care provider for asthma (HCP), or any asthma care (AAC). Using SUDAAN, we performed survey-weighted difference-in-differences analyses, adjusting for demographics. Subgroup analyses were stratified by demographics.Results: Our study population included 6445 participants from 25 states plus Puerto Rico. In 2015-2016 compared to 2012-2013, HIC was more common in ME jurisdictions (P < 0.001) but unchanged in non-ME jurisdictions. Adjusted difference-in-differences analyses showed ME was associated with a statistically significant 13.36 percentage-point increase in HIC (standard error =0.053). Cost barriers to MED, HCP, and AAC did not change significantly for either group in descriptive and difference-in-differences analyses. In subgroup analyses, we noted variation in outcomes by demographics and 2014 ME status.Conclusions: We found ME significantly affected HIC among low-income adults with asthma, but not cost barriers to asthma-related health care. Strategies to reduce cost barriers to asthma care could further improve health care access among low-income adults with asthma in ME jurisdictions.

      2. The potential for a population at a given location to utilize a health service can be estimated using a newly developed measure called the supply-concentric demand accumulation (SCDA) spatial availability index. Spatial availability is the amount of demand at the given location that can be satisfied by the supply of services at a facility, after discounting the intervening demand among other populations that are located nearer to a facility location than the given population location. This differs from spatial accessibility measures which treat absolute distance or travel time as the factor that impedes utilization. The SCDA is illustrated using pulmonary rehabilitation (PR), which is a treatment for people with chronic obstructive pulmonary disease (COPD). The spatial availability of PR was estimated for each Census block group in Georgia using the 1105 residents who utilized one of 45 PR facilities located in or around Georgia. Data was provided by the Centers for Medicare & Medicaid Services. The geographic patterns of the SCDA spatial availability index and the two-step floating catchment area (2SFCA) spatial accessibility index were compared with the observed PR utilization rate using bivariate local indicators of spatial association. The SCDA index was more associated with PR utilization (Morans I = 0.607, P < 0.001) than was the 2SFCA (Morans I = 0.321, P < 0.001). These results suggest that the measures of spatial availability may be a better way to estimate the health care utilization potential than measures of spatial accessibility.

      3. Access and cost-related non-adherence to prescription medications among lupus cases and controls: the Michigan Lupus Epidemiology & Surveillance (MILES) Programexternal icon
        Minhas D, Marder W, Harlow S, Hassett AL, Zick SM, Gordon C, Barbour KE, Helmick CG, Wang L, Lee J, Padda A, McCune WJ, Somers EC.
        Arthritis Care Res (Hoboken). 2020 Aug 2.
        BACKGROUND: Medication access and adherence are important determinants of health outcomes. We investigated factors associated with access and cost-related non-adherence to prescriptions in a population-based cohort of systemic lupus erythematosus (SLE) patients and controls. METHODS: Detailed sociodemographic and prescription data were collected by structured interview in 2014-2015 from participants in the Michigan Lupus Epidemiology & Surveillance (MILES) Cohort. We compared access between cases and frequency-matched controls and examined associated factors in separate multivariable logistic regression models. RESULTS: 654 participants (462 SLE cases, 192 controls) completed the baseline visit; 584 (89%) were female, 285 (44%) black, and mean age was 53 years. SLE cases and controls reported similar frequencies of being unable to access prescribed medications (12.1% vs 9.4%, respectively; p=NS). SLE patients were twice as likely as controls to report cost-related prescription non-adherence in the preceding 12 months to save money (21.7% vs 10.4%; p=0.001), but also more likely to ask their doctor for lower cost alternatives (23.8% vs 15.6%, p=0.02). Disparities were found in association with income, race and health insurance status, but main findings persisted after adjusting for these and other variables in multivariable models. CONCLUSION: SLE patients were more likely than controls from the general population to report cost-related prescription non-adherence, including skipping doses, taking less medicine and delaying filling prescriptions, yet less than 1 in 4 patients asked providers for lower cost medications. Consideration of medication costs in patient decision-making could provide a meaningful avenue for improving access and adherence to medications.

      4. Costs and cost-effectiveness of the patient-centered HIV Care Model: A collaboration between community-based pharmacists and primary medical providersexternal icon
        Shrestha RK, Schommer JC, Taitel MS, Garza OW, Camp NM, Akinbosoye OE, Clay PG, Byrd KK.
        J Acquir Immune Defic Syndr. 2020 Jul 23.
        BACKGROUND: The Patient-centered HIV Care Model (PCHCM) is an evidence-informed structural intervention that integrates community-based pharmacists with primary medical providers to improve rates of HIV viral suppression. This report assesses the costs and cost-effectiveness of the PCHCM. SETTING: Patient-centered HIV Care Model METHODS:: Three project sites, each composed of a medical clinic and one or two community-based HIV-specialized pharmacies, were included in the analyses. PCHCM required patient data sharing between medical providers and pharmacists and collaborative therapy-related decision making. Intervention effectiveness was measured as the incremental number of patients virally suppressed (HIV RNA <200 copies/mL at the last test in a 12-month measurement period). Micro-costing direct measurement methods were used to estimate intervention. The cost per patient, cost per patient visit, and incremental cost per patient virally suppressed were calculated from the health care providers' perspective. Additionally, the number of HIV transmissions averted, lifetime HIV treatment cost saved, quality-adjusted life years (QALYs) saved, and cost per QALY saved were calculated from the societal perspective, using standard methods and reported values from the published literature. RESULTS: Overall, the PCHCM annual intervention cost for the three project sites was $226,741. The average cost per patient, cost per patient visit, and incremental cost per patient virally suppressed were $813, $48, and $5,039, respectively. The intervention averted 2.75 HIV transmissions and saved 12.22 QALYs and nearly $1.28 million in lifetime HIV treatment costs. The intervention was cost saving overall and at each project site. CONCLUSIONS: The PCHCM can be delivered at a relatively low cost and is a cost-saving intervention to assist patients in achieving viral suppression and preventing HIV transmission.

