Volume 12, Issue 31, September 8, 2020

CDC Science Clips: Volume 12, Issue 31, September 8, 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
      • PURPOSE: Despite widespread promotion of breast and cervical cancer (BCC) screening, uptake remains low in rural communities. Barriers to healthcare, which often result in poorer health outcomes, differentially impact residents of rural communities. Effective interventions addressing the unique needs of rural women may target these barriers and increase BCC screening participation. Our objective is to review and assess the published literature on interventions to increase BCC screening in rural communities. METHODS: A systematic scoping review of PubMed/Medline was performed to identify BCC screening interventions conducted in rural settings. English language articles from peer-reviewed journals published from January 2006 to October 2019 were included if they reported results for BCC screening interventions in rural communities in the United States. RESULTS: We reviewed 228 articles and identified eight articles consistent with our inclusion criteria. Studies varied in sample population characteristics, geographic location, design, and mode of intervention delivery. Interventions included patient navigation strategies, educational outreach programs, peer counseling, and small media initiatives. Interventions focused on promoting uptake of initial or one-time screening rather than targeted repeat screening, and few studies detailed the cost-effectiveness of the interventions. CONCLUSION: This review may inform efforts to develop strategies to increase BCC screening among rural women. Additional cancer prevention and control research gaps in rural communities include the examination of the theoretical foundations, design, delivery, and cost-effectiveness of BCC screening interventions for rural communities. Future research might focus on methods to promote repeat BCC screening and effective translation of these interventions for other rural populations.

    • Communicable Diseases
      • Acute cardiovascular events associated with influenza in hospitalized adults : A cross-sectional studyexternal icon
        Chow EJ, Rolfes MA, O'Halloran A, Anderson EJ, Bennett NM, Billing L, Chai S, Dufort E, Herlihy R, Kim S, Lynfield R, McMullen C, Monroe ML, Schaffner W, Spencer M, Talbot HK, Thomas A, Yousey-Hindes K, Reed C, Garg S.
        Ann Intern Med. 2020 Aug 25.
        BACKGROUND: Influenza may contribute to the burden of acute cardiovascular events during annual influenza epidemics. OBJECTIVE: To examine acute cardiovascular events and determine risk factors for acute heart failure (aHF) and acute ischemic heart disease (aIHD) in adults with a hospitalization associated with laboratory-confirmed influenza. DESIGN: Cross-sectional study. SETTING: U.S. Influenza Hospitalization Surveillance Network during the 2010-to-2011 through 2017-to-2018 influenza seasons. PARTICIPANTS: Adults hospitalized with laboratory-confirmed influenza and identified through influenza testing ordered by a practitioner. MEASUREMENTS: Acute cardiovascular events were ascertained using discharge codes from the International Classification of Diseases (ICD), Ninth Revision, Clinical Modification, and ICD, 10th Revision. Age, sex, race/ethnicity, tobacco use, chronic conditions, influenza vaccination, influenza antiviral medication, and influenza type or subtype were included as exposures in logistic regression models, and marginal adjusted risk ratios and 95% CIs were estimated to describe factors associated with aHF or aIHD. RESULTS: Among 89 999 adults with laboratory-confirmed influenza, 80 261 had complete medical record abstractions and available ICD codes (median age, 69 years [interquartile range, 54 to 81 years]) and 11.7% had an acute cardiovascular event. The most common such events (non-mutually exclusive) were aHF (6.2%) and aIHD (5.7%). Older age, tobacco use, underlying cardiovascular disease, diabetes, and renal disease were significantly associated with higher risk for aHF and aIHD in adults hospitalized with laboratory-confirmed influenza. LIMITATION: Underdetection of cases was likely because influenza testing was based on practitioner orders. Acute cardiovascular events were identified by ICD discharge codes and may be subject to misclassification bias. CONCLUSION: In this population-based study of adults hospitalized with influenza, almost 12% of patients had an acute cardiovascular event. Clinicians should ensure high rates of influenza vaccination, especially in those with underlying chronic conditions, to protect against acute cardiovascular events associated with influenza. PRIMARY FUNDING SOURCE: Centers for Disease Control and Prevention.

      • Chlamydia and gonorrhea: Shifting age-based positivity among young females, 2010-2017external icon
        Kaufman HW, Gift TL, Kreisel K, Niles JK, Alagia DP.
        Am J Prev Med. 2020 Aug 20.
        INTRODUCTION: This study aims to determine if and how the age distribution of Chlamydia trachomatis and Neisseria gonorrhoeae infections in women evolved from 2010 to 2017, given changes in sexual practices over this time. METHODS: All Chlamydia trachomatis/Neisseria gonorrhoeae co-testing laboratory results from females aged 12-30 years tested at Quest Diagnostics during 2010-2017 (n=17,794,680) were evaluated to assess trends in Chlamydia trachomatis and Neisseria gonorrhoeae positivity over time. Data were collected and analyzed in November 2018. RESULTS: Age-based positivity shifted toward older ages from 2010 to 2017 for both Chlamydia trachomatis and Neisseria gonorrhoeae. There was a declining trend in Chlamydia trachomatis positivity from 2010 to 2017 for the youngest age group (12-17 years; 17% decline, 8.9% to 7.4%, p<0.0001) but increasing trends for both those aged 18-24 years (21% increase, 6.1% to 7.4%, p<0.0001) and 25-30 years (50% increase, 2.2% to 3.3%, p<0.0001). The Chlamydia trachomatis positivity rate for 27-year-olds in 2017 (3.5%) and 24-year-olds in 2010 (3.5%) was the same. Similarly, there was a declining trend in Neisseria gonorrhoeae positivity from 2010 to 2017 for the youngest age group (12-17 years; 14% decline, 1.33% vs 1.17%, p<0.0001) but increasing trends for both those aged 18-24 years (27% increase, 0.79% vs 1.00%, p<0.0001) and 25-30 years (117% increase, 0.29% vs 0.63%, p<0.0001). For Neisseria gonorrhoeae, 30-year-old women tested in 2017 had an identical positivity rate to 23-year-old women tested in 2010, at 0.5%. CONCLUSIONS: Healthcare providers may want to consider this positivity rate age shift in Chlamydia trachomatis and Neisseria gonorrhoeae to inform prevention and control strategies, including considering the potential for increased risk in women aged 25-30 years.

    • Disease Reservoirs and Vectors
      • Aedes aegypti (L) is an anthropophilic mosquito involved in the transmission of a variety of viral pathogens worldwide including dengue, chikungunya, yellow fever, and Zika viruses. This species, native to Africa, is well established in the continental U.S. (CONUS) and occasionally contributes to localized outbreaks of viral diseases. In the last seven decades, mosquito control programs in the CONUS have been focused on vectors of eastern equine encephalitis, St. Louis encephalitis, and West Nile viruses, as well as nuisance species. Aedes aegypti receives little control focus except during outbreak periods, which has led to a lack of information on appropriate and effective control options targeting Ae. aegypti in the CONUS. As such, in the event of an Ae. aegypti-borne arboviral outbreak in the CONUS, there are limited evidence-based control recommendations or protocols in place. Autochthonous outbreaks of Ae. aegypti-borne pathogens have occurred recently in the CONUS, including dengue outbreaks in 2010 and 2013, a chikungunya outbreak in 2014, and the 2016 outbreak of Zika virus. The increasing frequency of Ae. aegypti-borne outbreaks necessitates increased attention and research on control of this species to prevent and mitigate future outbreaks. This review consolidates and synthesizes the available literature on control of Ae. aegypti, specifically within the CONUS, focusing on data generated through operational applications as well as field and semifield experiments. The purpose of this review is to identify and highlight areas where additional research is needed. The review covers chemical control and insecticide resistance, biological control, source reduction, trapping, and alternative techniques.

    • Health Economics
      • National health care expenditures associated with disabilityexternal icon
        Khavjou OA, Anderson WL, Honeycutt AA, Bates LG, Razzaghi H, Hollis ND, Grosse SD.
        Med Care. 2020 Sep;58(9):826-832.
        BACKGROUND: In 2003, national disability-associated health care expenditures (DAHE) were $398 billion. Updated estimates will improve our understanding of current DAHE. OBJECTIVE: The objective of this study was to estimate national DAHE for the US adult population and analyze spending by insurance and service categories and to assess changes in spending over the past decade. RESEARCH DESIGN: Data from the 2013-2015 Medical Expenditure Panel Survey were used to estimate DAHE for noninstitutionalized adults. These estimates were reconciled with National Health Expenditure Accounts (NHEA) data and adjusted to 2017 medical prices. Expenditures for institutionalized adults were added from NHEA data. MEASURES: National DAHE in total, by insurance and service categories, and percentage of total expenditures associated with disability. RESULTS: DAHE in 2015 were $868 billion (at 2017 prices), representing 36% of total national health care spending (up from 27% in 2003). DAHE per person with disability increased from $13,395 in 2003 to $17,431 in 2015, whereas nondisability per-person spending remained constant (about $6700). Public insurers paid 69% of DAHE. Medicare paid the largest portion ($324.7 billion), and Medicaid DAHE were $277.2 billion. More than half (54%) of all Medicare expenditures and 72% of all Medicaid expenditures were associated with disability. CONCLUSIONS: The share of health care expenditures associated with disability has increased substantially over the past decade. The high proportion of DAHE paid by public insurers reinforces the importance of public programs designed to improve health care for people with disabilities and emphasizes the need for evaluating programs and health services available to this vulnerable population.

    • Immunity and Immunization
      • Real-world effectiveness of rotavirus vaccines, 2006-19: a literature review and meta-analysisexternal icon
        Burnett E, Parashar UD, Tate JE.
        Lancet Glob Health. 2020 Sep;8(9):e1195-e1202.
        BACKGROUND: Since licensure in 2006, rotavirus vaccines have been introduced in more than 100 countries. The efficacy of rotavirus vaccines is variable in settings with different child mortality levels. We did an updated review of the published literature to assess the real-world effectiveness of rotavirus vaccines in a range of settings. METHODS: In this literature review and meta-analysis, we included observational, post-licensure studies of rotavirus vaccines, published from Jan 1, 2006, to Dec 31, 2019, in English, with laboratory-confirmed rotavirus as the endpoint. In addition to product-specific results for Rotarix (GlaxoSmithKline Biologicals, Rixensart, Belgium) or RotaTeq (Merck, West Point, PA, USA), we included Rotarix and RotaTeq mixed series, and non-product-specific vaccine effectiveness estimates from countries where Rotarix and RotaTeq are both available. Studies of other infant rotavirus vaccines were excluded because little or no post-licensure data were available. We fitted random-effects regression models to estimate vaccine effectiveness among children younger than 12 months and aged 12-23 months. On the basis of 2017 UNICEF mortality estimates for children younger than 5 years, countries were stratified as having low (lowest quartile), medium (second quartile), or high mortality (third and fourth quartiles). FINDINGS: We identified and screened 1703 articles, of which 60 studies from 32 countries were included. 31 studies were from countries with low child mortality, eight were from medium-mortality countries, and 21 were from high-mortality countries. Rotarix vaccine effectiveness against laboratory-confirmed rotavirus among children younger than 12 months old was 86% (95% CI 81-90) in low-mortality countries, 77% (66-85) in medium-mortality countries, and 63% (54-70) in high-mortality countries. Rotarix vaccine effectiveness among children aged 12-23 months was 86% (81-90) in low-mortality countries, 54% (23-73) in medium-mortality countries, and 58% (38-72) in high-mortality countries. RotaTeq vaccine effectiveness among children younger than 12 months was 86% (76-92) in low-mortality countries and 66% (51-76) in high-mortality countries. RotaTeq vaccine effectiveness among children aged 12-23 months was 84% (79-89) in low-mortality countries. There was no substantial heterogeneity (I(2) range: 0-36%). Median vaccine effectiveness in low-mortality countries was similar for Rotarix (83%; IQR 78-91), RotaTeq (85%; 81-92), mixed series (86%; 70-91), and non-product-specific (89%; 75-91) vaccination. INTERPRETATION: Rotavirus vaccines were effective in preventing rotavirus diarrhoea, with higher performance in countries with lower child mortality. FUNDING: None.

    • Informatics
      • Exploratory analysis of machine learning approaches for surveillance of Zika-associated birth defectsexternal icon
        Lusk R, Zimmerman J, VanMaldeghem K, Kim S, Roth NM, Lavinder J, Fulton A, Raycraft M, Ellington SR, Galang RR.
        Birth Defects Res. 2020 Aug 19.
        In 2016, Centers for Disease Control and Prevention (CDC) established surveillance of pregnant women with Zika virus infection and their infants in the U.S. states, territories, and freely associated states. To identify cases of Zika-associated birth defects, subject matter experts review data reported from medical records of completed pregnancies to identify findings that meet surveillance case criteria (manual review). The volume of reported data increased over the course of the Zika virus outbreak in the Americas, challenging the resources of the surveillance system to conduct manual review. Machine learning was explored as a possible method for predicting case status. Ensemble models (using machine learning algorithms including support vector machines, logistic regression, random forests, k-nearest neighbors, gradient boosted trees, and decision trees) were developed and trained using data collected from January 2016-October 2017. Models were developed separately, on data from the U.S. states, non-Puerto Rico territories, and freely associated states (referred to as the U.S. Zika Pregnancy and Infant Registry [USZPIR]) and data from Puerto Rico (referred to as the Zika Active Pregnancy Surveillance System [ZAPSS]) due to differences in data collection and storage methods. The machine learning models demonstrated high sensitivity for identifying cases while potentially reducing volume of data for manual review (USZPIR: 96% sensitivity, 25% reduction in review volume; ZAPSS: 97% sensitivity, 50% reduction in review volume). Machine learning models show potential for identifying cases of Zika-associated birth defects and for reducing volume of data for manual review, a potential benefit in other public health emergency response settings.

