Volume 12, Issue 30, September 1, 2020

CDC Science Clips: Volume 12, Issue 30, September 1, 2020

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

  1. Top Articles of the Week
    Selected weekly by a senior CDC scientist from the standard sections listed below.
    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions
      • INTRODUCTION: Baby boomers, people born from 1946 through 1964, represent a substantial portion of the US population. Generally, baby boomers have more chronic disease and disability than those in the previous generation. Frequently, they also provide informal care to others. The objective of our study was to estimate the prevalence of informal caregiving among baby boomers and compare the health of baby boomer caregivers and noncaregivers. METHODS: Using data from the Behavioral Risk Factor Surveillance System (2015-2017) for 44 states, the District of Columbia, and Puerto Rico, we classified 109,268 baby boomers as caregivers or noncaregivers and compared their general health (poor or fair vs good, very good, or excellent), chronic health conditions, and frequent mental distress (FMD). FMD was defined as 14 days or more of poor mental health in the past month. We used log-binomial regression to calculate prevalence ratios, adjusted for age and sex (aPRs), and to separately estimate aPRs for fair or poor health and FMD or at least one chronic health condition. RESULTS: One in 4 baby boomers (24.2%) were caregivers. In adjusted models, male caregivers had a higher prevalence of fair to poor health than noncaregivers (aPR = 1.17; 95% confidence interval [CI], 1.06-1.29; P = .001). More caregivers than noncaregivers had at least 1 chronic health condition (aPR = 1.10, 95% CI, 1.07-1.13; P < .001) and more often had FMD (aPR = 1.39; 95% CI, 1.26-1.53; P < .001). CONCLUSION: Our study showed these caregivers had more chronic health conditions and more often had FMD than noncaregivers. The health of baby boomer caregivers is a public health priority, as these caregivers might need support to maintain their own physical and mental health.

    • Communicable Diseases
      • Mortality in adults with multidrug-resistant tuberculosis and HIV by antiretroviral therapy and tuberculosis drug use: an individual patient data meta-analysisexternal icon
        Bisson GP, Bastos M, Campbell JR, Bang D, Brust JC, Isaakadis P, Lange C, Menzies D, Migliori GB, Pape JW, Palmero D, Baghei P, Tabarsi P, Viiklepp P, Vilbrun S, Walsh J, Marks SM.
        Lancet. 2020 Aug 8;396(10248):402-411.
        BACKGROUND: HIV-infection is associated with increased mortality during multidrug-resistant tuberculosis treatment, but the extent to which the use of antiretroviral therapy (ART) and anti-tuberculosis medications modify this risk are unclear. Our objective was to evaluate how use of these treatments altered mortality risk in HIV-positive adults with multidrug-resistant tuberculosis. METHODS: We did an individual patient data meta-analysis of adults 18 years or older with confirmed or presumed multidrug-resistant tuberculosis initiating tuberculosis treatment between 1993 and 2016. Data included ART use and anti-tuberculosis medications grouped according to WHO effectiveness categories. The primary analysis compared HIV-positive with HIV-negative patients in terms of death during multidrug-resistant tuberculosis treatment, excluding those lost to follow up, and was stratified by ART use. Analyses used logistic regression after exact matching on country World Bank income classification and drug resistance and propensity-score matching on age, sex, geographic site, year of multidrug-resistant tuberculosis treatment initiation, previous tuberculosis treatment, directly observed therapy, and acid-fast-bacilli smear-positivity to obtain adjusted odds ratios (aORs) and 95% CIs. Secondary analyses were conducted among those with HIV-infection. FINDINGS: We included 11 920 multidrug-resistant tuberculosis patients. 2997 (25%) were HIV-positive and on ART, 886 (7%) were HIV-positive and not on ART, and 1749 (15%) had extensively drug-resistant tuberculosis. By use of HIV-negative patients as reference, the aOR of death was 2·4 (95% CI 2·0-2·9) for all patients with HIV-infection, 1·8 (1·5-2·2) for HIV-positive patients on ART, and 4·2 (3·0-5·9) for HIV-positive patients with no or unknown ART. Among patients with HIV, use of at least one WHO Group A drug and specific use of moxifloxacin, levofloxacin, bedaquiline, or linezolid were associated with significantly decreased odds of death. INTERPRETATION: Use of ART and more effective anti-tuberculosis drugs is associated with lower odds of death among HIV-positive patients with multidrug-resistant tuberculosis. Access to these therapies should be urgently pursued. FUNDING: American Thoracic Society, Canadian Institutes of Health Research, US Centers for Disease Control and Prevention, European Respiratory Society, Infectious Diseases Society of America.

      • Point prevalence testing of residents for SARS-CoV-2 in a subset of Connecticut nursing homesexternal icon
        Parikh S, O'Laughlin K, Ehrlich HY, Campbell L, Harizaj A, Durante A, Leung V.
        Jama. 2020 Aug 10.
        This study describes the point prevalence of polymerase chain reaction tests positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among residents of a sample of Connecticut nursing homes in the first half of May 2020.

      • COVID-19 in Americans aboard the Diamond Princess cruise shipexternal icon
        Plucinski MM, Wallace M, Uehara A, Kurbatova EV, Tobolowsky FA, Schneider ZD, Ishizumi A, Bozio CH, Kobayashi M, Toda M, Stewart A, Wagner RL, Moriarty LF, Murray R, Queen K, Tao Y, Paden C, Mauldin MR, Zhang J, Li Y, Elkins CA, Lu X, Herzig CT, Novak R, Bower W, Medley AM, Acosta AM, Knust B, Cantey PT, Pesik NT, Halsey ES, Cetron MS, Tong S, Marston BJ, Friedman CR.
        Clin Infect Dis. 2020 Aug 12.
        BACKGROUND: The Diamond Princess cruise ship was the site of a large outbreak of coronavirus disease 2019 (COVID-19). Of 437 Americans and their travel companions on the ship, 114 (26%) tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). METHODS: We interviewed 229 American passengers and crew after disembarkation following a ship-based quarantine to identify risk factors for infection and characterize transmission onboard the ship. RESULTS: The attack rate for passengers in single-person cabins or without infected cabinmates was 18% (58/329), compared with 63% (27/43) for those sharing a cabin with an asymptomatic infected cabinmate, and 81% (25/31) for those with a symptomatic infected cabinmate. Whole genome sequences from specimens from passengers who shared cabins clustered together. Of 66 SARS-CoV-2-positive American travelers with complete symptom information, 14 (21%) were asymptomatic while on the ship. Among SARS-CoV-2-positive Americans, 10 (9%) required intensive care, of whom 7 were ≥70 years. CONCLUSION: Our findings highlight the high risk of SARS-CoV-2 transmission on cruise ships. High rates of SARS-CoV-2 positivity in cabinmates of individuals with asymptomatic infections suggest that triage by symptom status in shared quarters is insufficient to halt transmission. A high rate of intensive care unit admission among older individuals complicates the prospect of future cruise travel during the pandemic, given typical cruise passenger demographics. The magnitude and severe outcomes of this outbreak were major factors contributing to the Centers for Disease Control and Prevention's decision to halt cruise ship travel in U.S. waters in March 2020.

    • Genetics and Genomics
    • Healthcare Associated Infections
      • Transmission of eastern equine encephalitis virus from an organ donor to 3 transplant recipientsexternal icon
        Pouch SM, Katugaha SB, Shieh WJ, Annambhotla P, Walker WL, Basavaraju SV, Jones J, Huynh T, Reagan-Steiner S, Bhatnagar J, Grimm K, Stramer SL, Gabel J, Lyon GM, Mehta AK, Kandiah P, Neujahr DC, Javidfar J, Subramanian RM, Parekh SM, Shah P, Cooper L, Psotka MA, Radcliffe R, Williams C, Zaki SR, Staples JE, Fischer M, Panella AJ, Lanciotti RS, Laven JJ, Kosoy O, Rabe IB, Gould CV.
        Clin Infect Dis. 2019 Jul 18;69(3):450-458.
        BACKGROUND: In fall 2017, 3 solid organ transplant (SOT) recipients from a common donor developed encephalitis within 1 week of transplantation, prompting suspicion of transplant-transmitted infection. Eastern equine encephalitis virus (EEEV) infection was identified during testing of endomyocardial tissue from the heart recipient. METHODS: We reviewed medical records of the organ donor and transplant recipients and tested serum, whole blood, cerebrospinal fluid, and tissue from the donor and recipients for evidence of EEEV infection by multiple assays. We investigated blood transfusion as a possible source of organ donor infection by testing remaining components and serum specimens from blood donors. We reviewed data from the pretransplant organ donor evaluation and local EEEV surveillance. RESULTS: We found laboratory evidence of recent EEEV infection in all organ recipients and the common donor. Serum collected from the organ donor upon hospital admission tested negative, but subsequent samples obtained prior to organ recovery were positive for EEEV RNA. There was no evidence of EEEV infection among donors of the 8 blood products transfused into the organ donor or in products derived from these donations. Veterinary and mosquito surveillance showed recent EEEV activity in counties nearby the organ donor's county of residence. Neuroinvasive EEEV infection directly contributed to the death of 1 organ recipient and likely contributed to death in another. CONCLUSIONS: Our investigation demonstrated EEEV transmission through SOT. Mosquito-borne transmission of EEEV to the organ donor was the likely source of infection. Clinicians should be aware of EEEV as a cause of transplant-associated encephalitis.

    • Immunity and Immunization
      • Rotavirus vaccine effectiveness and impact in Uzbekistan, the first country to introduce in central Asiaexternal icon
        Eraliev U, Latipov R, Tursunova D, Wasley A, Daniels D, Ismoilov U, Akramova M, Sultanova M, Yuldashova D, Barakaev B, Mutalova V, Tuychiev L, Musabaev E, Sharapov S, Pleshkov B, Videbaek D, Huseynov S, Safaeva K, Mijatovic-Rustempasic S, Bowen MD, Parashar UD, Cortese MM.
        Hum Vaccin Immunother. 2020 Aug 5:1-7.
        Uzbekistan, the most populous country in central Asia, was the first in the region to introduce rotavirus vaccine into its national immunization program. Rotarix (GlaxoSmithKline Biologicals, RV1) was introduced in June 2014, with doses recommended at age 2 and 3 months. To evaluate vaccine impact, active surveillance for rotavirus diarrhea was reestablished in 2014 at 2 hospitals in Tashkent and Bukhara which had also performed surveillance during the pre-vaccine period 2005-2009. Children aged <5 y admitted with acute diarrhea had stool specimens collected and tested for rotavirus by enzyme immunoassay. Proportions testing rotavirus-positive in post-vaccine years were compared with the pre-vaccine period. Vaccine records were obtained and effectiveness of 2 RV1 doses vs 0 doses was estimated using rotavirus-case and test-negative design among children enrolled from Bukhara city. In 2015 and 2016, 8%-15% of infants and 10%-16% of children aged<5 y hospitalized with acute diarrhea at the sites tested rotavirus-positive, compared with 26% of infants and 27% of children aged<5 y in pre-vaccine period (reductions in proportion positive of 42%-68%, p <.001). Vaccine effectiveness of 2 RV1 doses vs 0 doses in protecting against hospitalization for rotavirus disease among those aged ≥6 months was 51% (95% CI 2-75) and is based on cases predominantly of genotype G2P[4]. Vaccine effectiveness point estimates tended to be higher against cases with higher illness severity (e.g., clinical severity based on modified Vesikari score ≥11). Our data demonstrate that the monovalent rotavirus vaccine is effective in reducing the likelihood of hospitalization for rotavirus disease in young children in Uzbekistan.

      • Restoring immunization services provided by the Vaccines for Children Program in Puerto Rico after Hurricanes Irma and Maria, 2017-2019external icon
        Luna-Pinto SC, Rivera A, Cardona I, Rijo C, Alvarez V, Rodriguez J, Yoerg B, Shapiro CN, Patel A.
        J Public Health Manag Pract. 2020 Aug 6.
        CONTEXT: In September 2017, Hurricanes Irma and Maria impacted Puerto Rico, causing significant disruption of immunization services and vaccine losses due to widespread infrastructure and electrical grid damage and resulting cold chain failures. OBJECTIVE: To describe posthurricane efforts undertaken to restore and strengthen immunization services provided by Puerto Rico's federally funded Vaccines for Children (VFC) Program, a network of clinics that provide vaccines to eligible children. DESIGN: Historical records were reviewed to characterize Puerto Rico's prehurricane immunization system. Site visits to assess VFC clinic posthurricane operational status were conducted by the Puerto Rico Department of Health, working with the Centers for Disease Control and Prevention and other partners. Infrastructure repair and acquisition of backup generators, temperature data loggers, and replacement vaccines were carried out to restore operations. RESULTS: Prior to the hurricanes, 224 VFC clinics throughout the island provided immunizations. An initial assessment 10 days after Hurricane Maria showed that only 11 (5%) of the clinics were operational. Reasons included ongoing power outages; difficulties in obtaining generator fuel; equipment or facility damage; and damaged vaccines. The VFC clinics were restored incrementally; 123 (55%) were operational by December 2017, 193 (86%) by May 2018, and 204 (91%) by May 2019. Long-term recovery activities are underway and focus on strengthening Puerto Rico's immunization system to withstand future disasters, including improving backup power systems. CONCLUSION: Through coordinated efforts of the Puerto Rico Department of Health, the Centers for Disease Control and Prevention, and other partners, the operational status of VFC clinics posthurricanes was assessed and operations restored. Emergency plans for vaccine storage and handling, which called for alternative vaccine storage locations and backup generators, were inadequate to address disasters of the magnitude of Hurricanes Irma and Maria; such plans need to consider the possibility of large-scale disasters that result in long-term power outages.

    • Informatics
      • Bibliometric analysis of research studies based on federally funded children's health surveysexternal icon
        Lebrun-Harris LA, Parasuraman SR, Norton C, Livinski AA, Ghandour R, Blumberg SJ, Kogan MD.
        Acad Pediatr. 2020 Aug 10.
        OBJECTIVE: Bibliometric analyses are commonly used to measure the productivity of researchers or institutions but rarely used to assess the scientific contribution of national surveys/datasets. We applied bibliometric methods to quantify the contributions of the National Survey of Children's Health (NSCH) and the National Survey of Children with Special Health Care Needs (NS-CSHCN) to the body of pediatric health-related research. We also examined dissemination to non-research audiences by analyzing media coverage of statistics and research produced from the surveys. METHODS: We conducted a search of the Web of Science database to identify peer-reviewed articles related to the NSCH and NS-CSHCN published between 2002 and 2019. We summarized information about citation counts, publishing journals, key research areas, and institutions using the surveys. We used the Lexis Advance database Nexis to assess media coverage. RESULTS: The publication set included 716 NSCH/NS-CSHCN journal articles published between 2002 and June 2019. These publications have in turn been cited 22,449 times, including in 1,614 review articles. Over 180 journals have published NSCH/NS-CSHCN articles, and the most commonly covered research areas are in pediatrics; public, environmental and occupational health; psychology; and health care sciences and services. Over 500 institutions have used NSCH/NS-CSHCN data to publish journal articles, and over 950 news media articles have cited statistics or research produced by the surveys. CONCLUSIONS: NSCH/NS-CSHCN data are widely used by government, academic, and media institutions. Bibliometric methods provide a systematic approach to quantify and describe the contributions to the scientific literature made possible with these data.

