Volume 12, Issue 33, September 22, 2020

CDC Science Clips: Volume 12, Issue 33, September 22, 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!

September is National Suicide Prevention Month, a time to think about ways we can help prevent suicide.  Suicide is a growing public health crisis.  In 2018, suicide was the fourth overall leading cause of death among people 10-54 and it took the lives of more than 48,000 people in the United States.  Rates of suicide have increased 35% between 1999 and 2018. National Suicide Prevention Month is an opportunity to raise awareness about suicide and the role that we all can play in prevention.  CDC’s vision is, “No lives lost to suicide.” To reach this vision, CDC’s mission is to use data, science, and partnerships to identify and implement effective suicide prevention strategiespdf icon that foster healthy and resilient communities across the United States. Just as there is no single cause of suicide, there is no single solution. CDC’s new strategic plan outlines a comprehensive public health approach to suicide prevention.  

Suicide prevention is everyone’s business. During National Suicide Prevention Month, you can #BeThereexternal icon and #BeThe1Toexternal icon help a friend, loved one, or coworker. Everyone can learn the warning signs and how to get help.

  1. Key Scientific Articles in Featured Topic Areas
    • Injury and Violence - National Suicide Prevention Month
      1. National suicide prevention programmes that have been successful in reducing rates or keeping them low have been intentional, with collective alignment of local, regional and national priorities. Prevention efforts must begin well before individuals become suicidal, complementing readily available clinical services that address the needs of acutely distressed persons. These efforts, which focus on the antecedent risks and vulnerabilities of key populations, have the potential to diminish premature mortality from multiple causes, even as reducing suicide is the outcome of primary interest. In this commentary, I consider four key challenges that must be confronted in order to develop effective, broadly reaching systemic strategies that, at once, can be adapted locally while being implemented nationally - challenges that are framed in a social-ecological context. They involve defining the scope of the problem, meeting essential data needs, developing and modelling measurable implementation strategies and building prevention efforts based on shared culture and values.

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

      3. State suicide rates among adolescents and young adults aged 10-24: United States, 2000-2018pdf icon
        Curtin SC.
        National Vital Statistics Reports. 2020 ;69(11):Hyattsville, MD: National Center for Health Statistics.

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

      5. Suicides among incarcerated persons in 18 U.S. states: Findings from the National Violent Death Reporting System, 2003-2014external icon
        Dixon KJ, Ertl AM, Leavitt RA, Sheats KJ, Fowler KA, Jack SP.
        J Correct Health Care. 2020 Jul;26(3):279-291.
        Using data from the National Violent Death Reporting System (2003-2014), this study examined the characteristics and contributing circumstances of suicides in correctional facilities. χ(2) and logistic regression analyses revealed that, compared to nonincarcerated suicide decedents, incarcerated suicide decedents had significantly lower odds of positive toxicology for substances but significantly higher odds of substance abuse problems. Descriptive subanalyses indicated that incarcerated suicide decedents often were incarcerated for personal crimes. They often died ≤ 1 week of incarceration, in a cell (frequently single-person or segregation), by hanging, using bedding material. Positive toxicology was more common for incarcerated decedents who died shortly after versus later in their incarceration. Findings highlight the need for enhanced detection and treatment of suicidal behavior, especially during early and vulnerable periods of incarceration.

      6. Association between state minimum wages and suicide rates in the U.Sexternal icon
        Gertner AK, Rotter JS, Shafer PR.
        Am J Prev Med. 2019 May;56(5):648-654.
        INTRODUCTION: The suicide rate in the U.S. has been increasing in recent years. Previous studies have consistently identified financial stress as a contributing factor in suicides. Nevertheless, there has been little research on the effect of economic policies that can alleviate financial stress on suicide rates. The purpose of this study is to determine whether increases in state minimum wages have been associated with changes in state suicide rates. METHODS: A retrospective panel data study was conducted. In 2018, linear regression models with state fixed effects were used to estimate the relationship between changes in state minimum wages and suicide rates for all 50U.S. states between 2006 and 2016. Models controlled for time-varying state characteristics that could be associated with changes in minimum wages and suicide rates. RESULTS: There were approximately 432,000 deaths by suicide in the study period. A one-dollar increase in the real minimum wage was associated on average with a 1.9% decrease in the annual state suicide rate in adjusted analyses. This negative association was most consistent in years since 2011. An annual decrease of 1.9% in the suicide rate during the study period would have resulted in roughly 8,000 fewer deaths by suicide. Analyses by race and sex did not reveal substantial variation in the association between minimum wages and suicides. CONCLUSIONS: Increases in real minimum wages have been associated with slower growth in state suicide rates in recent years. Increasing the minimum wage could represent a strategy for addressing increases in suicide rates.

      7. Increase in suicide mortality in the United States, 1999-2018external icon
        Hedegaard H, Curtin SC, Warner M.
        NCHS Data Brief. 2020 Apr(362):1-8.
        Suicide is the 10th leading cause of death for all ages in the United States (1). Suicide is a major contributor to premature mortality as it ranks as the second leading cause of death for ages 10-34 and the fourth leading cause for ages 35-54 (1). Despite national goals to lower the suicide rate (2), several recent reports have documented a steady increase in suicide rates in recent years (3-6). This data brief uses final mortality data from the National Vital Statistics System (NVSS) to update trends in suicide rates from 1999 through 2018 and to describe differences by sex, age group, and urbanicity of county of residence.

      8. Suicidal ideation and behaviors among high school students - Youth Risk Behavior Survey, United States, 2019external icon
        Ivey-Stephenson AZ, Demissie Z, Crosby AE, Stone DM, Gaylor E, Wilkins N, Lowry R, Brown M.
        MMWR Suppl. 2020 Aug 21;69(1):47-55.
        Suicide is the second leading cause of death among high school-aged youths 14-18 years after unintentional injuries. This report summarizes data regarding suicidal ideation (i.e., seriously considered suicide) and behaviors (i.e., made a suicide plan, attempted suicide, and made a suicide attempt requiring medical treatment) from CDC's 2019 Youth Risk Behavior Survey. Results are reported overall and by sex, grade, race/ethnicity, sexual identity, and sex of sexual contacts, overall and within sex groups. Trends in suicide attempts during 2009-2019 are also reported by sex, race/ethnicity, and grade. During 2009-2019, prevalence of suicide attempts increased overall and among female, non-Hispanic white, non-Hispanic black, and 12th-grade students. Data from 2019 reflect substantial differences by demographics regarding suicidal ideation and behaviors. For example, during 2019, a total of 18.8% of students reported having seriously considered suicide, with prevalence estimates highest among females (24.1%); white non-Hispanic students (19.1%); students who reported having sex with persons of the same sex or with both sexes (54.2%); and students who identified as lesbian, gay, or bisexual (46.8%). Among all students, 8.9% reported having attempted suicide, with prevalence estimates highest among females (11.0%); black non-Hispanic students (11.8%); students who reported having sex with persons of the same sex or with both sexes (30.3%); and students who identified as lesbian, gay, or bisexual (23.4%). Comprehensive suicide prevention can address these differences and reduce prevalence of suicidal ideation and behaviors by implementing programs, practices, and policies that prevent suicide (e.g., parenting programs), supporting persons currently at risk (e.g., psychotherapy), preventing reattempts (e.g., emergency department follow-up), and attending to persons who have lost a friend or loved one to suicide.

      9. Tailored activation of middle-aged men to promote discussion of recent active suicide thoughts: A randomized controlled trialexternal icon
        Jerant A, Duberstein P, Kravitz RL, Stone DM, Cipri C, Franks P.
        J Gen Intern Med. 2020 Jul;35(7):2050-2058.
        PURPOSE: Middle-aged men are at high risk of suicide. While about half of those who kill themselves visit a primary care clinician (PCC) shortly before death, in current practice, few spontaneously disclose their thoughts of suicide during the visits, and PCCs seldom inquire about such thoughts. In a randomized controlled trial, we examined the effect of a tailored interactive computer program designed to encourage middle-aged men's discussion of suicide with PCCs. METHODS: We recruited men 35-74 years old reporting recent (within 4 weeks) active suicide thoughts from the panels of 42 PCCs (the unit of randomization) in eight offices within a single California health system. In the office before a visit, men viewed the intervention corresponding to their PCC's random group assignment: Men and Providers Preventing Suicide (MAPS) (20 PCCs), providing tailored multimedia promoting discussion of suicide thoughts, or control (22 PCCs), composed of a sleep hygiene video plus brief non-tailored text encouraging discussion of suicide thoughts. Logistic regressions, adjusting for patient nesting within physicians, examined MAPS' effect on patient-reported suicide discussion in the subsequent office visit. RESULTS: Sixteen of the randomized PCCs had no patients enroll in the trial. From the panels of the remaining 26 PCCs (12 MAPS, 14 control), 48 men (MAPS 21, control 27) were enrolled (a mean of 1.8 (range 1-5) per PCC), with a mean age of 55.9 years (SD 11.4). Suicide discussion was more likely among MAPS patients (15/21 [65%]) than controls (8/27 [35%]). Logistic regression showed men viewing MAPS were more likely than controls to discuss suicide with their PCC (OR 5.91, 95% CI 1.59-21.94; P = 0.008; nesting-adjusted predicted effect 71% vs. 30%). CONCLUSIONS: In addressing barriers to discussing suicide, the tailored MAPS program activated middle-aged men with active suicide thoughts to engage with PCCs around this customarily taboo topic.

      10. Trends in violence victimization and suicide risk by sexual identity among high school students - Youth Risk Behavior Survey, United States, 2015-2019external icon
        Johns MM, Lowry R, Haderxhanaj LT, Rasberry CN, Robin L, Scales L, Stone D, Suarez NA.
        MMWR Suppl. 2020 Aug 21;69(1):19-27.
        Lesbian, gay, and bisexual (LGB) youths continue to experience more violence victimization and suicide risk than heterosexual youths; however, few studies have examined whether the proportion of LGB youths affected by these outcomes has varied over time, and no studies have assessed such trends in a nationally representative sample. This report analyzes national trends in violence victimization and suicide risk among high school students by self-reported sexual identity (LGB or heterosexual) and evaluates differences in these trends among LGB students by sex (male or female) and race/ethnicity (non-Hispanic black, non-Hispanic white, or Hispanic). Data for this analysis were derived from the 2015, 2017, and 2019 cycles of CDC's Youth Risk Behavior Survey (YRBS), a cross-sectional, school-based survey conducted biennially since 1991. Logistic regression models assessed linear trends in prevalence of violence victimization and indicators of suicide risk among LGB and heterosexual students during 2015-2019; in subsequent models, sex-stratified (controlling for race/ethnicity and grade) and race/ethnicity-stratified (controlling for sex and grade) linear trends were examined for students self-identifying as LGB during 2015-2019. Results demonstrated that LGB students experienced more violence victimization and reported more suicide risk behaviors than heterosexual youths. Among LGB youths, differences in the proportion reporting violence victimization and suicide risk by sex and race/ethnicity were found. Across analyses, very few linear trends in these outcomes were observed among LGB students. Results highlight the continued need for comprehensive intervention strategies within schools and communities with the express goal of reducing violence victimization and preventing suicide risk behaviors among LGB students.

      11. Traumatic brain injury-related deaths from firearm suicide: United States, 2008-2017external icon
        Miller GF, Kegler SR, Stone DM.
        Am J Public Health. 2020 Jun;110(6):897-899.
        Objectives. To document the increasing influence of firearm suicide on the incidence of traumatic brain injury (TBI)-related death in the United States.Methods. We used national vital statistics data from 2008 to 2017 to identify TBI-related deaths, overall and by cause, among US residents. National counts stratified by year, sex, and age group (to facilitate age adjustment) were merged with corresponding population estimates to calculate incidence rates.Results. During the 10-year period beginning in 2008, when it became the leading cause of TBI-related death in the United States, firearm suicide accounted for nearly half (48.3%) of the increase in the absolute incidence of TBI-related death when combining all injury categories showing absolute increases. Rates of TBI-related firearm suicide increased among both males and females.Conclusions. Safe storage of firearms among people at risk and training of health care providers and community members to identify and support people who may be thinking of suicide are part of a comprehensive public health approach to suicide prevention.Public Health Implications. States, communities, and health care systems can save lives by prioritizing comprehensive suicide prevention.

      12. Suicide research, prevention, and COVID-19: Towards a global response and the establishment of an international research collaborationexternal icon
        Niederkrotenthaler T, Gunnell D, Arensman E, Pirkis J, Appleby L, Hawton K, John A, Kapur N, Khan M, O’Connor R, Platt S.
        Crisis. 2020 .

      13. Suicide prevention programs: Evidence base and best practiceexternal icon
        Platt S, Niederkrotenthaler T.
        Crisis. 2020 ;41(Suppl 1):S99-S124.
        This chapter presents a narrative synthesis of the evidence relating to the effectiveness of 13 different approaches (interventions) that have been incorporated into national suicide prevention programs. These approaches are presented in an analytic framework that distinguishes between national and community-based multilevel programs, prevention, and treatment/maintenance. The primary source of evidence are six reviews of reviews published since 2005, supplemented by a small number of systematic reviews and primary studies. We report strongly supportive evidence concerning the effectiveness of structural interventions (restrictions on access to bridges, tall buildings, and railways) and restriction on access to pharmacological agents. Weakly supportive evidence of effectiveness is available for community-based multilevel programs; restrictions on access to firearms and ligature points in institutional settings; settings-based programs (in schools, communities, workplaces, prisons, and the armed forces); education and training targeted at primary care physicians; lithium; cognitive behavioral therapy and dialectical behavioral therapy; and brief contact. There is insufficient or conflicting evidence concerning the effectiveness of the remaining approaches. We conclude that the evidence base for effective suicide prevention is far from convincing. Major improvement in the extent and quality of collaboration between researchers, policymakers, and practitioners and a considerable increase in funding for evaluation studies in suicide prevention are required if the current knowledge gap about effective interventions is to be bridged.

      14. Suicide rates have continued to rise in the United States. Speculations for this rise proliferate but the causes for the increase remain unknown. While research focuses on identifying causes, the health care system is an important site for identification of patients at risk. Forty percent of individuals who die by suicide were seen in primary care in the month prior to suicide. The Zero Suicide model describes a comprehensive approach for health care systems to aid in identification and intervention of suicidal patients. While this model promises to improve care of suicidal patients, the need for innovation in our approach to understanding and caring for suicidal patients is pressing. Use of technology to enhance moment-to-moment monitoring of at-risk individuals offers promise and the possibility of intervening close to escalation of acute suicidal states. Further, once identified, suicidal individuals are often difficult to engage in treatment. Novel approaches to engagement and treatment that are effective and acceptable to suicidal patients ought to be developed. Specifically, males are much more likely than females to die by suicide. At the same time, males are less likely to seek and remain in the treatments we have to offer. Innovation should seek to identify strategies that are acceptable to males. Additionally, while about half of psychiatric inpatient admissions are suicide related, there is a paucity of suicide-specific psychosocial interventions available for inpatient settings. Innovation in monitoring and treatment offer promise in helping to reduce suicidal behavior in the United States.

      15. Adherence to suicide reporting guidelines by news shared on a social networking platformexternal icon
        Sumner SA, Burke M, Kooti F.
        Proc Natl Acad Sci U S A. 2020 Jul 14;117(28):16267-16272.
        Rates of suicide in the United States are at a more than 20-y high. Suicide contagion, or spread of suicide-related thoughts and behaviors through exposure to sensationalized and harmful content is a well-recognized phenomenon. Health authorities have published guidelines for news media reporting on suicide to help prevent contagion; however, uptake of recommendations remains limited. A key barrier to widespread voluntary uptake of suicide-reporting guidelines is that more sensational content is perceived to be more engaging to readers and thus enhances publisher visibility and engagement; however, no empirical information exists on the actual influence of adherence to safe-reporting practices on reader engagement. Hence, we conducted a study to analyze adherence to suicide-reporting guidelines on news shared on social media and to assess how adherence affects reader engagement. Our analysis of Facebook data revealed that harmful elements were prevalent in news articles about suicide shared on social media while the presence of protective elements was generally rare. Contrary to popular perception, closer adherence to safe-reporting practices was associated with a greater likelihood of an article being reshared (adjusted odds ratio [AOR] = 1.19, 95% confidence interval [CI] = 1.10 to 1.27) and receiving positive engagement ("love" reactions) (AOR = 1.20, 95% CI = 1.13 to 1.26). Mean safe-reporting scores were lower in the US than other English-speaking nations and variation existed by publisher characteristics. Our results provide empirical evidence that improved adherence to suicide-reporting guidelines may benefit not only the health of individuals, but also support publisher goals of reach and engagement.