      5. Differential association of HIV funding with HIV mortality by race/ethnicity, United States, 1999-2017external icon
        Truman BI, Moonesinghe R, Brown YT, Chang MH, Mermin JH, Dean HD.
        Public Health Rep. 2020 Jul/Aug;135(1_suppl):149s-157s.
        OBJECTIVE: Federal funds have been spent to reduce the disproportionate effects of HIV/AIDS on racial/ethnic minority groups in the United States. We investigated the association between federal domestic HIV funding and age-adjusted HIV death rates by race/ethnicity in the United States during 1999-2017. METHODS: We analyzed HIV funding data from the Kaiser Family Foundation by federal fiscal year (FFY) and US age-adjusted death rates (AADRs) by race/ethnicity (Hispanic, non-Hispanic white, non-Hispanic black, and Asian/Pacific Islander and American Indian/Alaska Native [API+AI/AN]) from Centers for Disease Control and Prevention WONDER detailed mortality files. We fit joinpoint regression models to estimate the annual percentage change (APC), average APC, and changes in AADRs per billion US dollars in HIV funding, with 95% confidence intervals (CIs). For 19 data points, the number of joinpoints ranged from 0 to 4 on the basis of rules set by the program or by the user. A Monte Carlo permutation test indicated significant (P < .05) changes at joinpoints, and 2-sided t tests indicated significant APCs in AADRs. RESULTS: Domestic HIV funding increased from $10.7 billion in FFY 1999 to $26.3 billion in FFY 2017, but AADRs decreased at different rates for each racial/ethnic group. The average rate of change in AADR per US billion dollars was -9.4% (95% CI, -10.9% to -7.8%) for Hispanic residents, -7.8% (95% CI, -9.0% to -6.6%) for non-Hispanic black residents, -6.7% (95% CI, -9.3% to -4.0%) for non-Hispanic white residents, and -5.2% (95% CI, -7.8% to -2.5%) for non-Hispanic API+AI/AN residents. CONCLUSIONS: Increased domestic HIV funding was associated with faster decreases in age-adjusted HIV death rates for Hispanic and non-Hispanic black residents than for residents in other racial/ethnic groups. Increasing US HIV funding could be associated with decreasing future racial/ethnic disparities in the rate of HIV-related deaths.

      6. OBJECTIVE: We examined changes in glucose-lowering medication spending and quantified the magnitude of factors that are contributing to these changes. RESEARCH DESIGN AND METHODS: Using the Medical Expenditure Panel Survey, we estimated the change in spending on glucose-lowering medications during 2005-2007 and 2015-2017 among adults aged ≥18 years with diabetes. We decomposed the increase in total spending by medication groups: for insulin, by human and analog; and for noninsulin, by metformin, older, newer, and combination medications. For each group, we quantified the contributions by the number of users and cost-per-user. Costs were in 2017 U.S. dollars. RESULTS: National spending on glucose-lowering medications increased by $40.6 billion (240%), of which insulin and noninsulin medications contributed $28.6 billion (169%) and $12.0 billion (71%), respectively. For insulin, the increase was mainly associated with higher expenditures from analogs (156%). For noninsulin, the increase was a net effect of higher cost for newer medications (+88%) and decreased cost for older medications (-34%). Most of the increase in insulin spending came from the increase in cost-per-user. However, the increase in the number of users contributed more than cost-per-user in the rise of most noninsulin groups. CONCLUSIONS: The increase in national spending on glucose-lowering medications during the past decade was mostly associated with the increased costs for insulin, analogs in particular, and newer noninsulin medicines; and cost-per-user had a larger effect than the number of users. Understanding the factors contributing to the increase helps identify ways to curb the growth in costs.

    • Informatics
      1. Detection of diabetes status and type in youth using electronic health records: The SEARCH for Diabetes in Youth Studyexternal icon
        Wells BJ, Lenoir KM, Wagenknecht LE, Mayer-Davis EJ, Lawrence JM, Dabelea D, Pihoker C, Saydah S, Casanova R, Turley C, Liese AD, Standiford D, Kahn MG, Hamman R, Divers J.
        Diabetes Care. 2020 Jul 31.
        OBJECTIVE: Diabetes surveillance often requires manual medical chart reviews to confirm status and type. This project aimed to create an electronic health record (EHR)-based procedure for improving surveillance efficiency through automation of case identification. RESEARCH DESIGN AND METHODS: Youth (<20 years old) with potential evidence of diabetes (N = 8,682) were identified from EHRs at three children's hospitals participating in the SEARCH for Diabetes in Youth Study. True diabetes status/type was determined by manual chart reviews. Multinomial regression was compared with an ICD-10 rule-based algorithm in the ability to correctly identify diabetes status and type. Subsequently, the investigators evaluated a scenario of combining the rule-based algorithm with targeted chart reviews where the algorithm performed poorly. RESULTS: The sample included 5,308 true cases (89.2% type 1 diabetes). The rule-based algorithm outperformed regression for overall accuracy (0.955 vs 0.936). Type 1 diabetes was classified well by both methods: sensitivity (Se) (>0.95), specificity (Sp) (>0.96), and positive predictive value (PPV) (>0.97). In contrast, the PPVs for type 2 diabetes were 0.642 and 0.778 for the rule-based algorithm and the multinomial regression, respectively. Combination of the rule-based method with chart reviews (n = 695, 7.9%) of persons predicted to have non-type 1 diabetes resulted in perfect PPV for the cases reviewed while increasing overall accuracy (0.983). The Se, Sp, and PPV for type 2 diabetes using the combined method were ≥0.91. CONCLUSIONS: An ICD-10 algorithm combined with targeted chart reviews accurately identified diabetes status/type and could be an attractive option for diabetes surveillance in youth.

    • Injury and Violence
      1. Suicides among incarcerated persons in 18 U.S. states: Findings From the National Violent Death Reporting System, 2003-2014external icon
        Dixon KJ, Ertl AM, Leavitt RA, Sheats KJ, Fowler KA, Jack SP.
        J Correct Health Care. 2020 Jul 31.
        Using data from the National Violent Death Reporting System (2003-2014), this study examined the characteristics and contributing circumstances of suicides in correctional facilities. χ(2) and logistic regression analyses revealed that, compared to nonincarcerated suicide decedents, incarcerated suicide decedents had significantly lower odds of positive toxicology for substances but significantly higher odds of substance abuse problems. Descriptive subanalyses indicated that incarcerated suicide decedents often were incarcerated for personal crimes. They often died ≤ 1 week of incarceration, in a cell (frequently single-person or segregation), by hanging, using bedding material. Positive toxicology was more common for incarcerated decedents who died shortly after versus later in their incarceration. Findings highlight the need for enhanced detection and treatment of suicidal behavior, especially during early and vulnerable periods of incarceration.