    • Occupational Safety and Health
      • Cannabis and work: Need for more researchexternal icon
        Howard J, Osborne J.
        Am J Ind Med. 2020 Aug 14.
        Cannabis sativa is one of the oldest and most widely used plants in the world with a variety of industrial, medical, and nonmedical applications. Despite its long history, cannabis-derived products remain a source of controversy across the fields of medicine, law, and occupational safety and health. More favorable public attitudes about cannabis in the US have resulted in greater access to cannabis through legalization by states, leading to more consumption by workers. As more states adopt cannabis access laws, and as more workers choose to consume cannabis products, the implications for existing workplace policies, programs, and practices become more salient. Past workplace practices were grounded in a time when cannabis consumption was always viewed as problematic, considered a moral failing, and was universally illegal. Shifting cultural views and the changing legal status of cannabis indicate a need for research into the implications and challenges relating to cannabis and work. This commentary suggests research needs in the following areas: (a) data about industries and occupations where cannabis consumption among workers is most prevalent; (b) adverse health consequences of cannabis consumption among workers; (c) workplace supported recovery programs; (d) hazards to workers in the emerging cannabis industry; (e) relationship between cannabis consumption and occupational injuries; (f) ways to assess performance deficits and impairment from cannabis consumption; (g) consumption of synthetic cannabinoids to evade detection by drug testing; (h) cannabis consumption and its effect on occupational driving; and (i) ways to craft workplace policies and practices that take into consideration conflicting state and federal laws pertaining to cannabis.

    • Substance Use and Abuse
      • Distribution of drinks consumed by U.S. adults by average daily alcohol consumption: A comparison of 2 nationwide surveysexternal icon
        Esser MB, Sacks JJ, Sherk A, Karriker-Jaffe KJ, Greenfield TK, Pierannunzi C, Brewer RD.
        Am J Prev Med. 2020 Jul 31.
        INTRODUCTION: Estimates of alcohol consumption in the Behavioral Risk Factor Surveillance System are generally lower than those in other surveys of U.S. adults. This study compares the estimates of adults' drinking patterns and the distribution of drinks consumed by average daily alcohol consumption from 2 nationwide telephone surveys. METHODS: The 2014-2015 National Alcohol Survey (n=7,067) and the 2015 Behavioral Risk Factor Surveillance System (n=408,069) were used to assess alcohol consumption among adults (≥18 years), analyzed in 2019. The weighted prevalence of binge-level drinking and the distribution of drinks consumed by average daily alcohol consumption (low, medium, high) were assessed for the previous 12 months using the National Alcohol Survey and the previous 30 days using the Behavioral Risk Factor Surveillance System, stratified by respondents' characteristics. RESULTS: The prevalence of binge-level drinking in a day was 26.1% for the National Alcohol Survey; the binge drinking prevalence was 17.4% for the Behavioral Risk Factor Surveillance System. The prevalence of high average daily alcohol consumption among current drinkers was 8.2% for the National Alcohol Survey, accounting for 51.0% of total drinks consumed, and 3.3% for the Behavioral Risk Factor Surveillance System, accounting for 27.7% of total drinks consumed. CONCLUSIONS: National Alcohol Survey yearly prevalence estimates of binge-level drinking in a day and high average daily consumption were consistently greater than Behavioral Risk Factor Surveillance System monthly binge drinking and high average daily consumption prevalence estimates. When planning and evaluating prevention strategies, the impact of different survey designs and methods on estimates of excessive drinking and related harms is important to consider.

    • Zoonotic and Vectorborne Diseases
      • National reporting of deaths after enhanced Ebola surveillance in Sierra Leoneexternal icon
        Jalloh MF, Kaiser R, Diop M, Jambai A, Redd JT, Bunnell RE, Castle E, Alpren C, Hersey S, Ekstrom AM, Nordenstedt H.
        PLoS Negl Trop Dis. 2020 Aug 18;14(8):e0008624.
        BACKGROUND: Sierra Leone experienced the largest documented epidemic of Ebola Virus Disease in 2014-2015. The government implemented a national tollfree telephone line (1-1-7) for public reporting of illness and deaths to improve the detection of Ebola cases. Reporting of deaths declined substantially after the epidemic ended. To inform routine mortality surveillance, we aimed to describe the trends in deaths reported to the 1-1-7 system and to quantify people's motivations to continue reporting deaths after the epidemic. METHODS: First, we described the monthly trends in the number of deaths reported to the 1-1-7 system between September 2014 and September 2019. Second, we conducted a telephone survey in April 2017 with a national sample of individuals who reported a death to the 1-1-7 system between December 2016 and April 2017. We described the reported deaths and used ordered logistic regression modeling to examine the potential drivers of reporting motivations. FINDINGS: Analysis of the number of deaths reported to the 1-1-7 system showed that 12% of the expected deaths were captured in 2017 compared to approximately 34% in 2016 and over 100% in 2015. We interviewed 1,291 death reporters in the survey. Family members reported 56% of the deaths. Nearly every respondent (94%) expressed that they wanted the 1-1-7 system to continue. The most common motivation to report was to obey the government's mandate (82%). Respondents felt more motivated to report if the decedent exhibited Ebola-like symptoms (adjusted odds ratio 2.3; 95% confidence interval 1.8-2.9). CONCLUSIONS: Motivation to report deaths that resembled Ebola in the post-outbreak setting may have been influenced by knowledge and experiences from the prolonged epidemic. Transitioning the system to a routine mortality surveillance tool may require a robust social mobilization component to match the high reporting levels during the epidemic, which exceeded more than 100% of expected deaths in 2015.

  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. Using surveillance to determine the number of individuals with sickle cell disease in California and Georgia, 2005-2016external icon
        Aluc A, Zhou M, Paulukonis ST, Snyder AB, Wong D, Hulihan MM.
        Pediatr Hematol Oncol. 2020 Aug 12:1-5.

      2. Global cardiovascular disease prevention and management: A collaboration of key organizations, groups, and investigators in low- and middle-income countriesexternal icon
        Olsen MH, Neupane D, Cobb LK, Frieden TR, Hall B, Lackland DT, Moran AE, Mukhtar Q, Weber M.
        J Clin Hypertens (Greenwich). 2020 Aug 14.

      3. Comparison of alternative full and brief versions of functional status scales among older adults in Chinaexternal icon
        Reich J, Thompson MG, Cowling BJ, Iuliano AD, Greene C, Chen Y, Phadnis R, Leung NH, Song Y, Fang VJ, Xu C, Dai Q, Zhang J, Zhang H, Havers F.
        PLoS One. 2020 ;15(8):e0234698.
        BACKGROUND: Brief assessments of functional status for community-dwelling older adults are needed given expanded interest in the measurement of functional decline. METHODS: As part of a 2015 prospective cohort study of older adults aged 60-89 years in Jiangsu Province, China, 1506 participants were randomly assigned to two groups; each group was administered one of two alternative 20-item versions of a scale to assess activities of daily living (ADL) and instrumental activities of daily living (IADL) drawn from multiple commonly-used scales. One version asked if they required help to perform activities (ADL-IADL-HELP-20), while the other version provided additional response options if activities could be done alone but with difficulty (ADL-IADL-DIFFICULTY-20). Item responses to both versions were compared using the binomial test for differences in proportion (with Wald 95% confidence interval [CI]). A brief 9-item scale (ADL-IADL-DIFFICULTY-9) was developed favoring items identified as difficult or requiring help by ≥4%, with low redundancy and/or residual correlations, and with significant correlations with age and other health indicators. We repeated assessment of the measurement properties of the brief scale in two subsequent samples of older adults in Hong Kong in 2016 (aged 70-79 years; n = 404) and 2017 (aged 65-82 years; n = 1854). RESULTS: Asking if an activity can be done alone but with difficulty increased the proportion of participants reporting restriction on 9 of 20 items, for which 95% CI for difference scores did not overlap with zero; the proportion with at least one limitation increased from 28.6% to 34.2% or an absolute increase of 5.6% (95% CI = 0.9-10.3%), which was a relative increase of 19.6%. The brief ADL-IADL-DIFFICULTY-9 maintained excellent internal consistency (α = 0.93) and had similar ceiling effect (68.1%), invariant item ordering (H trans = .41; medium), and correlations with age and other health measures compared with the 20-item version. The brief scale performed similarly when subsequently administered to older adults in Hong Kong. CONCLUSIONS: Asking if tasks can be done alone but with difficulty can modestly reduce ceiling effects. It's possible that the length of commonly-used scales can be reduced by over half if researchers are primarily interested in a summed indicator rather than an inventory of specific types of deficits.

      4. OBJECTIVES: To understand older adults' attitudes about future mobility and usefulness of mobility assessment materials. METHODS: Data came from a telephone survey of 1,000 older adults aged 60-74 years. After answering baseline questions, respondents received mobility assessment materials, then completed follow-up interviews. Respondents were asked about future mobility challenges. During baseline and follow-up, subjects were asked four questions about their mobility as they aged which measured thinking about mobility, thinking about protecting mobility, confidence in protecting mobility, and motivation to protect mobility. Differences in percent of respondents' attitudes between baseline and follow-up and 95% confidence intervals were calculated. RESULTS: Driving (42%) was the most commonly reported challenge. Significant increases from baseline to follow-up in thinking about mobility (25%), thinking about protecting mobility (39%), and confidence in protecting mobility (29%) were reported. DISCUSSION: Brief mobility assessment materials can encourage older adults to consider future mobility. Planning for changes can prolong safe mobility.

    • Communicable Diseases
      1. Corticosteroids added to initial intravenous immunoglobulin treatment for the prevention of coronary artery abnormalities in high-risk patients with Kawasaki diseaseexternal icon
        Ae R, Abrams JY, Maddox RA, Schonberger LB, Nakamura Y, Kuwabara M, Makino N, Matsubara Y, Kosami K, Sasahara T, Belay ED.
        J Am Heart Assoc. 2020 Aug 19:e015308.
        BACKGROUND Randomized controlled trials previously provided different conclusions about the superiority of adding corticosteroids to initial intravenous immunoglobulin treatment for the prevention of coronary artery abnormalities in patients with Kawasaki disease (KD). To further assess this issue, we analyzed large-scale data from nationwide KD surveys in Japan, where combination treatment (corticosteroids added to initial standard intravenous immunoglobulin treatment) has become commonly used for patients at high risk for KD. METHODS AND RESULTS Standard intravenous immunoglobulin treatment and combination treatment were compared using data from time periods with and without combination treatment. Outcome measures were coronary artery abnormalities and initial intravenous immunoglobulin treatment failure. Hospitals where ≥20% of patients received combination treatment were identified, and treatment and control groups were selected via matching by age, sex, illness day at initial treatment, and KD recurrence. Matched group selection and subsequent analyses were conducted 1000 times to minimize sampling bias and potential confounders (bootstrapping). From 115 hospitals, 1593 patients with KD in the treatment group and 1593 controls were selected for each of the 1000 sample iterations. The median proportion of patients who developed coronary artery abnormalities among the treatment group and controls were 4.6% (95% CI, 3.8%-5.8%) and 8.8% (95% CI, 7.5%-10.0%), respectively: an estimated risk ratio of 0.53 (0.41-0.67). A median of 14.1% (95% CI, 12.4%-15.9%) of the patients in the treatment group and 21.7% (95% CI, 19.8%-23.4%) in the controls had treatment failure: an estimated risk ratio of 0.65 (0.56-0.75). CONCLUSIONS Combination treatment reduced coronary artery abnormality risk by an estimated 47% and treatment failure by 35%. Multiple-dose corticosteroids may provide benefit in selected patients at high risk for KD.

      2. Trends in hepatitis B surveillance among pregnant women in New York City, 1998-2015external icon
        Arciuolo RJ, Lazaroff JE, Rosen JB, Lim S, Zucker JR.
        Public Health Rep. 2020 Aug 14.
        OBJECTIVE: Infants born to women with hepatitis B virus (HBV) infection are at high risk for chronic HBV infection and premature death. We examined epidemiologic trends among women with HBV infection who gave birth in New York City (NYC) to inform public health prevention activities. METHODS: We obtained data on HBV-infected women residing and giving birth in NYC during 1998-2015 from the NYC Perinatal HBV Prevention Program. We obtained citywide birth data from the NYC Office of Vital Statistics. We calculated the incidence of births to HBV-infected women per 100 000 live births and stratified by maternal race, birthplace, and age. We calculated annual percentage change (APC) in incidence of births to HBV-infected women by using joinpoint regression. RESULTS: Of 29 896 HBV-infected women included in the study, 28 195 (94.3%) were non-US-born, of whom 16 600 (58.9%) were born in China. Overall incidence of births to HBV-infected women per 100 000 live births increased from 1156 in 1998 to 1573 in 2006 (APC = 3.1%; P < .001) but declined to 1329 in 2015 (APC = -1.4%; P = .02). Incidence among US-born women declined from 1998 to 2015 (330 to 84; APC = -7.3%; P < .001) and among non-US-born women increased from 1998 to 2007 (1877 to 2864; APC = 3.6%; P < .001) but not thereafter. Incidence among women born in China increased from 1998 to 2006 (13 275 to 16 480; APC = 1.8%; P = .02) but decreased to 12 631 through 2015 (APC = -3.3%; P < .001). CONCLUSIONS: The incidence of births to HBV-infected women in NYC declined significantly among US-born women but not among non-US-born women, highlighting the need for successful vaccination programs worldwide.

      3. Accuracy of HBeAg to identify pregnant women at risk of transmitting hepatitis B virus to their neonates: a systematic review and meta-analysisexternal icon
        Boucheron P, Lu Y, Yoshida K, Zhao T, Funk AL, Lunel-Fabiani F, Guingané A, Tuaillon E, van Holten J, Chou R, Bulterys M, Shimakawa Y.
        Lancet Infect Dis. 2020 Aug 14.
        BACKGROUND: Prevention of mother-to-child transmission (MTCT) of hepatitis B virus (HBV) involves neonatal immunoprophylaxis, with a birth dose of hepatitis B vaccine and immune globulin, and provision of peripartum antiviral prophylaxis in highly viraemic women. However, access to assays to quantify HBV DNA levels remains inadequate in resource-poor settings. This study was commissioned by WHO and aimed to identify the HBV DNA threshold for MTCT, to assess the sensitivity and specificity of hepatitis B e antigen (HBeAg) testing to identify pregnant women with HBV DNA levels above this threshold, and to predict MTCT of HBV infection on the basis of HBeAg testing. METHODS: For this systematic review and meta-analysis, we searched the PubMed, EMBASE, Scopus, CENTRAL, CNKI, and Wanfang databases for studies of pregnant women with chronic HBV infection without concurrent antiviral therapy, published between Jan 1, 2000, and April 3, 2019. Studies were eligible for inclusion if MTCT in mother-child pairs could be stratified by different levels of maternal HBV DNA during pregnancy, if maternal HBeAg status could be stratified by HBV DNA level, and if the MTCT status of infants could be stratified by maternal HBeAg status during pregnancy. Studies that selected pregnant women on the basis of HBeAg serostatus or HBV DNA levels were excluded. Aggregate data were extracted from eligible studies by use of a pre-piloted form; study authors were contacted to clarify any uncertainties about potential duplication or if crucial information was missing. To pool sensitivities and specificities of maternal HBeAg to identify highly viraemic women and to predict MTCT events, we used the DerSimonian-Laird bivariate random effects model. This study is registered with PROSPERO, CRD42019138227. FINDINGS: Of 9007 articles identified, 67 articles (comprising 66 studies) met the inclusion criteria. The risk of MTCT despite infant immunoprophylaxis was negligible (0·04%, 95% CI 0·00-0·25) below a maternal HBV DNA level of 5·30 log(10) IU/mL (200 000 IU/mL) and increased above this threshold. The pooled sensitivity of HBeAg testing to identify HBV DNA levels of 5·30 log(10) IU/mL or greater in pregnant women was 88·2% (83·9-91·5) and pooled specificity was 92·6% (90·0-94·5). The pooled sensitivity of HBeAg testing in predicting MTCT of HBV infection despite infant immunoprophylaxis was 99·5% (95% CI 91·7-100) and pooled specificity was 62·2% (55·2-68·7). INTERPRETATION: Maternal HBV DNA of 5·30 log(10) IU/mL or greater appears to be the optimal threshold for MTCT of HBV infection despite infant immunoprophylaxis. HBeAg is accurate to identify women with HBV DNA levels above this threshold and has high sensitivity to predict cases of immunoprophylaxis failure. In areas where HBV DNA assays are unavailable, HBeAg can be used as an alternative to assess eligibility for antiviral prophylaxis. FUNDING: World Health Organization.