      16. National trends in hospitalizations for self-directed violence related to opioids and/or depression - United States, 2000-2015external icon
        Wang J, Sumner SA, Holland KM, Halpin J, Ivey-Stephenson A, Crosby AE.
        Prev Med. 2020 May;134:106051.
        This study examined national trends in self-directed violence in the context of changes in opioid use and depression to better inform prevention measures. Using 2000-2015 National Inpatient Sample (NIS) data, we identified 625,064 hospitalizations for self-directed violence among persons aged ≥10 years in the United States. Based on whether co-listing opioid related diagnosis and depression, we categorized hospitalizations for self-directed violence into four comorbid categories as 1) related to opioids alone; 2) related to depression alone; 3) related to both opioids and depression; and 4) related to neither opioids nor depression. Census population estimates served as the denominator for calculating hospitalization rates for self-directed violence. Hospitalization rates for self-directed violence related to opioids doubled from 5.1 per 100,000 persons in 2000 to 11.0 in 2015. The rate of increase was highest for self-directed violence related to both opioids and depression, which increased 9.4% annually during 2000-2011 and then decreased 4.3% annually during 2011-2015. Hospitalizations for self-directed violence related to depression alone remained the predominant category, accounting for approximately 60% of hospitalizations for self-directed violence; the rates among females aged 10-24 years were the highest among all subgroups, and rose 7.8% annually since 2011 reaching 93.2 per 100,000 persons in 2015. These findings highlight the importance of assessing the risk for self-directed violence among patients misusing opioids and the importance of treating opioid use disorder and depression, particularly when they co-occur. Prevention and treatment of depression is especially important for young females.

      17. Trends in the incidence and lethality of suicidal acts in the United States, 2006 to 2015external icon
        Wang J, Sumner SA, Simon TR, Crosby AE, Annor FB, Gaylor E, Xu L, Holland KM.
        JAMA Psychiatry. 2020 Jul 1;77(7):684-693.
        IMPORTANCE: Understanding changes in the incidence rates and lethality of suicidal acts may explain increasing suicide rates. OBJECTIVE: To examine trends in the incidence rates and lethality of suicidal acts from 2006 to 2015 among persons aged 10 to 74 years. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study was conducted from May 2, 2018, to January 30, 2019. Medically treated nonfatal suicide attempts were identified from the 2006 to 2015 Nationwide Inpatient Sample and Nationwide Emergency Department Sample databases. Suicides were identified from the 2006 to 2015 mortality files of the National Vital Statistics System. MAIN OUTCOMES AND MEASURES: The incidence rate of suicidal acts was calculated by dividing the number of total suicidal acts by the US population. Lethality was measured through the case fatality rates (CFRs) of suicidal acts by dividing the number of suicides by the total number of suicidal acts. RESULTS: A total of 1 222 419 (unweighted) suicidal acts, which included both suicides and nonfatal suicide attempts, were identified from 2006 to 2015. Overall, the incidence rates of total suicidal acts increased 10% from 2006 to 2015 (annual percentage change [APC], 0.8%; 95% CI, 0.3%-1.3%), and the CFRs of suicidal acts increased 13% during the 2006 to 2015 period (APC, 2.3%; 95% CI, 1.3%-3.3%). In subgroup analyses, incidence rates increased by 1.1% (95% CI, 0.6%-1.6%) per year for female individuals during the 2006 to 2015 period but remained stable for male individuals. The CFRs increased for both sexes (APC, 5.0% [95% CI, 3.1%-6.9%] since 2010 for female individuals; 1.6% [95% CI, 0.6%-2.5%] since 2009 for male individuals). Incidence rates increased among adolescents from 2011 to 2015 and among older adults aged 65 to 74 years throughout the 2006 to 2015 period. Conversely, the CFRs increased since 2009 among persons aged 20 to 44 years (APC, 3.7%; 95% CI, 2.5%-5.0%) and since 2012 for those aged 45 to 64 years (APC, 2.7%; 95% CI, 0.0%-5.4%). Persons aged 20 to 44 years and 45 to 64 years experienced increases in suicidal acts by more lethal means, whereas adolescents and older adults aged 65 to 74 years showed increased incidence by all means. CONCLUSIONS AND RELEVANCE: This study found increased suicidal acts among female persons, adolescents, and older adults aged 65 to 74 years, implying the need to address emerging or exacerbating suicide risk factors for these populations. The findings on the increased lethality particularly among persons aged 20 to 64 years highlighted the need to reduce access to materials that could be used as lethal means among persons at risk of suicide. These findings on population-level epidemiologic patterns can be used to guide the development of comprehensive suicide prevention strategies.

      18. Syndromic surveillance of suicidal ideation and self-directed violence - United States, January 2017-December 2018external icon
        Zwald ML, Holland KM, Annor FB, Kite-Powell A, Sumner SA, Bowen DA, Vivolo-Kantor AM, Stone DM, Crosby AE.
        MMWR Morb Mortal Wkly Rep. 2020 Jan 31;69(4):103-108.
        Suicide is a growing public health problem in the United States, claiming approximately 47,000 lives in 2017 (1). However, deaths from suicide represent only a small part of a larger problem because each year millions of persons experience suicidal ideation and engage in suicidal and nonsuicidal self-directed violence, both risk factors for suicide (2). Emergency departments (EDs) are an important setting for monitoring these events in near real time (3-5). From 2001 to 2016, ED visit rates for nonfatal self-harm increased 42% among persons aged ≥10 years (1). Using data from CDC's National Syndromic Surveillance Program (NSSP), ED visits for suicidal ideation, self-directed violence, or both among persons aged ≥10 years during January 2017-December 2018 were examined by sex, age group, and U.S. region. During the 24-month period, the rate of ED visits for suicidal ideation, self-directed violence, or both increased 25.5% overall, with an average increase of 1.2% per month. Suicide prevention requires comprehensive and multisectoral approaches to addressing risk at personal, relationship, community, and societal levels. ED syndromic surveillance data can provide timely trend information and can support more targeted and prompt public health investigation and response. CDC's Preventing Suicide: A Technical Package of Policy, Programs, and Practices includes tailored suicide prevention strategies for health care settings (6).

  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. OBJECTIVES: To estimate the prevalence of unmet needs for assistance among middle-aged and older adults with subjective cognitive decline (SCD) in the US and to evaluate whether unmet needs were associated with health-related quality of life (HRQOL). DESIGN: Cross-sectional. SETTING: US - 50 states, District of Columbia, and Puerto Rico. PARTICIPANTS: Community-dwelling adults aged 45 years and older who completed the Cognitive Decline module on the 2015--2018 Behavioral Risk Factor Surveillance System reported experiencing SCD and always, usually, or sometimes needed assistance with day-to-day activities because of SCD (n = 6,568). MEASUREMENTS: We defined SCD as confusion or memory loss that was happening more often or getting worse over the past 12 months. Respondents with SCD were considered to have an unmet need for assistance if they sometimes, rarely, or never got the help they needed with day-to-day activities. We measured three domains of HRQOL: (1) mental (frequent mental distress, ≥14 days of poor mental health in the past 30 days), (2) physical (frequent physical distress, ≥14 days of poor physical health in the past 30 days), and (3) social (SCD always, usually, or sometimes interfered with the ability to work, volunteer, or engage in social activities outside the home). We used log-binomial regression models to estimate prevalence ratios (PRs). All estimates were weighted. RESULTS: In total, 40.2% of people who needed SCD-related assistance reported an unmet need. Among respondents without depression, an unmet need was associated with a higher prevalence of frequent mental distress (PR = 1.55, 95% CI: 1.12-2.13, p = 0.007). Frequent physical distress and social limitations did not differ between people with met and unmet needs. CONCLUSIONS: Middle-aged and older adults with SCD-related needs for assistance frequently did not have those needs met, which could negatively impact their mental health. Interventions to identify and meet the unmet needs among people with SCD may improve HRQOL.

      2. Cancers associated with human papillomavirus in American Indian and Alaska Native populations - United States, 2013-2017external icon
        Melkonian SC, Henley SJ, Senkomago V, Thomas CC, Jim MA, Apostolou A, Saraiya M.
        MMWR Morb Mortal Wkly Rep. 2020 Sep 18;69(37):1283-1287.
        Human papillomavirus (HPV) causes most cervical cancers and some cancers of the penis, vulva, vagina, oropharynx, and anus. Cervical precancers can be detected through screening. HPV vaccination with the 9-valent HPV vaccine (9vHPV) can prevent approximately 92% of HPV-attributable cancers (1).* Previous studies have shown lower incidence of HPV-associated cancers in non-Hispanic American Indian and Alaska Native (AI/AN) populations compared with other racial subgroups (2); however, these rates might have been underestimated as a result of racial misclassification. Previous studies have shown that cancer registry data corrected for racial misclassification resulted in more accurate cancer incidence estimates for AI/AN populations (3,4). In addition, regional variations in cancer incidence among AI/AN populations suggest that nationally aggregated data might not adequately describe cancer outcomes within these populations (5). These variations might, in part, result from geographic disparities in the use of health services, such as cancer screening or vaccination (6). CDC analyzed data for 2013-2017 from central cancer registries linked with the Indian Health Service (IHS) patient registration database to assess the incidence of HPV-associated cancers and to estimate the number of cancers caused by HPV among AI/AN populations overall and by region. During 2013-2017, an estimated 1,030 HPV-associated cancers were reported in AI/AN populations. Of these cancers, 740 (72%) were determined to be attributable to HPV types targeted by 9vHPV; the majority were cervical cancers in females and oropharyngeal cancers in males. These data can help identify regions where AI/AN populations have disproportionately high rates of HPV-associated cancers and inform targeted regional vaccination and screening programs in AI/AN communities.

      3. A method for calculating BMI z-scores and percentiles above the 95(th) percentile of the CDC growth chartsexternal icon
        Wei R, Ogden CL, Parsons VL, Freedman DS, Hales CM.
        Ann Hum Biol. 2020 Sep 9:1-8.
        BACKGROUND: The 2000 CDC growth charts are based on national data collected between 1963 and 1994 and include a set of selected percentiles between the 3(rd) and 97(th) and LMS parameters that can be used to obtain other percentiles and associated z-scores. Obesity is defined as a sex- and age-specific body mass index (BMI) at or above the 95(th) percentile. Extrapolating beyond the 97(th) percentile is not recommended and leads to compressed z-score values. AIM: This study attempts to overcome this limitation by constructing a new method for calculating BMI distributions above the 95(th) percentile using an extended reference population. SUBJECTS AND METHODS: Data from youth at or above the 95(th) percentile of BMI-for-age in national surveys between 1963 and 2016 were modelled as half-normal distributions. Scale parameters for these distributions were estimated at each sex-specific 6-month age-interval, from 24 to 239 months, and then smoothed as a function of age using regression procedures. RESULTS: The modelled distributions above the 95(th) percentile can be used to calculate percentiles and non-compressed z-scores for extreme BMI values among youth. CONCLUSION: This method can be used, in conjunction with the current CDC BMI-for-age growth charts, to track extreme values of BMI among youth.

    • Communicable Diseases
      1. BACKGROUND: Merely having the tools to end HIV is insufficient. Effectively ending the epidemic necessitates addressing barriers that impede engagement in biomedical and behavioral prevention and wide scale implementation and utilization of existing interventions. This qualitative study identifies suggestions for increasing access to, engagement in, and impact of HIV prevention among women living in cities in high HIV burden counties in the eastern US. METHODS: Data analyzed for the current study were collected via a qualitative sub-study within the HIV Prevention Trials Network Study 064 (HPTN 064), a multisite observational cohort study designed to estimate HIV incidence among women residing in communities with elevated HIV prevalence who also reported personal or partner characteristics associated with increased risk of HIV acquisition. Focus group and interview participants in the qualitative sub-study (N = 288) were from four cities in the eastern US. RESULTS: Thematic analyses revealed four themes describing women's most frequently stated ideas for improving prevention efforts: 1) Promote Multilevel Empowerment, 2) Create Engaging Program Content, 3) Build "Market Demand", and 4) Ensure Accessibility. We conducted additional analyses to identify contradictory patterns in the data, which revealed an additional three themes: 1) Address Structural Risk Factors, 2) Increase Engagement via Pleasure Promotion, 3) Expand Awareness of and Access to Prevention Resources. CONCLUSIONS: Findings may be useful for enhancing women's engagement in and uptake of behavioral and biomedical HIV prevention resources, improving policy, and addressing multilevel risk factors. TRIAL REGISTRATION: NCT00995176 , prospectively registered.

      2. Substantial need for PrEP among MSM in Hanoi, Vietnamexternal icon
        Bhatia R, Le Minh G, Thanh LA, Thai TT, Bui H, Ngoc LB, Vu D, Abdul-Quader A.
        Sex Transm Dis. 2020 Sep 2.
        We utilized data from the HIM-Hanoi cohort to determine the proportion of HIV-negative MSM with PrEP indications in Hanoi. Among 717 MSM, 537 (72.2% [66.6-77.3%]) had ≥1 PrEP indication, signaling substantial need for PrEP scale-up. Condomless anal intercourse was the most frequent indication (68.7% [60.3-76.1%]), followed by previous/current STI (59.4% [51.0-67.2%]).

      3. SARS-CoV-2-associated deaths among persons aged <21 years - United States, February 12-July 31, 2020external icon
        Bixler D, Miller AD, Mattison CP, Taylor B, Komatsu K, Peterson Pompa X, Moon S, Karmarkar E, Liu CY, Openshaw JJ, Plotzker RE, Rosen HE, Alden N, Kawasaki B, Siniscalchi A, Leapley A, Drenzek C, Tobin-D'Angelo M, Kauerauf J, Reid H, Hawkins E, White K, Ahmed F, Hand J, Richardson G, Sokol T, Eckel S, Collins J, Holzbauer S, Kollmann L, Larson L, Schiffman E, Kittle TS, Hertin K, Kraushaar V, Raman D, LeGarde V, Kinsinger L, Peek-Bullock M, Lifshitz J, Ojo M, Arciuolo RJ, Davidson A, Huynh M, Lash MK, Latash J, Lee EH, Li L, McGibbon E, McIntosh-Beckles N, Pouchet R, Ramachandran JS, Reilly KH, Dufort E, Pulver W, Zamcheck A, Wilson E, de Fijter S, Naqvi O, Nalluswami K, Waller K, Bell LJ, Burch AK, Radcliffe R, Fiscus MD, Lewis A, Kolsin J, Pont S, Salinas A, Sanders K, Barbeau B, Althomsons S, Atti S, Brown JS, Chang A, Clarke KR, Datta SD, Iskander J, Leitgeb B, Pindyck T, Priyamvada L, Reagan-Steiner S, Scott NA, Viens LJ, Zhong J, Koumans EH.
        MMWR Morb Mortal Wkly Rep. 2020 Sep 18;69(37):1324-1329.
        Since February 12, 2020, approximately 6.5 million cases of SARS-CoV-2 infection, the cause of coronavirus disease 2019 (COVID-19), and 190,000 SARS-CoV-2-associated deaths have been reported in the United States (1,2). Symptoms associated with SARS-CoV-2 infection are milder in children compared with adults (3). Persons aged <21 years constitute 26% of the U.S. population (4), and this report describes characteristics of U.S. persons in that population who died in association with SARS-CoV-2 infection, as reported by public health jurisdictions. Among 121 SARS-CoV-2-associated deaths reported to CDC among persons aged <21 years in the United States during February 12-July 31, 2020, 63% occurred in males, 10% of decedents were aged <1 year, 20% were aged 1-9 years, 70% were aged 10-20 years, 45% were Hispanic persons, 29% were non-Hispanic Black (Black) persons, and 4% were non-Hispanic American Indian or Alaska Native (AI/AN) persons. Among these 121 decedents, 91 (75%) had an underlying medical condition,* 79 (65%) died after admission to a hospital, and 39 (32%) died at home or in the emergency department (ED).(†) These data show that nearly three quarters of SARS-CoV-2-associated deaths among infants, children, adolescents, and young adults have occurred in persons aged 10-20 years, with a disproportionate percentage among young adults aged 18-20 years and among Hispanics, Blacks, AI/ANs, and persons with underlying medical conditions. Careful monitoring of SARS-CoV-2 infections, deaths, and other severe outcomes among persons aged <21 years remains particularly important as schools reopen in the United States. Ongoing evaluation of effectiveness of prevention and control strategies will also be important to inform public health guidance for schools and parents and other caregivers.