    • Laboratory Sciences
      1. Prothrombin time, activated partial thromboplastin time, and fibrinogen reference intervals for inbred strain 13/N guinea pigs (Cavia porcellus) and validation of low volume sample analysisexternal icon
        Condrey JA, Flietstra T, Nestor KM, Schlosser EL, Coleman-McCray JD, Genzer SC, Welch SR, Spengler JR.
        Microorganisms. 2020 Jul 27;8(8).
        Inbred strain 13/N guinea pigs are used as small animal models for the study of hemorrhagic fever viruses. Coagulation abnormalities, including prolonged clotting times and bleeding, are characteristic of hemorrhagic fever in humans; patients often meet criteria for disseminated intravascular coagulation (DIC). Comprehensively evaluating coagulation function is critical in model development and studies of viral pathogenesis and therapeutic efficacy. Here, using the VetScan VSpro veterinary point-of-care platform, we developed reference intervals in both juvenile and adult strain 13/N guinea pigs for three coagulation parameters: prothrombin time (PT), activated partial thromboplastin time (aPTT), and fibrinogen. In addition, for situations or species with limited availability of blood for clinical analysis, we investigated the validity of a modified collection approach for low-volume (0.1 mL) blood sample analysis of PT and aPTT.

      2. Validation of the bag-mediated filtration system for environmental surveillance of poliovirus in Nairobi, Kenyaexternal icon
        Fagnant-Sperati CS, Ren Y, Zhou NA, Komen E, Mwangi B, Hassan J, Chepkurui A, Nzunza R, Nyangao J, van Zyl WB, Wolfaardt M, Matsapola PN, Ngwana FB, Jeffries-Miles S, Coulliette-Salmond A, Peñaranda S, Vega E, Shirai JH, Kossik AL, Beck NK, Boyle DS, Burns CC, Taylor MB, Borus P, Scott Meschke J.
        J Appl Microbiol. 2020 Aug 2.
        AIMS: This study compared the bag-mediated filtration system (BMFS) and standard WHO two-phase separation methods for poliovirus (PV) environmental surveillance, examined factors impacting PV detection, and monitored Sabin-like (SL) PV type 2 presence with withdrawal of oral polio vaccine type 2 (OPV2) in April 2016. METHODS AND RESULTS: Environmental samples were collected in Nairobi, Kenya (Sept 2015-Feb 2017), concentrated via BMFS and two-phase separation methods, then assayed using the WHO PV isolation algorithm and intratypic differentiation diagnostic screening kit. SL1, SL2, and SL3 were detected at higher rates in BMFS than two-phase samples (p<0.05). In BMFS samples, SL PV detection did not significantly differ with volume filtered, filtration time, or filter shipment time (p>0.05), while SL3 was detected less frequently with higher shipment temperatures (p=0.027). SL2 was detected more frequently before OPV2 withdrawal in BMFS and two-phase samples (p<1x10(-5) ). CONCLUSIONS: PV was detected at higher rates with the BMFS, a method that includes a secondary concentration step, than using the standard WHO two-phase method. SL2 disappearance from the environment was commensurate with OPV2 withdrawal. SIGNIFICANCE AND IMPACT OF THE STUDY: The BMFS offers comparable or improved PV detection under the conditions in this study, relative to the two-phase method.

      3. The genus Chryseobacterium in the family Weeksellaceae is known to be polyphyletic. Amino acid identity (AAI) values were calculated from whole-genome sequences of species of the genus Chryseobacterium, and their distribution was found to be multi-modal. These naturally-occurring non-continuities were leveraged to standardise genus assignment of these species. We speculate that this multi-modal distribution is a consequence of loss of biodiversity during major extinction events, leading to the concept that a bacterial genus corresponds to a set of species that diversified since the Permian extinction. Transfer of nine species (Chryseobacterium arachidiradicis, Chryseobacterium bovis , Chryseobacterium caeni , Chryseobacterium hispanicum , Chryseobacterium hominis , Chryseobacterium hungaricum, Chryseobacterium molle , Chryseobacterium pallidum and Chryseobacterium zeae) to the genus Epilithonimonas and eleven (Chryseobacterium anthropi, Chryseobacterium antarcticum, Chryseobacterium carnis, Chryseobacterium chaponense, Chryseobacterium haifense, Chryseobacterium jeonii, Chryseobacterium montanum, Chryseobacterium palustre, Chryseobacterium solincola, Chryseobacterium treverense and Chryseobacterium yonginense) to the genus Kaistella is proposed. Two novel species are described: Kaistella daneshvariae sp. nov. and Epilithonimonas vandammei sp. nov. Evidence is presented to support the assignment of Planobacterium taklimakanense to a genus apart from Chryseobacterium, to which Planobacterium salipaludis comb nov. also belongs. The novel genus Halpernia is proposed, to contain the type species Halpernia frigidisoli comb. nov., along with Halpernia humi comb. nov., and Halpernia marina comb. nov.

      4. Utility of MALDI-TOF MS for differentiation of Neisseria gonorrhoeae isolates with dissimilar azithromycin susceptibility profilesexternal icon
        Pham CD, Pettus K, Nash EE, Liu H, St Cyr SB, Schlanger K, Papp J, Gartin J, Dorji T, Akullo K, Kersh EN.
        J Antimicrob Chemother. 2020 Jul 31.
        BACKGROUND: Antibiotic-resistant gonorrhoea has been a chronic public health burden since the mid-1930s. Recent emergence of isolates resistant to the current recommended antibiotics for gonorrhoea further magnifies the threat of untreatable gonorrhoea. The lack of new, effective antibiotics highlights the need for better understanding of the population structure of Neisseria gonorrhoeae in order to provide greater insight on how to curtail the spread of antimicrobial-resistant N. gonorrhoeae. OBJECTIVES: To explore a potential application of MALDI-TOF MS to differentiate N. gonorrhoeae displaying different levels of susceptibility to the antibiotic azithromycin. METHODS: We conducted MALDI-TOF MS using the Bruker Biotyper on 392 N. gonorrhoeae isolates collected through the Gonococcal Isolate Surveillance Project (GISP) and/or the Strengthening the United States Response to Resistant Gonorrhea (SURRG) project. The MALDI-TOF MS spectra were visually analysed to assess the presence of distinctive peak(s). Statistical analysis was performed to assess the relationship between gonococcal isolates with the distinct protein peak and antibiotic susceptibility. RESULTS: In this study, we were able to differentiate N. gonorrhoeae isolates into two distinct subpopulations using MALDI-TOF MS. Isolates were distinguished by the presence or absence of a spectral peak at 11 300 Da. Notably, these two groups exhibited different levels of susceptibility to azithromycin. CONCLUSIONS: We have shown that in addition to its ability to identify N. gonorrhoeae, MALDI-TOF MS could also be used to differentiate gonococcal isolates with different levels of susceptibility to azithromycin.