      4. Treatment of chronic viral hepatitis C (HCV) infection with direct-acting antiviral agents (DAAs) results in cure, or sustained viral response (SVR), in more than 90% of patients. However, there are subsets of patients who have persistent liver inflammation and fibrosis and develop hepatocellular carcinoma (HCC) despite achieving SVR. A possible reason for these phenomena may be the presence of virus particles in liver tissue but not blood, otherwise defined as occult infection. OBJECTIVE: To describe liver histologic findings following successful DAA therapy, test HCV RNA by (liver) tissue polymerase chain reaction in treated cases, and identify predictive markers for HCC development in treated cases. DESIGN. A total of 96 identified patients were divided into 4 groups, each differentiated by the presence or absence of SVR and HCC. Groups were compared for several clinicopathologic variablesincluding degree of inflammation and fibrosis, and the 'directionality' of fibrosis in cirrhotic livers using the novel progressive-indeterminate-regressive scoring system. RESULTS: Overall, we found a significant decrease in inflammation in SVR patients. None of the patients showed regression of their cirrhosis following treatment. No evidence of occult HCV infection was seen in 40 livers tested, including 21 with HCC. The number of patients who developed HCC was similar in the SVR and non-SVR groups, and increased inflammation and fibrosis were associated with HCC development. CONCLUSIONS. Following DAA-SVR there appears to be an overall decrease in inflammation, but the fibrosis tends to persist, at least in the short term (median follow-up of 20.2 months).

      5. Progress toward hepatitis B and hepatitis C elimination using a catalytic funding model - Tashkent, Uzbekistan, December 6, 2019-March 15, 2020external icon
        Dunn R, Musabaev E, Razavi H, Sadirova S, Bakieva S, Razavi-Shearer K, Brigida K, Kamili S, Averhoff F, Nasrullah M.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 28;69(34):1161-1165.
        In 2016, the World Health Organization (WHO) set hepatitis elimination targets of 90% reduction in incidence and 65% reduction in mortality worldwide by 2030 (1). Hepatitis B virus (HBV) and hepatitis C virus (HCV) infection prevalences are high in Uzbekistan, which lacks funding for meeting WHO's targets. In the absence of large financial donor programs for eliminating HBV and HCV infections, insufficient funding is an important barrier to achieving those targets in Uzbekistan and other low- and middle-income countries. A pilot program using a catalytic funding model, including simplified test-and-treat strategies, was launched in Tashkent, Uzbekistan, in December 2019. Catalytic funding is a mechanism by which the total cost of a program is paid for by multiple funding sources but is begun with upfront capital that is considerably less than the total program cost. Ongoing costs, including those for testing and treatment, are covered by payments from 80% of the enrolled patients, who purchase medications at a small premium that subsidizes the 20% who cannot afford treatment and therefore receive free medication. The 1-year pilot program set a target of testing 250,000 adults for HBV and HCV infection and treating all patients who have active infection, including those who had a positive test result for hepatitis B surface antigen (HBsAg) and those who had a positive test result for HCV core antigen. During the first 3 months of the program, 24,821 persons were tested for HBV and HCV infections. Among those tested, 1,084 (4.4%) had positive test results for HBsAg, and 1,075 (4.3%) had positive test results for HCV antibody (anti-HCV). Among those infected, 275 (25.4%) initiated treatment for HBV, and 163 (15.2%) initiated treatment for HCV, of whom 86.5% paid for medications and 13.5% received medications at no cost. Early results demonstrate willingness of patients to pay for treatment if costs are low, which can offset elimination costs. However, improvements across the continuum of care are needed to recover the upfront investment. Lessons learned from this program, including the effectiveness of using simplified test-and-treat guidelines, general practitioners in lieu of specialist physicians, and innovative financing to reduce costs, can guide similar initiatives in other countries and help curb the global epidemic of viral hepatitis, especially among low- and middle-income countries.

      6. A new method for estimating HIV incidence from a single cross-sectional surveyexternal icon
        Fellows IE, Shiraishi RW, Cherutich P, Achia T, Young PW, Kim AA.
        PLoS One. 2020 ;15(8):e0237221.
        Estimating incidence from cross-sectional data sources is both important to the understanding of the HIV epidemic and challenging from a methodological standpoint. We develop a new incidence estimator that measures the size of the undiagnosed population and the amount of time spent undiagnosed in order to infer incidence and transmission rates. The estimator is calculated using commonly collected information on testing history and HIV status and, thus, can be deployed in many HIV surveys without additional cost. If ART biomarker status and/or viral load information is available, the estimator can be adjusted for biases in self-reported testing history. The performance of the estimator is explored in two large surveys in Kenya, where we find our point estimates to be consistent with assay-derived estimates, with much smaller standard errors.

      7. Alcohol use among HIV-positive women of childbearing age, United States, 2013-2014external icon
        Frazier EL, Esser MB, McKnight-Eily LR, Zhou W, Chavez PR.
        AIDS Care. 2020 Aug 18:1-13.
        More than one-quarter of the adults living with diagnosed HIV infection in the US are women. Binge drinking (i.e., ≥4 alcoholic drinks per occasion for women) is associated with poor HIV treatment compliance, HIV incidence, and unplanned pregnancy. However, little is known about the prevalence of binge drinking among women of childbearing age who are living with HIV (WLWH) and health risk behaviours among those who binge drink. Using the 2013-2014 data cycles of Medical Monitoring Project, we assessed the weighted prevalence of drinking patterns by socio-demographic, clinical and reproductive characteristics of 946 WLWH. Logistic regression was used to calculate unadjusted and adjusted prevalence ratios and 95% confidence intervals. Overall, 39% of WLWH reported current drinking and 10% reported binge drinking. Compared to non-drinkers, binge drinkers were less likely to adhere to antiretroviral therapy (ART) or be virally suppressed. In multivariate analyses, binge drinking among WLWH was associated with smoking, drug use, and reduced ART adherence compared to non-drinkers, increasing the likelihood of negative clinical outcomes. WLWH may benefit from a comprehensive approach to reducing binge drinking including alcohol screening and brief interventions and evidence-based policy strategies that could potentially improve adherence to HIV treatment.

      8. Efficacy and safety of antiviral prophylaxis during pregnancy to prevent mother-to-child transmission of hepatitis B virus: a systematic review and meta-analysisexternal icon
        Funk AL, Lu Y, Yoshida K, Zhao T, Boucheron P, van Holten J, Chou R, Bulterys M, Shimakawa Y.
        Lancet Infect Dis. 2020 Aug 14.
        BACKGROUND: To eliminate mother-to-child transmission (MTCT) of hepatitis B virus (HBV), peripartum antiviral prophylaxis might be required for pregnant women infected with HBV who have a high risk of MTCT despite infant immunoprophylaxis. We aimed to determine the efficacy and safety of peripartum antiviral prophylaxis to inform the 2020 WHO guidelines. METHODS: In this systematic review and meta-analysis, we searched PubMed, Embase, Scopus, CENTRAL, CNKI, and Wanfang for randomised controlled trials and non-randomised studies of peripartum antiviral prophylaxis versus placebo or no prophylaxis, with no language restriction, published from database inception until March 28, 2019. We used search terms covering HBV, antiviral therapy, and pregnancy. We included studies that enrolled pregnant women with chronic infection with HBV who received antiviral prophylaxis anytime during pregnancy; that included any of the following antivirals: adefovir, emtricitabine, entecavir, lamivudine, telbivudine, tenofovir alafenamide fumarate, and tenofovir disoproxil fumarate; and that reported the following outcomes: MTCT, indicated by infant HBsAg positivity or HBV DNA positivity, or both, at age 6-12 months, and any infant or maternal adverse events. Two reviewers independently extracted data. Our primary endpoint was MTCT based on infant HBsAg positivity. We assessed pooled odds ratios (ORs) of the efficacy of peripartum antiviral prophylaxis to reduce the risk of MTCT. We assessed safety of prophylaxis by pooling risk differences. The protocol for the systematic review was pre-registered in PROSPERO, CRD42019134614. FINDINGS: Of 7463 articles identified, 595 articles were eligible for full-text review and 129 studies (in 157 articles) were included. The following antivirals were assessed in the meta-analysis: tenofovir disoproxil fumarate 300 mg (19 studies, with 1092 mothers and 1072 infants), lamivudine 100-150 mg (40 studies, with 2080 mothers and 2007 infants), and telbivudine 600 mg (83 studies, with 6036 mothers and 5971 infants). The pooled ORs for randomised controlled trials were similar, at 0·10 (95% CI 0·03-0·35) for tenofovir disoproxil fumarate, 0·16 (0·10-0·26) for lamivudine, and 0·14 (0·09-0·21) for telbivudine. The pooled ORs in non-randomised studies were 0·17 (0·10-0·29) for tenofovir disoproxil fumarate, 0·17 (0·12-0·24) for lamivudine, and 0·09 (0·06-0·12) for telbivudine. We found no increased risk of any infant or maternal safety outcomes after peripartum antiviral prophylaxis. INTERPRETATION: Peripartum antiviral prophylaxis is highly effective at reducing the risk of HBV MTCT. Our findings support the 2020 WHO recommendation of administering antivirals during pregnancy, specifically tenofovir disoproxil fumarate, for the prevention of HBV MTCT. FUNDING: World Health Organization.

      9. Modeling the impact of PrEP programs for adolescent sexual minority males based on empirical estimates for the PrEP continuum of careexternal icon
        Hamilton DT, Rosenberg ES, Sullivan PS, Wang LY, Dunville RL, Barrios LC, Aslam M, Mustanski B, Goodreau SM.
        J Adolesc Health. 2020 Aug 11.
        PURPOSE: Pre-exposure prophylaxis (PrEP)-an effective and safe intervention to prevent HIV transmission-was recently approved by the Food and Drug Administration for use by adolescents. Informed by studies of sexual behavior and PrEP adherence, retention, and promotion, we model the potential impact of PrEP use among at-risk adolescent sexual minority males. METHODS: We simulate an HIV epidemic among men who have sex with men (MSM) aged 13-39. We assume adult MSM ages 19-39 have had PrEP available for 3 years with 20% coverage among eligible MSM based on the Centers for Disease Control and Prevention guidelines. PrEP interventions for ages 16-18 are then simulated using adherence and retention profiles drawn from the ATN113 and Enhancing Preexposure Prophylaxis in Community studies across a range of uptake parameters (10%-100%). Partnerships across age groups were modeled using parameterizations from the RADAR study. We compare the percent of incident infections averted (impact), person-years on PrEP per infection averted (efficiency), and changes in prevalence over 10 years. RESULTS: As compared to no PrEP use, baseline PrEP adherence and retention among adolescent sexual minority males drawn from the ATN113 and Enhancing Preexposure Prophylaxis in Community studies averted from 2.8% to 41.0% of HIV infections depending on the fraction of eligible adolescent sexual minority males that initiated PrEP at their annual health-care visit. Improved adherence and retention achieved with an array of focused interventions from real-world settings increased the percent of infections averted by as much as 26%-70%. CONCLUSIONS: Empirically demonstrated improvements in the PrEP continuum of care in response to existing interventions can substantially reduce incident HIV infections among adolescent sexual minority males.

      10. COVID-19 among American Indian and Alaska Native persons - 23 states, January 31-July 3, 2020external icon
        Hatcher SM, Agnew-Brune C, Anderson M, Zambrano LD, Rose CE, Jim MA, Baugher A, Liu GS, Patel SV, Evans ME, Pindyck T, Dubray CL, Rainey JJ, Chen J, Sadowski C, Winglee K, Penman-Aguilar A, Dixit A, Claw E, Parshall C, Provost E, Ayala A, Gonzalez G, Ritchey J, Davis J, Warren-Mears V, Joshi S, Weiser T, Echo-Hawk A, Dominguez A, Poel A, Duke C, Ransby I, Apostolou A, McCollum J.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 28;69(34):1166-1169.
        Although non-Hispanic American Indian and Alaska Native (AI/AN) persons account for 0.7% of the U.S. population,* a recent analysis reported that 1.3% of coronavirus disease 2019 (COVID-19) cases reported to CDC with known race and ethnicity were among AI/AN persons (1). To assess the impact of COVID-19 among the AI/AN population, reports of laboratory-confirmed COVID-19 cases during January 22(†)-July 3, 2020 were analyzed. The analysis was limited to 23 states(§) with >70% complete race/ethnicity information and five or more laboratory-confirmed COVID-19 cases among both AI/AN persons (alone or in combination with other races and ethnicities) and non-Hispanic white (white) persons. Among 424,899 COVID-19 cases reported by these states, 340,059 (80%) had complete race/ethnicity information; among these 340,059 cases, 9,072 (2.7%) occurred among AI/AN persons, and 138,960 (40.9%) among white persons. Among 340,059 cases with complete patient race/ethnicity data, the cumulative incidence among AI/AN persons in these 23 states was 594 per 100,000 AI/AN population (95% confidence interval [CI] = 203-1,740), compared with 169 per 100,000 white population (95% CI = 137-209) (rate ratio [RR] = 3.5; 95% CI = 1.2-10.1). AI/AN persons with COVID-19 were younger (median age = 40 years; interquartile range [IQR] = 26-56 years) than were white persons (median age = 51 years; IQR = 32-67 years). More complete case report data and timely, culturally responsive, and evidence-based public health efforts that leverage the strengths of AI/AN communities are needed to decrease COVID-19 transmission and improve patient outcomes.

      11. Uptake and retention on HIV pre-exposure prophylaxis among key and priority populations in South-Central Ugandaexternal icon
        Kagaayi J, Batte J, Nakawooya H, Kigozi B, Nakigozi G, Stromdahl S, Ekstrom AM, Chang LW, Gray R, Reynolds SJ, Komaketch P, Alamo S, Serwadda D.
        J Int AIDS Soc. 2020 Aug;23(8):e25588.
        INTRODUCTION: Pre-exposure prophylaxis (PrEP) programmes have been initiated in sub-Saharan Africa to prevent HIV acquisition in key populations at increased risk. However, data on PrEP uptake and retention in high-risk African communities are limited. We evaluated PrEP uptake and retention in HIV hyperendemic fishing villages and trading centres in south-central Uganda between April 2018 and March 2019. METHODS: PrEP eligibility was assessed using a national risk screening tool. Programme data were used to evaluate uptake and retention over 12 months. Multivariable modified Poisson regression estimated adjusted prevalence ratios (aPR) and 95% Confidence intervals (CIs) of uptake associated with covariates. We used Kaplan-Meier analysis to estimate retention and multivariable Cox regression to estimate adjusted relative hazards (aRH) and 95% CIs of discontinuation associated with covariates. RESULTS AND DISCUSSION: Of the 2985 HIV-negative individuals screened; 2750 (92.1 %) were eligible; of whom 2,536 (92.2%) accepted PrEP. Male (aPR = 0.91, 95% CI = 0.85 to 0.97) and female (aPR = 0.85, 95% CI = 0.77 to 0.94) fisher folk were less likely to accept compared to HIV-discordant couples. Median retention was 45.4 days for both men and women, whereas retention was higher among women (log rank, p < 0.001) overall. PrEP discontinuation was higher among female sex workers (aRH = 1.42, 95% CI = 1.09 to 1.83) and female fisher folk (aRH = 1.99, 95% CI = 1.46 to 2.72), compared to women in discordant couples. Male fisher folk (aRH = 1.37, 95% CI = 1.07 to 1.76) and male truck drivers (aRH = 1.49, 95% CI = 1.14 to 1.94) were more likely to discontinue compared to men in discordant couples. Women 30 to 34 years tended to have lower discontinuation rates compared to adolescents 15 to 19 years (RH = 0.78 [95% CI = 0.63 to 0.96]). CONCLUSIONS: PrEP uptake was high, but retention was very low especially among those at the highest risk of HIV: fisher folk, sex workers and truck drivers and adolescent girls. Research on reasons for PrEP discontinuation could help optimize retention.

