Issue 37, October 20, 2020

CDC Science Clips: Volume 12, Issue 37, October 20, 2020

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

  1. Top Articles of the Week
    Selected weekly by a senior CDC scientist from the standard sections listed below.
    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions
      • Preventing breast, cervical, and colorectal cancer deaths: Assessing the impact of increased screeningexternal icon
        Sharma KP, Grosse SD, Maciosek MV, Joseph D, Roy K, Richardson LC, Jaffe H.
        Prev Chronic Dis. 2020 Oct 8;17:E123.
        INTRODUCTION: The US Preventive Services Task Force (USPSTF) recommends select preventive clinical services, including cancer screening. However, screening for cancers remains underutilized in the United States. The Centers for Disease Control and Prevention leads initiatives to increase breast, cervical, and colorectal cancer (CRC) screening. We assessed the number of avoidable deaths from increased screening, according to USPSTF recommendations, for CRC and female breast and cervical cancers. METHODS: We used model-based estimates of avoidable deaths for the lifetime of single-year age cohorts under the current and increased use of screening scenarios (data year 2016; analysis, 2018). We calculated prevented cancer deaths for each 1% increase in screening uptake and extrapolated to current level of screening (2016), current level plus 10 percentage points, and increasing screening to 90% and 100% of the eligible population. RESULTS: Increased use of screening from current levels to 100% would prevent an additional 2,821 deaths from breast cancer, 6,834 deaths from cervical cancer, and 35,530 deaths from CRC over a lifetime of the respective single-year cohort. Increasing use of CRC screening would prevent approximately 8.5 times as many deaths as the equivalent increase in use of breast cancer screening (women only), although twice as many people (men and women) would have to be screened for CRC. CONCLUSIONS: A large number of deaths could be avoided by increasing breast, cervical, and CRC screening. Public health programs incorporating strategies shown to be effective can help increase screening rates.

    • Communicable Diseases
      • Severe acute respiratory syndrome coronavirus 2 prevalence, seroprevalence, and exposure among evacuees from Wuhan, China, 2020external icon
        Hallowell BD, Carlson CM, Jacobs JR, Pomeroy M, Steinberg J, Tenforde MW, McDonald E, Foster L, Feldstein LR, Rolfes MA, Haynes A, Abedi GR, Odongo GS, Saruwatari K, Rider EC, Douville G, Bhakta N, Maniatis P, Lindstrom S, Thornburg NJ, Lu X, Whitaker BL, Kamili S, Sakthivel SK, Wang L, Malapati L, Murray JR, Lynch B, Cetron M, Brown C, Roohi S, Rotz L, Borntrager D, Ishii K, Moser K, Rasheed M, Freeman B, Lester S, Corbett KS, Abiona OM, Hutchinson GB, Graham BS, Pesik N, Mahon B, Braden C, Behravesh CB, Stewart R, Knight N, Hall AJ, Killerby ME.
        Emerg Infect Dis. 2020 Sep;26(9):1998-2004.
        To determine prevalence of, seroprevalence of, and potential exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among a cohort of evacuees returning to the United States from Wuhan, China, in January 2020, we conducted a cross-sectional study of quarantined evacuees from 1 repatriation flight. Overall, 193 of 195 evacuees completed exposure surveys and submitted upper respiratory or serum specimens or both at arrival in the United States. Nearly all evacuees had taken preventive measures to limit potential exposure while in Wuhan, and none had detectable SARS-CoV-2 in upper respiratory tract specimens, suggesting the absence of asymptomatic respiratory shedding among this group at the time of testing. Evidence of antibodies to SARS-CoV-2 was detected in 1 evacuee, who reported experiencing no symptoms or high-risk exposures in the previous 2 months. These findings demonstrated that this group of evacuees posed a low risk of introducing SARS-CoV-2 to the United States.