      4. Association between CMS quality ratings and COVID-19 outbreaks in nursing homes - West Virginia, March 17-June 11, 2020external icon
        Bui DP, See I, Hesse EM, Varela K, Harvey RR, August EM, Winquist A, Mullins S, McBee S, Thomasson E, Atkins A.
        MMWR Morb Mortal Wkly Rep. 2020 Sep 18;69(37):1300-1304.
        Nursing homes are high-risk settings for outbreaks of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1,2). During the COVID-19 pandemic, U.S. health departments worked to improve infection prevention and control (IPC) practices in nursing homes to prevent outbreaks and limit the spread of COVID-19 in affected facilities; however, limited resources have hampered health departments' ability to rapidly provide IPC support to all nursing homes within their jurisdictions. Since 2008, the Centers for Medicare & Medicaid Services (CMS) has published health inspection results and quality ratings based on their Five-Star Quality Rating System for all CMS-certified nursing homes (3); these ratings might be associated with facility-level risk factors for COVID-19 outbreaks. On April 17, 2020, West Virginia became the first state to mandate and conduct COVID-19 testing for all nursing home residents and staff members to identify and reduce transmission of SARS-CoV-2 in these settings (4). West Virginia's census of nursing home outbreaks was used to examine associations between CMS star ratings and COVID-19 outbreaks. Outbreaks, defined as two or more cases within 14 days (with at least one resident case), were identified in 14 (11%) of 123 nursing homes. Compared with 1-star-rated (lowest rated) nursing homes, the odds of a COVID-19 outbreak were 87% lower among 2- to 3-star-rated facilities (adjusted odds ratio [aOR] = 0.13, 95% confidence interval [CI] = 0.03-0.54) and 94% lower among 4- to 5-star-rated facilities (aOR = 0.06, 95% CI = 0.006-0.39). Health departments could use star ratings to help identify priority nursing homes in their jurisdictions to inform the allocation of IPC resources. Efforts to mitigate outbreaks in high-risk nursing homes are necessary to reduce overall COVID-19 mortality and associated disparities. Moreover, such efforts should incorporate activities to improve the overall quality of life and care of nursing home residents and staff members and address the social and health inequities that have been recognized as a prominent feature of the COVID-19 pandemic in the United States (5).

      5. Unnamed partners from syphilis partner services interviews, 7 jurisdictionsexternal icon
        Cope AB, Bernstein K, Matthias J, Rahman M, Diesel J, Pugsley RA, Schillinger JA, Chew Ng RA, Sachdev D, Shaw R, Nguyen TQ, Klingler EJ, Mobley VL, Samoff E, Peterman TA.
        Sex Transm Dis. 2020 Sep 2.
        BACKGROUND: Reducing transmission depends on the percentage of infected partners treated; if many are missed, impact on transmission will be low. Traditional partner services metrics evaluate the number of partners found and treated. We estimated the proportion of partners of syphilis patients not locatable for intervention. METHODS: We reviewed records of early syphilis cases (primary, secondary, early latent) reported during 2015-2017 in seven jurisdictions (Florida, Louisiana, Michigan, North Carolina, Virginia, New York City, and San Francisco). Among interviewed syphilis patients, we determined the proportion who reported named partners (with locating information), reported unnamed partners (no locating information), and did not report partners. For patients with no reported partners, we estimated their range of unreported partners to be between one and the average number of partners for patients who reported partners. RESULTS: Among 29,719 syphilis patients, 23,613 (80%) were interviewed and 18,581 (63%) reported 84,224 sex partners (average=4.5; 20,853 (25%) named and 63,371 (75%) unnamed). An estimated 11,138 to 54,521 partners were unreported. Thus, 74,509 to 117,892 (of 95,362 to 138,745) partners were not reached by partner services (78-85%). Among interviewed patients, 71% reported ≥1 unnamed partner or reported no partners; this proportion was higher for men who reported sex with men [MSM] (75%), compared to men who reported sex with women only (65%), and women (44%). CONCLUSION: Approximately 80% of sex partners were either unnamed or unreported. Partner services may be less successful at interrupting transmission in MSM networks where a higher proportion of partners are unnamed or unreported.

      6. Potential contributions of clinical and community testing in identifying persons with undiagnosed HIV infection in the United Statesexternal icon
        Kahn JG, Bendavid E, Dietz PM, Hutchinson A, Horvath H, McCabe D, Wolitski RJ.
        J Int Assoc Provid AIDS Care. 2020 Jan-Dec;19.
        BACKGROUND: An estimated 166,155 individuals in the United States have undiagnosed HIV infection. We modeled the numbers of HIV-infected individuals who could be diagnosed in clinical and community settings by broadly implementing HIV screening guidelines. SETTING: United States. METHODS: We modeled testing for general population (once lifetime) and high-risk populations (annual): men who have sex with men, people who inject drugs, and high-risk heterosexuals. We used published data on HIV infections, HIV testing, engagement in clinical care, and risk status disclosure. RESULTS: In clinical settings, about 76 million never-tested low-risk and 2.6 million high-risk individuals would be tested, yielding 36,000 and 55,000 HIV diagnoses, respectively. In community settings, 30 million low-risk and 4.4 million high-risk individuals would be tested, yielding 75,000 HIV diagnoses. CONCLUSION: HIV testing in clinical and community settings diagnoses similar numbers of individuals. Lifetime and risk-based testing are both needed to substantially reduce undiagnosed HIV.

      7. HIV incidence among men who have sex with men and transgender women in four provinces in Thailandexternal icon
        Kritsanavarin U, Bloss E, Manopaiboon C, Khawcharoenporn T, Harnlakon P, Vasanti-Uppapokakorn M, Kitwattanachai P, Naprasert S, Phiphatthananon T, Visavakum P, Jetsawang B, Mock PA.
        Int J STD AIDS. 2020 Sep 9.
        The HIV epidemic in Thailand is concentrated in key populations, with the highest rates in men who have sex with men (MSM) and transgender women (TG). Previous studies of HIV incidence in these groups have been limited mostly to Bangkok. We measured HIV incidence in MSM and TG in four provinces and evaluated factors associated with incident infections to inform public health prevention efforts. An analysis was conducted using data collected during a prospective observational cohort study during April 2015-May 2018 in outpatient clinics in five hospitals across four provinces in Thailand. MSM and TG aged ≥18 years, who were not known to be HIV-infected, and who reported anal intercourse with a male or TG without a condom in the past six months were enrolled. Participants were followed-up every 6 months for 18 months with questionnaires and HIV testing. A total of 40 HIV seroconversions occurred during follow-up, resulting in an HIV incidence of 3.5 per 100 person-years (95% CI 2.5, 4.8). Multivariate analyses indicated that identifying as gay (adjusted hazard ratio [AHR] 4.9; 95% CI 1.7-14.2), having receptive anal sex in the past six months (AHR 3.6; 95% CI 1.4-9.5), using alcohol (AHR 3.3; 95% CI 1.3-8.3), and taking alkyl nitrites (AHR 4.4; 95% CI 1.7-11.2) in the past six months were all independently associated with HIV infection. Overall this study found a lower HIV incidence in the highest risk population in Thailand compared with similar studies in Bangkok. Accelerated prevention efforts are needed to make the goal of 'zero new infections' possible in Thailand.

      8. Transmission dynamics of COVID-19 outbreaks associated with child care facilities - Salt Lake City, Utah, April-July 2020external icon
        Lopez AS, Hill M, Antezano J, Vilven D, Rutner T, Bogdanow L, Claflin C, Kracalik IT, Fields VL, Dunn A, Tate JE, Kirking HL, Kiphibane T, Risk I, Tran CH.
        MMWR Morb Mortal Wkly Rep. 2020 Sep 18;69(37):1319-1323.
        Reports suggest that children aged ≥10 years can efficiently transmit SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1,2). However, limited data are available on SARS-CoV-2 transmission from young children, particularly in child care settings (3). To better understand transmission from young children, contact tracing data collected from three COVID-19 outbreaks in child care facilities in Salt Lake County, Utah, during April 1-July 10, 2020, were retrospectively reviewed to explore attack rates and transmission patterns. A total of 184 persons, including 110 (60%) children had a known epidemiologic link to one of these three facilities. Among these persons, 31 confirmed COVID-19 cases occurred; 13 (42%) in children. Among pediatric patients with facility-associated confirmed COVID-19, all had mild or no symptoms. Twelve children acquired COVID-19 in child care facilities. Transmission was documented from these children to at least 12 (26%) of 46 nonfacility contacts (confirmed or probable cases). One parent was hospitalized. Transmission was observed from two of three children with confirmed, asymptomatic COVID-19. Detailed contact tracing data show that children can play a role in transmission from child care settings to household contacts. Having SARS-CoV-2 testing available, timely results, and testing of contacts of persons with COVID-19 in child care settings regardless of symptoms can help prevent transmission. CDC guidance for child care programs recommends the use of face masks, particularly among staff members, especially when children are too young to wear masks, along with hand hygiene, frequent cleaning and disinfecting of high-touch surfaces, and staying home when ill to reduce SARS-CoV-2 transmission (4).

      9. Towards achieving the 90-90-90 HIV targets: results from the south African 2017 national HIV surveyexternal icon
        Marinda E, Simbayi L, Zuma K, Zungu N, Moyo S, Kondlo L, Jooste S, Nadol P, Igumbor E, Dietrich C, Briggs-Hagen M.
        BMC Public Health. 2020 Sep 9;20(1):1375.
        BACKGROUND: Measuring progress towards the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 treatment targets is key to assessing progress towards turning the HIV epidemic tide. In 2017, the UNAIDS model estimated that 75% of people living with HIV (PLHIV) globally knew their HIV positive status, 79% of those who knew their status were on antiretroviral therapy (ART), and 81% of those who knew their HIV status and were on ART had a suppressed viral load. The fifth South African national HIV sero-behavioural survey collected nationally representative data that enabled the empirical estimation of these 90-90-90 targets for the country stratified by a variety of key factors. METHODS: To evaluate progress towards achievement of the 90-90-90 targets for South Africa, data obtained from a national, representative, cross-sectional population-based multi-stage stratified cluster random survey conducted in 2017 were analysed. The Fifth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM V), collected behavioural and biomarker data from individuals residing in households from 1000 randomly selected Small Area Layers (SALs), across all nine provinces of the country. Structured questionnaires were used to collect socio-demographic data, knowledge and perceptions about HIV, and related risk behaviours. Blood samples were collected to test for HIV infection, antiretroviral use, and viral suppression (defined as < 1000 copies/ml). Weighted proportions of study participants aged 15 years and older who tested HIV positive were computed for those who reported awareness of their status (1st 90), and among these, those who were currently on ART (2nd 90) and of these, those who were virally suppressed (3rd 90). RESULTS: Among persons 15 years and older who were HIV positive, 84.8% were aware of their HIV positive status, of whom 70.7% were currently on ART, with 87.4% of these estimated to have suppressed viral load at the time of the survey. These estimates varied by sex, age, and geo-location type. Relatively higher percentages across all three indicators for women compared to men were observed: 88.7% versus 78.2% for those aware of their status, 72.3% versus 67.7% for on ART, and 89.8% versus 82.3% for viral suppression. Knowing one's positive HIV status increased with age: 74.0, 85.8, and 88.1% for age groups 15-24 years old, 25-49 years old and 50-64 years old, although for those 65 years and older, 78.7% knew their HIV positive status. A similar pattern was observed for the 2nd 90, among those who knew their HIV positive status, 51.7% of 15 to 24 year olds, 70.5% of those aged 25-49 years old, 82.9% of those aged 50-64 years old and 82.4% of those aged 65 years or older were currently on ART. Viral suppression for the above mentioned aged groups, among those who were on ART was 85.2, 87.2, 89.5, and 84.6% respectively. The 90-90-90 indicators for urban areas were 87.7, 66.5, and 87.2%, for rural settings was 85.8, 79.8, and 88.4%, while in commercial farming communities it was 56.2, 67.6 and 81.4%. CONCLUSIONS: South Africa appears to be on track to achieve the first 90 indicator by 2020. However, it is behind on the second 90 indicator with ART coverage that was ~ 20-percentage points below the target among people who knew their HIV status, this indicates deficiencies around linkage to and retention on ART. Overall viral suppression among those on ART is approaching the target at 87.4%, but this must be interpreted in the context of low reported ART coverage as well as with variation by age and sex. Targeted diagnosis, awareness, and treatment programs for men, young people aged 15-24 years old, people who reside in farming communities, and in specific provinces are needed. More nuanced 90-90-90 estimates within provinces, specifically looking at more granular sub-national level (e.g. districts), are needed to identify gaps in specific regions and to inform provincial interventions.

      10. How adequate is measles surveillance in the United States? Investigations of measles-like illness, 2010-2017external icon
        McKay SL, Leung J, Gastañaduy PA, Routh JA, Harpaz R.
        Hum Vaccin Immunother. 2020 Sep 3:1-7.
        Given the availability of an effective and safe vaccine, the World Health Organization (WHO) declared that global measles eradication is achievable, and measles elimination goals have since been established as interim steps toward eradication. As part of a strategy to maintain elimination, the Pan American Health Organization (PAHO) and WHO stipulate a minimum annual reporting rate of discarded non-measles cases of ≥2 per 100,000 population, in order to ensure sensitive surveillance and adequate investigative effort. With its effective vaccination program, the United States in 2000 was among the first countries to verify elimination, although subsequently, it has not routinely reported discarded rates. We estimated MLI investigation rates among insured individuals during 2010-2017, using data from the MarketScan® databases. We defined "MLI investigations" as measles serologic testing within 5 days following diagnostic codes for measles-compatible symptoms and conditions. We provide a rationale for pre-specifying three subgroups for analysis: children aged ≤15 years; males aged 16-22 years excluding data from summer months; and males aged ≥23 years. MLI investigation rates ranged from 6.6─26.4 per 100,000, remaining stable over time except during the 2015 measles outbreaks when rates increased, particularly among young children. In addition to high vaccine uptake, measles elimination requires ongoing vigilance by clinicians and high-quality, case-based surveillance. Estimated rates of MLI investigations in this U.S. population suggesting that the quality of measles surveillance is sufficiently sensitive to detect endemic measles circulation if it were to be occurring.

      11. Progress toward poliovirus containment implementation - worldwide, 2019-2020external icon
        Moffett DB, Llewellyn A, Singh H, Saxentoff E, Partridge J, Boualam L, Pallansch M, Wassilak S, Asghar H, Roesel S, Grabovac V, Rey-Benito G, Barnor J, Theo A, Swan J, Iakovenko M, Baig N, Gurung S, Pandel E, Zaffran M.
        MMWR Morb Mortal Wkly Rep. 2020 Sep 18;69(37):1330-1333.
        Since 1988, when World Health Organization (WHO) Member States and partners launched the Global Polio Eradication Initiative, the number of wild poliovirus (WPV) cases has declined from 350,000 in 125 countries to 176 in only two countries in 2019 (1). The Global Commission for the Certification of Poliomyelitis Eradication (GCC) declared two of the three WPV types, type 2 (WPV2) and type 3 (WPV3), eradicated globally in 2015 and 2019, respectively (1). Wild poliovirus type 1 (WPV1) remains endemic in Afghanistan and Pakistan (1). Containment under strict biorisk management measures is vital to prevent reintroduction of eradicated polioviruses into communities from poliovirus facilities. In 2015, Member States committed to contain type 2 polioviruses (PV2) in poliovirus-essential facilities (PEFs) certified in accordance with a global standard (2). Member states agreed to report national PV2 inventories annually, destroy unneeded PV2 materials, and, if retaining PV2 materials, establish national authorities for containment (NACs) and a PEF auditing process. Since declaration of WPV3 eradication in October 2019, these activities are also required with WPV3 materials. Despite challenges faced during 2019-2020, including the coronavirus disease 2019 (COVID-19) pandemic, the global poliovirus containment program continues to work toward important milestones. To maintain progress, all WHO Member States are urged to adhere to the agreed containment resolutions, including officially establishing legally empowered NACs and submission of PEF Certificates of Participation.

      12. Factors associated with HIV testing among Atlanta's homeless youthexternal icon
        Myles RL, Best J, Bautista G, Wright ER, LaBoy A, Demissie Z, Dean HD.
        AIDS Educ Prev. 2020 Aug;32(4):325-336.
        Homeless youth experience increased risk of contracting HIV, making HIV testing imperative in this population. We analyzed factors associated with HIV testing among homeless youth in Atlanta, Georgia using data from the 2015 Atlanta Youth Count and Needs Assessment. The analysis included 693 homeless youth aged 14-25 years, of whom 88.4% reported ever being tested for HIV, and 74.6% reported being tested within the previous year. Prevalence of ever testing for HIV was significantly higher among youth who reported risk factors for HIV (sexually active, transactional sex, or ever having an STI). Higher prevalence of testing within the last year was significantly associated with experiencing physical abuse or transactional sex. However, reporting ≥ 4 sexual partners or not using condoms were not associated with higher testing. Although testing prevalence among homeless youth was high, homeless youth engaging in certain high risk behaviors could benefit from further promotion of HIV testing.