      5. Characterization of highly pathogenic avian influenza H5Nx viruses in the ferret modelexternal icon
        Pulit-Penaloza JA, Brock N, Pappas C, Sun X, Belser JA, Zeng H, Tumpey TM, Maines TR.
        Sci Rep. 2020 Jul 29;10(1):12700.
        Highly pathogenic avian influenza (HPAI) H5 viruses, of the A/goose/Guangdong/1/1996 lineage, have exhibited substantial geographic spread worldwide since the first detection of H5N1 virus in 1996. Accumulation of mutations in the HA gene has resulted in several phylogenetic clades, while reassortment with other avian influenza viruses has led to the emergence of new virus subtypes (H5Nx), notably H5N2, H5N6, and H5N8. H5Nx viruses represent a threat to both the poultry industry and human health and can cause lethal human disease following virus exposure. Here, HPAI H5N6 and H5N2 viruses (isolated between 2014 and 2017) of the clade were assessed for their capacity to replicate in human respiratory tract cells, and to cause disease and transmit in the ferret model. All H5N6 viruses possessed increased virulence in ferrets compared to the H5N2 virus; however, pathogenicity profiles varied among the H5N6 viruses tested, from mild infection with sporadic virus dissemination beyond the respiratory tract, to severe disease with fatal outcome. Limited transmission between co-housed ferrets was observed with the H5N6 viruses but not with the H5N2 virus. In vitro evaluation of H5Nx virus replication in Calu-3 cells and the identification of mammalian adaptation markers in key genes associated with pathogenesis supports these findings.

      6. Experimental study on thermal runaway and vented gases of lithium-ion cellsexternal icon
        Yuan L, Dubaniewicz T, Zlochower I, Thomas R, Rayyan N.
        Process Saf Environ Prot. 2020 ;144:186-192.
        Lithium-ion (Li-ion) batteries have become more prevalent in mining to power a wide range of devices from handheld tools to mobile mining equipment. However, the benefits associated with using Li-ion batteries may come with a higher risk of a fire or an explosion. The major cause for a Li-ion battery fire is thermal runaway. If unmitigated, a thermal runaway can lead to cell rupture and the venting of toxic and highly flammables gases. Those flammable gases can cause a fire or explosion if ignited. In this study, researchers from the National Institute for Occupational Safety and Health (NIOSH) conducted experiments to monitor the heating of a Li-ion cell with different battery chemistries using an accelerating rate calorimeter (ARC). Inside the ARC, the cell was exposed to increasing temperatures until it reached a thermal runaway. Samples of vented gases after the thermal runaway were collected and analyzed using a gas chromatograph. Major gas components were identified, and their concentrations were measured. The results of this study can be useful in reducing the hazard of Li-ion battery fires.

      7. Development and optimization of thermal contrast amplification lateral flow immunoassays for ultrasensitive HIV p24 protein detectionexternal icon
        Zhan L, Granade T, Liu Y, Wei X, Youngpairoj A, Sullivan V, Johnson J, Bischof J.
        Microsyst and Nanoeng. 2020 ;6(1).
        Detection of human immunodeficiency virus (HIV) p24 protein at a single pg/ml concentration in point-of-care (POC) settings is important because it can facilitate acute HIV infection diagnosis with a detection sensitivity approaching that of laboratory-based assays. However, the limit of detection (LOD) of lateral flow immunoassays (LFAs), the most prominent POC diagnostic platform, falls short of that of laboratory protein detection methods such as enzyme-linked immunosorbent assay (ELISA). Here, we report the development and optimization of a thermal contrast amplification (TCA) LFA that will allow ultrasensitive detection of 8 pg/ml p24 protein spiked into human serum at POC, approaching the LOD of a laboratory test. To achieve this aim, we pursued several innovations as follows: (a) defining a new quantitative figure of merit for LFA design based on the specific to nonspecific binding ratio (BR); (b) using different sizes and shapes of gold nanoparticles (GNPs) in the systematic optimization of TCA LFA designs; and (c) exploring new laser wavelengths and power regimes for TCA LFA designs. First, we optimized the blocking buffer for the membrane and running buffer by quantitatively measuring the BR using a TCA reader. The TCA reader interprets the thermal signal (i.e., temperature) of GNPs within the membrane when irradiated by a laser at the plasmon resonance wavelength of the particle. This process results in higher detection and quantitation of GNPs than in traditional visual detection (i.e., color intensity). Further, we investigated the effect of laser power (30, 100, 200 mW), GNP size and shape (30 and 100 nm gold spheres, 150 nm gold-silica shells), and laser wavelength (532, 800 nm). Applying these innovations to a new TCA LFA design, we demonstrated that 100 nm spheres with a 100 mW 532 nm laser provided the best performance (i.e., LOD = 8 pg/ml). This LOD is significantly better than that of the current colorimetric LFA and is in the range of the laboratory-based p24 ELISA. In summary, this TCA LFA for p24 protein shows promise for detecting acute HIV infection in POC settings.

    • Military Medicine and Health
      1. Alterations in high-order diffusion imaging in veterans with Gulf War Illness is associated with chemical weapons exposure and mild traumatic brain injuryexternal icon
        Cheng CH, Koo BB, Calderazzo S, Quinn E, Aenlle K, Steele L, Klimas N, Krengel M, Janulewicz P, Toomey R, Michalovicz L, Kelly KA, Heeren T, Little D, O'Callaghan J, Sullivan K.
        Brain Behav Immun. 2020 Jul 31.
        The complex etiology behind Gulf War Illness (GWI) has been attributed to the combined exposure to neurotoxicant chemicals, brain injuries, and some combat experiences. Chronic GWI symptoms have been shown to be associated with intensified neuroinflammatory responses in animal and human studies. To investigate the neuroinflammatory responses and potential causes in Gulf War (GW) veterans, we focused on the effects of chemical/biological weapons (CBW) exposure and mild traumatic brain injury (mTBI) during the war. We applied a novel MRI diffusion processing method, Neurite density imaging (NDI), on high-order diffusion imaging to estimate microstructural alterations of brain imaging in Gulf War veterans with and without GWI, and collected plasma proinflammatory cytokine samples as well as self-reported health symptom scores. Our study identified microstructural changes specific to GWI in the frontal and limbic regions due to CBW and mTBI, and further showed distinctive microstructural patterns such that widespread changes were associated with CBW and more focal changes on diffusion imaging were observed in GW veterans with an mTBI during the war. In addition, microstructural alterations on brain imaging correlated with upregulated blood proinflammatory cytokine markers TNFRI and TNFRII and with worse outcomes on self-reported symptom measures for fatigue and sleep functioning. Taken together, these results suggest TNF signaling mediated inflammation affects frontal and limbic regions of the brain, which may contribute to the fatigue and sleep symptoms of the disease and suggest a strong neuroinflammatory component to GWI. These results also suggest exposures to chemical weapons and mTBI during the war are associated with different patterns of peripheral and central inflammation and highlight the brain regions vulnerable to further subtle microscale morphological changes and chronic signaling to nearby glia.