      • The feasibility of recruiting and retaining men who have sex with men and transgender women in a multinational prospective HIV prevention research cohort study in sub-Saharan Africa (HPTN 075)external icon
        Sandfort TG, L. Hamilton E, Marais A, Guo X, Sugarman J, Chen YQ, Cummings V, Dadabhai S, Dominguez K, Panchia R, Schnabel D, Zulu F, Reynolds D, Radebe O, Mbeda C, Kamba D, Kanyemba B, Ogendo A, Stirratt M, Chege W, Lucas J, Fawzy M, McKinstry LA, Eshleman SH.
        J Int AIDS Soc. 2020 Oct;23 Suppl 6(Suppl 6):e25600.
        INTRODUCTION: Men who have sex with men (MSM) and transgender women (TGW) in sub-Saharan Africa (SSA) are profoundly affected by HIV with high HIV prevalence and incidence. This population also faces strong social stigma and legal barriers, potentially impeding participation in research. To date, few multi-country longitudinal HIV research studies with MSM/TGW have been conducted in SSA. Primary objective of the HIV Prevention Trials Network (HPTN) 075 study was to assess feasibility of recruiting and retaining a multinational prospective cohort of MSM/TGW in SSA for HIV prevention research. METHODS: HPTN 075, conducted from 2015 to 2017, was designed to enroll 400 MSM/TGW at four sites in SSA (100 per site: Kisumu, Kenya; Blantyre, Malawi; Cape Town, South Africa; and Soweto, South Africa). The number of HIV-positive persons was capped at 20 per site; HIV-positive persons already in care were excluded from participation. The one-year study included five biobehavioural assessments. Community-based input and risk mitigation protocols were included in study design and conduct. RESULTS: Of 624 persons screened, 401 were enrolled. One in five participants was classified as transgender. Main reasons for ineligibility included: (a) being HIV positive after the cap was reached (29.6%); (b) not reporting anal intercourse with a man in the preceding three months (20.6%); and (c) being HIV positive and already in care (17.5%). Five (1.2%) participants died during the study (unrelated to study participation). 92.9% of the eligible participants (368/396) completed the final study visit and 86.1% participated in all visits. The main, overlapping reasons for early termination included being (a) unable to adhere to the visit schedule, predominantly because of relocation (46.4%), and (b) unable to contact the participant (32.1%). Participants reported strong motivation to participate and few participation barriers. Four participants reported social harms (loss of confidentiality and sexual harassment by study staff) that were successfully addressed. CONCLUSIONS: HPTN 075 successfully enrolled a multinational sample of MSM/TGW in SSA in a prospective HIV prevention research study with a high retention rate and few documented social harms. This supports the feasibility of conducting large-scale research trials in this population to address its urgent, unmet HIV prevention needs.

    • Disease Reservoirs and Vectors
      • Role of abandoned and vacant houses on Aedes aegypti productivityexternal icon
        Barrera R, Acevedo V, Amador M.
        Am J Trop Med Hyg. 2020 Oct 5.
        The control of container Aedes species by house inspections usually achieves insufficient coverage and impact because a percentage of residents are absent and some residents refuse inspections and treatments. In addition, another fraction of the buildings may be uninhabited, such as those for rent or sale, or abandoned. Although the productivity of Aedes aegypti has been investigated in abandoned lots, less is known about the importance of uninhabited buildings. We investigated Ae. aegypti pupal productivity in inhabited, vacant, and abandoned houses and its interaction with socioeconomic levels (SELs). We found pupae in containers of 386 houses (66 abandoned, 62 vacant, and 258 inhabited) in 19 neighborhoods in southern Puerto Rico from May to August 2017. Using a generalized linear model, we found a significant interaction between the status of the house (abandoned, vacant, and inhabited) and SELs (low, medium) on Ae. aegypti pupal abundance. More pupae were found in abandoned and inhabited houses of low SELs. The lowest productivity was found in vacant houses, regardless of the SEL. Most containers producing Ae. aegypti in low-SEL houses were discarded on backyards, whereas in medium SELs, most productivity came from containers in use. Septic tanks producing Ae. aegypti were found only in houses of low SELs, where most emerging mosquitoes came from inhabited houses. We did not find any pupae of Ae. aegypti on roofs. These results indicate that proper yard management could significantly reduce the production of Ae. aegypti and the risk of dengue infections in low-SEL neighborhoods.

    • Health Communication and Education
      • Ante La Duda, Pregunta: A social marketing campaign to improve contraceptive access during a public health emergencyexternal icon
        Powell R, Rosenthal J, August EM, Frey M, Garcia L, Sidibe T, Mendoza Z, Romero L, Lathrop E.
        Health Commun. 2020 Oct 4:1-8.
        During the 2016-2017 Zika virus outbreak, preventing unintended pregnancy was recognized as a primary strategy to reduce adverse Zika-related pregnancy and birth outcomes. To increase awareness and uptake of contraceptive services provided through the Zika Contraception Access Network (Z-CAN) in Puerto Rico, a multi-strategy campaign called Ante La Duda, Pregunta (ALDP) was developed. The principal aim was to increase awareness of Z-CAN services, which included same-day access to the full range of reversible contraceptives at no cost to women living in Puerto Rico who choose to delay or avoid pregnancy during the 2016-2017 Zika virus outbreak. Using diverse strategies, ALDP increased exposure to and engagement with the campaign in order to raise awareness of Z-CAN services in Puerto Rico. The ALDP social marketing campaign played an important role in the overall Z-CAN effort. Of all the strategies utilized, Facebook appears to have reached the most people. While the importance of a social marketing campaign communicating to raise awareness and create demand has long been known, through the ALDP campaign efforts, it was shown that an effective campaign, built on formative research, can be developed and implemented rapidly in an emergency response situation without compromising on content, quality, or reach.