    • Nutritional Sciences
      • Iron content of commercially available infant and toddler foods in the United States, 2015external icon
        Bates M, Gupta PM, Cogswell ME, Hamner HC, Perrine CG.
        Nutrients. 2020 Aug 13;12(8).
        OBJECTIVES: To describe the iron content of commercially available infant and toddler foods. METHODS: Nutrition Facts label data were used from a 2015 database of 1037 commercial infant and toddler food and drink products. Products were grouped into food categories on the basis of name, ingredients, target age, and reference amounts customarily consumed (RACC). Mean and median iron content per 100 g and per RACC were calculated. The proportion of products considered good and excellent sources of iron were determined on the basis of percent daily value (% DV) thresholds. RESULTS: Among products marketed for infants (aged 4-12 months), infant cereals had the highest mean (6.19 mg iron per RACC; 41.25 iron mg per 100 g) iron content. Among products marketed for toddlers (aged 12-36 months), vegetable-based mixtures or meals contained the highest mean iron in mg per RACC (mean: 2.97 mg) and dry, grain-based desserts had the highest mean iron in mg per 100 g (mean: 6.45 mg). Juice and drink products had the lowest mean iron contents in both infant and toddler products. CONCLUSIONS: Most commercially available infant cereals are considered to be an excellent source of iron, likely from fortification, but wide variability was observed in iron content by food category. Products that are considered good or excellent sources of iron (≥10% DV) can help consumers identify products with higher iron content, such as infant cereals or toddler vegetable-based mixtures/meals.

    • Social and Behavioral Sciences

  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. INTRODUCTION: Dental visits may provide an opportunity to counsel and screen for chronic disease prevention. However, few studies have used nationally representative data to assess the potential role of dental professionals in chronic disease prevention. We examined the percentage of US adults who reported chronic disease counseling and screening by dental professionals. METHODS: We analyzed data from the National Health and Nutrition Examination Survey 2011-2016 for 5,541 participants aged 30 or older who reported seeing a dental professional in the past year and estimated the percentage who reported receiving counseling about selected chronic disease prevention during the visit. We used logistic regressions to examine associations between risk factors and counseling. RESULTS: Overall, 4.0% (standard error [SE], 0.3) of adults were told by a dental professional about the benefits of checking blood glucose, 42.4% (SE, 2.9) giving up tobacco (among tobacco users), 26.6% (SE, 1.2) about checking for oral cancer, and 43.0% (SE, 1.8) had an oral cancer examination. Groups with risk factors were more likely to receive health behavior counseling than those without (eg, those previously told they had diabetes risk factors were more likely to receive blood glucose counseling than those without [8.1% vs 3.3%, P < .05]). The pattern for oral cancer counseling and receiving an oral cancer examination was different: adults without oral cancer risk factors (no tobacco use, normal/underweight, and/or excellent/very good health) were more likely to receive oral cancer counseling or screening. Adjusted analyses did not change these associations. CONCLUSION: Most adults were not counseled about chronic disease prevention during a visit with a dental professional. Current tobacco users and those with overweight or obesity were more likely to report receiving counseling.

      2. OBJECTIVE: To convert waist circumference (WC) measurements obtained by World Health Organization (WHO-WC) method to National Heart, Lung, and Blood Institute (NHLBI-WC) method. METHODS: During 2016, National Health and Nutrition Examination Survey participants aged 20 and older had two different WC measurements taken (n=2,405). Mean differences in WC between the NHLBI-WC and WHO-WC measurements were calculated. Multivariable prediction models were developed to predict NHLBI-WC from the measured WHO-WC. Sensitivity and specificity of abdominal obesity classification (AOC) were calculated for the measured WHO-WC and the predicted NHLBI-WC. Kappa coefficients were calculated to evaluate the agreements between AOC derived from NHLBI-WC and from WHO-WC and the predicted NHLBI-WC. RESULTS: The mean differences between NHLBI-WC and WHO-WC were 0.8 cm for males and 3.2 cm for females (p ≤ 0.05). Sensitivity of AOC for measured WHO-WC was 93% for males and 87% for females, and specificity of AOC was ≥ 97% for both genders. Sensitivity and specificity of AOC for predicted NHLBI-WC were ≥ 95% for both genders. The AOC derived from the predicted NHLBI-WC had higher agreements for both genders. CONCLUSION: The prediction equations provided may be used to predict NHLBI-WC from WHO-WC for comparability in WC estimates across studies.

      3. Electronic measurement of a clinical quality measure for inpatient hypoglycemic events: A multicenter validation studyexternal icon
        Santos CA, Conover C, Shehab N, Geller AI, Guerra YS, Kramer H, Kosacz NM, Zhang H, Budnitz DS, Trick WE.
        Med Care. 2020 Aug 21.
        BACKGROUND: Hypoglycemia related to antidiabetic drugs (ADDs) is important iatrogenic harm in hospitalized patients. Electronic identification of ADD-related hypoglycemia may be an efficient, reliable method to inform quality improvement. OBJECTIVE: Develop electronic queries of electronic health records for facility-wide and unit-specific inpatient hypoglycemia event rates and validate query findings with manual chart review. METHODS: Electronic queries were created to associate blood glucose (BG) values with ADD administration and inpatient location in 3 tertiary care hospitals with Patient-Centered Outcomes Research Network (PCORnet) databases. Queries were based on National Quality Forum criteria with hypoglycemia thresholds <40 and <54 mg/dL, and validated using a stratified random sample of 321 BG events. Sensitivity and specificity were calculated with manual chart review as the reference standard. RESULTS: The sensitivity and specificity of queries for hypoglycemia events were 97.3% [95% confidence interval (CI), 90.5%-99.7%] and 100.0% (95% CI, 92.6%-100.0%), respectively for BG <40 mg/dL, and 97.7% (95% CI, 93.3%-99.5%) and 100.0% (95% CI, 95.3%-100.0%), respectively for <54 mg/dL. The sensitivity and specificity of the query for identifying ADD days were 91.8% (95% CI, 89.2%-94.0%) and 99.0% (95% CI, 97.5%-99.7%). Of 48 events missed by the queries, 37 (77.1%) were due to incomplete identification of insulin administered by infusion. Facility-wide hypoglycemia rates were 0.4%-0.8% (BG <40 mg/dL) and 1.9%-3.0% (BG <54 mg/dL); rates varied by patient care unit. CONCLUSIONS: Electronic queries can accurately identify inpatient hypoglycemia. Implementation in non-PCORnet-participating facilities should be assessed, with particular attention to patient location and insulin infusions.

      4. Evaluation of CDC's Hemophilia Surveillance Program - universal data collection (1998-2011) and community counts (2011-2019), United Statesexternal icon
        Schieve LA, Byams VR, Dupervil B, Oakley MA, Miller CH, Soucie JM, Abe K, Bean CJ, Hooper WC.
        MMWR Surveill Summ. 2020 Sep 4;69(5):1-18.
        PROBLEM/CONDITION: Hemophilia is an X-linked genetic disorder that primarily affects males and results in deficiencies in blood-clotting proteins. Hemophilia A is a deficiency in factor VIII, and hemophilia B is a deficiency in factor IX. Approximately one in 5,000 males are born with hemophilia, and hemophilia A is about four times as common as hemophilia B. Both disorders are characterized by spontaneous internal bleeding and excessive bleeding after injuries or surgery. Hemophilia can lead to repeated bleeding into the joints and associated chronic joint disease, neurologic damage, damage to other organ systems, and death. Although no precise national U.S. prevalence estimates for hemophilia exist because of the difficulty identifying cases among persons who receive care from various types of health care providers, two previous state-based studies estimated hemophilia prevalence at 13.4 and 19.4 per 100,000 males. In addition, these studies showed that 67% and 82% of persons with hemophilia received care in a federally funded hemophilia treatment center (HTC), and 86% and 94% of those with the most severe cases of hemophilia (i.e., those with the lowest levels of clotting factor activity in the circulating blood) received care in a federally funded HTC. As of January 2020, the United States had 144 HTCs. PERIOD COVERED: 1998-2019. DESCRIPTION OF THE SYSTEM: Surveillance for hemophilia, which is a complex, chronic condition, is challenging because of its low prevalence, the difficulty in ascertaining cases uniformly, and the challenges in routinely characterizing and tracking associated health complications. Over time, two systems involving many stakeholders have been used to conduct ongoing hemophilia surveillance. During 1998-2011, CDC and the HTCs collaborated to establish the Universal Data Collection (UDC) surveillance system. The purposes of the UDC surveillance system were to monitor human immunodeficiency virus (HIV) and bloodborne viral hepatitis in persons with hemophilia, thereby tracking blood safety, and to track the prevalence of and trends in complications associated with hemophilia. HTC staff collected clinical data and blood specimens from UDC participants and submitted them to CDC. CDC tested specimens for viral hepatitis and HIV. In 2011, the UDC surveillance system was replaced by a new hemophilia surveillance system called Community Counts. CDC and the HTCs established Community Counts to expand laboratory testing and the collection of clinical data to better identify and track emerging health issues in persons with hemophilia. RESULTS: This report is the first comprehensive summary of CDC's hemophilia surveillance program, which comprises both UDC and Community Counts. Data generated from these surveillance systems have been used in the development of public health and clinical guidelines and practices to improve the safety of U.S. blood products and either prevent hemophilia-related complications or identify complications early. Several factors have played a role in the effectiveness of the UDC and Community Counts systems, including 1) a stable data collection design that was developed and is continually reviewed in close partnership with HTC regional leaders and providers to ensure surveillance activities are focused on maximizing the scientific and clinical impact; 2) flexibility to respond to emerging health priorities through periodic updates to data collection elements and special studies; 3) high data quality for many clinical indicators and state-of-the-art laboratory testing methods for hemophilia treatment product inhibitors (developed and refined in part based on CDC research); 4) timely data and specimen collection and submission, laboratory specimen testing, analysis, and reporting; and 5) the largest and most representative sample of persons with hemophilia in the United States and one of the largest and most comprehensive data collection systems on hemophilia worldwide. INTERPRETATION: CDC has successfully developed, implemented, and maintained a surveillance system for hemophilia. The program can serve as an example of how to conduct surveillance for a complex chronic disease by involving stakeholders, improving and building new infrastructure, expanding data collection (e.g., new diagnostic assays), providing testing guidance, establishing a registry with specimen collection, and integrating laboratory findings in clinical practice for the individual patient. PUBLIC HEALTH ACTION: Hemophilia is associated with substantial lifelong morbidity, excess premature deaths, and extensive health care needs throughout life. Through monitoring data from Community Counts, CDC will continue to characterize the benefits and adverse events associated with existing or new hemophilia treatment products, thereby contributing to maximizing the health and longevity of persons with hemophilia.

      5. Stall in heart disease death rates, evidence from Maine, 1999-2017external icon
        Sinatra JA, Huston SL.
        Prev Chronic Dis. 2020 Aug 20;17:E86.
        INTRODUCTION: Since the 1950s, heart disease deaths have declined in the United States, but recent reports indicate a plateau in this decline. Heart disease death rates increased in Maine from 2011-2015. We examined reasons for the trend change in Maine's heart disease death rates, including the contributing types of heart disease. METHODS: We obtained Maine's annual heart disease death data for 1999-2017 from CDC's Wide-ranging Online Data for Epidemiologic Research (CDC WONDER). We used joinpoint regression to determine changes in trend and annual percentage change (APC) in death rates for heart disease overall and by demographic groups, types of heart disease, and geographic area. RESULTS: Joinpoint modeling showed that Maine's age-adjusted heart disease death rates decreased during 1999-2010 (-4.2% APC), then plateaued during 2010-2017 (-0.1% APC). Death rates flattened for both sexes and age groups ≥45 years. Although death rates for acute myocardial infarction (AMI) decreased through 2017, hypertensive heart disease (HHD) and heart failure death rates increased. Death rates attributable to diabetes-related heart disease and non-AMI ischemic heart disease (IHD) plateaued. CONCLUSION: Declines in Maine's heart disease death rates have plateaued, similar to national trends. Flattening rates appear to be driven by adverse trends in HHD, heart failure, diabetes-related heart disease, and non-AMI IHD. Increased efforts to address cardiovascular disease risk factors, chronic heart disease, and access to care are necessary to continue the decrease in heart disease deaths in Maine.