      13. Impact of social distancing and travel restrictions on non-COVID-19 respiratory hospital admissions in young children in rural Alaskaexternal icon
        Nolen LD, Seeman S, Bruden D, Klejka J, Desnoyers C, Tiesinga J, Singleton R.
        Clin Infect Dis. 2020 Sep 5.
        Hospitalizations due to non-COVID-19 respiratory illnesses decreased dramatically after social distancing was implemented in a high-risk population in rural Alaska. Our data from the past ten respiratory seasons show that this decline is unprecedented. This demonstrates the potential secondary benefits of implementing social distancing and travel restrictions on respiratory illnesses.

      14. STEPS to Care: Translating an evidence-informed HIV care coordination program into a field-tested online practice improvement toolkitexternal icon
        O'Donnell L, Irvine MK, Wilkes AL, Rwan J, Myint UA, Leow DM, Whittier D, Harriman G, Bessler P, Higa D, Courtenay-Quirk C.
        AIDS Educ Prev. 2020 Aug;32(4):296-310.
        Increasing care engagement is essential to meet HIV prevention goals and achieve viral suppression. It is difficult, however, for agencies to establish the systems and practice improvements required to ensure coordinated care, especially for clients with complex health needs. We describe the theory-driven, field-informed transfer process used to translate key components of the evidence-informed Ryan White Part A New York City Care Coordination Program into an online practice improvement toolkit, STEPS to Care (StC), with the potential to support broader dissemination. Informed by analyses of qualitative and quantitative data collected from eight agencies, we describe our four phases: (1) review of StC strategies and key elements, (2) translation into a three-part toolkit: Care Team Coordination, Patient Navigation, and HIV Self-Management, (3) pilot testing, and (4) toolkit refinement for national dissemination. Lessons learned can guide the translation of evidence-informed strategies to online environments, a needed step to achieve wide-scale implemention.

      15. Decreased influenza activity during the COVID-19 pandemic - United States, Australia, Chile, and South Africa, 2020external icon
        Olsen SJ, Azziz-Baumgartner E, Budd AP, Brammer L, Sullivan S, Pineda RF, Cohen C, Fry AM.
        MMWR Morb Mortal Wkly Rep. 2020 Sep 18;69(37):1305-1309.
        After recognition of widespread community transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), by mid- to late February 2020, indicators of influenza activity began to decline in the Northern Hemisphere. These changes were attributed to both artifactual changes related to declines in routine health seeking for respiratory illness as well as real changes in influenza virus circulation because of widespread implementation of measures to mitigate transmission of SARS-CoV-2. Data from clinical laboratories in the United States indicated a 61% decrease in the number of specimens submitted (from a median of 49,696 per week during September 29, 2019-February 29, 2020, to 19,537 during March 1-May 16, 2020) and a 98% decrease in influenza activity as measured by percentage of submitted specimens testing positive (from a median of 19.34% to 0.33%). Interseasonal (i.e., summer) circulation of influenza in the United States (May 17-August 8, 2020) is currently at historical lows (median = 0.20% tests positive in 2020 versus 2.35% in 2019, 1.04% in 2018, and 2.36% in 2017). Influenza data reported to the World Health Organization's (WHO's) FluNet platform from three Southern Hemisphere countries that serve as robust sentinel sites for influenza from Oceania (Australia), South America (Chile), and Southern Africa (South Africa) showed very low influenza activity during June-August 2020, the months that constitute the typical Southern Hemisphere influenza season. In countries or jurisdictions where extensive community mitigation measures are maintained (e.g., face masks, social distancing, school closures, and teleworking), those locations might have little influenza circulation during the upcoming 2020-21 Northern Hemisphere influenza season. The use of community mitigation measures for the COVID-19 pandemic, plus influenza vaccination, are likely to be effective in reducing the incidence and impact of influenza, and some of these mitigation measures could have a role in preventing influenza in future seasons. However, given the novelty of the COVID-19 pandemic and the uncertainty of continued community mitigation measures, it is important to plan for seasonal influenza circulation in the United States this fall and winter. Influenza vaccination of all persons aged ≥6 months remains the best method for influenza prevention and is especially important this season when SARS-CoV-2 and influenza virus might cocirculate (1).

      16. Establishing best practices in a response to an HIV cluster: An example from a surge response in West Virginiaexternal icon
        Quilter L, Agnew-Brune C, Broussard D, Salmon M, Bradley H, Hogan V, Ridpath A, Burton K, Rose BC, Kirk N, Reynolds P, Varella L, Granado M, Gerard A, Thompson A, De La Garza G, Lee C, Bernstein K.
        Sex Transm Dis. 2020 Sep 2.

      17. Mathematical modeling study of school-based chlamydia screening: potential impact on chlamydia prevalence in intervention schools and surrounding communitiesexternal icon
        Rönn MM, Dunville R, Wang LY, Bellerose M, Malyuta Y, Menzies NA, Aslam M, Lewis F, Walker-Baban C, Asbel L, Parchem S, Masinter L, Perez E, Gift TL, Hsu K, Barrios LC, Salomon JA.
        BMC Public Health. 2020 Sep 5;20(1):1363.
        BACKGROUND: Chlamydia screening in high schools offers a way to reach adolescents outside of a traditional clinic setting. Using transmission dynamic modeling, we examined the potential impact of high-school-based chlamydia screening programs on the burden of infection within intervention schools and surrounding communities, under varying epidemiological and programmatic conditions. METHODS: A chlamydia transmission model was calibrated to epidemiological data from three different settings. Philadelphia and Chicago are two high-burden cities with existing school-based screening programs. Rural Iowa does not have an existing program but represents a low-burden setting. We modeled the effects of the two existing programs to analyze the potential influence of program coverage and student participation. All three settings were used to examine a broader set of hypothetical programs with varying coverage levels and time trends in participation. RESULTS: In the modeled Philadelphia program, prevalence among the intervention schools' sexually active 15-18 years old population was 4.34% (95% credible interval 3.75-4.71%)after 12 program years compared to 5.03% (4.39-5.43%) in absence of the program. In the modeled Chicago program, prevalence was estimated as 5.97% (2.60-7.88%) after 4 program years compared to 7.00% (3.08-9.29%) without the program. In the broader hypothetical scenarios including both high-burden and low-burden settings, impact of school-based screening programs was greater in absolute terms in the higher-prevalence settings, and benefits in the community were approximately proportional to population coverage of intervention schools. Most benefits were garnered if the student participation did not decline over time. CONCLUSIONS: Sustained high student participation in school-based screening programs and broad coverage of schools within a target community are likely needed to maximize program benefits in terms of reduced burden of chlamydia in the adolescent population.

      18. Community-wide HIV testing, linkage case management, and defaulter tracing in Bukoba, Tanzania: pre-intervention and post-intervention, population-based survey evaluationexternal icon
        Steiner C, MacKellar D, Cham HJ, Rwabiyago OE, Maruyama H, Msumi O, Pals S, Weber R, Kundi G, Byrd J, Kazaura K, Madevu-Matson C, Morales F, Justman J, Rutachunzibwa T, Rwebembera A.
        Lancet HIV. 2020 Sep 1.
        BACKGROUND: Community randomised trials have had mixed success in implementing combination prevention strategies that diagnose 90% of people living with HIV, initiate and retain on antiretroviral therapy (ART) 90% of those diagnosed, and achieve viral load suppression in 90% of those on ART (90-90-90). The Bukoba Combination Prevention Evaluation (BCPE) aimed to achieve 90-90-90 in Bukoba Municipal Council, Tanzania, by scaling up new HIV testing, linkage, and retention interventions. METHOD: We did population-based, cross-sectional surveys before and after our community-wide intervention in Bukoba-a mixed urban and rural council of approximately 150 000 residents located on the western shore of Lake Victoria in Tanzania. BCPE interventions were implemented in 11 government-supported health-care facilities throughout Bukoba from Oct 1, 2014, to March 31, 2017, when national ART-eligibility guidelines expanded from CD4 counts of less than 350 cells per μL (Oct 1, 2014-Dec 31, 2015) and 500 or less cells per μL (Jan 1, 2016-Sept 30, 2016) to any CD4 cell count (test and treat, Oct 1, 2016-March 31, 2017). We used pre-intervention (Nov 4, 2013-Jan 25, 2014) and post-intervention (June 21, 2017-Sept 20, 2017) population-based household surveys to assess population prevalence of undiagnosed HIV infection and ART coverage, and progress towards 90-90-90, among residents aged 18-49 years. FINDINGS: During the 2·5-year intervention, BCPE did 133 695 HIV tests, diagnosed and linked 3918 people living with HIV to HIV care at 11 Bukoba facilities, and returned to HIV care 604 patients who had stopped care. 4795 and 5067 residents aged 18-49 years participated in pre-intervention and post-intervention surveys. HIV prevalence before and after the intervention was similar: pre-intervention 8·9% (95% CI 7·5-10·4); post-intervention 8·4% (6·9-9·9). Prevalence of undiagnosed HIV infection decreased from 4·7% to 2·0% (prevalence ratio 0·42, 95% CI 0·31-0·57), and current ART use among all people living with HIV increased from 32·2% to 70·9% (2·20, 1·82-2·66) overall, 23·0% to 62·1% among men (2·70, 1·84-3·96), and 16·7% to 64·4% among people aged 18-29 years (3·87, 2·54-5·89). Of 436 and 435 people living with HIV aged 18-49 years who participated in pre-intervention and post-intervention surveys, previous HIV diagnosis increased from 47·4% (41·3-53·4) to 76·2% (71·8-80·6), ART use among diagnosed people living with HIV increased from 68·0% (60·9-75·2) to 93·1% (90·2-96·0), and viral load suppression of those on ART increased from 88·7% (83·6-93·8) to 91·3% (88·6-94·1). INTERPRETATION: BCPE findings suggest scaling up recommended HIV testing, linkage, and retention interventions can help reduce prevalence of undiagnosed HIV infection, increase ART use among all people living with HIV, and make substantial progress towards achieving 90-90-90 in a relatively short period. BCPE facility-based testing and linkage interventions are undergoing national scale up to help achieve 90-90-90 in Tanzania. FUNDING: US Presidents' Emergency Plan for AIDS Relief.

      19. Time to HIV testing of sexual contacts identified by HIV-positive index clients in Siaya County, Kenyaexternal icon
        Wekesa P, Kataka J, Owuor K, Nyabiage L, Miruka F, Wanjohi S, Omondi S.
        PLoS One. 2020 ;15(9):e0238794.
        There are no studies on time to test since notification among identified sexual contacts of HIV-positive index clients using program data in Siaya County and Kenya. We sought to understand time to HIV testing by contact characteristics after identification to inform targeted testing interventions. We retrospectively analyzed data from adult (aged ≥18 years) sexual contacts identified by HIV-positive index clients from 117 health facilities in Siaya County (June 2017-August 2018). We used Chi-square tests to assess for differences in characteristics of contacts by HIV testing. We performed Cox proportional hazards analysis and time to HIV testing of contacts analysis including time-varying covariates (cluster-adjusted by facility) to assess characteristics (age, sex, and relationship to index client) associated with time to HIV-testing since notification. Sexual contacts not tested were right censored at last follow-up date. We calculated hazard ratios with 95% confidence intervals to evaluate characteristics associated with time to testing. Of the 6,845 contacts included in this analysis, 3,858 (56.4%) were men. Most were aged 25-34 years (3,209 [46.9%]). Median time to contact testing was 14.5 days (interquartile range, 2.5-62). On multivariable analysis, contacts aged 18-24 years (aHR, 1.32 [95% CI: 1.01-1.73], p = 0.040) and 25-34 years (aHR, 1.18 [95% CI: 1.01-1.39], p = 0.038) had shorter time to HIV testing than those aged 35-44 years. Married polygamous (aHR, 1.12 [95% CI: 1.01-1.25], p = 0.039) and single contacts (aHR, 1.17 [95% CI: 1.08-1.27], p <0.001) had shorter time to HIV testing than married monogamous contacts. Non-spouse sexual contacts had shorter time to HIV testing than spouses, (aHR, 1.23 [95% CI: 1.15-1.32], p <0.001). We recommend enhanced differentiated partner services targeting older adults, married monogamous, and spouse sexual contacts to facilitate early diagnosis, same day treatment, and prevention in Western Kenya and sub-Saharan Africa at large.

      20. COVID-19 prevalence among people experiencing homelessness and homelessness service staff during early community transmission in Atlanta, Georgia, April-May 2020external icon
        Yoon JC, Montgomery MP, Buff AM, Boyd AT, Jamison C, Hernandez A, Schmit K, Shah S, Ajoku S, Holland DP, Prieto J, Smith S, Swancutt MA, Turner K, Andrews T, Flowers K, Wells A, Marchman C, Laney E, Bixler D, Cavanaugh S, Flowers N, Gaffga N, Ko JY, Paulin HN, Weng MK, Mosites E, Morris SB.
        Clin Infect Dis. 2020 Sep 8.
        BACKGROUND: In response to reported COVID-19 outbreaks among people experiencing homelessness (PEH) in other U.S. cities, we conducted multiple, proactive, facility-wide testing events for PEH living sheltered and unsheltered and homelessness service staff in Atlanta, Georgia. We describe SARS-CoV-2 prevalence and associated symptoms and review shelter infection prevention and control (IPC) policies. METHODS: PEH and staff were tested for SARS-CoV-2 by reverse transcription polymerase chain reaction (RT-PCR) during April 7-May 6, 2020. A subset of PEH and staff was screened for symptoms. Shelter assessments were conducted concurrently at a convenience sample of shelters using a standardized questionnaire. RESULTS: Overall, 2,875 individuals at 24 shelters and nine unsheltered outreach events underwent SARS-CoV-2 testing and 2,860 (99.5%) had conclusive test results. SARS-CoV-2 prevalence was 2.1% (36/1,684) among PEH living sheltered, 0.5% (3/628) among PEH living unsheltered, and 1.3% (7/548) among staff. Reporting fever, cough, or shortness of breath in the last week during symptom screening was 14% sensitive and 89% specific for identifying COVID-19 cases compared with RT-PCR. Prevalence by shelter ranged 0%-27.6%. Repeat testing 3-4 weeks later at four shelters documented decreased SARS-CoV-2 prevalence (0%-3.9%). Nine of 24 shelters completed shelter assessments and implemented IPC measures as part of the COVID-19 response. CONCLUSIONS: PEH living in shelters experienced higher SARS-CoV-2 prevalence compared with PEH living unsheltered. Facility-wide testing in congregate settings allowed for identification and isolation of COVID-19 cases and is an important strategy to interrupt SARS-CoV-2 transmission.

    • Disease Reservoirs and Vectors
      1. Possibility for reverse zoonotic transmission of SARS-CoV-2 to free-ranging wildlife: A case study of batsexternal icon
        Olival KJ, Cryan PM, Amman BR, Baric RS, Blehert DS, Brook CE, Calisher CH, Castle KT, Coleman JT, Daszak P, Epstein JH, Field H, Frick WF, Gilbert AT, Hayman DT, Ip HS, Karesh WB, Johnson CK, Kading RC, Kingston T, Lorch JM, Mendenhall IH, Peel AJ, Phelps KL, Plowright RK, Reeder DM, Reichard JD, Sleeman JM, Streicker DG, Towner JS, Wang LF.
        PLoS Pathog. 2020 Sep;16(9):e1008758.
        The COVID-19 pandemic highlights the substantial public health, economic, and societal consequences of virus spillover from a wildlife reservoir. Widespread human transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) also presents a new set of challenges when considering viral spillover from people to naïve wildlife and other animal populations. The establishment of new wildlife reservoirs for SARS-CoV-2 would further complicate public health control measures and could lead to wildlife health and conservation impacts. Given the likely bat origin of SARS-CoV-2 and related beta-coronaviruses (β-CoVs), free-ranging bats are a key group of concern for spillover from humans back to wildlife. Here, we review the diversity and natural host range of β-CoVs in bats and examine the risk of humans inadvertently infecting free-ranging bats with SARS-CoV-2. Our review of the global distribution and host range of β-CoV evolutionary lineages suggests that 40+ species of temperate-zone North American bats could be immunologically naïve and susceptible to infection by SARS-CoV-2. We highlight an urgent need to proactively connect the wellbeing of human and wildlife health during the current pandemic and to implement new tools to continue wildlife research while avoiding potentially severe health and conservation impacts of SARS-CoV-2 "spilling back" into free-ranging bat populations.

    • Environmental Health
      1. Mortality from forces of nature among older adults by race/ethnicity and genderexternal icon
        Adams RM, Evans CM, Mathews MC, Wolkin A, Peek L.
        J Appl Gerontol. 2020 Sep 10.
        Older adults are especially vulnerable to disasters due to high rates of chronic illness, disability, and social isolation. Limited research examines how gender, race/ethnicity, and forces of nature-defined here as different types of natural hazards, such as storms and earthquakes-intersect to shape older adults' disaster-related mortality risk. We compare mortality rates among older adults (60+ years) in the United States across gender, race/ethnicity, and hazard type using the Centers for Disease Control and Prevention's Wonder database. Our results demonstrate that older adult males have higher mortality rates than females. American Indian/Alaska Native (AI/AN) males have the highest mortality and are particularly impacted by excessive cold. Mortality is also high among Black males, especially due to cataclysmic storms. To address disparities, messaging and programs targeting the dangers of excessive cold should be emphasized for AI/AN older adult males, whereas efforts to reduce harm from cataclysmic storms should target Black older adult males.