    • Nutritional Sciences
      1. High sodium intake can lead to hypertension and increase the risk for heart disease and stroke; however, research is lacking on the effectiveness of community-based sodium reduction programs. From 2013 through 2016, the Centers for Disease Control and Prevention (CDC) funded 10 state and local health departments to implement sodium reduction strategies across diverse institutional food settings. Strategies of the Sodium Reduction in Communities Program (SRCP) are implementing food service guidelines, making menu modifications, enabling purchase of reuced-sodium foods, and providing consumer information. CDC aggregated awardee-reported performance measures to evaluate progress in increasing the access, availability, and purchase of reduced sodium foods. Evaluation results of the SRCP show the potential differential effects of sodium reduction strategies in a community setting and support the need for additional community-level efforts in this emerging area of public health.

      2. Top food category contributors to sodium and potassium intake - United States, 2015-2016external icon
        Woodruff RC, Zhao L, Ahuja JK, Gillespie C, Goldman J, Harris DM, Jackson SL, Moshfegh A, Rhodes D, Sebastian RS, Terry A, Cogswell ME.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 14;69(32):1064-1069.
        Most U.S. adults consume too much sodium and not enough potassium (1,2). For apparently healthy U.S. adults aged ≥19 years, guidelines recommend reducing sodium intake that exceeds 2,300 mg/day and consuming at least 3,400 mg/day of potassium for males and at least 2,600 mg/day for females* (1). Reducing population-level sodium intake can reduce blood pressure and prevent cardiovascular diseases, the leading causes of death in the United States (1,3). Adequate potassium intake might offset the hypertensive effects of excessive sodium intake (1). Data from the 2015-2016 What We Eat in America (WWEIA) dietary interview component of the National Health and Nutrition Examination Survey (NHANES)(†) were analyzed to identify top food categories contributing to sodium and potassium intake for U.S. residents aged ≥1 year. During 2015-2016, 40% of sodium consumed came from the top 10 food categories, which included prepared foods with sodium added (e.g., deli meat sandwiches and pizza). Approximately 43% of potassium consumed was from 10 food categories, which included foods naturally low in sodium (e.g., unflavored milk, fruit, vegetables) and prepared foods. These results can inform efforts to encourage consumption of foods naturally low in sodium, which might have the dual benefit of reducing sodium intake and increasing potassium intake, contributing to cardiovascular disease prevention.

    • Occupational Safety and Health
      1. Application of end-of-shift respirable crystalline silica monitoring to constructionexternal icon
        Chien CH, Huang G, Lopez B, Morea A, Sing SY, Wu CY, Kashon ML, Harper M.
        J Occup Environ Hyg. 2020 Aug 4:1-10.
        A pilot project was conducted to determine the effect of common construction dusts as interferences in a new portable end-of-shift (EoS), direct-on-filter (DoF) sampling and analysis method for respirable crystalline silica (RCS), in this case, quartz. Construction dusts were prepared from plaster, drywall, cement and brick by grinding, aerosolizing, and collecting respirable dust with high flow rate cyclones. Filters were loaded with different levels of commercial α-quartz powder Min-u-Sil 5, and different levels of interfering dusts, singly and in combination. Samples were analyzed by Fourier Transform Infrared Spectroscopy (FTIR). Good correlations were found between nominal quartz loading (0 µg, 25 µg, 50 µg, and 100 µg) adjusted for quartz in the interfering dust and FTIR absorbance alone and in the presence of all interfering dusts. The slopes of the correlations were similar whether the loading was quartz without interference, or with plaster, drywall, and cement dusts, regardless of quantity. The results show that (a) plaster and drywall dusts do not interfere substantially; (b) cement does not interfere, but a change in the intercept suggests an effect on the background absorbance of the filter; and (c) in addition to having a substantial quartz content, brick dust contains an additional material, probably a silicate mineral, which interferes with the quartz peak. Thus, the presence of cement leads to lower quartz values and brick leads to higher values, but overall, 83% of the quartz contents predicted from the calibration data agreed within 50% of the adjusted nominal loadings within the range 20-110 µg. This result is encouraging given the high levels of interfering dusts. Nine samples loaded with smaller amounts of all four dusts together gave results within 25% of the adjusted nominal loadings. A single mixture addition of the dusts to the filter gave tighter variance in results than sequential additions. Unexpectedly, the two Certified Reference Materials (CRMs) 1878a and 1878b, gave different results when used to calibrate XRD analysis of Min-u-Sil 5.

      2. Impact of repeated exposure and cleaning on protective properties of structural firefighting turnout gearexternal icon
        Horn GP, Kerber S, Andrews J, Kesler RM, Newman H, Stewart JW, Fent KW, Smith DL.
        Fire Technology. 2020 .
        The US fire service has become acutely aware of the need to clean PPE after fires. However, there is concern that damage from repeated cleaning may impact critical protection from fireground risk. Using a protocol that included repeated simulated fireground exposures (between 0 cycles and 40 cycles) and/or repeated cleaning with techniques common in the fire service, we found that several important protective properties of NFPA 1971 compliant turnout gear are significantly changed. Outer shell and thermal liner tear strength showed a statistically significant reduction when laundered as compared to wet or dry decontamination. Larger changes in outer shell tear strength resulted when the coat closure incorporated hook & dee clasps as compared with garments using zippered closures. Total Heat Loss was reduced for all samples that underwent any form of cleaning while Thermal Protective Performance was only increased in the gear that was laundered. These results suggest that some important protective properties of bunker gear can be decreased after repeated exposure/cleaning cycles relative to their levels when tested in a new condition. For the specific materials tested, outer shell trap tear strength in the fill direction and seam strength dropped below NFPA 1971 requirements after 40 laundering cycles. The findings for this study may have utility for setting preconditions for the measurement of certain performance properties in future editions of NFPA 1971.