    • Communicable Diseases
      1. BACKGROUND: Tuberculosis preventive treatment (TPT) is a critical intervention to reduce TB mortality among people living with HIV (PLHIV). To facilitate scale-up of TPT among PLHIV, the Nigeria Ministry of Health and the US Centers for Disease Control and Prevention (CDC) Nigeria, supported by US President's Emergency Plan for AIDS Relief (PEPFAR) implementing partners (IPs), launched a TPT-focused technical assistance strategy in high-volume antiretroviral treatment (ART) sites during 2018. SETTING: Nigeria has an estimated 1.9 million PLHIV, representing the second largest national burden of PLHIV in the world, and an estimated 53% of PLHIV are on ART. METHODS: In 50 high-volume ART sites, we assessed readiness for TPT scale-up through use of a standardized tool across five areas: clinical training, community education, patient management, commodities and logistics management, and recording and reporting. We deployed a site-level continuous quality improvement strategy to facilitate TPT scale-up. IPs rapidly disseminated best practices from these sites across all CDC-supported sites and reported aggregate data on monthly TPT initiations. RESULTS: Through this targeted assistance and rapid dissemination of best practices to all other sites, the number of PLHIV who initiated TPT across all CDC-supported sites increased from 6,622 in May 2018, when the approach was implemented, to 48,661 in September 2018. Gains in monthly TPT initiations were sustained through March 2019. CONCLUSION: Use of a standardized tool for assessing readiness for TPT scale-up provided a "checklist" of potential barriers to TPT scale-up to address at each site. The quality improvement approach allowed each site to design a specific plan to achieve desired TPT scale-up, and best practices were implemented concurrently at other, smaller sites. The approach could assist scale-up of TPT among PLHIV in other countries.

      2. Hydroxychloroquine and chloroquine prescribing patterns by provider specialty following initial reports of potential benefit for COVID-19 treatment - United States, January-June 2020external icon
        Bull-Otterson L, Gray EB, Budnitz DS, Strosnider HM, Schieber LZ, Courtney J, García MC, Brooks JT, Mac Kenzie WR, Gundlapalli AV.
        MMWR Morb Mortal Wkly Rep. 2020 Sep 4;69(35):1210-1215.
        Hydroxychloroquine and chloroquine, primarily used to treat autoimmune diseases and to prevent and treat malaria, received national attention in early March 2020, as potential treatment and prophylaxis for coronavirus disease 2019 (COVID-19) (1). On March 20, the Food and Drug Administration (FDA) issued an emergency use authorization (EUA) for chloroquine phosphate and hydroxychloroquine sulfate in the Strategic National Stockpile to be used by licensed health care providers to treat patients hospitalized with COVID-19 when the providers determine the potential benefit outweighs the potential risk to the patient.* Following reports of cardiac and other adverse events in patients receiving hydroxychloroquine for COVID-19 (2), on April 24, 2020, FDA issued a caution against its use(†) and on June 15, rescinded its EUA for hydroxychloroquine from the Strategic National Stockpile.(§) Following the FDA's issuance of caution and EUA rescindment, on May 12 and June 16, the federal COVID-19 Treatment Guidelines Panel issued recommendations against the use of hydroxychloroquine or chloroquine to treat COVID-19; the panel also noted that at that time no medication could be recommended for COVID-19 pre- or postexposure prophylaxis outside the setting of a clinical trial (3). However, public discussion concerning the effectiveness of these drugs on outcomes of COVID-19 (4,5), and clinical trials of hydroxychloroquine for prophylaxis of COVID-19 continue.(¶) In response to recent reports of notable increases in prescriptions for hydroxychloroquine or chloroquine (6), CDC analyzed outpatient retail pharmacy transaction data to identify potential differences in prescriptions dispensed by provider type during January-June 2020 compared with the same period in 2019. Before 2020, primary care providers and specialists who routinely prescribed hydroxychloroquine, such as rheumatologists and dermatologists, accounted for approximately 97% of new prescriptions. New prescriptions by specialists who did not typically prescribe these medications (defined as specialties accounting for ≤2% of new prescriptions before 2020) increased from 1,143 prescriptions in February 2020 to 75,569 in March 2020, an 80-fold increase from March 2019. Although dispensing trends are returning to prepandemic levels, continued adherence to current clinical guidelines for the indicated use of these medications will ensure their availability and benefit to patients for whom their use is indicated (3,4), because current data on treatment and pre- or postexposure prophylaxis for COVID-19 indicate that the potential benefits of these drugs do not appear to outweigh their risks.

      3. The hepatitis B care cascade using administrative claims data, 2016external icon
        Harris AM, Osinubi A, Nelson NP, Thompson WW.
        Am J Manag Care. 2020 Aug;26(8):331-338.
        OBJECTIVES: Monitoring care and treatment for persons with chronic hepatitis B (CHB) is essential for demonstrating progress in achieving national elimination goals. We sought to evaluate insurance claims data as a source for monitoring progression along the CHB care cascade. STUDY DESIGN: Longitudinal evaluation from diagnosis to treatment among commercially insured enrollees with CHB. METHODS: We used standardized procedure and diagnosis codes to identify enrollees (≥ 18 years) with CHB in large insurance claims databases to describe the CHB care cascade from 2008 to 2016. Linkage to care was defined as procedure codes for liver fibrosis assessment (alanine aminotransferase in conjunction with either hepatitis B virus DNA or hepatitis B e-antigen) more than 12 months after CHB diagnosis. Treatment was defined as a claim for any CHB prescription. We analyzed factors associated with linkage to care and treatment using unadjusted logistic regression and evaluated rates of diagnosis, linkage to care, and treatment over time. RESULTS: Of 16,644 individuals with CHB, 6004 (36%) were linked to care and 2926 (18%) were treated. Persons coinfected with HIV (odds ratio [OR], 0.46; 95% CI, 0.36-0.59) or hepatitis C (OR, 0.50; 95% CI, 0.34-0.73) were less likely to be linked to care, and persons coinfected with HIV (OR, 0.29; 95% CI, 0.19-0.44) were less likely to be treated. From 2009 to 2015, there was a significant decrease in CHB diagnoses but no change in the proportion linked to care and treatment. CONCLUSIONS: We identified gaps in linkage to care and treatment in commercially insured adults with CHB.

      4. Prevalence of cryptococcal antigen (CrAg) among HIV-positive patients in Eswatini, 2014-2015external icon
        Haumba SM, Toda M, Jeffries R, Ehrenkranz P, Pasipamire M, Ao T, Lukhele N, Mazibuko S, Mkhontfo M, Smith RM, Chiller T.
        Afr J Lab Med. 2020 ;9(1):933.
        BACKGROUND: Cryptococcal meningitis is a leading cause of death amongst people living with HIV. However, routine cryptococcal antigen (CrAg) screening was not in the national guidelines in Eswatini. OBJECTIVES: A cross-sectional study was conducted between August 2014 and March 2015 to examine CrAg prevalence at Mbabane Government Hospital in Eswatini. METHODS: We collected urine and whole blood from antiretroviral-therapy-naïve patients with HIV and a cluster of differentiation 4 (CD4) counts < 200 cells/mm(3) for plasma and urine CrAg lateral flow assay (LFA) screening at the national HIV reference laboratory. Two CD4 cut-off points were used to estimate CrAg prevalence: CD4 < 100 and < 200 cells/mm(3). Sensitivity and specificity of urine CrAg LFA was compared to plasma CrAg LFA. RESULTS: Plasma CrAg prevalence was 4% (8/182, 95% confidence interval [CI]: 2-8) amongst patients with CD4 counts of < 200 cells/mm(3), and 8% (8/102, 95% CI: 3-15) amongst patients with CD4 counts of < 100 cells/mm(3). Urine CrAg LFA had a sensitivity of 100% (95% CI: 59-100) and a specificity of 80% (95% CI: 72-86) compared with plasma CrAg LFA tests for patients with CD4 < 200 cells/mm(3). Forty-three per cent of 99 patients with CD4 < 100 were at World Health Organization clinical stages I or II. CONCLUSION: The prevalence of CrAg in Eswatini was higher than the current global estimate of 6% amongst HIV-positive people with CD4 < 100 cell/mm(3), indicating the importance of initiating a national screening programme. Mechanisms for CrAg testing, training, reporting, and drug and commodity supply issues are important considerations before national implementation.

      5. Factors associated with HIV and syphilis infection among female sex workers in three cities in Papua New Guinea: findings from Kauntim mi tu, a biobehavioral surveyexternal icon
        Kelly-Hanku A, Weikum D, Badman SG, Willie B, Boli-Neo R, Kupul M, Hou P, Gabuzzi J, Ase S, Amos A, Narokobi R, Aeno H, Pekon S, Coy K, Wapling J, Gare J, Dala N, Kaldor JM, Vallely AJ, Hakim AJ.
        Sex Health. 2020 Jul 23.
        Background:In this paper, factors associated with HIV and syphilis infection in three cities in Papua New Guinea are explored. Methods: Respondent-driven sampling surveys among FSW in Port Moresby, Lae, and Mt. Hagen (2016-17) were conducted. FSW who were aged ≥12 years, who were born female, who spoke English or Tok Pisin and who had sold or exchanged vaginal sex in the past 6 months were eligible to participate. Participants were interviewed face-to-face and offered rapid HIV and syphilis testing. Survey logistic procedures were used to identify factors associated with HIV and syphilis infection, including modern contraception use, physical violence and having a casual male partner. Weighted data analysis was conducted. Results: Overall, 2901 FSW (Port Moresby, 673; Lae, 709; and Mt. Hagen, 709) were enrolled in the study. HIV prevalence was 15.2% in Port Moresby, 11.9% in Lae and 19.6% in Mt. Hagen. Factors associated with HIV varied by city; for example, use of modern contraception in Port Moresby, experiences of physical violence in Lae and ever having tested for HIV in Mt. Hagen. No one variable was associated with HIV in all cities. Prevalence of syphilis infection was 7.1%, 7.0%, and 3.0% in Port Moresby, Lae, and Mt. Hagen, respectively. Factors associated with syphilis infection also varied by city and were only significant in Lae. Conclusion: The different factors associated with HIV and syphilis infection in each city highlight the complex HIV and syphilis epidemics among FSW and the importance of conducting surveys in multiple locations and developing local interventions.

      6. A protracted cholera outbreak among residents in an urban setting, Nairobi County, Kenya, 2015external icon
        Kigen HT, Boru W, Gura Z, Githuka G, Mulembani R, Rotich J, Abdi I, Galgalo T, Githuku J, Obonyo M, Muli R, Njeru I, Langat D, Nsubuga P, Kioko J, Lowther S.
        Pan Afr Med J. 2020 ;36:127.
        INTRODUCTION: in 2015, a cholera outbreak was confirmed in Nairobi county, Kenya, which we investigated to identify risk factors for infection and recommend control measures. METHODS: we analyzed national cholera surveillance data to describe epidemiological patterns and carried out a case-control study to find reasons for the Nairobi county outbreak. Suspected cholera cases were Nairobi residents aged >2 years with acute watery diarrhea (>4 stools/≤12 hours) and illness onset 1-14 May 2015. Confirmed cases had Vibrio cholerae isolated from stool. Case-patients were frequency-matched to persons without diarrhea (1:2 by age group, residence), interviewed using standardized questionaires. Logistic regression identified factors associated with case status. Household water was analyzed for fecal coliforms and Escherichia coli. RESULTS: during December 2014-June 2015, 4,218 cholera cases including 282 (6.7%) confirmed cases and 79 deaths (case-fatality rate [CFR] 1.9%) were reported from 14 of 47 Kenyan counties. Nairobi county reported 781 (19.0 %) cases (attack rate, 18/100,000 persons), including 607 (78%) hospitalisations, 20 deaths (CFR 2.6%) and 55 laboratory-confirmed cases (7.0%). Seven (70%) of 10 water samples from communal water points had coliforms; one had Escherichia coli. Factors associated with cholera in Nairobi were drinking untreated water (adjusted odds ratio [aOR] 6.5, 95% confidence interval [CI] 2.3-18.8), lacking health education (aOR 2.4, CI 1.1-7.9) and eating food outside home (aOR 2.4, 95% CI 1.2-5.7). CONCLUSION: we recommend safe water, health education, avoiding eating foods prepared outside home and improved sanitation in Nairobi county. Adherence to these practices could have prevented this protacted cholera outbreak.

      7. Estimating the effect of depression on HIV transmission risk behaviors among people who inject drugs in Vietnam: A causal approachexternal icon
        Levintow SN, Pence BW, Powers KA, Sripaipan T, Ha TV, Chu VA, Quan VM, Latkin CA, Go VF.
        AIDS Behav. 2020 Aug 24:1-9.
        The burden of depression and HIV is high among people who inject drugs (PWID), yet the effect of depression on transmission risk behaviors is not well understood in this population. Using causal inference methods, we analyzed data from 455 PWID living with HIV in Vietnam 2009-2013. Study visits every 6 months over 2 years measured depressive symptoms in the past week and injecting and sexual behaviors in the prior 3 months. Severe depressive symptoms (vs. mild/no symptoms) increased injection equipment sharing (risk difference [RD] = 3.9 percentage points, 95% CI -1.7, 9.6) but not condomless sex (RD = -1.8, 95% CI -6.4, 2.8) as reported 6 months later. The cross-sectional association with injection equipment sharing at the same visit (RD = 6.2, 95% CI 1.4, 11.0) was stronger than the longitudinal effect. Interventions on depression among PWID may decrease sharing of injection equipment and the corresponding risk of HIV transmission.Clinical trial registration NCT01689545.