    • Genetics and Genomics
      1. Since the completion of the Human Genome Project, progress toward translating genomic research discoveries to address population health issues has been limited. Several meetings of social and behavioral scientists have outlined priority research areas where advancement of translational research could increase population health benefits of genomic discoveries. In this review, we track the pace of progress, study size and design, and focus of genomics translational research from 2012 to 2018 and its concordance with five social and behavioral science recommended priorities. We conducted a review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Guidelines for Scoping Reviews. Steps involved completing a search in five databases and a hand search of bibliographies of relevant literature. Our search (from 2012 to 2018) yielded 4,538 unique studies; 117 were included in the final analyses. Two coders extracted data including items from the PICOTS framework. Analysis included descriptive statistics to help identify trends in pace, study size and design, and translational priority area. Among the 117 studies included in our final sample, nearly half focused on genomics applications that have evidence to support translation or implementation into practice (Centers for Disease Control and Prevention Tier 1 applications). Common study designs were cross-sectional (40.2%) and qualitative (24.8%), with average sample sizes of 716 across all studies. Most often, studies addressed public understanding of genetics and genomics (33.3%), risk communication (29.1%), and intervention development and testing of interventions to promote behavior change (19.7%). The number of studies that address social and behavioral science priority areas is extremely limited and the pace of this research continues to lag behind basic science advances. Much of the research identified in this review is descriptive and related to public understanding, risk communication, and intervention development and testing of interventions to promote behavior change. The field has been slow to develop and evaluate public health-friendly interventions and test implementation approaches that could enable health benefits and equitable access to genomic discoveries. As the completion of the human genome approaches its 20th anniversary, full engagement of transdisciplinary efforts to address translation challenges will be required to close this gap.

      2. Targeted metagenomics for clinical detection and discovery of bacterial tickborne pathogensexternal icon
        Kingry L, Sheldon S, Oatman S, Pritt B, Anacker M, Bjork J, Neitzel D, Strain A, Berry J, Sloan L, Respicio-Kingry L, Dietrich E, Bloch K, Moncayo A, Srinivasamoorthy G, Hu B, Hinckley A, Mead P, Kugeler K, Petersen J.
        J Clin Microbiol. 2020 Sep 2.
        Tickborne diseases, due to a diversity of bacterial pathogens, represent a significant and increasing public health threat throughout the northern hemisphere. A high-throughput 16S V1-V2 rDNA-based metagenomics assay was developed and evaluated using >13,000 residual samples from patients suspected of tickborne illness and >1000 controls. Taxonomic predictions for tickborne bacteria were exceptionally accurate, as independently validated by secondary testing. Overall, 881 specimens were positive for bacterial tickborne agents. Twelve tickborne bacterial species were detected, including two novel pathogens, representing a 100% increase in the number of tickborne bacteria identified compared to what was possible by initial PCR testing. In three blood specimens, two tickborne bacteria were simultaneously detected. Seven bacteria, not known to be tick-transmitted, were also confirmed unique to samples from persons suspected of tickborne illness. These results indicate 16S V1-V2 metagenomics can greatly simplify diagnosis and accelerate discovery of bacterial tickborne pathogens.

      3. Draft genome sequences of 81 Salmonella enterica strains from informal markets in Cambodiaexternal icon
        Schwan CL, Trinetta V, Balkey M, Cook PW, Phebus RK, Gragg S, Kastner J, Vipham JL, Lomonaco S.
        Microbiol Resour Announc. 2020 Sep 3;9(36).
        Salmonella enterica is an important global pathogen due to its contribution to human morbidity and death. The presence of S. enterica in Southeast Asian informal markets is amplified by cross-contamination between market surfaces and food products. Here, we describe the draft genome sequences of 81 Salmonella enterica isolates from informal markets in Cambodia.

    • Health Disparities
      1. Racial and ethnic disparities in fetal deaths - United States, 2015-2017external icon
        Pruitt SM, Hoyert DL, Anderson KN, Martin J, Waddell L, Duke C, Honein MA, Reefhuis J.
        MMWR Morb Mortal Wkly Rep. 2020 Sep 18;69(37):1277-1282.
        The spontaneous death or loss of a fetus during pregnancy is termed a fetal death. In the United States, national data on fetal deaths are available for losses at ≥20 weeks' gestation.* Deaths occurring during this period of pregnancy are commonly known as stillbirths. In 2017, approximately 23,000 fetal deaths were reported in the United States (1). Racial/ethnic disparities exist in the fetal mortality rate; however, much of the known disparity in fetal deaths is unexplained (2). CDC analyzed 2015-2017 U.S. fetal death report data and found that non-Hispanic Black (Black) women had more than twice the fetal mortality rate compared with non-Hispanic White (White) women and Hispanic women. Fetal mortality rates also varied by maternal state of residence. Cause of death analyses were conducted for jurisdictions where >50% of reports had a cause of death specified. Still, even in these jurisdictions, approximately 31% of fetal deaths had no cause of death reported on a fetal death report. There were differences by race and Hispanic origin in causes of death, with Black women having three times the rate of fetal deaths because of maternal complications compared with White women. The disparities suggest opportunities for prevention to reduce the U.S. fetal mortality rate. Improved documentation of cause of death on fetal death reports might help identify preventable causes and guide prevention efforts.

    • Health Economics
      1. BACKGROUND: Use of HIV preexposure prophylaxis (PrEP) has increased nationwide, but the magnitude and distribution of PrEP medication costs across the health care system are unknown. OBJECTIVE: To estimate out-of-pocket (OOP) and third-party payments using a large pharmacy database. DESIGN: Retrospective cohort study. SETTING: Prescriptions for tenofovir disoproxil fumarate with emtricitabine (TDF-FTC) for PrEP in the United States in the IQVIA Longitudinal Prescriptions database, which covers more than 90% of retail pharmacy prescriptions. MEASUREMENTS: Third-party, OOP, and total payments were compared by third-party payer, classified as commercial, Medicaid, Medicare, manufacturer assistance program, or other. Missing payment data were imputed using a generalized linear model to estimate overall PrEP medication payments. RESULTS: Annual PrEP prescriptions increased from 73 739 to 1 100 684 during 2014 to 2018. Over that period, the average total payment for 30 TDF-FTC tablets increased from $1350 to $1638 (5.0% compound annual growth rate) and the average OOP payment increased from $54 to $94 (14.9% compound annual growth rate). Of the $1638 in total payments per 30 TDF-FTC tablets in 2018, OOP payments accounted for $94 (5.7%) and third-party payments for $1544 (94.3%). Out-of-pocket payments per 30 tablets were lower among Medicaid recipients ($3) than among those with Medicare ($80) or commercial insurance ($107). Payments for PrEP medication in the IQVIA database in 2018 totaled $2.08 billion; $1.68 billion (80.7%) originated from prescriptions for persons with commercial insurance, $200 million (9.6%) for those with Medicaid, $48 million (2.3%) for those with Medicare, and $127 million (6.1%) for those with manufacturer assistance. LIMITATION: The IQVIA database does not capture every prescription nationwide. CONCLUSION: Third-party and OOP payments per 30 TDF-FTC tablets increased annually. The $2.08 billion in PrEP medication payments in 2018 is an underestimation of national costs. High costs to the health care system may hinder PrEP expansion. PRIMARY FUNDING SOURCE: Centers for Disease Control and Prevention.

      2. OBJECTIVE: To use medical claims data to determine patterns of healthcare utilization in children with intellectual and developmental disabilities, including frequency of service utilization, conditions that require hospital care, and costs. STUDY EESIGN: Medicaid administrative claims from four states (Iowa, Massachusetts, New York, and South Carolina) from years 2008-2013 were analyzed, including 108,789 children (75,417 male; 33,372 female) under 18 years with intellectual and developmental disabilities. Diagnoses included cerebral palsy, autism, fetal alcohol syndrome, Down syndrome/trisomy/autosomal deletions, other genetic conditions, and intellectual disability. Utilization of ED and inpatient hospital services were analyzed for 2012. RESULTS: Children with intellectual and developmental disabilities used both inpatient and ED care at 1.8 times that of the general population. Epilepsy/convulsions was the most frequent reason for hospitalization at 20 times the relative risk of the general population. Other frequent diagnoses requiring hospitalization were mood disorders, pneumonia, paralysis, and asthma. Annual per capita expenses for hospitalization and ED care were 100% higher for children with intellectual and developmental disabilities, compared with the general population ($153,348,562 and $76,654,361, respectively). CONCLUSIONS: Children with intellectual and developmental disabilities utilize significantly more ED and inpatient care than other children, which results in higher annual costs. Recognizing chronic conditions that increase risk for hospital care can provide guidance for developing outpatient care strategies that anticipate common clinical problems in intellectual and developmental disabilities and ensure responsive management before hospital care is needed.

      3. Treatment cost and access to care: experiences of young women diagnosed with breast cancerexternal icon
        Subramanian S, Tangka FK, Edwards P, Jones M, Flanigan T, Kaganova J, Smith K, Thomas CC, Hawkins NA, Rodriguez JL, Guy GP, Fairley T.
        Cancer Causes Control. 2020 Sep 8.
        PURPOSE: Breast cancer is the leading cause of cancer-related deaths in women younger than 40 years. We aim to evaluate cost as a barrier to care among female breast cancer patients diagnosed between 18 to 39 years. METHODS: In early 2017, we distributed a survey to women diagnosed with breast cancer between the ages of 18 and 39 years, as identified by the central cancer registries of California, Georgia, North Carolina, and Florida. We used multivariable statistics to explore cost-related barriers to receiving breast cancer care for the 830 women that completed the survey. RESULTS: About half of the women (47.4%) reported spending more on breast cancer care than expected, and almost two-thirds (65.3%) had not discussed costs with their care team. A third of the patients (31.8%) indicated forgoing care due to cost. Factors associated with not receiving anticipated care due to cost included age less than35 years at diagnosis, self-insurance, comorbid conditions, and late-stage diagnosis. CONCLUSION: Previous studies using breast cancer registry data have not included detailed insurance information and care received by young women. Young women with breast cancer frequently forgo breast cancer care due to cost. Our results highlight the potential for policies that facilitate optimal care for young breast cancer patients which could include the provision of comprehensive insurance coverage.

    • Healthcare Associated Infections
      1. Facilitators and challenges experienced by nursing homes enrolling in the CDC National Healthcare Safety Networkexternal icon
        Braun BI, Longo BA, Thomas R, Bell JM, Anttila A, Shen Y, Morton D, Rowe TA, Stone ND.
        Am J Infect Control. 2020 Sep 2.
        BACKGROUND: Standardized measurement of healthcare-associated infections is essential to improving nursing home (NH) resident safety, however voluntary enrollment of NHs in Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) requires several steps. We sought to prospectively identify NH structural, process or staff characteristics that affect enrollment and data submission among a cohort of NHs receiving facilitated implementation. METHODS: The evaluation employed a mixed methods approach. The meta-theoretical Consolidated Framework for Implementation Research was used to analyze reported facilitators and challenges. Primary and secondary outcomes were time to NHSN enrollment and data submission, respectively. RESULTS: Of 36 participating NHs, 27 (75%) completed NHSN enrollment and 21 (58%) submitted one or more months of infection data during the 8-month study period. Mean days to complete enrollment was 82 (SD=24, range=51-139) and days to first data submission was 112 (SD=45, range=71-245). Characteristics of NH staff liaisons associated with shorter time to enrollment included infection prevention and control (IPC) knowledge, personal confidence, and responsibility for IPC activities. Facility characteristics were not associated with outcomes. DISCUSSION: Time to NHSN enrollment and submission related more to characteristics of the person leading the process than to characteristics of the NH. CONCLUSIONS: External partnerships that provide real-time support and resources are important assets in promoting successful NH participation in NHSN.

      2. Nosocomial hepatitis A outbreak among healthcare workers and patients in a community hospital during an ongoing statewide outbreakexternal icon
        Brennan J, Mullins H, Tobey K, Jones C, Kainer MA, Fiscus M, May S, Dunn JR, Schaffner W, Jones TF.
        Infect Control Hosp Epidemiol. 2020 Sep 3:1-3.
        OBJECTIVE: The Tennessee Department of Health (TDH) investigated a hepatitis A virus (HAV) outbreak to identify risk factors for infection and make prevention recommendations. DESIGN: Case series. SETTING: Community hospital. PARTICIPANTS: Healthcare workers (HCWs) or patients with laboratory-confirmed acute HAV infection during October 1, 2018-January 10, 2019. METHODS: HCWs with suspected or confirmed hepatitis A infections were interviewed to assess their exposures and activities. Patient medical records and hospital administrative records were reviewed to identify common exposures. We conducted a site investigation to assess knowledge of infection control practices among HCWs. Serum specimens from ill persons were tested for HAV RNA by polymerase chain reaction (PCR) and genotyped. RESULTS: We identified 6 HCWs and 2 patients with laboratory-confirmed HAV infection. All cases likely resulted from exposure to a homeless patient with a history of recreational substance use and undiagnosed HAV infection. Breaches in hand hygiene and use of standard precautions were identified. HAV RNA was detected in 7 serum specimens and all belonged to an identical strain of HAV genotype 1b. CONCLUSIONS: A hepatitis A outbreak among hospital patients and HCWs resulted from exposure to a single patient with undiagnosed HAV infection. Breakdowns in infection control practices contributed to the outbreak. The likelihood of nosocomial transmission can be reduced with proper hand hygiene, standard precautions, and routine disinfection. During community outbreaks, medical providers can better prevent ongoing transmission by including hepatitis A in the differential diagnosis among patients with a history of recreational substance use and homelessness.

    • Immunity and Immunization
      1. BACKGROUND: Japanese encephalitis (JE) virus is an important cause of neurological disease in Asia. JE vaccine is recommended for travelers with higher JE risk itineraries. Inactivated Vero cell culture-derived JE vaccine (JE-VC) is the only JE vaccine currently available in the United States. An inactivated mouse brain-derived JE vaccine (JE-MB) previously was available but production was discontinued. One JE-VC dose administered to adults previously vaccinated with ≥3 doses of JE-MB provides good short-term protection for at least one month, but data on longer-term protection are limited. We evaluated non-inferiority of the JE virus neutralizing antibody response at 12-23 months in JE-MB-vaccinated adults administered one JE-VC dose compared with JE vaccine-naïve adults administered a JE-VC two-dose primary series. METHODS: We obtained archived sera from U.S. military personnel and performed a 50% plaque reduction neutralization test for anti-JE virus neutralizing antibodies. We compared the geometric mean titer (GMT) and seroprotection rate at 12-23 months after one JE-VC dose in previously JE-MB-vaccinated personnel and after the second JE-VC dose in previously JE vaccine-naïve personnel. Non-inferiority was concluded if the lower bound of the two-sided 95% confidence interval (CI) of the GMT ratio in previously vaccinated to vaccine-naïve personnel was >1/1.5. RESULTS: The GMT in previously JE-MB-vaccinated persons was 75 (95% CI 63-90) and in previously JE vaccine-naïve persons was 12 (95% CI 11-14), and seroprotection rates were 94% (235/250) and 54% (135/250), respectively. The ratio of GMTs was 6.3 (95% CI: 5.0-7.7), satisfying the criterion for non-inferiority. CONCLUSIONS: One JE-VC dose in previously JE-MB-vaccinated military personnel provides good protection for at least 1-2 years. The benefits of administration of a single JE-VC dose in previously JE-MB-vaccinated adults include a shorter time to completion of re-vaccination before travel, a decrease in the risk of adverse events, and reduced costs.