      3. The ability to identify hazards during a workplace examination is a critical skill for mineworkers to have in order to maintain a safe workplace. While research suggests that being able to successfully recognize hazards requires a complex set of competencies, it is unclear which competencies are most critical to adequately perform a workplace examination. This paper presents a hazard recognition competencies framework as an explanation of the competencies that affect mineworker hazard recognition. To better understand how the industry is selecting and preparing workplace examiners, researchers from the National Institute for Occupational Safety and Health (NIOSH) interviewed nine health and safety (H&S) professionals at surface stone, sand, and gravel mine sites throughout the USA. A primary purpose of these interviews was to verify the competencies included in the hazard recognition competencies framework and to understand why these competencies are critical. Finally, the results of this study are presented within the context of current NIOSH research findings related to hazard recognition.

    • Occupational Safety and Health - Mining
      1. Coal workers’ pneumoconiosis (CWP), commonly known as black lung, is caused by the inhalation of respirable coal mine dust and is a disabling and potentially fatal lung disease with no cure. Historically, CWP has taken a tremendous human and financial toll in the US coal mining industry. Recent health surveillance data indicates that CWP continues to occur at elevated levels. Respirable coal dust exposure must be controlled to prevent the development of CWP. The Pittsburgh Mining Research Division of the National Institute for Occupational Safety and Health (NIOSH) conducts laboratory and mine-site research to identify control technologies that can be used to successfully reduce respirable dust levels. Various technologies, using multiple methods of control, can be applied in order to reduce dust levels. An overview of CWP’s impact and a general methodology for controlling respirable dust in underground coal mines are discussed in this paper.

      2. Heinrich revisited: A new data-driven examination of the safety pyramidexternal icon
        Moore SM, Yorio PL, Haas EJ, Bell JL, Greenawald LA.
        Min Metall Explor. 2020 .
        Although researchers have struggled to replicate Heinrich’s safety triangle findings (Heinrich 1931) for various reasons (e.g., no access to his original database and it is unclear if the database was of a single establishment/operation or for an entire industry), the occupational safety community has continued to adopt and expand the applications of this theory (e.g., McSween 2003). Within the mining industry, the potential exists for operations and companies to use concepts from the safety triangle as a way to inform or challenge the practices employed within their health and safety management systems (HSMS) to prevent incidents (Backlund 2016). This paper considers data obtained from the Mine Safety and Health Administration’s databases and demonstrates the validity of applying the safety triangle theory at the mine level. The results support the use of this theory and demonstrate that lower severity incidents can predict fatalities in a subsequent year where significant nuances and caveats to applying the theory are identified and discussed.

      3. Mining operations, by their very nature, create a lot of dust, with varying percentages of silica content. Modern mining operators are well aware of the hazard created by respirable crystalline silica dust (RCS). Operators also need to recognize that silicosis is an irreversible occupational disease with terrible consequences including lung cancer, respiratory failure and tuberculosis. And there is no cure for silicosis - the only fix is to prevent the disease by limiting worker exposure. Based on the latest work-related lung disease surveillance report by the CDC, between 1990 and 1999, just over 20% of all total silica deaths occurred in the M/NM industry. And between 2000 and 2017, 12% of MSHA personal heath samples were greater than the MSHA PEL of 100 ug/m3 and 34% of those were greater than the OSHA PEL of 50 ug/m3. The benefit of real-time dust sensing lies in the ability to help the operator understand when certain exposures occurred. Pairing real-time sensing with Helmet-CAM technology, mine operators can also understand the specific tasks that led to those exposures. Further adding the use of an FTIR instrument and end-of-shift analysis can effectively yield silica estimation. All three of these approaches can be combined to estimate real-time silica concentrations. Importantly, to quantify worker exposure, there is no substitute for personal sampling. Complementary to personal sampling is area sampling, and when area sampling is conducted in real time then the dust levels present at mines in key areas can be quantified on a continuous, long-term basis. NIOSH has conducted many years of engineering control research and has published extensively on the topic. While the commonly used hierarchy of controls puts substitution as the best method for reducing worker exposures, often in mining the best controls are engineering-based, such as exhaust ventilation, dust capture systems, and total structure ventilation. Fueled by a growing global desire to understand indoor and outdoor air quality (most commonly combustion aerosols in the atmosphere), numerous &quot;low-cost&quot; particulate sensors have been developed and marketed to those interested in quantifying their local air quality. Further, studies have compared these sensors to research-grade federal environmental monitoring devices and, after some appropriate scaling factor is applied, the agreement can be quite good. NIOSH recently began a new research effort in the fall of 2019 which aims to evaluate the applicability of these sensors not to ambient aerosols, but to the perhaps more challenging role of measuring real-time mining dust levels. This work poses many challenges - larger and more varied dusts, higher dust concentrations, and harsh environments - but the potential to inexpensively quantify mining dust levels in real time is intriguing. If low-cost area dust sensing for mining becomes a reality, it's possible that plant operators could apply engineering controls more widely by justifying installations that would most efficiently reduce both area exposures and individual worker exposures, providing a significant health benefit.

      4. Design of a water curtain to reduce accumulations of float coal dust in longwall returnsexternal icon
        Seaman CE, Shahan MR, Beck TW, Mischler SE.
        Int J Min Sci Technol. 2020 .
        Accumulation of float coal dust (FCD) in underground mines is an explosion hazard that affects all underground coal mine workers. While this hazard is addressed by the application of rock dust, inadequate rock dusting practices can leave miners exposed to an explosion risk. Researchers at the National Institute for Occupational Safety and Health (NIOSH) have focused on developing a water curtain that removes FCD from the airstream, thereby reducing the buildup of FCD in mine airways. In this study, the number and spacing of the active sprays in the water curtain were varied to determine the optimal configuration to obtain peak knockdown efficiency (KE) while minimizing water consumption.