      12. The epidemiology of HIV among people born outside the United States, 2010-2017external icon
        Kerani RP, Satcher Johnson A, Buskin SE, Rao D, Golden MR, Hu X, Hall HI.
        Public Health Rep. 2020 Aug 17.
        OBJECTIVE: Although some studies have reported a higher incidence of HIV infection among non-US-born people than among US-born people, national data on this topic are scarce. We compared the epidemiology of HIV infection between US-born and non-US-born residents of the United States and examined the characteristics of non-US-born people with diagnosed HIV infection by region of birth (ROB). METHODS: We used a cross-sectional study design to produce national, population-based data describing HIV infection among US-born and non-US-born people. We analyzed National HIV Surveillance System data for people with HIV infection diagnosed during 2010-2017 and reported to the Centers for Disease Control and Prevention (CDC). We compared data on demographic characteristics, transmission risk category, and stage 3 infection (AIDS) classification within 3 months of HIV diagnosis, by nativity and ROB. RESULTS: During 2010-2017, 328 317 children and adult US residents were diagnosed with HIV infection and were reported to CDC: 214 973 (65.5%) were US-born, 50 301 (15.3%) were non-US-born, and 63 043 (19.2%) were missing data on country of birth. After adjusting for missing country of birth, 266 147 (81.1%) people were US-born and 62 170 (18.9%) were non-US-born. This group accounted for 15 928 of 65 645 (24.2%) HIV diagnoses among girls and women and 46 242 of 262 672 (17.6%) HIV diagnoses among boys and men. A larger percentage of non-US-born people than US-born people had stage 3 infection (AIDS) at HIV diagnosis (31.2% vs 23.9%). Among non-US-born people with HIV diagnoses, 19 876 (39.5%) resided in the South. CONCLUSIONS: Characterizing non-US-born people with HIV infection is essential for developing effective HIV interventions, particularly in areas with large immigrant populations.

      13. Genomic surveillance of Streptococcus pyogenes strains causing invasive disease, United States, 2016–2017external icon
        Li Y, Rivers J, Mathis S, Li Z, Velusamy S, Nanduri SA, Van Beneden CA, Snippes-Vagnone P, Lynfield R, McGee L, Chochua S, Metcalf BJ, Beall B.
        Front Microbiol. 2020 ;11.
        Background: Streptococcus pyogenes is a major cause of severe, invasive infections in humans. The bacterial pathogen harbors a wide array of virulence factors and exhibits high genomic diversity. Rapid changes of circulating strains in a community are common. Understanding the current prevalence and dynamics of S. pyogenes lineages could inform vaccine development and disease control strategies. Methods: We used whole-genome sequencing (WGS) to characterize all invasive S. pyogenes isolates obtained through the United States Center for Disease Control and Prevention’s Active Bacterial Core surveillance (ABCs) in 2016 and 2017. We determined the distribution of strain features, including emm type, antibiotic resistance determinants, and selected virulence factors. Changes in strain feature distribution between years 2016 and 2017 were evaluated. Phylogenetic analysis was used to identify expanding lineages within emm type. Results: Seventy-one emm types were identified from 3873 isolates characterized. The emm types targeted by a 30-valent M protein-based vaccine accounted for 3230 (89%) isolates. The relative frequencies of emm types collected during the 2 years were similar. While all isolates were penicillin-susceptible, erythromycin-resistant isolates increased from 273 (16% of 2016 isolates) to 432 (23% of 2017 isolates), mainly driven by increase of the erm-positive emm types 92 and 83. The prevalence of 24 virulence factors, including 11 streptococcal pyrogenic toxins, ranged from 6 to 90%. In each of three emm types (emm 49, 82, and 92), a subgroup of isolates significantly expanded between 2016 and 2017 compared to isolates outside of the subgroup (P-values < 0.0001). Specific genomic sequence changes were associated with these expanded lineages. Conclusions: While the overall population structure of invasive S. pyogenes isolates in the United States remained stable, some lineages, including several that were antibiotic-resistant, increased between 2016 and 2017. Continued genomic surveillance can help monitor and characterize bacterial features associated with emerging strains from invasive infections.

      14. Limited secondary transmission of SARS-CoV-2 in child care programs - Rhode Island, June 1-July 31, 2020external icon
        Link-Gelles R, DellaGrotta AL, Molina C, Clyne A, Campagna K, Lanzieri TM, Hast MA, Palipudi K, Dirlikov E, Bandy U.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 28;69(34):1170-1172.
        On June 1, 2020, with declines in coronavirus disease 2019 (COVID-19) cases and hospitalizations in Rhode Island,* child care programs in the state reopened after a nearly 3-month closure implemented as part of mitigation efforts. To reopen safely, the Rhode Island Department of Human Services (RIDHS) required licensed center- and home-based child care programs to reduce enrollment, initially to a maximum of 12 persons, including staff members, in stable groups (i.e., staff members and students not switching between groups) in physically separated spaces, increasing to a maximum of 20 persons on June 29. Additional requirements included universal use of masks for adults, daily symptom screening of adults and children, and enhanced cleaning and disinfection according to CDC guidelines.(†) As of July 31, 666 of 891 (75%) programs were approved to reopen, with capacity for 18,945 children, representing 74% of the state's January 2020 child care program population (25,749 children).

      15. Implementation of universal HIV testing and treatment to reduce HIV incidence in Botswana: the Ya Tsie Studyexternal icon
        Lockman S, Holme MP, Makhema J, Bachanas P, Moore J, Wirth KE, Lebelonyane R, Essex M.
        Curr HIV/AIDS Rep. 2020 Aug 14.
        PURPOSE OF REVIEW: Antiretroviral treatment (ART) can dramatically reduce the risk of HIV transmission, but the feasibility of scaling up HIV testing, linkage and treatment to very high population levels, and its impact on population HIV incidence, were unknown. We review key findings from a community-randomized trial in which we evaluated the impact of "universal test and treat" (UTT) on population HIV incidence in Botswana, a resource-constrained country with both high HIV prevalence and high ART coverage before study inception. RECENT FINDINGS: We conducted a community-randomized trial (the "Ya Tsie" trial or Botswana Combination Prevention Project (BCPP)) in 30 villages in Botswana from 2013 to 2018, with the goal of determining whether a combination of prevention interventions-with a focus on universal HIV testing and treatment-would reduce population-level HIV incidence. The intervention included universal HIV testing (home-based and mobile), active linkage to HIV care and treatment with patient tracing for persons not linking, universal ART coverage, rapid ART start (at the first clinic visit), and enhanced male circumcision services. Botswana had very high HIV diagnosis, treatment, and viral suppression levels (approaching the UNAIDS "90-90-90" targets) prior to intervention roll-out. By study end, we were able to exceed the overall 95-95-95 coverage target of 86%: an estimated 88% of all persons living with HIV were on ART and had viral suppression in the Ya Tsie intervention arm. In addition, annual HIV incidence was 30% lower in the intervention arm as compared with the control arm over a 29-month follow-up period. With universal HIV testing and relatively simple linkage activities, it was possible to achieve one of the highest reported population levels of HIV diagnosis, linkage to care, and viral suppression globally and to reduce population HIV incidence by about one-third over a short period of time (< 3 years). We were able to significantly increase population viral suppression and to decrease HIV incidence even in a resource-constrained setting with pre-existing very high testing and treatment coverage. Universal community-based HIV testing and tracing of individuals through the HIV care cascade were key intervention components.

      16. Notes from the field: Universal statewide laboratory testing for SARS-CoV-2 in nursing homes - West Virginia, April 21-May 8, 2020external icon
        McBee SM, Thomasson ED, Scott MA, Reed CL, Epstein L, Atkins A, Slemp CC.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 28;69(34):1177-1179.

      17. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Conflicts of Interest and Source of Funding: There are none to declare. The research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      18. Hepatitis A virus survival on drug paraphernaliaexternal icon
        Medrzycki M, Kamili S, Purdy MA.
        J Viral Hepat. 2020 Aug 18.
        The ongoing hepatitis A outbreaks in multiple states in the United States have concerned public health authorities since March 2017. The outbreaks have spread throughout 30 states and include primarily persons who use drugs, including persons who inject drugs (PWID) and persons experiencing homelessness. Contaminated drug injection paraphernalia and sharing of these items could potentially aid in transmission of hepatitis A virus (HAV) among these populations. We examined HAV survival on drug paraphernalia frequently shared among PWIDs. The effect of low pH on HAV survival using citric acid, which is frequently used by PWIDs during dose preparation, was investigated. We compared the plaque assay results with those concurrently obtained by qRT-PCR to establish whether HAV RNA levels could be used as surrogates for plaque assay results. HAV suspended in minimal essential media at room temperature infected FRhK4 cells for more than 17 weeks. HAV remained viable in syringes/needles for up to 10 weeks depending on the gauge of the needles and the syringe dead-volumes, and on cookers, tourniquets and cotton balls/filter surfaces for up to 4 weeks. HAV retained its infectivity for more than 10 weeks at pH as low as 2. In conclusion, our findings show that HAV survives and remains infective in or on injection drug use equipment for 1 to 10 weeks depending on the type of paraphernalia examined and environmental conditions. These findings suggest that contaminated drug paraphernalia can potentially facilitate the transmission of HAV within populations who share these items.

      19. Travel-related hepatitis E: a two decade GeoSentinel analysisexternal icon
        Nicolini LA, Stoney RJ, Vecchia AD, Grobusch M, Gautret P, Angelo KM, van Genderen PJ, Bottieau E, Leder K, Asgeirsson H, Leung D, Connor B, Pandey P, Toscanini F, Gobbi F, Castelli F, Bassetti M, Hamer DH.
        J Travel Med. 2020 Aug 12.
        BACKGROUND: Hepatitis E virus (HEV) is widely distributed worldwide and is endemic in developing countries. Travel-related HEV infection has been reported at national levels, but global data are missing. Moreover, the global availability of HEV diagnostic testing has not been explored so far. The aim of this study is to describe the epidemiology of hepatitis E virus (HEV) infections in returning travelers and availability of HEV diagnostic testing in the GeoSentinel surveillance network. METHODS: This was a multicenter retrospective cross-sectional study. All confirmed and probable HEV travel-related infections reported in the GeoSentinel Network between 1999 and 2018 were evaluated. GeoSentinel sites were asked to complete a survey in 2018 to assess the availability and accessibility of HEV diagnostic procedures (i.e. serology and molecular tests) throughout the study period. RESULTS: Overall, 165 travel related HEV infections were reported, mainly since 2010 (60%) and in tourists (50%). Travelers were exposed to hepatitis E in 27 countries; most travellers (62%) were exposed to HEV in South Asia. One patient was pregnant at the time of HEV infection and 14 had a concomitant gastrointestinal infection. No deaths were reported. In the 51% of patients with information available, there was no pre-travel consultation. Among 44 GeoSentinel sites that responded to the survey, 73% have access to HEV serology at a local level, while 55% could perform (at a local or central level) molecular diagnostics. CONCLUSION: Reported access to HEV diagnostic testing is suboptimal among sites that responded to the survey; this could negatively affect diagnosing HEV. Pre-travel consultations before travel to South Asia and other low income and high prevalence areas with a focus on food and water precautions could be helpful in preventing hepatitis E infection. Improved HEV diagnostic capacity should be implemented to prevent and correctly diagnose travel-related HEV infection.

      20. Timing of antiretroviral therapy initiation and risk of cancer among persons living with HIVexternal icon
        Silverberg MJ, Leyden W, Hernández-Ramírez RU, Qin L, Lin H, Justice AC, Hessol NA, Achenbach CJ, D'Souza G, Engels EA, Althoff KN, Mayor AM, Sterling TR, Kitahata MM, Bosch RJ, Saag MS, Rabkin CS, Horberg MA, Gill MJ, Grover S, Mathews WC, Li J, Crane HM, Gange SJ, Lau B, Moore RD, Dubrow R, Neugebauer RS.
        Clin Infect Dis. 2020 Aug 12.
        BACKGROUND: Persons living with HIV (PLWH) experience a high burden of cancer. It remains unknown which cancer types are reduced in PLWH with earlier initiation of antiretroviral therapy (ART). METHODS: We evaluated AIDS-free, ART-naive PLWH during 1996-2014 from 22 cohorts participating in the North American AIDS Cohort Collaboration on Research and Design. PLWH were followed from first observed CD4 of 350-500 cells/µl (baseline) until incident cancer, death, lost-to-follow-up or December 2014. Outcomes included six cancer groups and five individual cancers that were confirmed by chart review or cancer registry linkage. We evaluated the effect of earlier (in the first 6 months after baseline) versus deferred ART initiation on cancer risk. Marginal structural models were used with inverse probability weighting to account for time-dependent confounding and informative right-censoring, with weights informed by subject's age, sex, cohort, baseline year, race/ethnicity, HIV transmission risk, smoking, viral hepatitis, CD4, and AIDS diagnoses. RESULTS: Protective results for earlier ART were found for any cancer (adjusted hazard ratio [HR] 0.57; 95% confidence interval [CI] 0.37-0.86), AIDS-defining cancers (HR 0.23; 95% CI 0.11-0.49), any virus-related cancer (HR 0.30; 95% CI 0.16-0.54), Kaposi sarcoma (HR 0.25; 95% CI 0.10-0.61) and non-Hodgkin lymphoma (HR 0.22; 95% CI 0.06-0.73). By 15 years, there was also an observed reduced risk with earlier ART for virus-related NADCs (0.6% vs. 2.3%; adjusted risk difference -1.6; 95% CI -2.8, -0.5). CONCLUSIONS: Earlier ART initiation has potential to reduce the burden of virus-related cancers in PLWH, but not NADCs without known or suspected viral etiology.

      21. Cholera outbreak investigation, Bhadola, Delhi, India, April-May 2018external icon
        Singh A, Gupta R, Dikid T, Saroha E, Sharma NC, Sagar S, Gupta S, Bindra S, Khasnobis P, Jain SK, Singh S.
        Trans R Soc Trop Med Hyg. 2020 Aug 14.
        BACKGROUND: In the Gangetic plains of India, including Delhi, cholera is endemic. On 10 May 2018, staff at the north Delhi district surveillance unit identified a laboratory-confirmed cholera outbreak when five people tested positive for Vibrio cholerae O1 Ogawa serotype in Bhadola. We investigated to identify risk factors and recommend prevention measures. METHODS: We defined a case as ≥3 loose stools within 24 h in a Bhadola resident during 1 April-29 May 2018. We searched for cases house-to-house. In a 1 : 1 unmatched case control study, a control was defined as an absence of loose stools in a Bhadola resident during 1 April-29 May 2018. We selected cases and controls randomly. We tested stool samples for Vibrio cholerae by culture. We tested drinking water for fecal contamination. Using multivariable logistic regression we calculated adjusted ORs (aORs) with 95% CIs. RESULTS: We identified 129 cases; the median age was 14.5 y, 52% were females, 27% were hospitalized and there were no deaths. Symptoms were abdominal pain (54%), vomiting (44%) and fever (29%). Among 90 cases and controls, the odds of illness were higher for drinking untreated municipal water (aOR=2.3; 95% CI 1.0 to 6.2) and not knowing about diarrhea transmission (aOR=4.9; 95% CI 1.0 to 21.1). Of 12 stool samples, 6 (50%) tested positive for Vibrio cholerae O1 Ogawa serotype. Of 15 water samples, 8 (53%) showed growth of fecal coliforms. CONCLUSIONS: This laboratory-confirmed cholera outbreak associated with drinking untreated municipal water and lack of knowledge of diarrhea transmission triggered public health action in Bhadola, Delhi.