      2. Data on the implementation of VaxTrac electronic immunization registry in Sierra Leoneexternal icon
        Namageyo-Funa A, Jalloh MF, Gleason B, Wallace AS, Friedman M, Sesay T, Ocansey D, Jalloh MS, Feldstein LR, Conklin L, Hersey S, Singh T, Kaiser R.
        Data Brief. 2020 Oct;32:106167.
        Following the piloting of VaxTrac, an electronic immunization registry (EIR), we conducted a rapid assessment in November-December 2017 to evaluate the use of the EIR in 10 health facilities in Western Area Urban district in Sierra Leone [1]. In this data-in-brief report, we provide additional descriptive data from the assessment of the VaxTrac EIR in Sierra Leone. The assessment comprised aggregate data on vaccine doses administered that were abstracted from VaxTrac and three paper-based sources (daily tally sheets, register of children under the age of 2 years, and a summary form of doses administered). Data were abstracted for the following six vaccine doses in the immunization schedule in Sierra Leone: 1) Bacillus Calmette-Guérin vaccine, 2) first dose of pentavalent vaccine, 3) second dose of pentavalent vaccine, 4) third dose of pentavalent vaccine, 5) first dose of measles-containing vaccine, and 6) second dose of measles-containing vaccine. We descriptively analysed the abstracted data to examine the congruity between VaxTrac records and the three paper-based sources. Bar graphs were generated to visually depict the variations in number of administered vaccine doses by data source for each health facility. We provide the aggregated data for each vaccine dose abstracted by data source from each health facility as supplemental material (Excel file). The supplementary data reveal patterns in the congruity of vaccine doses captured that have implications for policy and programmatic decisions regarding the use of VaxTrac and other similar EIRs in low resource urban settings.

      3. Knowledge and attitudes towards influenza and influenza vaccination among pregnant women in Kenyaexternal icon
        Otieno NA, Nyawanda B, Otiato F, Adero M, Wairimu WN, Atito R, Wilson AD, Gonzalez-Casanova I, Malik FA, Verani JR, Widdowson MA, Omer SB, Chaves SS.
        Vaccine. 2020 Sep 3.
        BACKGROUND: Influenza vaccination during pregnancy benefits mothers and children. Kenya and other low- and middle-income countries have no official influenza vaccination policies to date but are moving towards issuing such policies. Understanding determinants of influenza vaccine uptake during pregnancy in these settings is important to inform policy decisions and vaccination rollout. METHODS: We interviewed a convenience sample of women at antenatal care facilities in four counties (Nairobi, Mombasa, Marsabit, Siaya) in Kenya. We described knowledge and attitudes regarding influenza vaccination and assessed factors associated with willingness to receive influenza vaccine. RESULTS: We enrolled 507 pregnant women, median age was 26 years (range 15-43). Almost half (n = 240) had primary or no education. Overall, 369 (72.8%) women had heard of influenza. Among those, 288 (78.1%) believed that a pregnant woman would be protected if vaccinated, 252 (68.3%) thought it was safe to receive a vaccine while pregnant, and 223 (60.4%) believed a baby would be protected if mother was vaccinated. If given opportunity, 309 (83.7%) pregnant women were willing to receive the vaccine. Factors associated with willingness to receive influenza vaccine were mothers' belief in protective effect (OR 3.87; 95% CI 1.56, 9.59) and safety (OR 5.32; 95% CI 2.35, 12.01) of influenza vaccines during pregnancy. CONCLUSION: Approximately one third of pregnant women interviewed had never heard of influenza. Willingness to receive influenza vaccine was high among women who had heard about influenza. If the Kenyan government recommends influenza vaccine for pregnant women, mitigation of safety concerns and education on the benefits of vaccination could be the most effective strategies to improve vaccine acceptance.

    • Informatics
      1. Clinical decision support for immunization uptake and use in immunization health information systemsexternal icon
        Shrader L, Myerburg S, Larson E.
        Online J Public Health Inform. 2020 ;12(1):e10.
        In the United States, immunization recommendations and their associated schedules are developed by the Advisory Committee on Immunization Practices (ACIP). To assist with the translation process and better harmonize the outcomes of existing clinical decision support tools, the Centers for Disease Control and Prevention (CDC) created clinical decision support for immunization (CDSi) resources for each set of ACIP recommendations. These resources are continually updated and refined as new vaccine recommendations and clarifications become available and will be available to health information systems for a coronavirus disease 2019 (COVID-19) vaccine when one becomes available for use in the United States Objectives: To assess awareness of CDSi resources, whether CDSi resources were being used by immunization-related health information systems, and perceived impact of CDSi resources on stakeholders' work Design: Online surveys conducted from 2015-2019 including qualitative and quantitative questions Participants: The main and technical contact from each of the 64 CDC-funded immunization information system (IIS) awardees, IIS vendors, and electronic health record vendors Results: Awareness of at least one resource increased from 75% of respondents in 2015 to 100% in 2019. Use of at least one CDSi resource also increased from 47% in 2015 to 78% in 2019. About 80% or more of users of CDSi are somewhat or very highly satisfied with the resources and report a somewhat or very positive impact from using them Conclusion: As awareness and use of CDSi resources increases, the likelihood that patients receive recommended immunizations at the right time will also increase. Rapid and precise integration of vaccine recommendations into health information systems will be particularly important when a COVID-19 vaccine becomes available to help facilitate vaccine implementation.

    • Injury and Violence
      1. Using behavioral science theory to enhance public health nursingexternal icon
        Sleet DA, Dellinger AM.
        Public Health Nurs. 2020 Sep 6.
        The application of behavioral science theory is instrumental in advancing nursing research and practice. Nurses can benefit from a thorough understanding of theoretical perspectives related to health behavior change. Behavioral science theory can provide a conceptual context for understanding patient behavior, it can guide research on the determinants of health behavior and health service delivery, and it can offer alternative approaches to nursing practice that may improve the effectiveness of patient care. The aim of this paper is to provide some examples of behavioral theories that can be used in nursing research and practice, and provide an example of how one theory, Stages of Change (Transtheoretical Model), can be applied to older adult fall prevention. Given the critical role behavior plays in premature morbidity and mortality, public health nurses and researchers can benefit by broadening the use of theory in the design and implementation of interventions, using behavioral theory as their guide.

    • Laboratory Sciences
      1. Next generation rapid diagnostic tests for meningitis diagnosisexternal icon
        Feagins AR, Ronveaux O, Taha MK, Caugant DA, Smith V, Fernandez K, Glennie L, Fox LM, Wang X.
        J Infect. 2020 Sep 1.
        Rapid diagnostic tests (RDTs) are increasingly recognized as valuable, transformative tools for the diagnosis of infectious diseases. Although there are a variety of meningitis RDTs currently available, certain product features restrict their use to specific levels of care and settings. For this reason, the development of meningitis RDTs for use at all levels of care, including those in low-resource settings, was included in the "Defeating Meningitis by 2030" roadmap. Here we address the limitations of available meningitis RDTs and present test options and specifications to consider when developing the next generation of meningitis RDTs.

      2. Exploring the role of chemokine receptor 6 (Ccr6) in the BXD mouse model of Gulf War illnessexternal icon
        Gao J, Xu F, Starlard-Davenport A, Miller DB, O’Callaghan JP, Jones BC, Lu L.
        Front Neurosci. 2020 ;14.
        Gulf War illness (GWI) is a chronic and multi-symptomatic disorder with persistent neuroimmune symptomatology. Chemokine receptor 6 (CCR6) has been shown to be involved in several inflammation disorders in humans. However, the causative relationship between CCR6 and neuroinflammation in GWI has not yet been investigated. By using RNA-seq data of prefrontal cortex (PFC) from 31 C57BL/6J X DBA/2J (BXD) recombinant inbred (RI) mouse strains and their parental strains under three chemical treatment groups – saline control (CTL), diisopropylfluorophosphate (DFP), and corticosterone combined with diisopropylfluorophosphate (CORT+DFP), we identified Ccr6 as a candidate gene underlying individual differences in susceptibility to GWI. The Ccr6 gene is cis-regulated and its expression is significantly correlated with CORT+DFP treatment. Its mean transcript abundance in PFC of BXD mice decreased 1.6-fold (p < 0.0001) in the CORT+DFP group. The response of Ccr6 to CORT+DFP is also significantly different (p < 0.0001) between the parental strains, suggesting Ccr6 is affected by both host genetic background and chemical treatments. Pearson product-moment correlation analysis revealed 1473 Ccr6-correlated genes (p < 0.05). Enrichment of these genes was seen in the immune, inflammation, cytokine, and neurological related categories. In addition, we also found five central nervous system-related phenotypes and fecal corticosterone concentration have significant correlation (p < 0.05) with expression of Ccr6 in the PFC. We further established a protein-protein interaction subnetwork for the Ccr6-correlated genes, which provides an insight on the interaction of G protein-coupled receptors, kallikrein-kinin system and neuroactive ligand-receptors. This analysis likely defines the heterogeneity and complexity of GWI. Therefore, our results suggest that Ccr6 is one of promising GWI biomarkers.

      3. Measuring and reducing biofilm in mosquito rearing containersexternal icon
        Hunt CM, Collins CM, Benedict MQ.
        Parasit Vectors. 2020 Sep 2;13(1):439.
        BACKGROUND: Mosquito rearing containers contain organic-rich water that nourishes numerous bacteria, some of which are capable of forming biofilms. Biofilm is broadly an extracellular polymeric matrix (EPS) in which living bacteria occur, and the accumulation of biofilm is possible during routine stock-keeping as most of these containers are re-used. Whether biofilm has an effect on the mosquito rearing is not a question that has been investigated, nor have measures to reduce biofilm in this context been systematically studied. METHODS: We measured biofilm accumulation in standard rearing containers by staining with crystal violet and determining the OD using a spectrophotometer. We also treated rearing containers with 0.1% sodium hypochlorite to determine its effectiveness in reducing biofilm abundance. Lastly, we performed an analysis of the relationship between the occurrence of biofilm and the likelihood of microbial blooms that were associated with larval death during trials of larval diets. RESULTS: We observed that soaking rearing containers overnight in 0.1% sodium hypochlorite greatly reduced biofilm, but we observed no relationship between the use of containers that had not been treated with bleach and subsequent microbial blooms. CONCLUSIONS: Larva rearing leaves detectable biofilm. While we were unable to correlate microbial blooms with the presence of biofilm, as a precaution, we recommend that plastic containers that are re-used be treated with 0.1% sodium hypochlorite occasionally.

      4. Lassa virus antigen distribution and inflammation in the ear of infected strain 13/N guinea pigsexternal icon
        Huynh T, Gary JM, Welch SR, Coleman-McCray J, Harmon JR, Kainulainen MH, Bollweg BC, Ritter JM, Shieh WJ, Nichol ST, Zaki SR, Spiropoulou CF, Spengler JR.
        Antiviral Res. 2020 Sep 5:104928.
        Sudden sensorineuronal hearing loss (SNHL) is reported in approximately one-third of survivors of Lassa fever (LF) and remains the most prominent cause of Lassa virus- (LASV) associated morbidity in convalescence. Using a guinea pig model of LF, and incorporating animals from LASV vaccine trials, we investigated viral antigen distribution and histopathology in the ear of infected animals to elucidate the pathogenesis of hearing loss associated with LASV infection. Antigen was detected only in animals that succumbed to disease and was found within structures of the inner ear that are intimately associated with neural detection and/or translation of auditory stimuli and in adjacent vasculature. No inflammation or viral cytopathic changes were observed in the inner ear or surrounding structures in these animals. In contrast, no viral antigen was detected in the ear of surviving animals. However, all survivors that exhibited clinical signs of disease during the course of infection developed perivascular mononuclear inflammation within and adjacent to the ear, indicating an ongoing inflammatory response in these animals that may contribute to hearing loss. These data contribute to the knowledge of LASV pathogenesis in the auditory system, support an immune-mediated process resulting in LASV-associated hearing loss, and demonstrate that vaccination protecting animals from clinical disease can also prevent infection-associated auditory pathology.

      5. 2020 taxonomic update for phylum Negarnaviricota (Riboviria: Orthornavirae), including the large orders Bunyavirales and Mononegaviralesexternal icon
        Kuhn JH, Adkins S, Alioto D, Alkhovsky SV, Amarasinghe GK, Anthony SJ, Avšič-Županc T, Ayllón MA, Bahl J, Balkema-Buschmann A, Ballinger MJ, Bartonička T, Basler C, Bavari S, Beer M, Bente DA, Bergeron É, Bird BH, Blair C, Blasdell KR, Bradfute SB, Breyta R, Briese T, Brown PA, Buchholz UJ, Buchmeier MJ, Bukreyev A, Burt F, Buzkan N, Calisher CH, Cao M, Casas I, Chamberlain J, Chandran K, Charrel RN, Chen B, Chiumenti M, Choi IR, Clegg JC, Crozier I, da Graça JV, Dal Bó E, Dávila AM, de la Torre JC, de Lamballerie X, de Swart RL, Di Bello PL, Di Paola N, Di Serio F, Dietzgen RG, Digiaro M, Dolja VV, Dolnik O, Drebot MA, Drexler JF, Dürrwald R, Dufkova L, Dundon WG, Duprex WP, Dye JM, Easton AJ, Ebihara H, Elbeaino T, Ergünay K, Fernandes J, Fooks AR, Formenty PB, Forth LF, Fouchier RA, Freitas-Astúa J, Gago-Zachert S, Gāo GF, García ML, García-Sastre A, Garrison AR, Gbakima A, Goldstein T, Gonzalez JJ, Griffiths A, Groschup MH, Günther S, Guterres A, Hall RA, Hammond J, Hassan M, Hepojoki J, Hepojoki S, Hetzel U, Hewson R, Hoffmann B, Hongo S, Höper D, Horie M, Hughes HR, Hyndman TH, Jambai A, Jardim R, Jiāng D, Jin Q, Jonson GB, Junglen S, Karadağ S, Keller KE, Klempa B, Klingström J, Kobinger G, Kondō H, Koonin EV, Krupovic M, Kurath G, Kuzmin IV, Laenen L, Lamb RA, Lambert AJ, Langevin SL, Lee B, Lemos ER, Leroy EM, Li D, Lǐ J, Liang M, Liú W, Liú Y, Lukashevich IS, Maes P, Marciel de Souza W, Marklewitz M, Marshall SH, Martelli GP, Martin RR, Marzano SL, Massart S, McCauley JW, Mielke-Ehret N, Minafra A, Minutolo M, Mirazimi A, Mühlbach HP, Mühlberger E, Naidu R, Natsuaki T, Navarro B, Navarro JA, Netesov SV, Neumann G, Nowotny N, Nunes MR, Nylund A, Økland AL, Oliveira RC, Palacios G, Pallas V, Pályi B, Papa A, Parrish CR, Pauvolid-Corrêa A, Pawęska JT, Payne S, Pérez DR, Pfaff F, Radoshitzky SR, Rahman AU, Ramos-González PL, Resende RO, Reyes CA, Rima BK, Romanowski V, Robles Luna G, Rota P, Rubbenstroth D, Runstadler JA, Ruzek D, Sabanadzovic S, Salát J, Sall AA, Salvato MS, Sarpkaya K, Sasaya T, Schwemmle M, Shabbir MZ, Shí X, Shí Z, Shirako Y, Simmonds P, Širmarová J, Sironi M, Smither S, Smura T, Song JW, Spann KM, Spengler JR, Stenglein MD, Stone DM, Straková P, Takada A, Tesh RB, Thornburg NJ, Tomonaga K, Tordo N, Towner JS, Turina M, Tzanetakis I, Ulrich RG, Vaira AM, van den Hoogen B, Varsani A, Vasilakis N, Verbeek M, Wahl V, Walker PJ, Wang H, Wang J, Wang X, Wang LF, Wèi T, Wells H, Whitfield AE, Williams JV, Wolf YI, Wú Z, Yang X, Yáng X, Yu X, Yutin N, Zerbini FM, Zhang T, Zhang YZ, Zhou G, Zhou X.
        Arch Virol. 2020 Sep 4.
        In March 2020, following the annual International Committee on Taxonomy of Viruses (ICTV) ratification vote on newly proposed taxa, the phylum Negarnaviricota was amended and emended. At the genus rank, 20 new genera were added, two were deleted, one was moved, and three were renamed. At the species rank, 160 species were added, four were deleted, ten were moved and renamed, and 30 species were renamed. This article presents the updated taxonomy of Negarnaviricota as now accepted by the ICTV.

      6. Toxicological analysis of aerosols derived from three electronic nicotine delivery systems using Normal human bronchial epithelial cellsexternal icon
        Pearce K, Gray N, Gaur P, Jeon J, Suarez A, Shannahan J, Pappas RS, Wright C.
        Toxicol In Vitro. 2020 Sep 4:104997.
        Electronic nicotine delivery systems (ENDS) are a rapidly growing global market advertised as a safer alternative to combustible cigarettes. However, comprehensive investigations of END aerosol physicochemical and toxicological properties have not been fully explored across brands to assess relative safety. In this study, we evaluated aerosols collected from three ENDS - Juul Fruit Medley (5% nicotine), Logic Power (2.4% nicotine), and Mistic (1.8% nicotine). ENDS aerosols were generated using standard machine puffing regimen and collected with a novel fluoropolymer condensation trap. Triple quadrupole-inductively coupled plasma-mass determined the presence of heavy metals in collected aerosols. The toxicological effects of ENDS aerosols on normal human bronchial epithelial cells (NHBE) were investigated using cellular viability, reactive oxygen species, oxidative stress assays, along with DNA damage assessments using the CometChip©. Results indicated the total metal concentrations within collected ENDS aerosols were higher for Mistic and Logic compared to Juul. Logic Power aerosols elicited higher reactive oxygen species levels than Mistic and Juul in NHBE after 24-h exposure. Similar dose-dependent reductions of cellular viability and total glutathione were found for each exposure. However, Logic and Juul aerosols caused greater single stranded DNA damage compared to Mistic. Our study indicates that regardless of brand, ENDS aerosols are toxic to upper airway epithelial cells and may pose a potential respiratory hazard to occasional and frequent users.