    • Immunity and Immunization
      • Vaccine effectiveness against pediatric influenza hospitalizations and emergency visitsexternal icon
        Campbell AP, Ogokeh C, Lively JY, Staat MA, Selvarangan R, Halasa NB, Englund JA, Boom JA, Weinberg GA, Williams JV, McNeal M, Harrison CJ, Stewart LS, Klein EJ, Sahni LC, Szilagyi PG, Michaels MG, Hickey RW, Moffat ME, Pahud BA, Schuster JE, Weddle GM, Rha B, Fry AM, Patel M.
        Pediatrics. 2020 Oct 5.
        BACKGROUND: Influenza A(H1N1)pdm09 viruses initially predominated during the US 2018-2019 season, with antigenically drifted influenza A(H3N2) viruses peaking later. We estimated vaccine effectiveness (VE) against laboratory-confirmed influenza-associated hospitalizations and emergency department (ED) visits among children in the New Vaccine Surveillance Network. METHODS: We tested children 6 months to 17 years with acute respiratory illness for influenza using molecular assays at 7 pediatric hospitals (ED patients <5 years at 3 sites). Vaccination status sources were parental report, state immunization information systems and/or provider records for inpatients, and parental report alone for ED patients. We estimated VE using a test-negative design, comparing odds of vaccination among children testing positive versus negative for influenza using multivariable logistic regression. RESULTS: Of 1792 inpatients, 226 (13%) were influenza-positive: 47% for influenza A(H3N2), 36% for A(H1N1)pdm09, 9% for A (not subtyped), and 7% for B viruses. Among 1944 ED children, 420 (22%) were influenza-positive: 48% for A(H3N2), 35% for A(H1N1)pdm09, 11% for A (not subtyped), and 5% for B viruses. VE was 41% (95% confidence interval [CI], 20% to 56%) against any influenza-related hospitalizations, 41% (95% CI, 11% to 61%) for A(H3N2), and 47% (95% CI, 16% to 67%) for A(H1N1)pdm09. VE was 51% (95% CI, 38% to 62%) against any influenza-related ED visits, 39% (95% CI, 15% to 56%) against A(H3N2), and 61% (95% CI, 44% to 73%) against A(H1N1)pdm09. CONCLUSIONS: The 2018-2019 influenza vaccine reduced pediatric influenza A-associated hospitalizations and ED visits by 40% to 60%, despite circulation of a drifted A(H3N2) clade.

    • Laboratory Sciences
      • Treatment with commonly used antiretroviral drugs induces a type I/III interferon signature in the gut in the absence of HIV infectionexternal icon
        Hughes SM, Levy CN, Calienes FL, Stekler JD, Pandey U, Vojtech L, Berard AR, Birse K, Noël-Romas L, Richardson B, Golden JB, Cartwright M, Collier AC, Stevens CE, Curlin ME, Holtz TH, Mugo N, Irungu E, Katabira E, Muwonge T, Lama JR, Baeten JM, Burgener A, Lingappa JR, McElrath MJ, Mackelprang R, McGowan I, Cranston RD, Cameron MJ, Hladik F.
        Cell Rep Med. 2020 Sep 22;1(6):100096.
        Tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) are used for HIV treatment and prevention. Previously, we found that topical rectal tenofovir gel caused immunological changes in the mucosa. Here, we assess the effect of oral TDF/FTC in three HIV pre-exposure prophylaxis trials, two with gastrointestinal and one with cervicovaginal biopsies. TDF/FTC induces type I/III interferon-related (IFN I/III) genes in the gastrointestinal tract, but not blood, with strong correlations between the two independent rectal biopsy groups (Spearman r = 0.91) and between the rectum and duodenum (r = 0.81). Gene set testing also indicates stimulation of the type I/III pathways in the ectocervix and of cellular proliferation in the duodenum. mRNA sequencing, digital droplet PCR, proteomics, and immunofluorescence confirm IFN I/III pathway stimulation in the gastrointestinal tract. Thus, oral TDF/FTC stimulates an IFN I/III signature throughout the gut, which could increase antiviral efficacy but also cause chronic immune activation in HIV prevention and treatment settings.