      8. We conducted a survey among women attending an urban public sexually transmitted disease clinic to determine type and frequency of intravaginal cleansing practices. Both intravaginal washing and douching were frequent, performed mostly for routine hygiene, and associated with self-report of STI and bacterial vaginosis (douching) and bacterial vaginosis (intravaginal washing).

      9. Timing of state and territorial COVID-19 stay-at-home orders and changes in population movement - United States, March 1-May 31, 2020external icon
        Moreland A, Herlihy C, Tynan MA, Sunshine G, McCord RF, Hilton C, Poovey J, Werner AK, Jones CD, Fulmer EB, Gundlapalli AV, Strosnider H, Potvien A, García MC, Honeycutt S, Baldwin G.
        MMWR Morb Mortal Wkly Rep. 2020 Sep 4;69(35):1198-1203.
        SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is thought to spread from person to person primarily by the respiratory route and mainly through close contact (1). Community mitigation strategies can lower the risk for disease transmission by limiting or preventing person-to-person interactions (2). U.S. states and territories began implementing various community mitigation policies in March 2020. One widely implemented strategy was the issuance of orders requiring persons to stay home, resulting in decreased population movement in some jurisdictions (3). Each state or territory has authority to enact its own laws and policies to protect the public's health, and jurisdictions varied widely in the type and timing of orders issued related to stay-at-home requirements. To identify the broader impact of these stay-at-home orders, using publicly accessible, anonymized location data from mobile devices, CDC and the Georgia Tech Research Institute analyzed changes in population movement relative to stay-at-home orders issued during March 1-May 31, 2020, by all 50 states, the District of Columbia, and five U.S. territories.* During this period, 42 states and territories issued mandatory stay-at-home orders. When counties subject to mandatory state- and territory-issued stay-at-home orders were stratified along rural-urban categories, movement decreased significantly relative to the preorder baseline in all strata. Mandatory stay-at-home orders can help reduce activities associated with the spread of COVID-19, including population movement and close person-to-person contact outside the household.

      10. The distribution and spread of susceptible and resistant Neisseria gonorrhoeae across demographic groups in a major metropolitan centerexternal icon
        Mortimer TD, Pathela P, Crawley A, Rakeman JL, Lin Y, Harris SR, Blank S, Schillinger JA, Grad YH.
        Clin Infect Dis. 2020 Aug 23.
        BACKGROUND: Genomic epidemiology studies of gonorrhea in the United States have primarily focused on national surveillance for antibiotic resistance, and patterns of local transmission between demographic groups of resistant and susceptible strains are unknown. METHODS: We analyzed a convenience sample of genome sequences, antibiotic susceptibility, and patient data from 897 gonococcal isolates cultured at the NYC Public Health Laboratory from NYC Department of Health and Mental Hygiene (DOHMH) Sexual Health Clinic (SHC) patients, primarily in 2012-13. We reconstructed the gonococcal phylogeny, defined transmission clusters using a 10 non-recombinant single nucleotide polymorphism threshold, tested for clustering of demographic groups, and placed NYC isolates in a global phylogenetic context. RESULTS: The NYC gonococcal phylogeny reflected global diversity with isolates from 22/23 of the prevalent global lineages (96%). Isolates clustered on the phylogeny by patient sexual behavior (p&0.001) and race/ethnicity (p&0.001). Minimum inhibitory concentrations were higher across antibiotics in isolates from men who have sex with men compared to heterosexuals (p&0.001) and white heterosexuals compared to black heterosexuals (p&0.01). In our dataset, all large transmission clusters (≥10 samples) of N. gonorrhoeae were susceptible to ciprofloxacin, ceftriaxone, and azithromycin and comprised isolates from patients across demographic groups. CONCLUSIONS: All large transmission clusters were susceptible to gonorrhea therapies, suggesting that resistance to empiric therapy was not a main driver of spread, even as risk for resistance varied across demographic groups. Further study of local transmission networks is needed to identify drivers of transmission.

      11. Respiratory illness caused by Corynebacterium diphtheriae and C. ulcerans, and use of diphtheria anti-toxin in the United States, 1996-2018. BACKGROUND: Respiratory diphtheria is a toxin-mediated disease caused by Corynebacterium diphtheriae. Diphtheria-like illness, clinically indistinguishable from diphtheria, is caused by C. ulcerans, a zoonotic bacterium that can also produce diphtheria toxin. In the United States, respiratory diphtheria is nationally notifiable: specimens from suspected cases are submitted to the Centers for Disease Control (CDC) for species and toxin confirmation, and diphtheria antitoxin (DAT) is obtained from CDC for treatment. We summarize the epidemiology of respiratory diphtheria and diphtheria-like illness and describe DAT use during 1996-2018 in the United States. METHODS: We described respiratory diphtheria cases reported to the National Notifiable Diseases Surveillance System (NNDSS) and C. ulcerans-related diphtheria-like illness identified through specimen submissions to CDC during 1996-2018. We reviewed DAT requests from 1997-2018. RESULTS: From 1996-2018, 14 respiratory diphtheria cases were reported to NNDSS. Among these 14 cases, 1 was toxigenic and 3 were non-toxigenic C. diphtheriae by culture and Elek, 6 were culture-negative but PCR-positive for diphtheria toxin gene, 1 was culture-positive without further testing, and the remaining 3 were either not tested or tested negative. Five cases of respiratory diphtheria-like illness caused by toxigenic C. ulcerans were identified. DAT was requested by healthcare providers for 151 suspected diphtheria cases between 1997-2018, with an average of 11 requests per year from 1997-2007, and 3 per year from 2008-2018. CONCLUSIONS: Respiratory diphtheria remains rare in the United States, and requests for DAT have declined. Incidental identification of C. ulcerans-related diphtheria-like illness suggests surveillance of this condition might be warranted.

      12. Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network - 13 academic medical centers, April-June 2020external icon
        Self WH, Tenforde MW, Stubblefield WB, Feldstein LR, Steingrub JS, Shapiro NI, Ginde AA, Prekker ME, Brown SM, Peltan ID, Gong MN, Aboodi MS, Khan A, Exline MC, Files DC, Gibbs KW, Lindsell CJ, Rice TW, Jones ID, Halasa N, Talbot HK, Grijalva CG, Casey JD, Hager DN, Qadir N, Henning DJ, Coughlin MM, Schiffer J, Semenova V, Li H, Thornburg NJ, Patel MM.
        MMWR Morb Mortal Wkly Rep. 2020 Sep 4;69(35):1221-1226.
        Health care personnel (HCP) caring for patients with coronavirus disease 2019 (COVID-19) might be at high risk for contracting SARS-CoV-2, the virus that causes COVID-19. Understanding the prevalence of and factors associated with SARS-CoV-2 infection among frontline HCP who care for COVID-19 patients are important for protecting both HCP and their patients. During April 3-June 19, 2020, serum specimens were collected from a convenience sample of frontline HCP who worked with COVID-19 patients at 13 geographically diverse academic medical centers in the United States, and specimens were tested for antibodies to SARS-CoV-2. Participants were asked about potential symptoms of COVID-19 experienced since February 1, 2020, previous testing for acute SARS-CoV-2 infection, and their use of personal protective equipment (PPE) in the past week. Among 3,248 participants, 194 (6.0%) had positive test results for SARS-CoV-2 antibodies. Seroprevalence by hospital ranged from 0.8% to 31.2% (median = 3.6%). Among the 194 seropositive participants, 56 (29%) reported no symptoms since February 1, 2020, 86 (44%) did not believe that they previously had COVID-19, and 133 (69%) did not report a previous COVID-19 diagnosis. Seroprevalence was lower among personnel who reported always wearing a face covering (defined in this study as a surgical mask, N95 respirator, or powered air purifying respirator [PAPR]) while caring for patients (5.6%), compared with that among those who did not (9.0%) (p = 0.012). Consistent with persons in the general population with SARS-CoV-2 infection, many frontline HCP with SARS-CoV-2 infection might be asymptomatic or minimally symptomatic during infection, and infection might be unrecognized. Enhanced screening, including frequent testing of frontline HCP, and universal use of face coverings in hospitals are two strategies that could reduce SARS-CoV-2 transmission.

      13. Collection of gender identity in national case notifications of chlamydia, gonorrhea, and primary and secondary syphilis, 2018external icon
        Torrone E, Grier L, Gadsden-Knowles K, Weinstock H, Stenger M.
        Sex Transm Dis. 2020 Sep;47(9):645-648.
        In 2018, 21 (41%) jurisdictions had begun reporting gender identity for sexually transmitted disease case notifications sent to the Centers for Disease Control and Prevention. Among jurisdictions with ≥70% of cases with reported gender identity and sex, 1.0% of primary and secondary syphilis cases were identified as transgender and 71% of transgender women with syphilis were concurrently coded as being male sex.

      14. The reported numbers of Covid-19 cases and deaths were compared for 18 countries (14 in Western Europe, plus Australia, Brazil, Israel and the USA) to assess the effect of historic and current national BCG immunizations. In view of the high death rate for Covid-19 patients over 70 years of age, and given the fact that BCG vaccination is typically given early in life, we compared countries that had introduced BCG in the 1950s with those that had not. No effect on Covid-19 case fatality rate (CFR) or number of deaths per population could be demonstrated. Since some countries test for Covid-19 more than others, the effect of tests performed per million population on reported deaths per million was also assessed, but again did not demonstrate an effect of BCG vaccination in the 1950s. Whether countries had never used the vaccine, had historically used it but since ceased to do so, or were presently vaccinating with BCG did not correlate with national total number of deaths or CFR. We conclude that there is currently no evidence for a beneficial effect of BCG vaccination on Covid-19 reported cases or fatalities.

      15. Cytokine biomarkers associated with clinical cases of acute flaccid myelitisexternal icon
        Weldon WC, Zhao K, Jost HA, Hetzler K, Ciomperlik-Patton J, Konopka-Anstadt JL, Oberste MS.
        J Clin Virol. 2020 Aug 18;131:104591.
        Acute flaccid myelitis (AFM) is a serious neurological illness first recognized in the United States in 2014, with subsequent outbreaks every two years. Following extensive etiologic testing by multiple laboratories of hundreds of specimens collected from patients diagnosed with AFM, no consistent cause of AFM has been identified. However, viruses, including enteroviruses, have been implicated through detection in non-sterile site specimens and antibody studies. Cytokines and chemokines play important roles in the modulation of the innate and adaptive immune response to pathogens. In the current study, we measured levels of cytokines and chemokines in serum and CSF collected from confirmed AFM patients and non-AFM control patients, to identify unique biomarkers as potential hallmarks of AFM pathogenesis. Analysis of ratios of cytokines and chemokines in the CSF compared to the serum indicate that the pro-inflammatory cytokines/chemokines IP-10 and IL-6 were significantly elevated in AFM patients compared to non-AFM patients. These results may provide additional insight into potential etiologies, pathogenic mechanisms, and treatments for AFM.

    • Disaster Control and Emergency Services
      1. The 6 E framework of public health preparedness for mass gatherings - lessons learned from Super Bowl LIII, Fulton County, Georgia, 2019external icon
        Murthy NC, Holland DP, Chamberlain AT, Smith S, Callahan J, Smith W.
        J Public Health Manag Pract. 2020 Aug 21.
        CONTEXT: On February 3, 2019, Atlanta, Georgia, hosted Super Bowl LIII, which is classified as a National Special Security Event. The festivities comprising this major sporting event brought approximately half a million people to Atlanta, which posed significant challenges to the local public health community. As the lead local agency for public health planning, preparedness, and response efforts, Fulton County Board of Health (FCBOH) needed to address multiple specific tasks based on core functional areas outlined in the Emergency Support Function (ESF) 8 (eg, bioterrorism preparedness and epidemiological surveillance). PROGRAM: To prepare for the Super Bowl, FCBOH developed a systematic approach to ensure community-wide public health preparedness for mass gatherings. This approach came to be known as the 6 E framework, which consists of (1) engaging stakeholders, (2) examining current capabilities and identifying gaps, (3) establishing roles and responsibilities, (4) executing plans to fill gaps, (5) exercising plans, and (6) evaluating impact. IMPLEMENTATION: We define each step of the 6 E framework and present practical examples of how FCBOH implemented each step when preparing for the Super Bowl. Challenges that FCBOH faced and the lessons learned in the process are illustrated. The 6 E framework provides a systematic approach to community preparedness and allows local health departments to tailor the approach to serve local public health needs. EVALUATION: The successful implementation of the 6 E framework allowed for stakeholders at the federal, state, and local levels (including law enforcement) to effectively coordinate an epidemiological investigation and response when 4 staff members reported gastrointestinal symptoms after eating at a feeding station. DISCUSSION: Preparation for the Super Bowl required months of diligent cross-sectoral and cross-jurisdictional partnership building, and the 6 E framework can help other local public health jurisdictions prepare to host major mass gatherings.