      22. Invasive group A streptococcal infections among people who inject drugs and people experiencing homelessness in the United States, 2010-2017external icon
        Valenciano SJ, Onukwube J, Spiller MW, Thomas A, Como-Sabetti K, Schaffner W, Farley M, Petit S, Watt JP, Spina N, Harrison LH, Alden NB, Torres S, Arvay ML, Beall B, Van Beneden CA.
        Clin Infect Dis. 2020 Jun 17.
        BACKGROUND: Reported outbreaks of invasive group A Streptococcus (iGAS) infections among people who inject drugs (PWID) and people experiencing homelessness (PEH) have increased, concurrent with rising US iGAS rates. We describe epidemiology among iGAS patients with these risk factors. METHODS: We analyzed iGAS infections from population-based Active Bacterial Core surveillance (ABCs) at 10 US sites from 2010 to 2017. Cases were defined as GAS isolated from a normally sterile site or from a wound in patients with necrotizing fasciitis or streptococcal toxic shock syndrome. GAS isolates were emm typed. We categorized iGAS patients into four categories: injection drug use (IDU) only, homelessness only, both, and neither. We calculated annual change in prevalence of these risk factors using log binomial regression models. We estimated national iGAS infection rates among PWID and PEH. RESULTS: We identified 12 386 iGAS cases; IDU, homelessness, or both were documented in ~13%. Skin infections and acute skin breakdown were common among iGAS patients with documented IDU or homelessness. Endocarditis was 10-fold more frequent among iGAS patients with documented IDU only versus those with neither risk factor. Average percentage yearly increase in prevalence of IDU and homelessness among iGAS patients was 17.5% and 20.0%, respectively. iGAS infection rates among people with documented IDU or homelessness were ~14-fold and 17- to 80-fold higher, respectively, than among people without those risks. CONCLUSIONS: IDU and homelessness likely contribute to increases in US incidence of iGAS infections. Improving management of skin breakdown and early recognition of skin infection could prevent iGAS infections in these patients.

      23. Primary indicators to systematically monitor COVID-19 mitigation and response - Kentucky, May 19-July 15, 2020external icon
        Varela K, Scott B, Prather J, Blau E, Rock P, Vaughan A, Halldin C, Griffing S, Pfeiffer H, Hines J, Dirlikov E, Thoroughman D.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 28;69(34):1173-1176.
        State and local health departments in the United States are using various indicators to identify differences in rates of reported coronavirus disease 2019 (COVID-19) and severe COVID-19 outcomes, including hospitalizations and deaths. To inform mitigation efforts, on May 19, 2020, the Kentucky Department for Public Health (KDPH) implemented a reporting system to monitor five indicators of state-level COVID-19 status to assess the ability to safely reopen: 1) composite syndromic surveillance data, 2) the number of new COVID-19 cases,* 3) the number of COVID-19-associated deaths,(†) 4) health care capacity data, and 5) public health capacity for contact tracing (contact tracing capacity). Using standardized methods, KDPH compiles an indicator monitoring report (IMR) to provide daily analysis of these five indicators, which are combined with publicly available data into a user-friendly composite status that KDPH and local policy makers use to assess state-level COVID-19 hazard status. During May 19-July 15, 2020, Kentucky reported 12,742 COVID-19 cases, and 299 COVID-19-related deaths (1). The mean composite state-level hazard status during May 19-July 15 was 2.5 (fair to moderate). IMR review led to county-level hotspot identification (identification of counties meeting criteria for temporal increases in number of cases and incidence) and facilitated collaboration among KDPH and local authorities on decisions regarding mitigation efforts. Kentucky's IMR might easily be adopted by state and local health departments in other jurisdictions to guide decision-making for COVID-19 mitigation, response, and reopening.

      24. Transmission of viral pathogens in a social network of university students: the eX-FLU Studyexternal icon
        Zivich PN, Eisenberg MC, Monto AS, Uzicanin A, Baric RS, Sheahan TP, Rainey JJ, Gao H, Aiello AE.
        Epidemiol Infect. 2020 Aug 14:1-19.

    • Environmental Health
      1. Gestational and childhood exposure to phthalates and child behaviorexternal icon
        Li N, Papandonatos GD, Calafat AM, Yolton K, Lanphear BP, Chen A, Braun JM.
        Environ Int. 2020 Aug 12;144:106036.
        BACKGROUND: Early-life phthalate exposures may adversely influence neurodevelopment by disrupting thyroid hormone homeostasis, altering brain lipid metabolism, or reducing gonadal hormone concentrations. Previous literature examining gestational phthalate exposure and child behavior were inconclusive and few prospective studies have examined childhood phthalate exposure, particularly phthalate mixtures. We investigated whether gestational and childhood phthalate exposures were associated with child behavior. METHODS: We used data from 314 mother-child pairs in the HOME Study, a longitudinal pregnancy and birth cohort that enrolled pregnant women from Cincinnati, Ohio. We quantified urinary concentrations of 11 phthalate metabolites in samples collected twice during gestation from women and six times from their children when they were ages 1, 2, 3, 4, 5, and 8 years. We assessed children's behavior at ages 2, 3, 4, 5, and 8 years using the Behavioral Assessment System for Children-2. Using linear mixed models, we estimated covariate-adjusted associations of measurement-error-corrected gestational and childhood phthalate metabolite concentrations (per interquartile range increase) with repeated child behavior assessments. We used Weighted Quantile Sum (WQS) regression to estimate the association of phthalate mixtures with child behavior. RESULTS: Gestational mono(3-carboxypropyl) phthalate (MCPP) concentrations were associated with more problem behaviors (internalizing: β = 0.9, 95% confidence interval [CI] = -0.1, 1.9; externalizing: β = 1.0, 95%CI = -0.1, 2.0; behavioral symptoms index [BSI]: β = 1.1, 95%CI = 0.1, 2.1). Higher childhood monobenzyl phthalate (MBzP) (β = 1.4; 95%CI = 0.0, 2.7), monocarboxynonyl phthalate (MCNP) (β = 3.2; 95%CI = 1.6, 4.8), monocarboxyoctyl phthalate (MCOP) (β = 0.9; 95%CI = 0.0, 1.7), MCPP (β = 1.8; 95%CI = 0.2, 3.5), and monoethyl phthalate (MEP) (β = 1.6; 95%CI = 0.1, 3.1) concentrations were associated with higher BSI composite scores. Consistent with this, the weighted childhood phthalate index was associated with more problem behaviors (internalizing: β = 1.5, 95%CI = -0.2, 3.1; externalizing: β = 1.7, 95%CI = 0.1, 3.5; BSI: β = 1.7, 95%CI = 0.2, 3.2); MBzP, MCNP, and MEP largely contributed to these associations. CONCLUSION: Our findings suggest that childhood exposure to phthalate mixtures may be associated with children's problem behaviors.

    • Food Safety
      1. Salmonellosis outbreak after a large-scale food event in Virginia, 2017external icon
        Shaw KA, Wright K, Privett K, Holloman K, Levine S, McCombs K, Turner L, Holsinger C, Woolard D.
        Public Health Rep. 2020 Aug 13.
        OBJECTIVES: The Virginia Department of Health (VDH) identified an outbreak of Salmonella serotype Javiana infections in Virginia after a chili and chowder cook-off with 11 competitors and about 2500 attendees on September 30, 2017. The objectives of this study were to assess the extent of the outbreak and identify the most likely source of exposure. METHODS: To identify people with suspected Salmonella infection, VDH used press releases and social media posts to recruit event attendees to take an online survey about foods eaten at the cook-off and any gastrointestinal (GI) symptoms experienced. VDH defined a case as reported GI illness that occurred within 1 week after eating food from the cook-off. Confirmed cases required a clinical specimen culture positive for Salmonella. Probable cases reported diarrhea or related clinical symptoms. "Not ill" people did not report GI illness. Investigators calculated unadjusted relative risks of illness and performed stratified analysis to address potential confounding. Available food samples were tested for Salmonella. Environmental health specialists interviewed food handlers and inspected restaurants where 3 competitors had prepared food. RESULTS: Of 438 survey responses, 171 (39%) met the case definition. Of all chilies and chowders consumed, Chowder A was associated with the highest relative risk of illness (8.9; 95% CI, 5.7-13.7). A Chowder A sample tested positive for Salmonella serotype Javiana. The environmental investigation did not identify an original contamination source but did find deficiencies in maintaining safe cooking temperatures. CONCLUSIONS: Epidemiologic and laboratory findings indicated that Chowder A was the most likely cause of outbreak. Recommendations to prevent future outbreaks include preparation of all food on-site to ensure safe temperatures during food preparation and service.

    • Global Health
      1. Health screening results of Cubans settling in Texas, USA, 2010-2015: A cross-sectional analysisexternal icon
        Seagle EE, Montour J, Lee D, Phares C, Jentes ES.
        PLoS Med. 2020 Aug;17(8):e1003233.
        BACKGROUND: Protecting the health of refugees and other migrant populations in the United States is key to ensuring successful resettlement. Therefore, to identify and address health concerns early, the US Centers for Disease Control and Prevention (CDC) recommends a domestic medical examination (screening for infectious and noninfectious diseases/conditions) shortly after arrival in the US. However, because refugee/migrant populations often have differing health patterns from one another and the US population, the collection and analysis of health information is key to developing population-specific clinical guidelines to guide the care of resettled individuals. Yet little is known regarding the health status of Cubans resettling in the US. Among the tens of thousands of Cuban migrants who have resettled in the US, some applied as refugees in Cuba, some applied for parole (a term used to indicate temporary US admission status for urgent humanitarian reasons or reasons of public benefit under US immigration law) in Cuba, and others applied for parole status after crossing the border. These groups were eligible for US government benefits to help them resettle, including a domestic medical examination. We reviewed health differences found in these examinations of those who were determined to be refugees or parolees in Cuba and those who were given parole status after arrival. METHODS AND FINDINGS: We conducted a retrospective cross-sectional analysis of the Texas Department of State Health Services database. Cubans who arrived from 2010 to 2015 and received a domestic medical examination in Texas were included. Those granted refugee/parolee status in Cuba were listed in federal databases for US-bound refugees/parolees; those who were paroled after arrival were not listed. Overall, 2,189 (20%) obtained either refugee or parolee status in Cuba, and 8,709 (80%) received parolee status after arrival. Approximately 62% of those who received parolee status after arrival at the border were male, compared with 49% of those who obtained prior refugee/parolee status in Cuba. Approximately one-half (45%) of those paroled after arrival were 19-34 years old (versus 26% among those who obtained refugee/parolee status in Cuba). Separate models were created for each screening indicator as the outcome, with entry route as the main exposure variable. Crude and adjusted prevalence ratios were estimated using PROC GENMOD procedures in SAS 9.4. Individuals paroled after arrival were less likely to screen positive for parasitic infections (9.6% versus 12.2%; adjusted prevalence ratio: 0.79, 0.71-0.88) and elevated blood lead levels (children ≤16 years old, 5.2% versus 12.3%; adjusted prevalence ratio: 0.42, 0.28-0.63). Limitations include potential disease misclassification, missing clinical information, and cross-sectional nature. CONCLUSIONS: Within-country variations in health status are often not examined in refugee populations, yet they are critical to understand granular health trends. Results suggests that the health profiles of Cuban Americans in Texas differed by entry route. This information could assist in developing targeted screenings and health interventions.

    • Health Behavior and Risk
      1. Truth be told: Adolescents' disclosure of sexual activity to healthcare providersexternal icon
        Liddon N, Pampati S, Steiner RJ, Hensel DJ, Tsung-Chieh F, Beckmeyer J, Herbenick D.
        J Adolesc Health. 2020 Aug 15.
        PURPOSE: The purpose of this study was to describe whether adolescent and young adult patients truthfully disclose sexual activity to providers during a sexual history and explore associations between disclosure and receipt of recommended services. METHODS: Data from the 2018 National Survey of Sexual Health and Behavior were used to describe self-reported disclsoure of sexually active 14- to 24-year-olds who had a health care visit in the previous year where a sexual history was taken (n = 196). We examined bivariate associations between disclosure and age, race/ethnicity, sex, sexual identity, and receipt of sexual health services. RESULTS: Most (88%) respondents reported telling their provider the truth about sexual activity. A higher proportion of the younger adolescents (14- to 17-year-olds) did not disclose compared with the 18- to 24-year-old respondents (25.4% vs 3.9%; p < .001). A higher proportion of patients who disclosed reported having a sexually transmitted disease test (69.6% vs 26.7%; p < .001); being offered a sexually transmitted disease test (44.3% vs 4.5%; p < .001); and being asked by providers about number of partners (54.3% vs 15.4%; p < .01). CONCLUSIONS: Most young patients disclose their sexual history to their provider, but younger patients might be less likely to do so. Positive patient-provider relationships may encourage disclosure of sexual activity and support receipt of indicated sexual and reproductive health services.

    • Health Disparities
      1. OBJECTIVES: Racial/ethnic disparities in HIV diagnosis rates remain despite the availability of effective treatment and prevention tools in the United States. In 2019, President Trump announced the "Ending the HIV Epidemic: A Plan for America" (EHE) initiative to reduce new HIV infections in the United States at least 75% by 2025 and at least 90% by 2030. The objective of this study was to show the potential effect of the EHE initiative on racial/ethnic disparities in HIV diagnosis rates at the national level. METHODS: We used 2017 HIV diagnoses data from the Centers for Disease Control and Prevention National HIV Surveillance System. We developed a counterfactual scenario to determine changes in racial/ethnic disparities if the 2017 HIV diagnosis rates were reduced by 75% in the geographic regions targeted by the EHE initiative. We used 4 measures to calculate results: rate ratio, population-attributable proportion (PAP), Gini coefficient, and Index of Disparity. RESULTS: The relative measures of racial/ethnic disparity decreased by 9%-21% in the EHE scenario compared with the 2017 HIV diagnoses data. The largest decrease was in the Hispanic/Latino:white rate ratio (-20.6%) and in the black:white rate ratio (-18.2%). The PAP measure decreased by 11.5%. The absolute versions of the Index of Disparity (unweighted and weighted) were approximately 50% lower in the EHE scenario than in the 2017 HIV diagnoses data. CONCLUSIONS: EHE efforts could reduce but will not eliminate racial/ethnic disparities in HIV diagnosis rates. Efforts to address racial/ethnic disparities should continue, and innovative approaches, specifically those that focus on social and structural factors, should be developed and implemented for populations that are disproportionately affected by HIV in the United States.

    • Health Economics
      1. Cost-effectiveness of interventions to manage diabetes: Has the evidence changed since 2008?external icon
        Siegel KR, Ali MK, Zhou X, Ng BP, Jawanda S, Proia K, Zhang X, Gregg EW, Albright AL, Zhang P.
        Diabetes Care. 2020 ;43(7):1557-1592.
        OBJECTIVE To synthesize updated evidence on the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbidities. RESEARCH DESIGN AND METHODS Weconducted a systematic literature review of studies from high-income countries evaluating the CE of diabetes management interventions recommended by the American Diabetes Association (ADA) and published in English between June 2008 and July 2017. We also incorporated studies from a previous CE review from the period 1985-2008. We classified the interventions based on their strength of evidence (strong, supportive, or uncertain) and levels of CE: Cost-saving (more health benefit at a lower cost), very cost-effective (£$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001-$50,000 per LYG or QALY), marginally cost-effective ($50,001-$100,000 per LYG or QALY), or not costeffective (>$100,000 per LYG or QALY). Costs were measured in 2017 U.S. dollars. RESULTS Seventy-three new studies met our inclusion criteria. These were combined with 49 studies from the previous review to yield 122 studies over the period 1985-2017. A large majority of the ADA-recommended interventions remain cost-effective. Specifically, we found strong evidence that the following ADA-recommended interventions are cost-saving or very cost-effective: In the cost-saving category are 1) ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB) therapy for intensive hypertension management compared with standard hypertension management, 2) ACEI/ARB therapy to prevent chronic kidney disease and/or end-stage renal disease in people with albuminuria compared with no ACEI/ARB therapy, 3) comprehensive foot care and patient education to prevent and treat foot ulcers among those at moderate/high risk of developing foot ulcers, 4) telemedicine for diabetic retinopathy screening compared with office screening, and 5) bariatric surgery compared with no surgery for individuals with type 2 diabetes (T2D) and obesity (BMI ‡30 kg/m2). In the very cost-effective category are 1) intensive glycemic management (targeting A1C <7%) compared with conventional glycemic management (targeting an A1C level of 8-10%) for individuals with newly diagnosed T2D, 2) multicomponent interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of cardiovascular disease with aspirin) compared with usual care, 3) statin therapy compared withnostatin therapy for individualswithT2Dandhistoryof cardiovascular disease,4) diabetes self-management education and support compared with usual care, 5) T2D screening every 3 years starting at age 45 years compared with no screening, 6) integrated, patient-centered care compared with usual care, 7) smoking cessation compared with no smoking cessation, 8) daily aspirin use as primary prevention for cardiovascular complications compared with usual care, 9) self-monitoring of blood glucose three times per day compared with once per day among those using insulin, 10) intensive glycemic management compared with conventional insulin therapy for T2D among adults aged ‡50 years, and 11) collaborative care for depression compared with usual care. CONCLUSIONS Complementing professional treatment recommendations, our systematic review provides an updated understanding of the potential value of interventions to manage diabetes and its complications and can assist clinicians and payers in prioritizing interventions and health care resources.