    • Parasitic Diseases
      1. Genetic evidence for imported malaria and local transmission in Richard Toll, Senegalexternal icon
        Daniels RF, Schaffner SF, Dieye Y, Dieng G, Hainsworth M, Fall FB, Diouf CN, Ndiop M, Cisse M, Gueye AB, Sarr O, Guinot P, Deme AB, Bei AK, Sy M, Thwing J, MacInnis B, Earle D, Guinovart C, Sene D, Hartl DL, Ndiaye D, Steketee RW, Wirth DF, Volkman SK.
        Malar J. 2020 Aug 3;19(1):276.
        BACKGROUND: Malaria elimination efforts can be undermined by imported malaria infections. Imported infections are classified based on travel history. METHODS: A genetic strategy was applied to better understand the contribution of imported infections and to test for local transmission in the very low prevalence region of Richard Toll, Senegal. RESULTS: Genetic relatedness analysis, based upon molecular barcode genotyping data derived from diagnostic material, provided evidence for both imported infections and ongoing local transmission in Richard Toll. Evidence for imported malaria included finding that a large proportion of Richard Toll parasites were genetically related to parasites from Thiès, Senegal, a region of moderate transmission with extensive available genotyping data. Evidence for ongoing local transmission included finding parasites of identical genotype that persisted across multiple transmission seasons as well as enrichment of highly related infections within the households of non-travellers compared to travellers. CONCLUSIONS: These data indicate that, while a large number of infections may have been imported, there remains ongoing local malaria transmission in Richard Toll. These proof-of-concept findings underscore the value of genetic data to identify parasite relatedness and patterns of transmission to inform optimal intervention selection and placement.

    • Physical Activity
      1. Disparities in youth sports participation in the U.S., 2017-2018external icon
        Hyde ET, Omura JD, Fulton JE, Lee SM, Piercy KL, Carlson SA.
        Am J Prev Med. 2020 Jul 30.
        INTRODUCTION: In 2019, the National Youth Sports Strategy was released and called for regular analysis, interpretation, and dissemination of U.S. youth sports surveillance data. The purpose of this study is to provide the recent national estimates of U.S. youth aged 6-17 years who participate in sports and examine the differences in participation by demographic characteristics, overall and across age groups. METHODS: Nationally representative data on parent-reported youth sports participation from the 2017-2018 National Survey of Children's Health (n=36,779) were analyzed in 2019. The prevalence and 95% CIs of youth sports participation were estimated by demographic characteristics, overall and by age group. Investigators assessed the significant (p<0.05) differences and trends in participation using pairwise t-tests and orthogonal polynomial contrasts and effect modification by age group using logistic regression models. RESULTS: Overall, 57.7% (95% CI=56.6, 58.9) of U.S. youth participated in sports. Participation was highest among youth who were aged 10-13 years, male, and white, non-Hispanic and increased with increasing parent/caregiver education and household income (all p<0.05). Differences in participation by demographic characteristics were more pronounced among younger youth. For example, prevalence by household income level ranged from 32.7% to 79.9% among children aged 6-9 years and from 41.6% to 67.2% among youth aged 14-17 years. CONCLUSIONS: Although nearly 6 in 10 U.S. youth participate in sports, substantial disparities exist, especially among younger children. Identifying and overcoming the barriers may help increase youth sports participation in the U.S.

    • Public Health Law
      1. Effect of CDC 2006 Revised HIV Testing Recommendations for Adults, Adolescents, Pregnant Women, and Newborns on state laws, 2018external icon
        Salvant Valentine S, Caldwell J, Tailor A.
        Public Health Rep. 2020 Jul/Aug;135(1_suppl):189s-196s.
        In 2006, the Centers for Disease Control and Prevention updated its recommendations for HIV testing of 4 population groups in health care settings: adults, adolescents, pregnant women, and newborns. Important components of the revised recommendations included opt-out routine HIV screening; eliminating prevention counseling for opt-out routine HIV screening; repeat HIV testing in the third trimester for all women at high risk for acquiring HIV and for women receiving health care in facilities and/or jurisdictions with high HIV burden; testing during labor and delivery for women with undocumented HIV status; and testing the newborn when the mother's HIV status is unknown. To assess the integration of these testing recommendations into state laws and to inform future recommendations, we researched and assessed statutes and regulations that addressed HIV testing in the 4 population groups in all 50 states and the District of Columbia in 2018. We then classified the laws, based on their consistency with the recommendations for each of the 4 population groups. Of 31 states and the District of Columbia that had relevant laws, all addressed at least 1 component of the recommendations. Although no state had laws that incorporated all the recommendations for all the population groups, 5 states (Delaware, Illinois, Louisiana, Maryland, and New Hampshire) had incorporated all the recommendations for adults and adolescents, and 4 states (Connecticut, Nevada, North Carolina, and West Virginia) had incorporated all the recommendations for pregnant women and newborns.

    • Social and Behavioral Sciences
      1. Community-based prevalence of externalizing and internalizing disorders among school-aged children and adolescents in four geographically dispersed school districts in the United Statesexternal icon
        Danielson ML, Bitsko RH, Holbrook JR, Charania SN, Claussen AH, McKeown RE, Cuffe SP, Owens JS, Evans SW, Kubicek L, Flory K.
        Child Psychiatry Hum Dev. 2020 Jul 30.
        The Project to Learn About Youth-Mental Health (PLAY-MH; 2014-2018) is a school-based, two-stage study designed to estimate the prevalence of selected mental disorders among K-12 students in four U.S.-based sites (Colorado, Florida, Ohio, and South Carolina). In Stage 1, teachers completed validated screeners to determine student risk status for externalizing or internalizing problems or tics; the percentage of students identified as being at high risk ranged from 17.8% to 34.4%. In Stage 2, parents completed a structured diagnostic interview to determine whether their child met criteria for fourteen externalizing or internalizing disorders; weighted prevalence estimates of meeting criteria for any disorder were similar in three sites (14.8%-17.8%) and higher in Ohio (33.3%). PLAY-MH produced point-in-time estimates of mental disorders in K-12 students, which may be used to supplement estimates from other modes of mental disorder surveillance and inform mental health screening and healthcare and educational services.

    • Substance Use and Abuse
      1. Association of self-reported abscess with high-risk injection-related behaviors among young persons who inject drugsexternal icon
        Asher AK, Zhong Y, Garfein RS, Cuevas-Mota J, Teshale E.
        J Assoc Nurses AIDS Care. 2019 Mar-Apr;30(2):142-150.
        Abscess is a common source of morbidity for people who inject drugs. We used data from the Study to Assess Hepatitis C Risk to measure prevalence of abscess and identify factors associated with the history of abscess. Of 541 participants, 388 (72%) were male and 149 (28%) were female. Almost half (n = 258, 48%) reported ever having an abscess. Persons who inject drugs with an abscess history were significantly more likely to have more injection partners (p = .01), inject heroin daily (p < .05), and share cookers (p = .001) and less likely to report using new syringes with each injection (p = .02). Most reported self-treating their last abscess and increasing drug use when having an abscess. High-risk injection-related activity was associated not only with infections such as HIV and hepatitis C virus but also with abscess. Nurses should screen patients presenting with abscess for high-risk practices and provide prevention education.