    • Environmental Health
      1. Urinary polycyclic aromatic hydrocarbons in relation to anthropometric measures and pubertal development in a cohort of Northern California girlsexternal icon
        Dobraca D, Laurent CA, Greenspan LC, Hiatt RA, Sjodin A, Kushi LH, Windham GC.
        Environ Epidemiol. 2020 Aug;4(4):e0102.
        BACKGROUND: Polycyclic aromatic hydrocarbons (PAHs) are a class of ubiquitous, environmental chemicals that may have endocrine disrupting capabilities. We investigated whether childhood exposure to PAHs was associated with adiposity and pubertal timing in a longitudinal study of 404 girls enrolled in the Northern California site of the Breast Cancer and the Environment Research Program cohort. METHODS: Baseline urinary samples from girls aged 6-8-years-old were assayed for 2-naphthol, fluorene metabolites, phenanthrene metabolites, 1-hydroxypyrene, and sum of PAH metabolites. Mixed-effects linear models were used to estimate how concentrations of PAH metabolites were related to changes in girl's body mass index (BMI) and waist-to-height ratio from age 7 through 16 years old. Accelerated failure time models were used to estimate age of pubertal onset (Tanner stages 2 or higher for breast and pubic hair development). RESULTS: Higher adiposity measurements among high tertiles of baseline PAH metabolites were evident at age 7 years old and increased thereafter (i.e., BMI for all PAH metabolites, waist-to-height ratio for fluorene and phenanthrene metabolites) or leveled off (i.e., waist-to-height ratio for 2-naphthol, 1-hydroxypyrene, sum of PAHs). Among girls overweight/obese at baseline, median age of breast development onset for high tertiles was 9.1-9.4 years old compared with 10-10.2 years old for low tertiles for all PAH metabolites; in contrast, found no association or slightly later onset of breast development for girls with normal weight at baseline. DISCUSSION: These results suggest that exposure to specific PAHs during childhood may influence adiposity throughout adolescence and effect pubertal timing.

    • Epidemiology and Surveillance
      1. Identifying incidents of public health significance using the National Poison Data System, 2013-2018external icon
        Carpenter JE, Chang AS, Bronstein AC, Thomas RG, Law RK.
        Am J Public Health. 2020 Aug 20:e1-e4.
        Data System. The American Association of Poison Control Centers (AAPCC) and the Centers for Disease Control and Prevention (CDC) jointly monitor the National Poison Data System (NPDS) for incidents of public health significance (IPHSs).Data Collection/Processing. NPDS is the data repository for US poison centers, which together cover all 50 states, the District of Columbia, and multiple territories. Information from calls to poison centers is uploaded to NPDS in near real time and continuously monitored for specific exposures and anomalies relative to historic data.Data Analysis/Dissemination. AAPCC and CDC toxicologists analyze NPDS-generated anomalies for evidence of public health significance. Presumptive results are confirmed with the receiving poison center to correctly identify IPHSs. Once verified, CDC notifies the state public health department.Implications. During 2013 to 2018, 3.7% of all NPDS-generated anomalies represented IPHSs. NPDS surveillance findings may be the first alert to state epidemiologists of IPHSs. Data are used locally and nationally to enhance situational awareness during a suspected or known public health threat. NPDS improves CDC's national surveillance capacity by identifying early markers of IPHSs. (Am J Public Health. Published online ahead of print August 20, 2020: e1-e4. doi:10.2105/AJPH.2020.305842).

    • Global Health
      1. Epidemiological, and clinical characteristics of international travelers with enteric fever and antibiotic resistance profiles of their isolates: A GeoSentinel Analysisexternal icon
        Hagmann SH, Angelo KM, Huits R, Plewes K, Eperon G, Grobusch MP, McCarthy A, Libman M, Caumes E, Leung DT, Asgeirsson H, Jensenius M, Schwartz E, Sánchez-Montalvá A, Kelly P, Pandey P, Leder K, Bourque DL, Yoshimura Y, Mockenhaupt FP, van Genderen PJ, Odolini S, Schlagenhauf P, Connor BA, Hamer DH.
        Antimicrob Agents Chemother. 2020 Aug 17.
        Background. Enteric fever, caused by Salmonella enterica serovar Typhi (S. Typhi) and Paratyphi (S. Paratyphi), is a common travel-related illness. Limited data are available on their antimicrobial resistance (AMR) patterns among travelers. Methods. Records with a culture-confirmed diagnosis seen during or after travel from January 2007 to December 2018 were obtained from GeoSentinel. Traveler demographics and antimicrobial susceptibility data were analyzed. Isolates were classified as 'non-susceptible' if intermediate or resistant, or 'susceptible' in accordance with participating site's national guidelines. Results. A total of 889 travelers (S. Typhi, n=474; S. Paratyphi, n=414; co-infection, n=1) were included; 114 (13%) were children <18 years. Most (41%) traveled to visit friends and relatives (VFRs) and acquired the infection in South Asia (71%). Child travelers with S. Typhi were most frequently VFRs (77%). The median trip duration was 31 days (interquartile range: 18-61 days) and 448 of 691 (65%) had no pre-travel consultation. Of 143 S. Typhi and 75 S. Paratyphi isolates with susceptibility data, non-susceptibility to antibiotics varied (fluoroquinolones: 65% vs 56% respectively; cotrimoxazole: 13% vs 0%; macrolides: 8% vs 16%). Two S. Typhi isolates (1.5%) from India were non-susceptible to 3(rd)-generation cephalosporins. S. Typhi fluoroquinolone non-susceptibility was highest when infection was acquired in South Asia (70 of 90; 78%) and sub-Saharan Africa (6 of 10; 60%). Conclusions. Enteric fever is an important travel-associated illness complicated by AMR. Our data contributes to a better understanding of region-specific AMR helping inform empirical treatment options. Prevention measures need to focus on high-risk travelers including VFRs and children.

    • Health Disparities
      1. Previous work has not examined how the association of sexual orientation and severe headache/migraine may be explained by differences between sexual minorities and heterosexuals in sociodemographic and health-related characteristics. Using data from the 2013-2018 National Health Interview Survey, regression decomposition was used to identify determinants of disparities in headache/migraine between sexual minorities collectively and heterosexuals, as well as between bisexual men and gay men, and bisexual women and lesbians. The prevalence of headache/migraine was the highest among bisexual women (36.8%), followed by lesbians (24.7%), bisexual men (22.8%), heterosexual women (19.7%), gay men (14.8%), and heterosexual men (9.8%). Across all models, the largest percentage of the disparity between sexual orientation/gender groups was attributable to age (range, 18.3%-42.2%), serious psychological distress (range, 6.6%-14.0%), and hours of regular sleep (range, 1.7%-8.2%). Although age accounted for the largest part of the disparity in headache/migraine by sexual orientation, several modifiable risk factors also played a role.

      2. Geographic access to obstetric critical care for women of reproductive age by race and ethnicityexternal icon
        Kroelinger CD, Brantley MD, Fuller TR, Okoroh EM, Monsour MJ, Cox S, Barfield WD.
        Am J Obstet Gynecol. 2020 Aug 21.
        BACKGROUND: The goal of risk-appropriate maternal care is for high-risk pregnant women to receive specialized obstetric services in facilities equipped with capabilities and staffing to provide care or transfer to facilities with resources available to provide care. In the United States (US), geographic access to obstetric critical care (OCC) varies. It is unknown if this variation in proximity to OCC differs by race, ethnicity, and region. OBJECTIVES: We examined the geographic access, defined as residence within 50 miles of a facility capable of providing risk-appropriate OCC services for women of reproductive age, by distribution of race and ethnicity. STUDY DESIGN: Descriptive spatial analysis was used to assess geographic distance to OCC for women of reproductive age by race and ethnicity. Data were analyzed geographically: nationally, by Department of Health and Human Services (HHS) regions, and by all 50 states and the District of Columbia. Dot density analysis was used to visualize geographic distributions of women by residence and OCC facilities across the US. Proximity analysis defined the proportion of women living within an approximate 50-mile radius of facilities. Source data included 2015 American Community Survey from the US Census Bureau and the 2015 American Hospital Association Annual Survey. RESULTS: Geographic access to OCC was greatest for Asian/Pacific Islander women of reproductive age (95.8%), followed by black (93.5%), Hispanic (91.4%), and white women of reproductive age (89.1%). American Indian/Alaska Native (AI/AN) women had more limited geographic access at 66% in all regions. Visualization of proximity to OCC indicated facilities were predominantly located in urban areas, which may limit access to women in frontier or rural areas of states including nationally recognized reservations where larger proportions of white and AI/AN women reside, respectively. CONCLUSIONS: Disparities in proximity to OCC exist in rural and frontier areas of the US, which impact white and AI/AN women, primarily. Examining insurance coverage, inter-state hospital referral networks, and transportation barriers may provide further insight into OCC accessibility. Further exploring the role of other equity-based measures of access on disparities beyond geography is warranted.

      3. BACKGROUND: Community Approaches to Reducing STDs (CARS), a unique initiative of the U.S. Centers for Disease Control and Prevention, promotes the use of community engagement to increase STD prevention, screening, and treatment and address locally prioritized STD-related social determinants of health within communities experiencing STD disparities, including youth; persons of color; and sexual and gender minorities. We sought to identify elements of community engagement as applied within CARS. METHODS AND MATERIALS: Between 2011-2018, we collected and analyzed archival and in-depth interview data to identify and explore community engagement across eight CARS sites. Five to 13 interview participants (mean=7) at each site were interviewed annually. Participants included project staff and leadership; community members; and representatives from local community organizations (e.g., health departments; lesbian, gay, bisexual, transgender, and queer [LGBTQ]-serving organizations; faith organizations; businesses; and HIV-service organizations) and universities. Data were analyzed using constant comparison, an approach to grounded theory development. RESULTS: Twelve critical elements of community engagement emerged, including commitment to engagement; partner flexibility; talented and trusted leadership; participation of diverse sectors; establishment of vision and mission; open communication; reducing power differentials; working through conflict; identifying and leveraging resources; and building a shared history. CONCLUSIONS: This study expands the community engagement literature within STD prevention, screening, and treatment by elucidating some of the critical elements of the approach and provides guidance for practitioners, researchers, and their partners as they develop, implement, and evaluate strategies to reduce STD disparities.

    • Health Economics
      1. Seasonal influenza vaccination in Kenya: an economic evaluation using dynamic transmission modellingexternal icon
        Dawa J, Emukule GO, Barasa E, Widdowson MA, Anzala O, van Leeuwen E, Baguelin M, Chaves SS, Eggo RM.
        BMC Med. 2020 Aug 20;18(1):223.
        BACKGROUND: There is substantial burden of seasonal influenza in Kenya, which led the government to consider introducing a national influenza vaccination programme. Given the cost implications of a nationwide programme, local economic evaluation data are needed to inform policy on the design and benefits of influenza vaccination. We set out to estimate the cost-effectiveness of seasonal influenza vaccination in Kenya. METHODS: We fitted an age-stratified dynamic transmission model to active surveillance data from patients with influenza from 2010 to 2018. Using a societal perspective, we developed a decision tree cost-effectiveness model and estimated the incremental cost-effectiveness ratio (ICER) per disability-adjusted life year (DALY) averted for three vaccine target groups: children 6-23 months (strategy I), 2-5 years (strategy II) and 6-14 years (strategy III) with either the Southern Hemisphere influenza vaccine (Strategy A) or Northern Hemisphere vaccine (Strategy B) or both (Strategy C: twice yearly vaccination campaigns, or Strategy D: year-round vaccination campaigns). We assessed cost-effectiveness by calculating incremental net monetary benefits (INMB) using a willingness-to-pay (WTP) threshold of 1-51% of the annual gross domestic product per capita ($17-$872). RESULTS: The mean number of infections across all ages was 2-15 million per year. When vaccination was well timed to influenza activity, the annual mean ICER per DALY averted for vaccinating children 6-23 months ranged between $749 and $1385 for strategy IA, $442 and $1877 for strategy IB, $678 and $4106 for strategy IC and $1147 and $7933 for strategy ID. For children 2-5 years, it ranged between $945 and $1573 for strategy IIA, $563 and $1869 for strategy IIB, $662 and $4085 for strategy IIC, and $1169 and $7897 for strategy IID. For children 6-14 years, it ranged between $923 and $3116 for strategy IIIA, $1005 and $2223 for strategy IIIB, $883 and $4727 for strategy IIIC and $1467 and $6813 for strategy IIID. Overall, no vaccination strategy was cost-effective at the minimum ($17) and median ($445) WTP thresholds. Vaccinating children 6-23 months once a year had the highest mean INMB value at $872 (WTP threshold upper limit); however, this strategy had very low probability of the highest net benefit. CONCLUSION: Vaccinating children 6-23 months once a year was the most favourable vaccination option; however, the strategy is unlikely to be cost-effective given the current WTP thresholds.