      2. Cost-effectiveness of diabetes prevention interventions targeting high-risk individuals and whole populations: A systematic reviewexternal icon
        Zhou X, Siegel KR, Ng BP, Jawanda S, Proia KK, Zhang X, Albright AL, Zhang P.
        Diabetes Care. 2020 ;43(7):1593-1616.
        OBJECTIVE Weconducted a systematic review of studies evaluating the cost-effectiveness (CE) of interventions to prevent type 2 diabetes (T2D) among high-risk individuals and whole populations. RESEARCH DESIGN AND METHODS Interventions targeting high-risk individuals are those that identify people at high risk of developing T2D and then treat them with either lifestyle or metformin interventions. Population-based prevention strategies are those that focus on the whole population regardless of the level of risk, creating public health impact through policy implementation, campaigns, and other environmental strategies. We systematically searched seven electronic databases for studies published in English between 2008 and 2017. We grouped lifestyle interventions targeting highrisk individuals by delivery method and personnel type. We used the median incremental cost-effectiveness ratio (ICER), measured in cost per quality-adjusted life year (QALY) or cost saved to measure the CE of interventions. We used the $50,000/QALY threshold to determine whether an intervention was cost-effective or not. ICERs are reported in 2017 U.S. dollars. RESULTS Our review included 39 studies: 28 on interventions targeting high-risk individuals and 11 targeting whole populations. Both lifestyle and metformin interventions in high-risk individuals were cost-effective from a health care system or a societal perspective, with median ICERs of $12,510/QALY and $17,089/QALY, respectively, compared with no intervention. Among lifestyle interventions, those that followed a Diabetes Prevention Program (DPP) curriculum had a median ICER of $6,212/QALY, while those that did not follow a DPP curriculum had a median ICER of $13,228/QALY. Compared with lifestyle interventions delivered one-on-one or by a health professional, those offered in a group setting or provided by a combination of health professionals and lay health workers had lower ICERs. Among populationbased interventions, taxing sugar-sweetened beverages was cost-saving from both the health care system and governmental perspectives. Evaluations of other population-based interventionsdincluding fruit and vegetable subsidies, community-based education programs, and modifications to the built environmentd showed inconsistent results. CONCLUSIONS Most of the T2D prevention interventions included in our review were found to be either cost-effective or cost-saving. Our findings may help decision makers set priorities and allocate resources for T2D prevention in real-world settings.

    • Healthcare Associated Infections
      1. Multistate outbreak of Burkholderia cepacia complex bloodstream infections after exposure to contaminated saline flush syringes: United States, 2016-2017external icon
        Brooks RB, Mitchell PK, Miller JR, Vasquez AM, Havlicek J, Lee H, Quinn M, Adams E, Baker D, Greeley R, Ross K, Daskalaki I, Walrath J, Moulton-Meissner H, Crist MB.
        Clin Infect Dis. 2019 Jul 18;69(3):445-449.
        BACKGROUND: Burkholderia cepacia complex (Bcc) has caused healthcare-associated outbreaks, often in association with contaminated products. The identification of 4 Bcc bloodstream infections in patients residing at a single skilled nursing facility (SNF) within 1 week led to an epidemiological investigation to identify additional cases and the outbreak source. METHODS: A case was initially defined via a blood culture yielding Bcc in a SNF resident receiving intravenous therapy after 1 August 2016. Multistate notifications were issued to identify additional cases. Public health authorities performed site visits at facilities with cases to conduct chart reviews and identify possible sources. Pulsed-field gel electrophoresis (PFGE) was performed on isolates from cases and suspect products. Facilities involved in manufacturing suspect products were inspected to assess possible root causes. RESULTS: An outbreak of 162 Bcc bloodstream infections across 59 nursing facilities in 5 states occurred during September 2016-January 2017. Isolates from patients and pre-filled saline flush syringes were closely related by PFGE, identifying contaminated flushes as the outbreak source and prompting a nationwide recall. Inspections of facilities at the saline flush manufacturer identified deficiencies that might have led to the failure to sterilize a specific case containing a partial lot of the product. CONCLUSIONS: Communication and coordination among key stakeholders, including healthcare facilities, public health authorities, and state and federal agencies, led to the rapid identification of an outbreak source and likely prevented many additional infections. Effective processes to ensure the sterilization of injectable products are essential to prevent similar outbreaks in the future.

      2. Notes from the field: Candida auris and carbapenemase-producing organism prevalence in a pediatric hospital providing long-term transitional care - Chicago, Illinois, 2019external icon
        McPherson TD, Walblay KA, Roop E, Soglin D, Valley A, Logan LK, Vallabhaneni S, Black SR, Pacilli M.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 28;69(34):1180-1181.

    • Immunity and Immunization
      1. Relative effectiveness of high dose versus standard dose influenza vaccines in older adult outpatients over four seasons, 2015-16 to 2018-19external icon
        Balasubramani GK, Choi WS, Nowalk MP, Zimmerman RK, Monto AS, Martin ET, Belongia EA, McLean HQ, Gaglani M, Murthy K, Jackson ML, Jackson LA, Chung JR, Spencer S, Fry AM, Patel M, Flannery B.
        Vaccine. 2020 Aug 12.
        BACKGROUND: New influenza vaccine formulations are designed to improve vaccine effectiveness and protect those most vulnerable to infection. High dose trivalent inactivated influenza vaccine (HD-IIV3), licensed for ages ≥65 years, produces greater antibody responses and efficacy in clinical trials, but post-licensure vaccine effectiveness (VE) compared to standard dose (SD-IIV3/4) vaccine remains an open question. METHODS: Using a test-negative, case control design and propensity analyses to adjust for confounding, US Influenza VE Network data from the 2015-2016 through 2018-2019 seasons were analyzed to determine relative VE (rVE) between HD-IIV3 and SD-IIV3/4 among outpatients ≥65 years old presenting with acute respiratory illness. Influenza vaccination status was derived from electronic medical records and immunization registries. RESULTS: Among 3861 enrollees, 2993 (78%) were vaccinated; 1573 (53%) received HD-IIV3 and 1420 (47%) received SD-IIV3/4. HD-IIV3 recipients differed from SD-IIV3/4 recipients by race, previous vaccination, number of outpatient visits in the previous year and timing of vaccination, and were balanced in the propensity model except the timing of vaccination. Compared with no vaccination, significant protection against any influenza A was observed from both HD-IIV3 (VE = 29%; 95%CI = 10%, 44%) and SD-IIV3/4 (VE = 24%; 95%CI = 5%, 39%); rVE = 18% (95%CI = 0%, 33%, SD as referent). When stratified by virus type, against A/H1N1, HD-IIV3 VE was 30% (95%CI = -7%, 54%), SD-IIV3/4 VE was 40% (95%CI = 10%, 61%), and rVE = -32%; (95%CI = -94%, 11%); Against A/H3N2, HD-IIV3 VE was 31% (95%CI = 9%, 47%), SD-IIV3/4 VE was 19% (95%CI = -5%, 37%), and rVE = 27%; (95% CI = 9%, 42%). CONCLUSIONS: Among adults ≥65 years of age, recipients of standard and high dose influenza vaccines differed significantly in their characteristics. After adjusting for these differences, high dose vaccine offered more protection against A/H3N2 and borderline significant protection against all influenza A requiring outpatient care during the 2015-2018 influenza seasons.

      2. Upsurge of conjugate vaccine serotype 4 invasive pneumococcal disease clusters among adults experiencing homelessness in California, Colorado, and New Mexicoexternal icon
        Beall B, Walker H, Tran T, Li Z, Varghese J, McGee L, Li Y, Metcalf BJ, Gierke R, Mosites E, Chochua S, Pilishvili T.
        J Infect Dis. 2020 Aug 15.
        After 7-valent pneumococcal conjugate vaccine introduction in the US in 2000, invasive pneumococcal disease (IPD) due to serotype 4 greatly decreased in children and adults. Starting in 2013, serotype 4 IPD incidence increased among adults >18 years old within three of ten Active Bacterial Core surveillance sites. Of 325 serotype 4 cases among adults in 2010-2018, 36% were from persons experiencing homelessness (PEH); incidence of serotype 4 IPD among PEH was 100-300 times higher than in the general population within these 3 areas. Genome sequencing for isolates recovered during 2015-2018 (n=246), revealed that increases in serotype 4 IPD were driven by lineages, ST10172, ST244, and ST695. Within each lineage, clusters of near-identical isolates indicated close temporal relatedness. Increases in serotype 4 IPD were limited to Colorado, California, and New Mexico, with highest increases observed among PEH, who were at increased risk for exposure to and infections caused by these strains.

      3. Assessment of VaxTrac electronic immunization registry in an urban district in Sierra Leone: Implications for data quality, defaulter tracking, and policyexternal icon
        Jalloh MF, Namageyo-Funa A, Gleason B, Wallace AS, Friedman M, Sesay T, Ocansey D, Jalloh MS, Feldstein LR, Conklin L, Hersey S, Singh T, Kaiser R.
        Vaccine. 2020 Sep 3;38(39):6103-6111.
        BACKGROUND: In 2016, the Sierra Leone Ministry of Health and Sanitation (MoHS) piloted VaxTrac, an electronic immunization registry (EIR), in an urban district to improve management of vaccination records and tracking of children who missed scheduled doses. We aimed to document lessons learned to inform decision-making on VaxTrac and similar EIRs' future use. METHODS: Ten out of 50 urban health facilities that implemented VaxTrac were purposively selected for inclusion in a rapid mixed-method assessment from November to December 2017. For a one-month period, records of six scheduled vaccine doses among children < 2 years old in VaxTrac were abstracted and compared to three paper-based records (register of under-two children, daily tally sheet, and monthly summary form). We used the under-two register as the reference gold standard for comparison purposes. We interviewed and observed 10 heath workers, one from each selected facility, who were using VaxTrac. RESULTS: Overall, VaxTrac captured < 65% of the vaccine doses reported in the paper-based sources, but in the largest health facility VaxTrac captured the highest number of doses. Two additional notable patterns emerged: 1) the aggregated data sources reported higher doses administered compared to the under-two register and VaxTrac; 2) data sources that need real-time data capture during the vaccination session reported fewer doses administered compared to the monthly HF2 summary form. Health workers expressed that the EIR helped them to shorten the time to manage, summarize, and report vaccination records. Workflows for data entry in VaxTrac were inconsistent among facilities and rarely integrated into existing processes. Data sharing restrictions contributed to duplicate records. CONCLUSION: Although VaxTrac helped to shorten the time to manage, summarize, and report vaccination records, data sharing restrictions coupled with inconsistent and inefficient workflows were major implementation challenges. Readiness-to-introduce and sustainability should be carefully considered before implementing an EIR.

      4. BACKGROUND: Post marketing safety evaluations of quadrivalent meningococcal diphtheria-toxoid conjugate vaccine (MenACWY-D) have focused on post-vaccination risk of Guillain Barré syndrome (GBS), adverse events (AEs) after maternal vaccination, and comparative studies with the newer quadrivalent meningococcal CRM(197) conjugate vaccine (MenACWY-CRM). To provide an updated general safety assessment, we reviewed reports of AEs following MenACWY-D submitted to the Vaccine Adverse Event Reporting System (VAERS). METHODS: VAERS is a national spontaneous reporting vaccine safety surveillance system co-administered by the Centers for Disease Control and Prevention and the U.S. Food and Drug Administration. We searched the VAERS database for U.S. reports of AEs after administration of MenACWY-D from January 2005 through June 2016. We conducted clinical reviews of serious reports after MenACWY-D administered alone, reports of MenACWY-D use during pregnancy, and reports of selected pre-specified outcomes. We screened for disproportionate reporting of AEs after MenACWY-D using empirical Bayesian data mining. RESULTS: VAERS received 13,075 U.S. reports after receipt of MenACWY-D; most (86%) described vaccination in adolescents, were classified as non-serious (94%), and described AEs consistent with pre-licensure studies. We did not find any evidence that reported deaths were related to vaccination. In serious reports, GBS and meningococcal infection were the most commonly reported medical conditions. Many reports of MenACWY-D use during pregnancy described inadvertent vaccination; most (61%) did not report any AE. CONCLUSIONS: Findings from our comprehensive review of reports to VAERS following MenACWY-D are consistent with data from pre-licensure studies and provide further reassurance on the safety of MenACWY-D.

      5. Trends in childhood influenza vaccination coverage, United States, 2012-2019external icon
        Santibanez TA, Srivastav A, Zhai Y, Singleton JA.
        Public Health Rep. 2020 Aug 12.
        OBJECTIVE: The objective was to compare estimates of childhood influenza vaccination across 7 consecutive influenza seasons based on 2 survey systems. METHODS: We analyzed data from the National Health Interview Survey (NHIS) and the National Immunization Survey-Flu (NIS-Flu) using Kaplan-Meier survival analysis to estimate receipt, based on parental report, of at least 1 dose of influenza vaccine among children aged 6 months to 17 years. RESULTS: We found no significant increasing trend in influenza vaccination coverage among children overall from 2012 to 2018 based on the NHIS or from 2012 to 2019 based on the NIS-Flu. We found 4 seasons with a significant increase in influenza vaccination coverage compared with the previous season (2012-2013 [NHIS, NIS-Flu], 2013-2014 [NIS-Flu], 2017-2018 [NHIS], and 2018-2019 [NIS-Flu]). As of the 2018-2019 season, based on NIS-Flu, influenza vaccination coverage was only 62.6%. Children with health conditions that put them at increased risk for complications from influenza had higher influenza vaccination coverage than children without these health conditions for all the seasons studied except 2014-2015. For all seasons studied, influenza vaccination coverage estimates for children were higher based on NIS-Flu data compared with NHIS data. Trends across seasons and differences in vaccination coverage between age groups were similar between the 2 surveys. CONCLUSIONS: Influenza vaccination coverage among children appears to have plateaued. Only about half of the children in the United States were vaccinated against influenza. Improvements in measurement of influenza vaccination and development and review of strategies to increase childhood influenza vaccination coverage are needed.

    • Informatics
      1. Can machine learning help identify patients at risk for recurrent sexually transmitted infections?external icon
        Elder HR, Gruber S, Willis SJ, Cocoros N, Callahan M, Flagg EW, Klompas M, Hsu KK.
        Sex Transm Dis. 2020 Aug 17.
        BACKGROUND: A substantial fraction of sexually transmitted infections (STIs) occur in patients who have previously been treated for an STI. We assessed whether routine electronic health record (EHR) data can predict which patients presenting with an incident STI are at greatest risk for additional STIs in the next 1-2 years. METHODS: We used structured EHR data on patients aged ≥15 years who acquired an incident STI diagnosis during 2008-2015 in eastern Massachusetts. We applied machine learning algorithms to model risk of acquiring ≥1 or ≥2 additional STIs diagnoses within 365 or 730 days following the initial diagnosis using over 180 different EHR variables. We performed sensitivity analysis incorporating state health department surveillance data to assess whether improving the accuracy of identifying STI cases improved algorithm performance. RESULTS: We identified 8,723 incident episodes of laboratory-confirmed gonorrhea, chlamydia, or syphilis. Bayesian Additive Regression Trees, the best performing algorithm of any single method, had a cross-validated area under the receiver operating curve (cv-AUC) of 0.75. Receiver-operator curves for this algorithm showed a poor balance between sensitivity and positive predictive value (PPV). A predictive probability threshold with a sensitivity of 91.5% had a corresponding PPV of 3.9%. A higher threshold with PPV of 29.5% had sensitivity of 11.7%. Attempting to improve classification of patients with and without repeat STIs diagnoses by incorporating health department surveillance data had minimal impact on cv-AUC. CONCLUSIONS: Machine algorithms using structured EHR data did not differentiate well between patients with and without repeat STIs diagnosis. Alternative strategies, able to account for socio-behavioral characteristics, could be explored.