      7. Development of a multiplex bead assay for the detection of IgG antibody responses to Guinea wormexternal icon
        Priest JW, Stuchlik O, Reed M, Soboslay P, Cama V, Roy SL.
        Am J Trop Med Hyg. 2020 Sep 8.
        The success of the Guinea Worm (GW) Eradication Program over the past three decades has been tempered by the persistence of GW disease in a few African nations and the potential for a future resurgence in cases. Domestic dogs are now a major concern as a disease reservoir as large numbers of cases of canine GW disease are now reported each year, mainly along the Chari River in Chad. As a first step toward the development of a serologic assay for dogs, archived human plasma samples from dracunculiasis-positive donors from Togo were used to select adult female GW antigens for peptide sequencing and cloning. Eight protein sequences of interest were expressed as recombinant glutathione-S-transferase (GST) fusion proteins, and the most promising proteins were coupled to carboxylated microspheres for use in multiplex assays. A thioredoxin-like protein (TRXL1) and a domain of unknown function (DUF148) were assessed for total IgG and IgG(4) reactivities using a panel of specimens from GW cases, uninfected donors, and individuals infected with various nematode worms, including Onchocerca volvulus. Both the DUF148-GST and the TRXL1-GST assays cross-reacted with O. volvulus sera, but the latter assay was always the more specific. The IgG(4) and total IgG TRXL1-GST assays both had sensitivities > 87% and specificities > 90%. Maximum specificity (> 96%) was obtained with the total IgG assay when reactivity to both antigens was used to define a positive case. Given the good performance of the human assay, we are now working to modify the assay for dog assessments.

      8. Gold nanoparticles (AuNP) are largely biocompatible; however, many studies have demonstrated their potential to modulate various immune cell functions. The potential allergenicity of AuNP remains unclear despite the recognition of gold as a common contact allergen. In these studies, AuNP (29 nm) dermal sensitization potential was assessed via Local Lymph Node Assay (LLNA). Soluble gold (III) chloride (AuCl(3)) caused lymph node (LN) expansion (SI 10.9), whereas bulk particles (Au, 942 nm) and AuNP did not. Next, the pulmonary immune effects of AuNP (10, 30, 90 µg) were assessed 1, 4, and 8 days post-aspiration. All markers of lung injury and inflammation remained unaltered, but a dose-responsive increase in LN size was observed. Finally, mice were dermally-sensitized to AuCl(3) then aspirated once, twice, or three times with Au or AuNP in doses normalized for mass or surface area (SA) to assess the impact of existing contact sensitivity to gold on lung immune responses. Sensitized animals exhibited enhanced responsivity to the metal, wherein subsequent immune alterations were largely conserved with respect to dose SA. The greatest increase in bronchoalveolar lavage (BAL) lymphocyte number was observed in the high dose group - simultaneous to preferential expansion of BAL/LN CD8+ T-cells. Comparatively, the lower SA-based doses of Au/AuNP caused more modest elevations in BAL lymphocyte influx (predominantly CD4+ phenotype), exposure-dependent increases in serum IgE, and selective expansion/activation of LN CD4+ T-cells and B-cells. Overall, these findings suggest that AuNP are unlikely to cause sensitization; however, established contact sensitivity to gold may increase immune responsivity following pulmonary AuNP exposure.

      9. Comparison of A(H3N2) neutralizing antibody responses elicited by 2018-2019 season quadrivalent influenza vaccines derived from eggs, cells, and recombinant hemagglutininexternal icon
        Wang W, Alvarado-Facundo E, Vassell R, Collins L, Colombo RE, Ganesan A, Geaney C, Hrncir D, Lalani T, Markelz AE, Maves RC, McClenathan B, Mende K, Richard SA, Schofield C, Seshadri S, Spooner C, Utz GC, Warkentien TE, Levine M, Coles CL, Burgess TH, Eichelberger M, Weiss CD.
        Clin Infect Dis. 2020 Sep 8.
        BACKGROUND: Low vaccine effectiveness against A(H3N2) influenza in seasons with little antigenic drift has been attributed to substitutions in hemagglutinin (HA) acquired during vaccine virus propagation in eggs. Clinical trials comparing recombinant HA vaccine (rHA) and cell-derived inactivated influenza vaccine (IIV) to egg-derived IIVs provide opportunities to assess how egg-adaptive substitutions influence HA immunogenicity. METHODS: Neutralization titers in pre- and post-immunization sera from 133 adults immunized with one of three types of influenza vaccines in a randomized, open-label trial during the 2018-2019 influenza season were measured against egg- and cell-derived A/Singapore/INFIMH-16-0019/2016-like and circulating A(H3N2) influenza viruses using HA-pseudoviruses. RESULTS: All vaccines elicited neutralizing antibodies to all H3 vaccine antigens, but the rHA vaccine elicited the highest titers and seroconversion rates against all strains tested. Egg- and cell-derived IIVs elicited responses similar to each other. Pre-immunization titers against H3 HA-pseudoviruses containing egg-adaptive substitutions T160K and L194P were high, but lower against H3 HA-pseudoviruses without those substitutions. All vaccines boosted neutralization titers against HA-pseudoviruses with egg-adaptive substitutions, but poorly neutralized wildtype 2019-2020 A/Kansas/14/2017 (H3N2) HA-pseudoviruses. CONCLUSION: Egg- and cell-derived 2018-2019 season influenza vaccines elicited similar neutralization titers and response rates, indicating that the cell-derived vaccine did not improve immunogenicity against the A(H3N2) viruses. The higher responses after rHA vaccination may be due to its higher HA content. All vaccines boosted titers to HA with egg-adaptive substitutions, suggesting boosting from past antigens or better exposure of HA epitopes. Studies comparing immunogenicity and effectiveness of different influenza vaccines across many seasons are needed.

    • Maternal and Child Health
      1. Culturally congruent parenting programs delivered during early childhood have the potential to support diverse families. Legacy for Children (Legacy) is a groupbased prevention program designed to promote child development by reinforcing sensitive, responsive mother–child relationships, building maternal self-efficacy, and fostering peer networks of support among mothers living in poverty (Perou et al., 2012). The Legacy program was translated and culturally adapted for Spanishspeaking Latina mothers and their infants with a feasibility trial conducted to determine the cultural congruency of the adaptation. Feasibility results were positive with no previous studies validating the adapted Legacy Spanish program. The current manuscript focuses on understanding factors of engagement of the culturally adapted model. Specifically, we examined the factors that were perceived to have enhanced or hindered both initial and sustained engagement in the adapted Legacy Spanish program for Latina mothers. Individual interviews were conducted with Latina mothers (N = 26) who attended the Legacy Spanish program. We used qualitative data analysis to identify broad themes in Latina mothers’ responses. Themes emerged regarding the importance of using home-based recruitment strategies and pairing verbal information with written brochures to foster initial engagement. Sustained engagement themes focused on the provision of support from other Latina mothers in the Legacy group and the relationships with the group leaders. Having group leaders who were perceived as genuine, kind, positive, “good” at teaching, and persistent emerged as themes that facilitated initial and ongoing engagement. Barriers to engagement centered primarily on logistics rather than characteristics of the program itself. Thus, Latina mothers attributed importance to aspects of the curriculum, logistics, and implementation with respect to program engagement. Application of similar engagement strategies could enhance the success of early childhood parenting programs and linkages with early educational programming.

    • Nutritional Sciences
      1. BACKGROUND: In 2015, the US Department of Agriculture set minimum education and training requirements (ie, professional standards) to ensure that school nutrition professionals have the knowledge and experience to operate school meal programs. No study to date has examined whether hiring requirements and qualifications of school food authority (SFA) directors have changed since 2015. OBJECTIVE: To assess changes in hiring requirements and qualifications of SFA directors since the US Department of Agriculture professional standards were established, overall and by district size. DESIGN: Cross-sectional analysis of nationally representative district-level data from the 2012 and 2016 cycles of the School Health Policies and Practices Study. PARTICIPANTS/SETTING: In 2012, 660 sampled districts completed the School Health Policies and Practices Study Nutrition Services questionnaire. In 2016, 599 sampled districts completed the questionnaire. MAIN OUTCOME MEASURES: Hiring requirements for newly hired SFA directors and reported qualifications of SFA directors. STATISTICAL ANALYSES PERFORMED: Differences in prevalence estimates from 2012 to 2016 for all districts and by district size were assessed with χ(2) tests. RESULTS: Significant increases were found for 3 hiring requirements: degree in nutrition or related field, registered dietitian credential, and food safety certification. Significant changes in 4 of the 5 reported qualifications were found including an increase in the percentage of district directors with a degree in nutrition or a related field and decreases in the percentage of directors with a School Nutrition Specialist credential from the School Nutrition Association, School Nutrition Association certifications, and certified dietary managers. Changes were found in small and medium districts, but not large districts. CONCLUSIONS: District hiring requirements and SFA director qualifications have changed since the implementation of the US Department of Agriculture professional standards, including some differences by district size. Future research could identify challenges facing districts in hiring directors who have a degree in nutrition or related fields or who have specialized nutrition credentials or certificates (eg, registered dietitians).

    • Occupational Safety and Health
      1. Ischaemic heart and cerebrovascular disease mortality in uranium enrichment workersexternal icon
        Anderson JL, Bertke SJ, Yiin J, Kelly-Reif K, Daniels RD.
        Occup Environ Med. 2020 Sep 3.
        OBJECTIVE: Linear and non-linear dose-response relationships between radiation absorbed dose to the lung from internally deposited uranium and external sources and circulatory system disease (CSD) mortality were examined in a cohort of 23 731 male and 5552 female US uranium enrichment workers. METHODS: Rate ratios (RRs) for categories of lung dose and linear excess relative rates (ERRs) per unit lung dose were estimated to evaluate the associations between lung absorbed dose and death from ischaemic heart disease (IHD) and cerebrovascular disease. RESULTS: There was a suggestion of modestly increased IHD risk in workers with internal uranium lung dose above 1 milligray (mGy) (RR=1.4, 95% CI 0.76 to 2.3) and a statistically significantly increased IHD risk with external dose exceeding 150 mGy (RR=1.3, 95% CI 1.1 to 1.6) compared with the lowest exposed groups. ERRs per milligray were positive for IHD and uranium internal dose and for both outcomes per gray external dose, although the CIs generally included the null. CONCLUSIONS: Non-linear dose-response models using restricted cubic splines revealed sublinear responses at lower internal doses, suggesting that linear models that are common in radioepidemiological cancer studies may poorly describe the association between uranium internal dose and CSD mortality.

      2. A cumulative risk perspective for occupational health and safety (OHS) professionalsexternal icon
        Niemeier RT, Williams PR, Rossner A, Clougherty JE, Rice GE.
        Int J Environ Res Public Health. 2020 Aug 31;17(17).
        Cumulative risk assessment (CRA) addresses the combined risk associated with chemical and non-chemical exposures. Although CRA approaches are utilized in environmental and ecological contexts, they are rarely applied in workplaces. In this perspectives article, we strive to raise awareness among occupational health and safety (OHS) professionals and foster the greater adoption of a CRA perspective in practice. Specifically, we provide an overview of CRA literature as well as preliminary guidance on when to consider a CRA approach in occupational settings and how to establish reasonable boundaries. Examples of possible workplace co-exposures and voluntary risk management actions are discussed. We also highlight important implications for workplace CRA research and practice. In particular, future needs include simple tools for identifying combinations of chemical and non-chemical exposures, uniform risk management guidelines, and risk communication materials. Further development of practical CRA methods and tools are essential to meet the needs of complex and changing work environments.

      3. A set of five Bonner spheres was used to measure the ambient neutron H*(10) dose around an orphan 241Am-Be neutron source shielded with different arrangements and types of neutron-absorbing materials. These results were compared to measurements obtained using a portable radiation dosemeter. The Bonner sphere measurement results identified the presence of a large thermal and intermediate neutron component from the shielded 241Am-Be source that was not revealed using the portable instrument.

    • Occupational Safety and Health - Mining
      1. Mineworkers face a challenging and dynamic work environment every workday. To maintain a safe workplace, mineworkers must be able to recognize worksite hazards while they perform their jobs. Though hazard recognition is a critical skill, recent research from the National Institute for Occupational Safety and Health (NIOSH) indicates that mineworkers fail to identify a significant number of hazards. To further the understanding of mineworkers’ hazard recognition ability and to begin to address hazard recognition performance, NIOSH researchers analyzed data collected during a laboratory research study to determine the effect of individual mineworker factors including risk attitude, work experience, and safety training on hazard recognition accuracy. The results of this study show that mineworker risk attitude and safety-specific work experience affect hazard recognition performance while hazard-specific safety training does not. These results suggest that some of these individual factors can be overcome through experience and training. Potential strategies that can be used to address these factors are also discussed.

    • Parasitic Diseases
      1. Towards harmonization of microscopy methods for malaria clinical research studiesexternal icon
        Dhorda M, Ba EH, Kevin Baird J, Barnwell J, Bell D, Carter JY, Dondorp A, Ekawati L, Gatton M, González I, Guérin PJ, Incardona S, Lilley K, Menard D, Nosten F, Obare P, Ogutu B, Olliaro PL, Price RN, Proux S, Ramsay AR, Reeder JC, Silamut K, Sokhna C.
        Malar J. 2020 Sep 4;19(1):324.
        Microscopy performed on stained films of peripheral blood for detection, identification and quantification of malaria parasites is an essential reference standard for clinical trials of drugs, vaccines and diagnostic tests for malaria. The value of data from such research is greatly enhanced if this reference standard is consistent across time and geography. Adherence to common standards and practices is a prerequisite to achieve this. The rationale for proposed research standards and procedures for the preparation, staining and microscopic examination of blood films for malaria parasites is presented here with the aim of improving the consistency and reliability of malaria microscopy performed in such studies. These standards constitute the core of a quality management system for clinical research studies employing microscopy as a reference standard. They can be used as the basis for the design of training and proficiency testing programmes as well as for procedures and quality assurance of malaria microscopy in clinical research.

      2. Integration of prevention and control measures for female genital schistosomiasis, HIV and cervical cancerpdf iconexternal icon
        Engels D, Hotez PJ, Ducker C, Gyapong M, Bustinduy AL, Secor WE, Harrison W, Theobald S, Thomson R, Gamba V, Masong MC, Lammie P, Govender K, Mbabazi PS, Malecela MN.
        Bull World Health Organ. 2020 ;98(9):615-624.
        Female genital schistosomiasis as a result of chronic infection with Schistosoma haematobium (commonly known as bilharzia) continues to be largely ignored by national and global health policy-makers. International attention for large-scale action against the disease focuses on whether it is a risk factor for the transmission of human immunodeficiency virus (HIV). Yet female genital schistosomiasis itself is linked to pain, bleeding and sub-or infertility, leading to social stigma, and is a common issue for women in schistosomiasis-endemic areas in sub-Saharan Africa. The disease should therefore be recognized as another component of a comprehensive health and human rights agenda for women and girls in Africa, alongside HIV and cervical cancer. Each of these three diseases has a targeted and proven preventive intervention: antiretroviral therapy and pre-exposure prophylaxis for HIV; human papilloma virus vaccine for cervical cancer; and praziquantel treatment for female genital schistosomiasis. We discuss how female genital schistosomiasis control can be integrated with HIV and cervical cancer care. Such a programme will be part of a broader framework of sexual and reproductive health and rights, women’s empowerment and social justice in Africa. Integrated approaches that join up multiple public health programmes have the potential to expand or create opportunities to reach more girls and women throughout their life course. We outline a pragmatic operational research agenda that has the potential to optimize joint implementation of a package of measures responding to the specific needs of girls and women.