      2. Within-trial cost-effectiveness of lifestyle intervention using a 3-tier shared care approach for pregnancy outcomes in Chinese women with gestational diabetesexternal icon
        Li W, Zhang C, Leng J, Shao P, Tian H, Zhang F, Dong L, Yu Z, Chan JC, Hu G, Zhang P, Yang X.
        PLoS One. 2020 ;15(8):e0237738.
        This study assessed within-trial cost-effectiveness of a shared care program (SC, n = 339) for pregnancy outcomes compared to usual care (UC, n = 361), as implemented in a randomized trial of Chinese women with gestational diabetes (GDM). SC consisted of an individualized dietary advice and physical activity counseling program. The UC was a one-time group education program. The effectiveness was measured by number needed to treat (NNT) to prevent one macrosomia/large for gestational age (LGA) infant. The cost-effectiveness was measured by incremental cost-effectiveness ratio in terms of cost (2012 Chinese Yuan/US dollar) per case of macrosomia and LGA prevented. The study took both a health care system and a societal perspective. This study found that the NNT was 16/14 for macrosomia/LGA. The incremental cost for treating a pregnant woman was ¥1,877 ($298) from a health care system perspective and ¥2,056 ($327) from a societal perspective. The cost of preventing a case of macrosomia/LGA from the two corresponding perspectives were ¥30,032/¥26,278 ($4,775/$4,178) and ¥32,896/¥28,784 ($5,230/$4,577), respectively. Considering the potential severe adverse health and economic consequences of a macrosomia/LGA infant, our findings suggest that implementing this lifestyle intervention for women with GDM is an efficient use of health care resources.

    • Healthcare Associated Infections
      1. Characteristics of clinical extrapulmonary nontuberculous mycobacteria isolates in Minnesota, 2013-2017external icon
        Taylor J, Vagnone PS, Smith K, Walters J, Wengenack N, Deml S, Ferrieri P, Lynfield R.
        Minn Med. 2020 Jun;103(3):39-43.
        Approximately 80 species of nontuberculous mycobacteria (NTM) that cause disease are found environmentally and in animal reservoirs. Typically, pulmonary NTM infections are sporadic; extrapulmonary NTM (ENTM) infections are commonly outbreak associated. Recent sources of ENTM outbreaks in Minnesota include contaminated heater-cooler units used during cardiac surgery and contaminated hormone injections. We examined patient demographics and characteristics of ENTM isolates characterized by four Minnesota reference laboratories during 2013-2017 to assess potential value of systematic laboratory-based ENTM surveillance in Minnesota. Laboratories characterized 490 ENTM isolates, representing an estimated burden of 1.8/100,000 people/year in Minnesota. Thirty-one species or complexes were identified; most common were M. avium complex (31%), M. chelonae (22%), M. fortuitum (11%), and M. abscessus (4%). Most common specimen collection sites included skin and soft tissue (38%), blood (15%), neck lymph node or tissue (12%), sinus (8%), joint or bone (5%), device or implant (4%), and eye (3%). Median age of patients was 55 years (range: 2-98 years); 18% were from patients aged <18 years, 20% aged 18-44 years, 28% aged 45-64 years and 34% aged >65 years. Sex was documented for 238 (49%) patients; 127 (53%) were males. County information was available for 313 patients (64%); approximately half (49%) resided in metropolitan Minneapolis-Saint Paul. Laboratory data can be used for ENTM surveillance in Minnesota. Implementing laboratory-based surveillance can detect ENTM cases, provide a mechanism for obtaining clinical and epidemiological information, and enable earlier identification of potential health care transmission or community clusters.

    • Immunity and Immunization
      1. A prospective cohort study of immunogenicity of quadrivalent human papillomavirus vaccination among Alaska Native Children, Alaska, United Statesexternal icon
        Bruce MG, Meites E, Bulkow L, Panicker G, Hurlburt D, Lecy D, Thompson G, Rudolph K, Unger ER, Hennessy T, Markowitz LE.
        Vaccine. 2020 Aug 16.
        OBJECTIVE: In the United States, HPV vaccination is routinely recommended at age 11 or 12 years; the series can be started at age 9. We conducted a cohort study to assess long-term immunogenicity of quadrivalent HPV vaccine (4vHPV) in an American Indian/Alaska Native (AI/AN) Indigenous population. METHODS: During 2011-2014, we enrolled AI/AN girls and boys aged 9-14 years, who were vaccinated with a 3-dose series of 4vHPV. Serum specimens were collected at five time points: immediately prior to doses 2 and 3, and at one month, one year, and two years after series completion. Antibody testing was performed using a multiplex virus-like-particle-IgG ELISA for 4vHPV types (HPV 6/11/16/18). RESULTS: Among 477 children (405 girls/72 boys) completing the 3-dose series, median age at enrollment was 11.2 years. Of the 477, 72 (15%) were tested before dose 2 and 70 (15%) before dose 3. Following series completion, 435 (91%) were tested at one month, 382 (80%) at one year, and 351 (74%) at two years. All tested participants had detectable antibody to 4vHPV types at all time points measured. Geometric mean concentrations (GMCs) for 4vHPV types at one month and two years post-series completion were 269.9 and 32.7 AU/ml for HPV6, 349.3 and 42.9 AU/ml for HPV11, 1240.2 and 168.3 IU/ml HPV16, and 493.2 and 52.2 IU/ml for HPV18. Among children tested after each dose, GMCs after doses 1 and 2 were 3.9 and 32.2 AU/ml for HPV6, 5.3 and 45.6 AU/ml for HPV11, 20.8 and 187.9 IU/ml for HPV16; and 6.6 and 49.7 IU/ml for HPV18. No serious adverse events were reported. CONCLUSION: All AI/AN children developed antibodies to all 4vHPV types after vaccination. GMCs rose after each dose, then decreased to a plateau over the subsequent two years. This cohort will continue to be followed to determine duration of antibody response.

      2. A case study of an influenza vaccination program for health care workers in Vietnamexternal icon
        Ha NT, Nguyen TT, Nguyen TX, Tran PD, Nguyen HM, Ha VT, Lafond KE, Seward JF, McFarland JW, Chu SY.
        BMC Health Serv Res. 2020 Aug 24;20(1):785.
        BACKGROUND: In 2017, the Vietnam Ministry of Health conducted a demonstration project to introduce seasonal influenza vaccination to health care workers. A total of 11,000 doses of influenza vaccine, single-dose prefilled syringes, were provided free to HCWs at 29 selected hospitals, clinics, and research institutes in four provinces: Hanoi, Khanh Hoa, Dak Lak and Ho Chi Minh City. METHODS: Before the campaign, a workshop was organized to discuss an implementation plan including technical requirements, cold chain, uptake reporting, and surveillance for adverse events following immunization. All sites distributed communication materials and encouraged their staff to register for vaccination. Following immunization sessions, sites sent reports on uptake and adverse events following immunization. Left-over vaccine was transferred to other sites to maximize vaccine use. RESULTS: The average uptake was 57% for all health care workers, with 11 sites achieving 90% and above. These 11 sites were small with less than 500 staff, including 5 primary hospitals, 3 preventive medicine units, and 2 referral hospitals. Among the six biggest sites with over 1000 staff, four sites had the lowest uptake (14-47%). Most of the high-uptake sites were from the central to the south; only one site, a referral hospital, was from the north. After redistribution of left-over vaccine, only 130 vaccine doses (1.2%) were not used and destroyed. Based on factors that affected uptake, including registration levels, differing communication strategies, availability of vaccination, and commitment by health facility leaders, we recommended ways to increase health care worker coverage; recommendations to improve reporting adverse events following immunization were also made. CONCLUSIONS: The project demonstrated that it was feasible to conduct influenza vaccination campaigns among health care workers in Vietnam. Improvements in promotion of registration, more intense pre-planning, especially at larger facilities, and wider, more consistent availability of communication materials will result in increased efficiency and coverage in this program's future expansion.

      3. BACKGROUND: Diabetes is associated with higher risk of hospitalization, morbidity, and mortality from influenza. We assessed influenza vaccination coverage among adults aged ≥ 18 years with diabetes during the 2007-08 through 2017-18 influenza seasons and identified factors independently associated with vaccination during the 2017-18 season. METHODS: We analyzed data from the 2007-2018 National Health Interview Surveys, using Kaplan-Meier survival analysis to estimate season-specific influenza vaccination coverage. Multivariate logistic regression was conducted to examine whether diabetes was independently associated with self-reported influenza vaccination in the past 12 months and identify factors independently associated with vaccination among adults with diabetes using the 2017-18 data. RESULTS: During the 2007-08 through 2017-18 influenza seasons, influenza vaccination coverage among adults aged ≥ 18 years with diabetes ranged from 62.6% to 64.8%. In the 2017-18 influenza season, coverage was significantly higher among adults with diabetes (64.8%) compared with those without diabetes (43.9%). Having diabetes was independently associated with an increased prevalence of vaccination after controlling for other factors. Among adults with diabetes, living at or above poverty level, having more physician contacts, having usual place for health care, and being unemployed were independently associated with increased prevalence of vaccination; being 18-64 years and non-Hispanic black were independently associated with decreased prevalence of vaccination. CONCLUSIONS: Despite specific recommendations for influenza vaccination among people with diabetes, more than one-third of adults with diabetes are unvaccinated. Targeted efforts are needed to increase influenza vaccination coverage among adults with diabetes.

      4. Assessment of missed opportunities for vaccination in Kenyan health facilities, 2016external icon
        Li AJ, Tabu C, Shendale S, Sergon K, Okoth PO, Mugoya IK, Machekanyanga Z, Onuekwusi IU, Sanderson C, Ogbuanu IU.
        PLoS One. 2020 ;15(8):e0237913.
        BACKGROUND: In November 2016, the Kenya National Vaccines and Immunization Programme conducted an assessment of missed opportunities for vaccination (MOV) using the World Health Organization (WHO) MOV methodology. A MOV includes any contact with health services during which an eligible individual does not receive all the vaccine doses for which he or she is eligible. METHODS: The MOV assessment in Kenya was conducted in 10 geographically diverse counties, comprising exit interviews with caregivers and knowledge, attitudes, and practices (KAP) surveys with health workers. On the survey dates, which covered a 4-day period in November 2016, all health workers and caregivers visiting the selected health facilities with children <24 months of age were eligible to participate. Health facilities (n = 4 per county) were purposively selected by size, location, ownership, and performance. We calculated the proportion of MOV among children eligible for vaccination and with documented vaccination histories (i.e., from a home-based record or health facility register), and stratified MOV by age and reason for visit. Timeliness of vaccine doses was also calculated. RESULTS: We conducted 677 age-eligible children exit interviews and 376 health worker KAP surveys. Of the 558 children with documented vaccination histories, 33% were visiting the health facility for a vaccination visit and 67% were for other reasons. A MOV was seen in 75% (244/324) of children eligible for vaccination with documented vaccination histories, with 57% (186/324) receiving no vaccinations. This included 55% of children visiting for a vaccination visit and 93% visiting for non-vaccination visits. Timeliness for multi-dose vaccine series doses decreased with subsequent doses. Among health workers, 25% (74/291) were unable to correctly identify the national vaccination schedule for vaccines administered during the first year of life. Among health workers who reported administering vaccines as part of their daily work, 39% (55/142) reported that they did not always have the materials they needed for patients seeking immunization services, such as vaccines, syringes, and vaccination recording documents. CONCLUSIONS: The MOV assessment in Kenya highlighted areas of improvement that could reduce MOV. The results suggest several interventions including standardizing health worker practices, implementing an orientation package for all health workers, and developing a stock management module to reduce stock-outs of vaccines and vaccination-related supplies. To improve vaccination coverage and equity in all counties in Kenya, interventions to reduce MOV should be considered as part of an overall immunization service improvement plan.

      5. BACKGROUND: Universal influenza vaccination has been recommended since 2010, yet influenza vaccination rates among children aged 6 months to 17 years remain low compared with other routinely recommended childhood vaccines. OBJECTIVE: Assess in-plan vaccination coverage, opportunities, and missed opportunities during the 2016-2017 influenza season. STUDY DESIGN: Retrospective analyses using 2016-2017 MarketScan® data for 2,768,799 privately insured children aged 1-17 years by the end of 2016 who were continuously enrolled in the same insurance plan during the 2016-2017 influenza season (defined as August 1, 2016 through May 31, 2017). We assessed in-plan vaccination coverage (percentage receiving ≥ 1 dose of influenza vaccine from August 2016-May 2017) and vaccination opportunities (percentage with ≥ 1 provider visit between September 2016 - May 2017). Among children who remained unvaccinated at the end of the season, those with ≥ 1 influenza vaccination opportunity between September 2016-May 2017 were determined to have a missed opportunity. RESULTS: In-plan vaccination coverage during the 2016-17 season was 67.7% in infants (born 2015), 49.5% in toddlers (born 2012-2014), 35.0% in school-aged children (born 2004-2011), and 22.3% in teenagers (born 1999-2003). Like vaccination coverage, vaccination opportunities decreased with age (infants: 97.7%, toddlers: 91.9%, school-aged children: 82.6%, teenagers: 79.3%). Among unvaccinated children, 93.1%, 84.1%, 73.6% and 73.6% of each age group had a missed opportunity for influenza vaccination. CONCLUSION: Opportunities for and coverage with influenza vaccination vary even among privately insured children. Along with continued efforts to reduce missed opportunities, effective strategies to bring children to their doctor for annual influenza vaccination are needed, particularly for older children.