      2. Evaluation of a health information exchange system for microcephaly case-finding - New York City, 2013-2015external icon
        Poirot E, Mills CW, Fair AD, Graham KA, Martinez E, Schreibstein L, Talati A, McVeigh KH.
        PLoS One. 2020 ;15(8):e0237392.
        BACKGROUND: Birth defects surveillance in the United States is conducted principally by review of routine but lagged reporting to statewide congenital malformations registries of diagnoses by hospitals or other health care providers, a process that is not designed to rapidly detect changes in prevalence. Health information exchange (HIE) systems are well suited for rapid surveillance, but information is limited about their effectiveness at detecting birth defects. We evaluated HIE data to detect microcephaly diagnosed at birth during January 1, 2013-December 31, 2015 before known introduction of Zika virus in North America. METHODS: Data from an HIE system were queried for microcephaly diagnostic codes on day of birth or during the first two days after birth at three Bronx hospitals for births to New York City resident mothers. Suspected cases identified by HIE data were compared with microcephaly cases that had been identified through direct inquiry of hospital records and confirmed by chart abstraction in a previous study of the same cohort. RESULTS: Of 16,910 live births, 43 suspected microcephaly cases were identified through an HIE system compared to 67 confirmed cases that had been identified as part of the prior study. A total of 39 confirmed cases were found by both studies (sensitivity = 58.21%, 95% CI: 45.52-70.15%; positive predictive value = 90.70%, 95% CI: 77.86-97.41%; negative predictive value = 99.83%, 95% CI: 99.76-99.89% for HIE data). CONCLUSION: Despite limitations, HIE systems could be used for rapid newborn microcephaly surveillance, especially in the many jurisdictions where more labor-intensive approaches are not feasible. Future work is needed to improve electronic medical record documentation quality to improve sensitivity and reduce misclassification.

    • Injury and Violence
      1. For this study, we explored the association between high school students' reported history of sport- or physical activity-related concussions and persistent feelings of sadness or hopelessness. Data from the 2017 national Youth Risk Behavior Survey (YRBS; N = 14,765) was used for this analysis. YRBS is administered to high school students throughout the country every 2 years. Findings from this study demonstrate that the prevalence of persistent feelings of sadness or hopelessness was 36.4% among students who reported sustaining one or more concussions. Compared to students who did not report having sustained a concussion, the odds of persistent feelings of sadness or hopelessness were significantly higher among students who had sustained one or more concussions (AOR = 1.41). These findings support the need for continued efforts by school nurses and other health care providers to identify students with a history of concussion and assess their mental health needs.

    • Laboratory Sciences
      1. Amylin, Abeta42, and amyloid in VZV vasculopathy cerebrospinal fluid and infected vascular cellsexternal icon
        Bubak AN, Beseler C, Como CN, Coughlan CM, Johnson NR, Hassell JE, Burnet AM, Mescher T, Schmid DS, Coleman C, Mahalingam R, Cohrs RJ, Boyd TD, Potter H, Shilleh AH, Russ HA, Nagel MA.
        J Infect Dis. 2020 Aug 18.
        BACKGROUND: VZV vasculopathy is characterized by persistent arterial inflammation leading to stroke. Studies show that VZV induces amyloid formation that may aggravate vasculitis. Thus, we determined if VZV central nervous system (CNS) infection produces amyloid. METHODS: Aβ peptides, amylin, and amyloid were measured in CSF from 16 VZV vasculopathy subjects and 36 stroke controls. To determine if infection induced amyloid deposition, mock- and VZV-infected quiescent primary human perineurial cells (qHPNCs), present in vasculature, were analyzed for intracellular amyloidogenic transcripts/proteins and amyloid. Supernatants were assayed for amyloidogenic peptides and ability to induce amyloid formation. To determine amylin's function during infection, amylin was knocked down with siRNA and viral cDNA quantitated. RESULTS: Compared to controls, VZV vasculopathy CSF had increased amyloid that positively correlated with amylin and anti-VZV antibody levels; Aβ40 was reduced and Aβ42 unchanged. Intracellular amylin, Aβ42, and amyloid were seen only in VZV-infected qHPNCs. VZV-infected supernatant formed amyloid fibrils following addition of amyloidogenic peptides. Amylin knockdown decreased viral cDNA. CONCLUSIONS: VZV infection increased levels of amyloidogenic peptides and amyloid in CSF and qHPNCs, indicating that VZV-induced amyloid deposition may contribute to persistent arterial inflammation in VZV vasculopathy. In addition, we identified a novel proviral function of amylin.

      2. Carbon nanotube filler enhances incinerated thermoplastics-induced cytotoxicity and metabolic disruption in vitroexternal icon
        Coyle JP, Derk RC, Kornberg TG, Singh D, Jensen J, Friend S, Mercer R, Stueckle TA, Demokritou P, Rojanasakul Y, Rojanasakul LW.
        Part Fibre Toxicol. 2020 Aug 12;17(1):40.
        BACKGROUND: Engineered nanomaterials are increasingly being incorporated into synthetic materials as fillers and additives. The potential pathological effects of end-of-lifecycle recycling and disposal of virgin and nano-enabled composites have not been adequately addressed, particularly following incineration. The current investigation aims to characterize the cytotoxicity of incinerated virgin thermoplastics vs. incinerated nano-enabled thermoplastic composites on two in vitro pulmonary models. Ultrafine particles released from thermally decomposed virgin polycarbonate or polyurethane, and their carbon nanotube (CNT)-enabled composites were collected and used for acute in vitro exposure to primary human small airway epithelial cell (pSAEC) and human bronchial epithelial cell (Beas-2B) models. Post-exposure, both cell lines were assessed for cytotoxicity, proliferative capacity, intracellular ROS generation, genotoxicity, and mitochondrial membrane potential. RESULTS: The treated Beas-2B cells demonstrated significant dose-dependent cellular responses, as well as parent matrix-dependent and CNT-dependent sensitivity. Cytotoxicity, enhancement in reactive oxygen species, and dissipation of ΔΨm caused by incinerated polycarbonate were significantly more potent than polyurethane analogues, and CNT filler enhanced the cellular responses compared to the incinerated parent particles. Such effects observed in Beas-2B were generally higher in magnitude compared to pSAEC at treatments examined, which was likely attributable to differences in respective lung cell types. CONCLUSIONS: Whilst the effect of the treatments on the distal respiratory airway epithelia remains limited in interpretation, the current in vitro respiratory bronchial epithelia model demonstrated profound sensitivity to the test particles at depositional doses relevant for occupational cohorts.

      3. Dynamics of protein synthesis in the initial steps of strobilation in the model cestode parasite Mesocestoides corti (syn. vogae)external icon
        de Lima JC, Floriani MA, Debarba JA, Paludo GP, Monteiro KM, Moura H, Barr JR, Zaha A, Ferreira HB.
        J Proteomics. 2020 Aug 13.
        Mesocestoides corti (syn. vogae) is a useful model for developmental studies of platyhelminth parasites of the Cestoda class, such as Taenia spp. or Echinococcus spp. It has been used in studies to characterize cestode strobilation, i.e. the development of larvae into adult worms. So far, little is known about the initial molecular events involved in cestode strobilation and, therefore, we carried out a study to characterize newly synthesized (NS) proteins upon strobilation induction. An approach based on bioorthogonal noncanonical amino acid tagging and mass spectrometry was used to label, isolate, identify, and quantify NS proteins in the initial steps of M. corti strobilation. Overall, 121 NS proteins were detected exclusively after induction of strobilation, including proteins related to development pathways, such as insulin and notch signaling. Metabolic changes that take place in the transition from the larval stage to adult worm were noted in special NS protein subsets related to developmental processes, such as focal adhesion, cell leading edge, and maintenance of location. The data shed light on mechanisms underlying early steps of cestode strobilation and enabled identification of possible developmental markers. We also consider the use of developmental responsive proteins as potential drug targets for developing novel anthelmintics. BIOLOGICAL SIGNIFICANCE: Larval cestodiases are life-threatening parasitic diseases that affect both man and domestic animals worldwide. Cestode parasites present complex life cycles, in which they undergo major morphological and physiological changes in the transition from one life-stage to the next. One of these transitions occurs during cestode strobilation, when the mostly undifferentiated and non-segmented larval or pre-adult form develops into a fully segmented and sexually differentiated (strobilated) adult worm. Although the proteomes of bona fide larvae and strobialted adults have been previously characterized for a few cestode species, little is still known about the dynamic of protein synthesis during the early steps of cestode strobilation. Now, the assessment of newly synthesized (NS) proteins within the first 48 h of strobilation the model cestode M. corti allowed to shed light on molecular mechanisms that are triggered by strobilation induction. The functional analyses of this repertoire of over a hundred NS proteins pointed out to changes in metabolism and activation of classical developmental signaling pathways in early strobilation. Many of the identified NS proteins may become valuable cestode developmental markers and their involvement in vital processes make them also good candidate targets for novel anthelmintic drugs.

      4. Microbiota of four tissue types in American alligators (Alligator mississippiensis) following extended dietary selenomethionine exposureexternal icon
        Kieran TJ, Goodman SJ, Finger JW, Thomas JC, Hamilton MT, Tuberville TD, Glenn TC.
        Bull Environ Contam Toxicol. 2020 Aug 13.
        Selenium represents an essential trace nutrient that is necessary for biological functions. Deficiencies can induce disease, but excess can induce toxicity. Selenium deficiency is a major concern in underdeveloped countries, while also posing as a toxic pollutant in waterways surrounding landfills, agricultural areas, and fossil fuel production sites. We examined the microbiome of selenomethionine (SeMet) fed American alligators (Alligator mississippiensis) at the beginning and end of a 7-week exposure experiment. Alligators were randomly divided into three groups: control and 1000 or 2000 ppm SeMet. DNA from before exposure (oral and cloaca swabs) and post-exposure (oral, cloaca, small & large intestines) sampling were extracted and amplified for bacterial 16 s rRNA. While treatment did not seem to have much effect, we observed a predominance of Fusobacteriaceae and Porpyromonodaceae across all tissue types. Cetobacterium and Clostridium are the most abundant genera as potential indicators of the aquatic and carrion feeding lifestyle of alligators.

      5. Arenaviruses, such as Lassa virus (LASV), can cause severe and fatal hemorrhagic fevers (e.g., Lassa fever, LF) in humans with no vaccines or therapeutics. Research on arenavirus-induced hemorrhagic fevers (AHFs) has been hampered by the highly virulent nature of these viral pathogens, which require high biocontainment laboratory, and the lack of an immune-competent small animal model that can recapitulate AHF disease and pathological features. Guinea pig infected with Pichinde virus (PICV), an arenavirus that does not cause disease in humans, has been established as a convenient surrogate animal model for AHFs as it can be handled in a conventional laboratory. The PICV strain P18, derived from sequential passaging of the virus 18 times in strain 13 inbred guinea pigs, causes severe febrile illness in guinea pigs that is reminiscent of lethal LF in humans. As inbred guinea pigs are not readily available and are difficult to maintain, outbred Hartley guinea pigs have been used but they show a high degree of disease heterogeneity upon virulent P18 PICV infection. Here, we describe an improved outbred guinea-pig infection model using recombinant rP18 PICV generated by reverse genetics technique followed by plaque purification, which consistently shows >90% mortality and virulent infection. Comprehensive virological, histopathological, and immunohistochemical analyses of the rP18-virus infected animals show similar features of human LASV infection. Our data demonstrate that this improved animal model can serve as a safe, affordable, and convenient surrogate small animal model for studying human LF pathogenesis and for evaluating efficacy of preventative or therapeutic approaches.

      6. Endogenous hormones and antiretroviral exposure in plasma, cervicovaginal fluid, and upper-layer packed cells of Malawian women living with HIVexternal icon
        Nicol MR, Cottrell ML, Corbett AH, Chinula L, Tegha G, Stanczyk FZ, Hurst S, Kourtis AP, Tang JH.
        AIDS Res Hum Retroviruses. 2020 Aug;36(8):641-646.
        Overlap in metabolism pathways of endogenous female sex hormones and antiretroviral drugs may lead to altered exposure to these compounds. In a family planning clinic in Lilongwe, Malawi, blood, blood cell, and cervicovaginal fluid (CVF) samples from seventy-three HIV positive Malawian women taken in follicular and luteal menstrual phases were assessed for estradiol and progesterone by chemiluminescent immunoassay, and for antiretroviral concentration by liquid chromatography-mass spectrometry. In both follicular and luteal phases, estradiol concentrations were lower in women receiving efavirenz compared with women on non-efavirenz regimens or no antiretroviral therapy (p < .01). Serum estradiol was moderately and negatively correlated with efavirenz plasma (r = -0.36, p < .001) and CVF (r = -0.50, p < .001) concentrations. Serum estradiol was a significant predictor of efavirenz CVF concentrations even after adjusting for efavirenz plasma concentrations (p = .02). In upper-layer packed cells (ULPCs), tenofovir diphosphate (TFVdp) concentrations were similar between follicular and luteal phases and were not correlated with estradiol or progesterone concentrations. Tenofovir concentrations in CVF were not associated with menstrual cycle or serum hormone concentrations. In CVF and plasma, efavirenz concentrations were negatively correlated with serum estradiol concentrations, suggesting a modulatory effect of estradiol on efavirenz metabolism and/or transport processes, and/or an effect of efavirenz on the metabolism of estradiol. Differences in CVF persisted even after adjusting for plasma concentrations, suggesting a mechanism specific to the female genital compartment separate from absorption or hepatic metabolism. In contrast, TFVdp concentrations in ULPC were not influenced by endogenous estradiol or progesterone concentrations.

      7. Detection of baloxavir resistant influenza A viruses using next generation sequencing and pyrosequencing methodsexternal icon
        Patel MC, Mishin VP, De La Cruz JA, Chesnokov A, Nguyen HT, Wilson MM, Barnes J, Kondor RJ, Wentworth DE, Gubareva LV.
        Antiviral Res. 2020 Aug 13:104906.
        Baloxavir, a new antiviral drug targeting cap-dependent endonuclease activity of polymerase acidic (PA) protein of influenza viruses, is now approved in multiple countries. Several substitutions at isoleucine 38 in PA protein (e.g., PA-I38T) have been associated with decreased baloxavir susceptibility in vitro and in vivo. In recent years, next generation sequencing (NGS) analysis and pyrosequencing have been used by CDC and U.S. Public Health Laboratories to monitor drug susceptibility of influenza viruses. Here we described an improved pyrosequencing assay for detecting influenza A viruses carrying substitutions at PA-38. Cyclic and customized orders of nucleotide dispensation were evaluated, and pyrosequencing results were compared to those generated using NGS. Our data showed that the customized nucleotide dispensation has improved the pyrosequencing assay performance in identification of double mixtures (e.g., PA-38I/T); however, identification of PA-38 variants in triple mixtures remains a challenge. While NGS analysis indicated the presence of PA-I38K in one clinical specimen and isolate, our attempts to detect this mutation by pyrosequencing or recover the virus carrying PA-I38K in cell culture were unsuccessful, raising a possibility of a rarely occurring sequencing error. Overall, pyrosequencing provides a convenient means to detect baloxavir resistant influenza viruses when NGS is unavailable or a faster turnaround time is required.