      2. Characteristics of marijuana use during pregnancy - eight states, Pregnancy Risk Assessment Monitoring System, 2017external icon
        Ko JY, Coy KC, Haight SC, Haegerich TM, Williams L, Cox S, Njai R, Grant AM.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 14;69(32):1058-1063.
        Marijuana is the most commonly used illicit substance under federal law in the United States (1); however, many states have legalized medical and adult nonmedical use. Evidence regarding the safety and health effects of cannabis use during pregnancy is largely inconclusive (2). Potential adverse health effects to exposed infants (e.g., lower birthweight) have been documented (2). To provide population-based estimates of use surrounding pregnancy, identify reasons for and mode of use, and understand characteristics of women who continue versus cease marijuana use during pregnancy, CDC analyzed data from eight states participating in the 2017 Pregnancy Risk Assessment Monitoring System (PRAMS) marijuana supplement. Overall, 9.8% of women self-reported marijuana use before pregnancy, 4.2% during pregnancy, and 5.5% after pregnancy. The most common reasons for use during pregnancy were to relieve stress or anxiety, nausea or vomiting, and pain. Smoking was the most common mode of use. In multivariable models that included age, race/ethnicity, marital status, education, insurance status, parity, trimester of entry into prenatal care, and cigarette and e-cigarette use during pregnancy, women who continued versus ceased marijuana use during pregnancy were more likely to be non-Hispanic white or other race/ethnicity than non-Hispanic black, be unmarried, have ≤12 years of education, and use cigarettes during pregnancy. The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) recommend refraining from marijuana use during pregnancy and lactation (3,4). Given the increasing number of states legalizing medical and adult nonmedical marijuana use, surveillance of perinatal marijuana use can inform clinical guidance, provider and patient education, and public health programs to support evidence-based approaches to addressing substance use.

      3. Nicotine exposure by device type among adult electronic nicotine delivery system users in the Population Assessment of Tobacco and Health Study, 2015-2016external icon
        Rostron BL, Coleman B, Cheng YC, Kimmel HL, Oniyide O, Wang L, Chang CM.
        Cancer Epidemiol Biomarkers Prev. 2020 Jul 29.
        BACKGROUND: Previous studies have examined the characteristics of open and closed system electronic nicotine delivery system (ENDS) users, but population-level information on nicotine exposure among these users has not been available. METHODS: We analyzed nicotine biomarker and survey data from Wave 3 of the Population Assessment of Tobacco and Health (PATH) Study collected from October 2015 to October 2016. We identified 277 exclusive ENDS users and 468 dual cigarette and ENDS users and analyzed concentrations of nicotine and its metabolites obtained from urine samples by device type and other characteristics such as frequency of use and e-liquid flavor. RESULTS: Among exclusive ENDS users, open system users had higher levels of total nicotine exposure (TNE-2) than closed system users (8.8 µmol/g creatinine (95% CI=5.3, 14.8 µmol/g) vs. 2.0 µmol/g (95% CI=0.7, 5.4 µmol/g). However, TNE-2 concentrations were similar when open and closed system users were stratified as daily (26.4 µmol/g (95% CI=20.1, 34.7 µmol/g) vs. 27.1 µmol/g (95% CI=16.4, 44.9 µmol/g)) and non-daily (0.5 µmol/g (95% CI=0.1, 1.9 µmol/g) vs. 0.2 µmol/g (95% CI=0.0, 0.7 µmol/g)) ENDS users. Dual users generally had higher nicotine exposure than exclusive users. CONCLUSIONS: Nicotine exposure was observed to be higher among exclusive open system ENDS users compared to closed system users, but levels were similar when users were stratified by frequency of use. IMPACT: These results suggest that exclusive ENDS users with similar use patterns receive comparable levels of nicotine, regardless of whether they use open or closed system devices.

      4. Notes from the field: Emergency visits for complications of injecting transmucosal buprenorphine products - United States, 2016-2018external icon
        Tanwar S, Geller AI, Lovegrove MC, Budnitz DS.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 14;69(32):1102-1103.

    • Zoonotic and Vectorborne Diseases
      1. Bat and Lyssavirus exposure among humans in area that celebrates bat festival, Nigeria, 2010 and 2013external icon
        Vora NM, Osinubi MO, Davis L, Abdurrahman M, Adedire EB, Akpan H, Aman-Oloniyo AF, Audu SW, Blau D, Dankoli RS, Ehimiyein AM, Ellison JA, Gbadegesin YH, Greenberg L, Haberling D, Hutson C, Idris JM, Kia GS, Lawal M, Matthias SY, Mshelbwala PP, Niezgoda M, Ogunkoya AB, Ogunniyi AO, Okara GC, Olugasa BO, Ossai OP, Oyemakinde A, Person MK, Rupprecht CE, Saliman OA, Sani M, Sanni-Adeniyi OA, Satheshkumar PS, Smith TG, Soleye MO, Wallace RM, Yennan SK, Recuenco S.
        Emerg Infect Dis. 2020 Jul;26(7):1399-1408.
        Using questionnaires and serologic testing, we evaluated bat and lyssavirus exposure among persons in an area of Nigeria that celebrates a bat festival. Bats from festival caves underwent serologic testing for phylogroup II lyssaviruses (Lagos bat virus, Shimoni bat virus, Mokola virus). The enrolled households consisted of 2,112 persons, among whom 213 (10%) were reported to have ever had bat contact (having touched a bat, having been bitten by a bat, or having been scratched by a bat) and 52 (2%) to have ever been bitten by a bat. Of 203 participants with bat contact, 3 (1%) had received rabies vaccination. No participant had neutralizing antibodies to phylogroup II lyssaviruses, but >50% of bats had neutralizing antibodies to these lyssaviruses. Even though we found no evidence of phylogroup II lyssavirus exposure among humans, persons interacting with bats in the area could benefit from practicing bat-related health precautions.

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

Page last reviewed: August 24, 2020, 12:00 AM