    • Injury and Violence
      1. Changing the culture: Improving helmet utilization to prevent traumatic brain injuryexternal icon
        Lucke-Wold B, Pierre K, Dawoud F, Guttierez M.
        J Emerg Med Forecast. 2020 ;3(1).
        BACKGROUND: Several groups have instituted helmet initiatives with varying success across the world. Helmet use has been well documented to prevent traumatic brain injury. Despite the known benefits, many people, including university students, refuse to utilize helmets when riding bikes, mopeds, or motorcycles. We recognized a need within our community regarding the lack of helmet use at University of Florida and developed a program to institute change. METHODOLOGY: We identified community champions and hosted weekly round table discussion initiatives. Through these round table discussions we identified events already going on within the community and developed new opportunities to promote helmet use. We had stories from survivors and parents, utilized school administration support, and partnered with local bike shops. RESULTS: The pilot initiative was successful in increasing awareness across the city and got stakeholders excited in the process. It also spearheaded more data driven initiatives that will look at reduction of traumatic brain injuries in the clinical setting. CONCLUSION: This project highlights the University of Florida Helmet Initiative that has already generated renewed interest in safety and traumatic brain injury prevention. The school of nursing has implemented safety protocols and further support is being garnered by the administration across campus. Most importantly we have identified community champions that will carry the work forward.

    • Laboratory Sciences
      1. ICTV virus taxonomy profile: Nairoviridaeexternal icon
        Garrison AR, Alkhovsky SV, Avsic-Zupanc T, Bente DA, Bergeron E, Burt F, Di Paola N, Ergunay K, Hewson R, Kuhn JH, Mirazimi A, Papa A, Sall AA, Spengler JR, Palacios G, Consortium IR.
        J Gen Virol. 2020 Aug;101(8):798-799.
        Members of the family Nairoviridae produce enveloped virions with three single-stranded RNA segments comprising 17.1 to 22.8 kb in total. These viruses are maintained in arthropods and transmitted by ticks to mammals or birds. Crimean-Congo hemorrhagic fever virus is tick-borne and is endemic in most of Asia, Africa, Southern and Eastern Europe whereas Nairobi sheep disease virus, which is also tick-borne, causes lethal haemorrhagic gastroenteritis in small ruminants in Africa and India. This is a summary of the International Committee on Taxonomy of Viruses (ICTV) Report on the family Nairoviridae, which is available at

      2. Indoor secondary organic aerosols: Towards an improved representation of their formation and composition in modelsexternal icon
        Kruza M, McFiggans G, Waring MS, Wells JR, Carslaw N.
        Atmospheric Environment. 2020 ;240.
        The formation of secondary organic aerosol (SOA) indoors is one of the many consequences of the rich and complex chemistry that occurs therein. Given particulate matter has well documented health effects, we need to understand the mechanism for SOA formation indoors and its resulting composition. This study evaluates some uncertainties that exist in quantifying gas-to-particle partitioning of SOA-forming compounds using an indoor detailed chemical model. In particular, we investigate the impacts of using different methods to estimate compound vapour pressures as well as simulating the formation of highly oxygenated organic molecules (HOM) via auto-oxidation on SOA formation indoors. Estimation of vapour pressures for 136 α-pinene oxidation species by six investigated methods led to standard deviations of 28–216%. Inclusion of HOM formation improved model performance across three of the six assessed vapour pressure estimation methods when comparing against experimental data, particularly when the NO2 concentration was relatively high. We also explored the predicted SOA composition using two product classification methods, the first assuming the molecule is dominated by one functionality according to its name, and the second accounting for the fractional weighting of each functional group within a molecule. The SOA composition was dominated by the HOM species when the NO2-to-α-terpineol ratio was high for both product classification methods, as these conditions promoted formation of the nitrate radical and hence formation of HOM monomers. As the NO2-to-α-terpineol ratio decreased, peroxides and acids dominated the simple classification, whereas for the fractional classification, carbonyl and alcohol groups became more important.

      3. Mutations in the neuraminidase-like protein of bat influenza H18N11 virus enhance virus replication in mammalian cells, mice, and ferretsexternal icon
        Zhong G, Fan S, Hatta M, Nakatsu S, Walters KB, Lopes TJ, Wang JI, Ozawa M, Karasin A, Li Y, Tong S, Donis RO, Neumann G, Kawaoka Y.
        J Virol. 2020 Feb 14;94(5).
        To characterize bat influenza H18N11 virus, we propagated a reverse genetics-generated H18N11 virus in Madin-Darby canine kidney subclone II cells and detected two mammal-adapting mutations in the neuraminidase (NA)-like protein (NA-F144C and NA-T342A, N2 numbering) that increased the virus titers in three mammalian cell lines (i.e., Madin-Darby canine kidney, Madin-Darby canine kidney subclone II, and human lung adenocarcinoma [Calu-3] cells). In mice, wild-type H18N11 virus replicated only in the lungs of the infected animals, whereas the NA-T342A and NA-F144C/T342A mutant viruses were detected in the nasal turbinates, in addition to the lungs. Bat influenza viruses have not been tested for their virulence or organ tropism in ferrets. We detected wild-type and single mutant viruses each possessing NA-F144C or NA-T342A in the nasal turbinates of one or several infected ferrets, respectively. A mutant virus possessing both the NA-F144C and NA-T342A mutations was isolated from both the lung and the trachea, suggesting that it has a broader organ tropism than the wild-type virus. However, none of the H18N11 viruses caused symptoms in mice or ferrets. The NA-F144C/T342A double mutation did not substantially affect virion morphology or the release of virions from cells. Collectively, our data demonstrate that the propagation of bat influenza H18N11 virus in mammalian cells can result in mammal-adapting mutations that may increase the replicative ability and/or organ tropism of the virus; overall, however, these viruses did not replicate to high titers throughout the respiratory tract of mice and ferrets.IMPORTANCE Bats are reservoirs for several severe zoonotic pathogens. The genomes of influenza A viruses of the H17N10 and H18N11 subtypes have been identified in bats, but no live virus has been isolated. The characterization of artificially generated bat influenza H18N11 virus in mammalian cell lines and animal models revealed that this virus can acquire mammal-adapting mutations that may increase its zoonotic potential; however, the wild-type and mutant viruses did not replicate to high titers in all infected animals.

    • Maternal and Child Health
      1. Periconceptional stressors and social support and risk for adverse birth outcomesexternal icon
        Weber KA, Carmichael SL, Yang W, Tinker SC, Shaw GM.
        BMC Pregnancy Childbirth. 2020 Aug 24;20(1):487.
        BACKGROUND: The prevalence of preterm birth and low birth weight has been increasing slightly in recent years. A few studies have suggested that psychosocial stress during pregnancy may increase risk for these adverse birth outcomes. To extend those observations, we analyzed various major life event stressors separately and cumulatively as potential risk factors for preterm birth and low birth weight using granular categories of each outcome in a large, population-based study. Additionally, we assessed if greater social support buffered any effects. METHODS: Data were from a nested prevalence study of 4395 women in the National Birth Defects Prevention Study who delivered live-born non-malformed infants (controls) between 2006 and 2011. Participants completed a standardized, computer-assisted interview between 6 weeks and 24 months after delivery that included questions on stress and social support from 3 months before pregnancy to the 3rd month of pregnancy. Cumulative stress and support indices were also calculated. Preterm birth was divided into "early preterm" (< 32 weeks), "late preterm" (32-36 weeks) and "term." Low birthweight was divided into "very low birth weight" (< 1500 g), "low birth weight" (1500-2499 g) and "normal birth weight" (≥2500 g). Relative risks and 95% confidence intervals (95% CI) were calculated using Poisson regression. RESULTS: For women reporting relationship difficulties, there was a suggestive risk of early preterm birth (RR: 1.9, 95%CI: 0.9-3.9) and very low birthweight (RR: 2.0, 95%CI: 0.9-4.4). For women reporting that they or someone close to them were victims of abuse, violence, or crime, there was an increased risk of low birthweight (RR: 1.8, 95%CI: 1.1-2.7) and late preterm birth (RR: 1.5, 95%CI: 1.0-2.2). There were no strong associations observed between social support questions and the various outcomes. CONCLUSIONS: Our results add some support to prior evidence that certain stressors may be associated with increase selected adverse birth outcomes risk. We did not find strong evidence that social support buffered the observed risks in our study.

      2. Treatment use among children with Tourette syndrome living in the United States, 2014external icon
        Wolicki SB, Bitsko RH, Holbrook JR, Danielson ML, Zablotsky B, Scahill L, Walkup JT, Woods DW, Mink JW.
        Psychiatry Res. 2020 Aug 18;293:113400.
        Treatment of Tourette syndrome (TS) can be complicated by changes over time in tic expression, severity, and co-occurring disorders. Using the 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome, this study provides descriptive estimates of the use of behavioral interventions and medication among children living with TS. Parent-reported data on 115 children aged 5-17 years ever diagnosed with TS were analyzed to provide descriptive, unweighted results. Overall, 77.4% of children had current or past use of any TS treatment; 59.1% ever used behavioral interventions and 56.1% had ever taken TS medication. Children with "moderate" or "severe" versus "mild" TS, ≥1 co-occurring disorders, and tics that interfered with functioning were significantly more likely to have used one or more TS treatments. Side effects were reported for 84.4% of children who took TS medication. Most parents of children with current TS (87.2%) were satisfied with the management of their child's TS. However, parents of children with "moderate" or "severe" current TS were significantly more dissatisfied compared to parents of children with "mild" TS. Findings from this study could be used to inform efforts to support children living with TS and their families.

    • Occupational Safety and Health
      1. Introduction: Vessel disasters (e.g., sinkings, capsizings) are a leading contributor to fatalities in the U.S. commercial fishing industry. Primary prevention strategies are needed to reduce the occurrence of vessel disasters, which can only be done by developing an understanding of their causes and risk factors. If less serious vessel casualties (e.g., loss of propulsion, fire, flooding) are predictors of future disasters, then reducing vessel casualties should in turn reduce vessel disasters and the accompanying loss of life. Method: This case-control study examined the association between vessel casualties and disasters using fishing vessels in Alaska during 2010–2015. Results: The findings show that vessels that experienced casualties within a preceding 10-year period were at increased odds of disaster. Other significant predictors included safety decal status and hull material. Practical Applications: The results of this analysis emphasize the importance of implementing vessel-specific preventive maintenance plans. At an industry level, specific prevention policies should be developed focusing on high-risk fleets to identify and correct a wide range of safety deficits before they have catastrophic and fatal consequences.

      2. Nonfatal occupational injuries to younger workers - United States, 2012-2018external icon
        Guerin RJ, Reichard AA, Derk S, Hendricks KJ, Menger-Ogle LM, Okun AH.
        MMWR Morb Mortal Wkly Rep. 2020 Sep 4;69(35):1204-1209.
        Adolescents and young adults represent approximately 13% of the U.S. workforce (1). Compared with adult workers, young workers (aged 15-24 years) experience higher rates of job-related injury (2,3). To describe injuries among young workers and inform research and prevention activities, CDC's National Institute for Occupational Safety and Health (NIOSH) analyzed national data for 2012-2018 from the occupational supplement to the National Electronic Injury Surveillance System* (NEISS-Work) and for 2018 from the Bureau of Labor Statistics (BLS) Survey of Occupational Injuries and Illnesses (SOII).(†) During the 7-year period, an estimated 3.2 million (95% confidence interval [CI] = 2.6-3.7) nonfatal, job-related injuries to young workers were treated in hospital emergency departments (EDs). From 2012 to 2018, annual rates of work-related injuries(§) treated in the ED (ED-treated injuries) declined overall across all age groups but ranged from 1.2 to 2.3 times higher for workers aged 15-24 years compared with those for adults aged 25-44 years. Workers aged 18-19 years had the highest rate of ED-treated injuries. In 2018, among all age groups, workers in service occupations(¶) had the highest percentage of injuries requiring at least 1 day away from work. Among workers aged 15-17 years, those in the leisure and hospitality industry had the highest percentage of work-related injuries requiring at least 1 day away from work. Occupational injuries can have long-term impacts on health (4). The disproportionate risk of injury among young workers highlights the need for sustained, targeted public health efforts to prepare this population with essential workplace safety and health competencies before they enter the workforce and to provide high-quality safety training and close supervision on the job. NIOSH and its partners developed a free curriculum to teach adolescents workplace safety and health competencies, which includes identification of workplace hazards and methods for addressing them, how to understand their rights and responsibilities as workers, and how to voice concerns about work safety issues (5).