      3. A systematic review of the literature on mechanisms of 5-nitroimidazole resistance in Trichomonas vaginalisexternal icon
        Graves KJ, Novak J, Secor WE, Kissinger PJ, Schwebke JR, Muzny CA.
        Parasitology. 2020 Jul 30:1-9.
        BACKGROUND: Trichomonas vaginalis is the most common non-viral sexually transmitted infection. 5-Nitroimidazoles [metronidazole (MTZ) and tinidazole (TDZ)] are FDA-approved treatments. To better understand treatment failure, we conducted a systematic review on mechanisms of 5-nitroimidazole resistance. METHODS: PubMed, ScienceDirect and EMBASE databases were searched using keywords Trichomonas vaginalis, trichomoniasis, 5-nitroimidazole, metronidazole, tinidazole and drug resistance. Non-English language articles and articles on other treatments were excluded. RESULTS: The search yielded 606 articles, of which 550 were excluded, leaving 58 articles. Trichomonas vaginalis resistance varies and is higher with MTZ (2.2-9.6%) than TDZ (0-2%). Resistance can be aerobic or anaerobic and is relative rather than absolute. Differential expression of enzymes involved in trichomonad energy production and antioxidant defenses affects 5-nitroimidazole drug activation; reduced expression of pyruvate:ferredoxin oxidoreductase, ferredoxin, nitroreductase, hydrogenase, thioredoxin reductase and flavin reductase are implicated in drug resistance. Trichomonas vaginalis infection with Mycoplasma hominis or T. vaginalis virus has also been associated with resistance. Trichomonas vaginalis has two genotypes, with greater resistance seen in type 2 (vs type 1) populations. DISCUSSION: 5-Nitroimidazole resistance results from differential expression of enzymes involved in energy production or antioxidant defenses, along with genetic mutations in the T. vaginalis genome. Alternative treatments outside of the 5-nitroimidazole class are needed.

    • Substance Use and Abuse
      1. E-cigarette unit sales, by product and flavor type - United States, 2014-2020external icon
        Ali FR, Diaz MC, Vallone D, Tynan MA, Cordova J, Seaman EL, Trivers KF, Schillo BA, Talley B, King BA.
        MMWR Morb Mortal Wkly Rep. 2020 Sep 18;69(37):1313-1318.
        Since electronic cigarettes (e-cigarettes) entered the U.S. marketplace in 2007, the landscape has evolved to include different product types (e.g., prefilled cartridge-based and disposable products) and flavored e-liquids (e.g., fruit, candy, mint, menthol, and tobacco flavors), which have contributed to increases in youth use (1,2). E-cigarettes have been the most commonly used tobacco product among U.S. youths since 2014; in 2019, 27.5% of high school students reported current e-cigarette use (3). To assess trends in unit sales of e-cigarettes in the United States by product and flavor type, CDC, CDC Foundation, and Truth Initiative analyzed retail scanner data during September 14, 2014-May 17, 2020, from Information Resources, Inc. (IRI). During this period, total e-cigarette sales increased by 122.2%, from 7.7 million to 17.1 million units per 4-week interval. By product type, the proportion of total sales that was prefilled cartridge products increased during September 2014-August 2019 (47.5% to 89.4%). During August 2019-May 2020, the proportion of total sales that was disposable products increased from 10.3% to 19.8%, while the proportion that was prefilled cartridge products decreased (89.4% to 80.2%). Among prefilled cartridge sales, the proportion of mint sales increased during September 2014-August 2019 (<0.1% to 47.6%); during August 2019-May 2020, mint sales decreased (47.6% to 0.3%), as menthol sales increased (10.7% to 61.8%). Among disposable e-cigarette sales during September 2014-May 2020, the proportion of mint sales increased (<0.1% to 10.5%), although tobacco-flavored (52.2% to 17.2%) and menthol-flavored (30.3% to 10.2%) sales decreased; during the same period, sales of all other flavors combined increased (17.2% to 62.1%). E-cigarette sales increased during 2014-2020, but fluctuations occurred overall and by product and flavor type, which could be attributed to consumer preferences and accessibility. Continued monitoring of e-cigarette sales and use is critical to inform strategies at the national, state, and community levels to minimize the risks of e-cigarettes on individual- and population-level health. As part of a comprehensive approach to prevent and reduce youth e-cigarettes use, such strategies could include those that address youth-appealing product innovations and flavors.

      2. Urinary acrylonitrile metabolite concentrations before and after smoked, vaporized, and oral cannabis in frequent and occasional cannabis usersexternal icon
        Ashley DL, De Jesús VR, Abulseoud OA, Huestis MA, Milan DF, Blount BC.
        Int J Environ Res Public Health. 2020 Sep 4;17(18).
        Cannabis use through smoking, vaping, or ingestion is increasing, but only limited studies have investigated the resulting exposure to harmful chemicals. N-acetyl-S-(2-cyanoethyl)-L-cysteine (2CYEMA), a urinary metabolite of acrylonitrile, a possible carcinogen, is elevated in the urine of past-30-day cannabis users compared to non-cannabis users. Five frequent and five occasional cannabis users smoked and vaped cannabis on separate days; one also consumed cannabis orally. Urine samples were collected before and up to 72 h post dose and urinary 2CYEMA was quantified. We compared 2CYEMA pre-exposure levels, maximum concentration, time at maximum concentration for occasional versus frequent users following different exposure routes, and measured half-life of elimination. Smoking cannabis joints rapidly (within 10 min) increased 2CYEMA in the urine of occasional cannabis users, but not in frequent users. Urine 2CYEMA did not consistently increase following vaping or ingestion in either study group. Cigarette smokers had high pre-exposure concentrations of 2CYEMA. Following cannabis smoking, the half-lives of 2CYEMA ranged from 2.5 to 9.0 h. 2CYEMA is an effective biomarker of cannabis smoke exposure, including smoke from a single cannabis joint, however, not from vaping or when consumed orally. When using 2CYEMA to evaluate exposure in cannabis users, investigators should collect the details about tobacco smoking, route of consumption, and time since last use as possible covariates.

      3. Revisiting the association between worldwide implementation of the MPOWER package and smoking prevalence, 2008-2017external icon
        Husain MJ, Datta BK, Nargis N, Iglesias R, Perucic AM, Ahluwalia IB, Tripp A, Fatehin S, Husain MM, Kostova D, Richter P.
        Tob Control. 2020 Sep 6.
        BACKGROUND: We revisited the association between progress in MPOWER implementation from 2008 to 2016 and smoking prevalence from 2009 to 2017 and offered an in-depth understanding of differential outcomes for various country groups. METHODS: We used data from six rounds of the WHO Reports on the Global Tobacco Epidemic and calculated a composite MPOWER Score for each country in each period. We categorised the countries in four initial conditions based on their tobacco control preparedness measured by MPOWER score in 2008 and smoking burden measured by age-adjusted adult daily smoking prevalence in 2006: (1) High MPOWER - high prevalence (HM-HP). (2) High MPOWER - low prevalence (HM-LP). (3) Low MPOWER - high prevalence (LM-HP). (4) Low MPOWER - low prevalence (LM-LP). We estimated the association of age-adjusted adult daily smoking prevalence with MPOWER Score and cigarette tax rates using two-way fixed-effects panel regression models including both year and country fixed effects. RESULTS: A unit increase of the MPOWER Score was associated with 0.39 and 0.50 percentage points decrease in adult daily smoking prevalence for HM-HP and HM-LP countries, respectively. When tax rate was controlled for separately from MPOWE, an increase in tax rate showed a negative association with daily smoking prevalence for HM-HP and LM-LP countries, while the MPOWE Score showed a negative association for all initial condition country groups except for LM-LP countries. CONCLUSION: A decade after the introduction of the WHO MPOWER package, we observed that the countries with higher initial tobacco control preparedness and higher smoking burden were able to reduce the adult daily smoking prevalence significantly.

      4. Biomarkers of exposure among USA adult hookah users: Results from wave 1 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2014)external icon
        Travers MJ, Rivard C, Sharma E, Retzky S, Yucesoy B, Goniewicz ML, Stanton CA, Chen J, Callahan-Lyon P, Kimmel HL, Xia B, Wang Y, Sosnoff CS, De Jesús VR, Blount BC, Hecht SS, Hyland A.
        Int J Environ Res Public Health. 2020 Sep 2;17(17).
        Hookah smoking has become common in the USA, especially among young adults. This study measured biomarkers of exposure to known tobacco product toxicants in a population-based sample of exclusive, established hookah users. Urinary biomarker data from 1753 adults in Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study were used to compare geometric mean concentrations of biomarkers of exposure in exclusive, established past 30-day hookah users to never users of tobacco. Geometric mean ratios were calculated comparing hookah user groups with never users adjusting for age, sex, race/ethnicity, education, past 30-day marijuana use, secondhand smoke exposure and creatinine. Past 30-day hookah users (n = 98) had 10.6 times the urinary cotinine level of never tobacco users. Compared to never tobacco users, past 30-day hookah users had 2.3 times the level of the carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), a metabolite of the tobacco-specific nitrosamine (TSNA) 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), 1.3 times higher polycyclic aromatic hydrocarbons (PAHs) 3-hydroxyfluorene and 1-hydroxypyrene, 1.8 times higher levels of acrylonitrile, 1.3 times higher levels of acrylamide, and 1.2 times higher levels of acrolein exposure. These data indicate that hookah use is a significant source of exposure to nicotine, carcinogens, and respiratory toxicants.

      5. E-cigarette use among middle and high school students - United States, 2020external icon
        Wang TW, Neff LJ, Park-Lee E, Ren C, Cullen KA, King BA.
        MMWR Morb Mortal Wkly Rep. 2020 Sep 18;69(37):1310-1312.
        The use of any tobacco product by youths is unsafe, including electronic cigarettes (e-cigarettes) (1). Most e-cigarettes contain nicotine, which is highly addictive, can harm the developing adolescent brain, and can increase risk for future addiction to other drugs (1). E-cigarette use has increased considerably among U.S. youths since 2011 (1,2). Multiple factors have contributed to this increase, including youth-appealing flavors and product innovations (1-3). Amid the widespread use of e-cigarettes and popularity of certain products among youths, on February 6, 2020, the Food and Drug Administration (FDA) implemented a policy prioritizing enforcement against the manufacture, distribution, and sale of certain unauthorized flavored prefilled pod or cartridge-based e-cigarettes (excluding tobacco or menthol).

    • Zoonotic and Vectorborne Diseases
      1. Association of biosecurity and hygiene practices with environmental contamination with influenza A viruses in live bird markets, Bangladeshexternal icon
        Chowdhury S, Azziz-Baumgartner E, Kile JC, Hoque MA, Rahman MZ, Hossain ME, Ghosh PK, Ahmed SS, Kennedy ED, Sturm-Ramirez K, Gurley ES.
        Emerg Infect Dis. 2020 Sep;26(9):2087-2096.
        In Bangladesh, live bird market environments are frequently contaminated with avian influenza viruses. Shop-level biosecurity practices might increase risk for environmental contamination. We sought to determine which shop-level biosecurity practices were associated with environmental contamination. We surveyed 800 poultry shops to describe biosecurity practices and collect environmental samples. Samples from 205 (26%) shops were positive for influenza A viral RNA, 108 (14%) for H9, and 60 (8%) for H5. Shops that slaughtered poultry, kept poultry overnight, remained open without rest days, had uneven muddy floors, held poultry on the floor, and housed sick and healthy poultry together were more frequently positive for influenza A viruses. Reported monthly cleaning seemed protective, but disinfection practices were not otherwise associated with influenza A virus detection. Slaughtering, keeping poultry overnight, weekly rest days, infrastructure, and disinfection practices could be targets for interventions to reduce environmental contamination.

      2. Cohort Profile: Congenital Zika virus infection and child neurodevelopmental outcomes; Zika en Embarazadas y Niños (ZEN) cohort study in Colombiaexternal icon
        Gonzalez M, Tong VT, Rodriguez H, Valencia D, Acosta J, Honein MA, Ospina ML.
        Epidemiol Health. 2020 Aug 31:e2020060.
        Zika en Embarazadas y Niños (ZEN) is a prospective cohort study designed to identify risk factors and modifiers for Zika virus (ZIKV) infection in pregnant women, partners, and infants, as well as assess the risk for adverse maternal, fetal, infant, and childhood outcomes of ZIKV and other congenital infections. ZIKV infection during pregnancy may be associated with long-term sequelae. 1519 pregnant women and 287 partners were enrolled from three departments within Colombia between February 2017 and January 2018. 1108 infants born to the pregnant women were enrolled in the study and followed to 6 months. Data include baseline questionnaires at enrollment, repeated symptoms and study follow-up questionnaires, lab testing to detect ZIKV and other congenital infections, medical record abstraction, infant physical, eye and hearing exams and developmental screeners. Follow-up of 850 mother-child dyads occurred at 9, 12, and 18 months, with developmental screenings, physical exams and parent questionnaires. Data will be pooled with those from other prospective cohort studies for an individual participant data meta-analysis on ZIKV infection during pregnancy and characterize pregnancy outcomes and sequelae in children.

      3. Global perspectives on arbovirus outbreaks: A 2020 snapshotexternal icon
        Kading RC, Brault AC, Beckham JD.
        Trop Med Infect Dis. 2020 Sep 7;5(3).

      4. Characteristics of Ebola virus disease survivor blood and semen in Liberia: Serology and RT-PCRexternal icon
        Kofman A, Linderman S, Su K, Purpura LJ, Ervin E, Brown S, Morales-Betoulle M, Graziano J, Cannon DL, Klena JD, Desamu-Thorpe R, Fankhauser J, Orone R, Soka M, Glaybo U, Massaquoi M, Nysenswah T, Nichol ST, Kollie J, Kiawu A, Freeman E, Giah G, Tony H, Faikai M, Jawara M, Kamara K, Kamara S, Flowers B, Mohammed K, Chiriboga D, Williams DE, Hinrichs SH, Ahmed R, Vonhm B, Rollin PE, Choi MJ.
        Clin Infect Dis. 2020 Sep 7.
        INTRODUCTION: Ebola virus (EBOV), species Zaire ebolavirus, may persist in the semen of male survivors of Ebola Virus Disease (EVD). We conducted a study of male survivors of the 2014-2016 EVD outbreak in Liberia and evaluated their immune responses to EBOV. We report here findings from the serologic testing of blood for EBOV-specific antibodies, molecular testing for EBOV in blood and semen, and serologic testing of peripheral blood mononuclear cells (PBMCs) in a subset of study participants. METHODS: We tested for EBOV RNA in blood by qRT-PCR, and for anti-EBOV-specific IgM and IgG antibodies by enzyme-linked immunosorbent assay (ELISA) for 126 study participants. We performed peripheral blood mononuclear cell (PBMC) analysis on a subgroup of 26 IgG-negative participants. RESULTS: All 126 participants tested negative for EBOV RNA in blood by qRT-PCR. The blood of 26 participants tested negative for EBOV-specific IgG antibodies by ELISA. PBMCs were collected from 23/26 EBOV IgG-negative participants. Of these, 1/23 participants had PBMCs which produced anti-EBOV-specific IgG antibodies upon stimulation with EBOV-specific GP and NP antigens. DISCUSSION: The blood of EVD survivors, collected when they did not have symptoms meeting the case definition for acute or relapsed EVD, is unlikely to pose a risk for EBOV transmission. We identified one IgM/IgG negative participant who had PBMCs which produced anti-EBOV-specific antibodies upon stimulation. Immunogenicity following acute EBOV infection may exist along a spectrum and absence of antibody response should not be exclusionary in determining an individual's status as a survivor of EVD.

      5. Exportation of monkeypox virus from the African continentexternal icon
        Mauldin MR, McCollum AM, Nakazawa YJ, Mandra A, Whitehouse ER, Davidson W, Zhao H, Gao J, Li Y, Doty J, Yinka-Ogunleye A, Akinpelu A, Aruna O, Naidoo D, Lewandowski K, Afrough B, Graham V, Aarons E, Hewson R, Vipond R, Dunning J, Chand M, Brown C, Cohen-Gihon I, Erez N, Shifman O, Israeli O, Sharon M, Schwartz E, Beth-Din A, Zvi A, Mak TM, Ng YK, Cui L, Lin RT, Olson VA, Brooks T, Paran N, Ihekweazu C, Reynolds MG.
        J Infect Dis. 2020 Sep 3.
        BACKGROUND: The largest West African monkeypox outbreak began September 2017, in Nigeria. Four individuals traveling from Nigeria to the UK (2), Israel, and Singapore became the first human monkeypox cases exported from Africa, and a related nosocomial transmission event in the UK became the first confirmed human-to-human monkeypox transmission event outside of Africa. METHODS: Epidemiological and molecular data for exported and Nigerian cases were analyzed jointly to better understand the exportations in the temporal and geographic context of the outbreak. RESULTS: Isolates from all travelers and a Bayelsa case shared a most recent common ancestor and traveled to Bayelsa, Delta, or Rivers states. Genetic variation for this cluster was lower than would be expected from a random sampling of genomes from this outbreak, but data did not support direct links between travelers. CONCLUSIONS: Monophyly of exportation cases and the Bayelsa sample, along with the intermediate levels of genetic variation suggest a small pool of related isolates is the likely source for the exported infections. This may be the result of the level of genetic variation present in monkeypox isolates circulating within the contiguous region of Bayelsa, Delta, and Rivers states, or another more restricted, yet unidentified source pool.

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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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