      8. Following a radiological or nuclear incident, the National Response Plan has given the Department of Health and Human Services/Centers for Disease Control and Prevention the responsibility for assessing population’s contamination with radionuclides. In the public health response to the incident, valuable information could be obtained in a timely and accurate manner by using liquid scintillation counting techniques to determine who has been contaminated above background for alpha and beta emitting radionuclides. The calibration plays a major role in this process therefore, knowing the effect of quench agents on calibration is essential.

    • Maternal and Child Health
      1. Support for transition from adolescent to adult health care among adolescents with and without mental, behavioral, and developmental disorders - United States, 2016-2017external icon
        Leeb RT, Danielson ML, Bitsko RH, Cree RA, Godfred-Cato S, Hughes MM, Powell P, Firchow B, Hart LC, Lebrun-Harris LA.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 28;69(34):1156-1160.
        Clinical guidelines recommend that primary care providers (PCPs) provide guidance and support to ensure a planned transition from pediatric to adult health care for adolescents, beginning at age 12 years (1). However, most adolescents do not receive the recommended health care transition planning (2). This is particularly concerning for adolescents with diagnosed mental, behavioral, and developmental disorders (MBDDs) (3), who account for approximately 20% of U.S. adolescents (4). Childhood MBDDs are linked to increased long-term morbidity and mortality; timely health care transition planning might mitigate adverse outcomes (5,6). CDC analyzed pooled, parent-reported data from the 2016 and 2017 National Survey of Children's Health (NSCH), comparing adolescents, aged 12-17 years, with and without MBDDs on a composite measure and specific indicators of recommended health care transition planning by PCPs. Overall, approximately 15% of adolescents received recommended health care transition planning: 15.8% (95% confidence interval [CI] = 14.1%-17.5%) of adolescents with MBDDs, compared with 14.2% (95% CI = 13.2%-15.3%) of adolescents without MBDDs. Relative to peers without MBDDs and after adjusting for age, adolescents with anxiety were 36% more likely to receive recommended health care transition planning, and those with depression were 69% more likely; adolescents with autism spectrum disorder (ASD) were 35% less likely to receive such transition planning, and those with developmental delay* were 25% less likely. Fewer than 20% of adolescents with MBDDs receiving current treatment met the transition measure. These findings suggest that a minority of adolescents with MBDDs receive recommended transition planning, indicating a potential missed public health opportunity to prevent morbidity and mortality in a population at high risk for health care disengagement (1). Improving access to comprehensive and coordinated programs and services,(†) as well as increasing provider training concerning adolescents' unique mental and physical health care needs (7), could help increase the number of adolescents benefiting from successful health care transitions (4).

    • Occupational Safety and Health - Mining
      1. Some of the common and serious hazards in underground mines are the dangers of being pinned, crushed, or struck by a large mining machine such as a scoop or a continuous mining machine (CMM). Proximity detection systems (PDSs) have been applied to protect miners from these hazards. The primary components of PDSs that are currently approved by the Mine Safety and Health Administration (MSHA) for use in underground coal mines are machine-mounted magnetic field generators and a miner-worn component (MWC), which measures the strength of the magnetic fields produced by the generators. Since these systems are magnetic field based, they can be adversely impacted by nearby cables due to parasitic coupling. Some mobile equipment in underground mines is electrically powered by long trailing cables that are pulled through the mine behind the equipment. Because the components of the PDS (generators and MWC) are frequently in close proximity to these cables, parasitic coupling can occur. Researchers from the National Institute for Occupational Safety and Health investigated the influence of trailing cables on the performance of PDSs. In particular, a three-phase model was proposed to describe the coupling process. The factors for controlling the magnetic field coupled from a field generator to a trailing cable were experimentally studied. The results show that the coupling is primarily controlled by two factors: The distance between the PDS components and the cable and the impedance between the cable and the ground. The coupling can be mitigated by either maintaining some minimum separation distance between the PDS components and the cable or increasing the impedance between the cable and the ground. The results presented in this article can help PDS manufacturers to design systems that are more immune to these effects.

    • Parasitic Diseases
      1. Assessment of molecular markers of anti-malarial drug resistance among children participating in a therapeutic efficacy study in western Kenyaexternal icon
        Chebore W, Zhou Z, Westercamp N, Otieno K, Shi YP, Sergent SB, Rondini KA, Svigel SS, Guyah B, Udhayakumar V, Halsey ES, Samuels AM, Kariuki S.
        Malar J. 2020 Aug 14;19(1):291.
        BACKGROUND: Anti-malarial drug resistance remains a major threat to global malaria control efforts. In Africa, Plasmodium falciparum remains susceptible to artemisinin-based combination therapy (ACT), but the emergence of resistant parasites in multiple countries in Southeast Asia and concerns over emergence and/or spread of resistant parasites in Africa warrants continuous monitoring. The World Health Organization recommends that surveillance for molecular markers of resistance be included within therapeutic efficacy studies (TES). The current study assessed molecular markers associated with resistance to Artemether-lumefantrine (AL) and Dihydroartemisinin-piperaquine (DP) from samples collected from children aged 6-59 months enrolled in a TES conducted in Siaya County, western Kenya from 2016 to 2017. METHODS: Three hundred and twenty-three samples collected pre-treatment (day-0) and 110 samples collected at the day of recurrent parasitaemia (up to day 42) were tested for the presence of drug resistance markers in the Pfk13 propeller domain, and the Pfmdr1 and Pfcrt genes by Sanger sequencing. Additionally, the Pfpm2 gene copy number was assessed by real-time polymerase chain reaction. RESULTS: No mutations previously associated with artemisinin resistance were detected in the Pfk13 propeller region. However, other non-synonymous mutations in the Pfk13 propeller region were detected. The most common mutation found on day-0 and at day of recurrence in the Pfmdr1 multidrug resistance marker was at codon 184F. Very few mutations were found in the Pfcrt marker (< 5%). Within the DP arm, all recrudescent cases (8 sample pairs) that were tested for Pfpm2 gene copy number had a single gene copy. None of the associations between observed mutations and treatment outcomes were statistically significant. CONCLUSION: The results indicate absence of Pfk13 mutations associated with parasite resistance to artemisinin in this area and a very high proportion of wild-type parasites for Pfcrt. Although the frequency of Pfmdr1 184F mutations was high in these samples, the association with treatment failure did not reach statistical significance. As the spread of artemisinin-resistant parasites remains a possibility, continued monitoring for molecular markers of ACT resistance is needed to complement clinical data to inform treatment policy in Kenya and other malaria-endemic regions.

      2. Molecular and epidemiological characterization of imported malaria cases in Chileexternal icon
        Escobar DF, Lucchi NW, Abdallah R, Valenzuela MT, Udhayakumar V, Jercic MI, Chenet SM.
        Malar J. 2020 Aug 13;19(1):289.
        BACKGROUND: Chile is one of the South American countries certified as malaria-free since 1945. However, the recent increase of imported malaria cases and the presence of the vector Anopheles pseudopunctipennis in previously endemic areas in Chile require an active malaria surveillance programme. METHODS: Specimens from 268 suspected malaria cases-all imported-collected between 2015 and 2018 at the Public Health Institute of Chile (ISP), were diagnosed by microscopy and positive cases were included for epidemiological analysis. A photo-induced electron transfer fluorogenic primer real-time PCR (PET-PCR) was used to confirm the presence of malaria parasites in available blood samples. Sanger sequencing of drug resistance molecular markers (pfk13, pfcrt and pfmdr1) and microsatellite (MS) analysis were performed in confirmed Plasmodium falciparum samples and results were related to origin of infection. RESULTS: Out of the 268 suspected cases, 65 were Plasmodium spp. positive by microscopy. A total of 63% of the malaria patients were male and 37% were female; 43/65 of the patients acquired infections in South American endemic countries. Species confirmation of available blood samples by PET-PCR revealed that 15 samples were positive for P. falciparum, 27 for Plasmodium vivax and 4 were mixed infections. The P. falciparum samples sequenced contained four mutant pfcrt genotypes (CVMNT, CVMET, CVIET and SVMNT) and three mutant pfmdr1 genotypes (Y184F/S1034C/N1042D/D1246Y, Y184F/N1042D/D1246Y and Y184F). MS analysis confirmed that all P. falciparum samples presented different haplotypes according to the suspected country of origin. Four patients with P. vivax infection returned to the health facilities due to relapses. CONCLUSION: The timely detection of polymorphisms associated with drug resistance will contribute to understanding if current drug policies in the country are appropriate for treatment of imported malaria cases and provide information about the most frequent resistant genotypes entering Chile.

      3. Stability testing of dried Plasmodium falciparum positive quality control samples for malaria rapid diagnostic tests in Liberia and Beninexternal icon
        Ramani S, Kohar HT, Pratt O, Denon YE, Reed CM, Thomas P, Powell SE, Aidoo M.
        Malar J. 2020 Aug 12;19(1):288.
        BACKGROUND: Malaria rapid diagnostic tests (RDTs) are largely responsible for the gains made in the proportion of malaria cases confirmed with a parasitological test. However, quality assurance programs to support their use remain a challenge. A dried tube specimen (DTS) method was developed that showed potential for use as a stable source of quality control (QC) sample for RDTs and for use in external quality assessments or proficiency testing (PT). DTS was further assessed with focus on sample stability under field settings in Benin and Liberia. METHODS: DTS were prepared using Plasmodium falciparum 3D7 or W2 strains at concentrations of 1000, 500 or 0 parasites/µL and tested for baseline reactivity at the Centers for Disease Control and Prevention, Atlanta before shipping. In Benin and Liberia, DTS were stored under refrigeration in a reference laboratory (RL) or in health centres under ambient temperatures. Seven rounds of testing were performed at 4-week intervals during which DTS were tested on RDTs stored at the RL or at health centres. Observed DTS reactivity at the RL and health centres were compared to expected reactivity to determine DTS stability. DTS were also assembled into a PT panel and tested by health facility staff at the mid and end time-points of the study. Daily maximum and minimum storage temperatures for RDTs and DTS were recorded. RESULTS: In Benin, DTS, irrespective of storage conditions, produced the expected reactivity at all time points. However, evidence of degradation was observed at weeks 20 and 24 for DTS stored at ambient temperatures at the health centres and not those stored under refrigeration at the RL. In Liberia, sample degradation was observed starting at week 8 especially among DTS stored at the health facilities. The degradation was associated with prolonged storage of DTS under ambient temperature prior to study commencement and less than optimal storage temperatures at the RL. Use of DTS in a PT enabled identification of health worker errors in performing the tests. CONCLUSION: DTS is a feasible tool for use as QC material and for PT under field conditions. Long-term (> 5 months) storage of DTS requires refrigeration.

    • Reproductive Health
      1. Research indicates that upwards to 30% of US urban Black male adolescents report first sex younger than age 13; however, there is limited literature on the sexual and reproductive health outcomes and contexts of these early first sex experiences. This exploratory study described sexual and reproductive health histories and explored personal, partner and parent contextual factors associated with first sex experiences occurring at 13 years or younger among a sample of US urban young men aged 15-24. Participants were assessed on their demographics and sexual health histories and a subset of young men were assessed on the contextual factors related to their first sex experience. Pearson chi-squared tests examined factors associated with early first sex and Fisher's exact tests examined associated contextual factors. First sex at 13 years or younger was reported by 29% of young men. A higher proportion of young men who had first sex at 13 or younger than those who had sex onset at 14 or older reported having got someone pregnant, having a "much older" first partner, and relationship satisfaction with their mother (16%) and father (12%). Study findings highlight the need to better understand urban young men's early first sex experiences, including the support needed to promote their healthy sexual development.

      2. Beyond adequate: Factors associated with quality of antenatal care in western Tanzaniaexternal icon
        Young MR, Morof D, Lathrop E, Haddad L, Blanton C, Maro G, Serbanescu F.
        Int J Gynaecol Obstet. 2020 Aug 16.
        OBJECTIVE: To determine quality of antenatal care (ANC). Most literature focuses on ANC attendance and services. Less is known about quality of care (QoC). METHOD: Data were analyzed from the 2016 Kigoma Reproductive Health Survey, a population-based survey of reproductive-aged women. Women with singleton term live births were included and principal component analysis (PCA) was used to create an ANC quality index using linear combinations of weights of the first principal component. Nineteen variables were selected for the index. The index was then used to assign a QoC score for each woman and linear regression used to identify factors associated with receiving higher QoC. RESULTS: A total of 3178 women received some ANC. Variables that explained the most variance in the QoC index included: gave urine (0.35); gave blood (0.34); and blood pressure measured (0.30). In multivariable linear regression, factors associated with higher QoC included: ANC at a hospital (versus dispensary); older age; higher level of education; working outside the home; higher socioeconomic status; and having lower parity. CONCLUSION: Using PCA methods, several basic components of ANC including maternal physical assessment were identified as important indicators of quality. This approach provides an affordable and effective means of evaluating ANC programs.

    • Substance Use and Abuse
      1. OBJECTIVE: We assessed overdose mortality by opioid types involved as well as interrelationships between nonmedical use of prescription opioids (NUPO) and heroin and injection drug use (IDU) among adolescents. METHOD: We examined 2010 and 2016 overdose data by drug type for decedents in the United States ages 15-19 years from the Multiple Cause of Death Files. We also analyzed data from the 2017 National Youth Risk Behavior Survey, a nationally representative survey of high school students. We assessed lifetime NUPO and calculated heroin use and IDU by frequency of lifetime NUPO. Adjusted prevalence ratios (aPRs) were generated, and linear contrast analysis determined dose-response relationships between frequency of lifetime NUPO and the two outcomes. RESULTS: The percentage of deaths involving prescription opioids that also involved illicit opioids such as heroin or fentanyl was 5.5% in 2010 and 25.0% in 2016. We observed a positive dose-response relationship with frequency of lifetime NUPO; aPRs were highest for 20 or more times of NUPO and heroin use (aPR = 49.49, 95% CI [33.39, 73.34]) and IDU (aPR = 44.37, 95% CI [23.16, 84.99]). However, aPRs for heroin and IDU were high even among those reporting just one or two occasions of NUPO (aPRs = 9.25, 95% CI [5.90, 14.49] and 6.63, 95% CI [3.99, 11.02], respectively). CONCLUSIONS: Adolescent prescription opioid overdose deaths now frequently involve illicit opioids. Heroin use and IDU are higher among students reporting even a few instances of NUPO, indicating that students with any NUPO are an important risk group. Clinical, community, and school-based efforts can address NUPO, noting these associations.

      2. Nonfatal drug and polydrug overdoses treated in emergency departments - 29 states, 2018-2019external icon
        Liu S, Scholl L, Hoots B, Seth P.
        MMWR Morb Mortal Wkly Rep. 2020 Aug 28;69(34):1149-1155.
        The U.S. drug overdose epidemic continues to cause substantial morbidity and mortality. In 2017, 967,615 nonfatal drug overdoses were treated in emergency departments (EDs), a 4.3% increase from 2016 in all overdoses and a 3.1% increase in opioid-involved overdoses (1). During 2017 and 2018, syndromic surveillance revealed that 37.2% of overdoses treated in EDs in 18 states involved multiple drugs (2). To describe changes in rates and proportions of suspected nonfatal drug and polydrug overdoses treated in EDs, CDC analyzed syndromic surveillance data from 2018 to 2019 in 29 states. Rates of overdoses involving opioids, cocaine, and amphetamines increased 9.7%, 11.0%, and 18.3%, respectively, and the rate of benzodiazepine-involved overdoses decreased 3.0%. Overdoses co-involving opioids and amphetamines increased from 2018 to 2019, overall, in both sexes, and in most age groups. In 2019, 23.6%, 17.1%, and 18.7% of overdoses involving cocaine, amphetamine, and benzodiazepines, respectively, also involved opioids. Expanding overdose prevention, treatment, and response efforts is needed to reduce the number of drug and polydrug overdoses. This includes linkage into treatment, harm reduction services, and community-based programs for persons who use drugs; expanding overdose prevention efforts, including increased naloxone provision, to persons who use stimulants; addressing the illicit drug supply; and identifying specific risk factors for populations using these drugs. Continued surveillance with expanded coverage of additional jurisdictions of the evolving drug overdose epidemic is important to the success of these efforts.

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