      3. The objective of this study is to assess ambient temperatures' and extreme heat events' contribution to work-related emergency department (ED) visits for hyperthermia in the southeastern United States to inform prevention. Through a collaborative network and established data framework, work-related ED hyperthermia visits in five participating southeastern U.S. states were analyzed using a time stratified case-crossover design. For exposure metrics, day- and location-specific measures of ambient temperatures and county-specific identification of extreme heat events were used. From 2010 to 2012, 5,017 work-related hyperthermia ED visits were seen; 2,298 (~46%) of these visits occurred on days when the daily maximum heat index was at temperatures the Occupational Safety and Health Administration designates as having "lower" or "moderate" heat risk. A 14% increase in risk of ED visit was seen for a 1°F increase in average daily mean temperature, modeled as linear predictor across all temperatures. A 54% increase in risk was seen for work-related hyperthermia ED visits during extreme heat events (two or more consecutive days of unusually high temperatures) when controlling for average daily mean temperature. Despite ambient heat being a well-known risk to workers' health, this study's findings indicate ambient heat contributed to work-related ED hyperthermia visits in these five states. Used alone, existing OSHA heat-risk levels for ambient temperatures did not appear to successfully communicate workers' risk for hyperthermia in this study. Findings should inform future heat-alert communications and policies, heat prevention efforts, and heat-illness prevention research for workers in the southeastern United States.

      4. New metrics needed in the evaluation of hearing hazard associated with industrial noise exposureexternal icon
        Zhang M, Xie H, Zhou J, Sun X, Hu W, Zou H, Zhou L, Li J, Zhang M, Kardous CA, Morata TC, Murphy WJ, Zhang JH, Qiu W.
        Ear Hear. 2020 Aug 19.
        OBJECTIVES: To evaluate (1) the accuracy of the International Organization for Standardization (ISO) standard ISO 1999 [(2013), International Organization for Standardization, Geneva, Switzerland] predictions of noise-induced permanent threshold shift (NIPTS) in workers exposed to various types of high-intensity noise levels, and (2) the role of the kurtosis metric in assessing noise-induced hearing loss (NIHL). DESIGN: Audiometric and shift-long noise exposure data were acquired from a population (N = 2,333) of screened workers from 34 industries in China. The entire cohort was exclusively divided into subgroups based on four noise exposure levels (85 ≤ LAeq.8h < 88, 88 ≤ LAeq.8h < 91, 91 ≤ LAeq.8h < 94, and 94 ≤ LAeq.8h ≤ 100 dBA), two exposure durations (D ≤ 10 years and D > 10 years), and four kurtosis categories (Gaussian, low-, medium-, and high-kurtosis). Predicted NIPTS was calculated using the ISO 1999 model for each participant and the actual measured NIPTS was corrected for age and sex also using ISO 1999. The prediction accuracy of the ISO 1999 model was evaluated by comparing the NIPTS predicted by ISO 1999 with the actual NIPTS. The relation between kurtosis and NIPTS was also investigated. RESULTS: Overall, using the average NIPTS value across the four audiometric test frequencies (2, 3, 4, and 6 kHz), the ISO 1999 predictions significantly (p < 0.001) underestimated the NIPTS by 7.5 dB on average in participants exposed to Gaussian noise and by 13.6 dB on average in participants exposed to non-Gaussian noise with high kurtosis. The extent of the underestimation of NIPTS by ISO 1999 increased with an increase in noise kurtosis value. For a fixed range of noise exposure level and duration, the actual measured NIPTS increased as the kurtosis of the noise increased. The noise with kurtosis greater than 75 produced the highest NIPTS. CONCLUSIONS: The applicability of the ISO 1999 prediction model to different types of noise exposures needs to be carefully reexamined. A better understanding of the role of the kurtosis metric in NIHL may lead to its incorporation into a new and more accurate model of hearing loss due to noise exposure.

    • Parasitic Diseases
      1. Malaria risk and prevention in Asian migrants to Angolaexternal icon
        Martins JF, Marques C, Nieto-Andrade B, Kelley J, Patel D, Nace D, Herman C, Barratt J, Ponce de Leon G, Talundzic E, Rogier E, Halsey ES, Plucinski MM.
        Am J Trop Med Hyg. 2020 Aug 17.
        The number of Asian migrants working in sub-Saharan developing countries like Angola has been increasing. Their malaria risk, prevention, and care-seeking practices have not been characterized. A cross-sectional survey was conducted in 733 Chinese and Southeast Asian migrants in Angola. Respondents were interviewed and provided blood samples. Samples were analyzed to detect Plasmodium antigen and characterize host anti-Plasmodium response. Positive samples were genotyped using the pfs47 marker. Most respondents (72%; 95% CI: 68-75) reported using bed nets, but less than 1% reported using chemoprophylaxis. Depending on the assay, 1-4% of respondents had evidence of active malaria infection. By contrast, 55% (95% CI: 52-59) were seropositive for Plasmodium antibodies. Most infections were Plasmodium falciparum, but infection and/or exposure to Plasmodium vivax and Plasmodium malariae was also detected. Seroprevalence by time in Angola showed most exposure occurred locally. One respondent had sufficiently high parasitemia for pfs47 genotyping, which showed that the infection was likely locally acquired despite recent travel to home country. Asian migrants to Angola are at substantial risk of malaria. Employers should consider enhanced malaria prevention programs, including chemoprophylaxis; embassies should encourage prevention practices. Angolan healthcare workers should be aware of high malaria exposure in Asian migrants.

      2. Safety, tolerability, and immunogenicity of Plasmodium falciparum sporozoite vaccine administered by direct venous inoculation to infants and young children: Findings from an age de-escalation, dose-escalation, double-blind, randomized controlled study in western Kenyaexternal icon
        Steinhardt LC, Richie TL, Yego R, Akach D, Hamel MJ, Gutman JR, Wiegand RE, Nzuu EL, Dungani A, Kc N, Murshedkar T, Church LW, Sim BK, Billingsley PF, James ER, Abebe Y, Kariuki S, Samuels AM, Otieno K, Sang T, Kachur SP, Styers D, Schlessman K, Abarbanell G, Hoffman SL, Seder RA, Oneko M.
        Clin Infect Dis. 2020 Aug 14;71(4):1063-1071.
        BACKGROUND: The whole Plasmodium falciparum sporozoite (PfSPZ) vaccine is being evaluated for malaria prevention. The vaccine is administered intravenously for maximal efficacy. Direct venous inoculation (DVI) with PfSPZ vaccine has been safe, tolerable, and feasible in adults, but safety data for children and infants are limited. METHODS: We conducted an age de-escalation, dose-escalation randomized controlled trial in Siaya County, western Kenya. Children and infants (aged 5-9 years, 13-59 months, and 5-12 months) were enrolled into 13 age-dose cohorts of 12 participants and randomized 2:1 to vaccine or normal saline placebo in escalating doses: 1.35 × 105, 2.7 × 105, 4.5 × 105, 9.0 × 105, and 1.8 × 106 PfSPZ, with the 2 highest doses given twice, 8 weeks apart. Solicited adverse events (AEs) were monitored for 8 days after vaccination, unsolicited AEs for 29 days, and serious AEs throughout the study. Blood taken prevaccination and 1 week postvaccination was tested for immunoglobulin G antibodies to P. falciparum circumsporozoite protein (PfCSP) using enzyme-linked immunosorbent assay. RESULTS: Rates of AEs were similar in vaccinees and controls for solicited (35.7% vs 41.5%) and unsolicited (83.9% vs 92.5%) AEs, respectively. No related grade 3 AEs, serious AEs, or grade 3 laboratory abnormalities occurred. Most (79.0%) vaccinations were administered by a single DVI. Among those in the 9.0 × 105 and 1.8 × 106 PfSPZ groups, 36 of 45 (80.0%) vaccinees and 4 of 21 (19.0%) placebo controls developed antibodies to PfCSP (P < .001). CONCLUSIONS: PfSPZ vaccine in doses as high as 1.8 × 106 can be administered to infants and children by DVI, and was safe, well tolerated, and immunogenic. CLINICAL TRIALS REGISTRATION: NCT02687373.

    • Statistics as Topic
      1. Data from the National Health and Nutrition Examination Survey (NHANES) have been linked to the Center for Medicare and Medicaid Services' Medicaid Enrollment and Claims Files. As not all survey participants provide sufficient information to be eligible for record linkage, linked data often includes fewer records than the original survey data. This project presents an application of multiple imputation (MI) for handling missing Medicaid/CHIP status due to linkage refusals in linked NHANES-Medicaid data using the linked 1999-2004 NHANES data. By examining multiple outcomes and subgroups among children, the analyses compare the results from a multi-purpose dataset produced from a single MI model to that of individualized MI models. Outcomes examined here include obesity, untreated dental caries, attention deficit hyperactivity disorder (ADHD), and exposure to second hand smoke.

    • Substance Use and Abuse
      1. Vital signs: Characteristics of drug overdose deaths involving opioids and stimulants - 24 states and the District of Columbia, January-June 2019external icon
        O'Donnell J, Gladden RM, Mattson CL, Hunter CT, Davis NL.
        MMWR Morb Mortal Wkly Rep. 2020 Sep 4;69(35):1189-1197.
        INTRODUCTION: Provisional estimates indicate that drug overdose deaths increased in 2019 after a slight decrease in 2018. In 2018, overdose deaths primarily involved opioids, with continued increases in deaths involving illicitly manufactured fentanyls (IMFs). Deaths involving stimulants such as cocaine and methamphetamine are also increasing, mainly in combination with opioids. METHODS: CDC analyzed data on drug overdose deaths during January-June 2019 from 24 states and the District of Columbia (DC) in the State Unintentional Drug Overdose Reporting System to describe characteristics and circumstances of opioid- and stimulant-involved overdose deaths. RESULTS: Among 16,236 drug overdose deaths in 24 states and DC, 7,936 (48.9%) involved opioids without stimulants, 5,301 (32.6%) involved opioids and stimulants, 2,056 (12.7%) involved stimulants without opioids, and 943 (5.8%) involved neither opioids nor stimulants. Approximately 80% of overdose deaths involved one or more opioid, and IMFs were involved in three of four opioid-involved overdose deaths. IMFs, heroin, cocaine, or methamphetamine (alone or in combination) were involved in 83.8% of overdose deaths. More than three in five (62.7%) overdose deaths had documentation of at least one potential opportunity for overdose prevention intervention. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Identifying opportunities to intervene before an overdose death and implementing evidence-based prevention policies, programs, and practices could save lives. Strategies should address characteristics of overdoses involving IMFs, such as rapid overdose progression, as well as opioid and stimulant co-involvement. These efforts should be complemented by efforts to prevent initiation of prescription opioid and stimulant misuse and illicit drug use.

    • Zoonotic and Vectorborne Diseases
      1. BACKGROUND: During the Zika virus (ZIKV) outbreak, an urgent need existed for strong partnerships to disseminate Zika-related information to pregnant women and women of child-bearing age. METHODS: The Centers for Disease Control and Prevention (CDC) partnered with MotherToBaby, a national organization experienced in providing information about exposures during pregnancy to healthcare providers and the public, to disseminate accurate information about ZIKV infection during pregnancy. Partnership activities included regular information sharing, cross-linking information for the public, and promoting common messaging. Following the ZIKV outbreak, we reviewed common inquiries received as well as key strategies and lessons learned from the partnership. RESULTS: Between June 2016 and June 2019, MotherToBaby received 5,387 Zika-related inquiries from the public and health care providers. The majority (90%) of inquires came from preconception, pregnant, and breastfeeding women. Concerns about travel, pregnancy, sexual transmission, and preconception guidelines comprised the top information requests. Live chat was the preferred method of communication for Zika-related inquiries. Key strategies and lessons learned from this partnership included: capitalizing on existing nationwide infrastructure and expertise, prominently referring to partners as a resource, promoting shared messaging using online resources and social media, holding regular calls to share information, and collecting data to identify common questions and revise messaging. CONCLUSIONS: This examination of strategies, lessons learned, and metrics from MotherToBaby and CDC's partnership during the ZIKV outbreak can be applied to future partnerships to address emerging public health threats.

      2. OBJECTIVE: To evaluate the inclusion and exclusion of nutritional content in guidance materials related to nutritional care for hospitalised Ebola Virus Disease (EVD) patients of any age with the aim to provide recommendations for future revised nutritional care guidelines in Ebola Treatment Units (ETU). DESIGN: Qualitative and quantitative analyses of ETU protocols and other guidance materials were conducted. Materials were obtained from practitioners, their organisations and governments active in EVD outbreaks since 2014. SETTING: Guinea, Liberia, Sierra Leone and Democratic Republic of Congo. RESULTS: Guidance materials showed a wide variety of topics. Most contained information on different feeding phases during illness, the use of specialised products, what and how to feed children aged 0-23 months, and meal and snack frequency for different age groups. Most materials lacked guidance on how to assess or accommodate patients' dietary preferences, how to obtain feedback on nutritional care from patients or how to assess whether patients need feeding support. These aspects are particularly relevant to prevent deterioration of the patients' nutritional status. There was limited guidance on operational aspects of food preparation and provision. CONCLUSIONS: Since 2014, numerous materials have been developed by organisations and governments on nutritional support in ETU. Although every EVD outbreak response must be contextualised because of the complexity of EVD and its case management, it is important to resolve technical differences and to provide comprehensive and more practical guidance. The findings of this study may inform future revised guidelines from normative UN organisations and governments of countries affected by EVD.

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CDC Science Clips Production Staff

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

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