      • Remdesivir targets a structurally analogous region of the Ebola virus and SARS-CoV-2 polymerasesexternal icon
        Lo MK, Albariño CG, Perry JK, Chang S, Tchesnokov EP, Guerrero L, Chakrabarti A, Shrivastava-Ranjan P, Chatterjee P, McMullan LK, Martin R, Jordan R, Götte M, Montgomery JM, Nichol ST, Flint M, Porter D, Spiropoulou CF.
        Proc Natl Acad Sci U S A. 2020 Oct 7.
        Remdesivir is a broad-spectrum antiviral nucleotide prodrug that has been clinically evaluated in Ebola virus patients and recently received emergency use authorization (EUA) for treatment of COVID-19. With approvals from the Federal Select Agent Program and the Centers for Disease Control and Prevention's Institutional Biosecurity Board, we characterized the resistance profile of remdesivir by serially passaging Ebola virus under remdesivir selection; we generated lineages with low-level reduced susceptibility to remdesivir after 35 passages. We found that a single amino acid substitution, F548S, in the Ebola virus polymerase conferred low-level reduced susceptibility to remdesivir. The F548 residue is highly conserved in filoviruses but should be subject to specific surveillance among novel filoviruses, in newly emerging variants in ongoing outbreaks, and also in Ebola virus patients undergoing remdesivir therapy. Homology modeling suggests that the Ebola virus polymerase F548 residue lies in the F-motif of the polymerase active site, a region that was previously identified as susceptible to resistance mutations in coronaviruses. Our data suggest that molecular surveillance of this region of the polymerase in remdesivir-treated COVID-19 patients is also warranted.

    • Nutritional Sciences
      • Ultra-processed foods and excess heart age among U.S. adultsexternal icon
        Yang Q, Zhang Z, Steele EM, Moore LV, Jackson SL.
        Am J Prev Med. 2020 Oct 1.
        INTRODUCTION: A high percentage of total calories from ultra-processed foods has been associated with several cardiovascular disease risk factors. No study has examined the association between ultra-processed foods and heart age. This study examines the association between ultra-processed foods and excess heart age (difference between estimated heart age and chronological age) among U.S. adults. METHODS: The National Health and Nutrition Examination Survey (2009-2016) data for participants aged 30-74 years without cardiovascular disease or stroke (n=12,640) was used. Ultra-processed food was assigned based on NOVA classification of food processing, with ultra-processed food being the highest level. This study estimated the usual percentage of calories from ultra-processed foods and used sex-specific Framingham heart age algorithms to calculate heart age. The multivariable linear or logistic regression was used to examine the association between ultra-processed foods and excess heart age or likelihood of excess heart age being ≥10 years. Data analyses were conducted in 2020. RESULTS: The median usual percentage of calories from ultra-processed foods was 54.5% (IQR=45.8%‒63.1%). Adjusted excess heart age increased from 7.0 years (95% CI=6.4, 7.6) in the lowest quintile (Q1) to 9.9 years (95% CI=9.2, 10.5) in the highest quintile (Q5) (p<0.001). Compared with Q1, AORs for excess heart age of ≥10 years were 1.16 (95% CI=1.08, 1.25) in Q2, 1.29 (95% CI=1.14, 1.46) in Q3, 1.43 (95% CI=1.20, 1.71) in Q4, and 1.66 (95% CI=1.29, 2.14) in Q5 (p<0.001). The pattern of association was largely consistent across subgroups. CONCLUSIONS: U.S. adults consumed more than half of total daily calories from ultra-processed foods. A higher percentage of calories from ultra-processed foods was associated with higher excess heart age and likelihood of excess heart age of ≥10 years.

    • Occupational Safety and Health
      • Impact of select PPE design elements and repeated laundering in firefighter protection from smoke exposureexternal icon
        Mayer AC, Horn GP, Fent KW, Bertke SJ, Kerber S, Kesler RM, Newman H, Smith DL.
        J Occup Environ Hyg. 2020 Sep 29:1-10.
        As the Fire Service becomes more aware of the potential health effects from occupational exposure to hazardous contaminants, personal protective equipment (PPE) manufacturers, and fire departments have responded by developing and implementing improved means of firefighter protection, including more frequent laundering of PPE after exposures. While laboratory testing of new PPE designs and the effect of laundering on PPE fabric provides a useful way to evaluate these approaches, laboratory scale testing does not necessarily translate to full garment protection. Utilizing a fireground smoke exposure simulator, along with air and/or filter-substrate sampling for polycyclic aromatic hydrocarbons (PAHs) and benzene, this pilot study tested the chemical-protective capabilities of firefighting PPE of different designs (knit hood vs. particulate-blocking hood, turnout jacket with zipper closure vs. hook & dee closure), including the impact of repeatedly exposing and cleaning (through laundering or decontamination on-scene) PPE 40 times. Overall, PAH contamination on filters under hoods in the neck region were higher (median PAHs = 14.7 µg) than samples taken under jackets in the chest region (median PAHs = 7.05 µg). PAH levels measured under particulate-blocking hoods were lower than levels found under knit hoods. Similarly, zippered closures were found to provide a greater reduction in PAHs compared to hook & dee closures. However, neither design element completely eliminated contaminant ingress. Measurements for benzene under turnout jackets were similar to ambient chamber air concentrations, indicating little to no attenuation from the PPE. The effect of laundering or on-scene decontamination on contaminant breakthrough appeared to depend on the type of contaminant. Benzene breakthrough was negatively associated with laundering, while PAH breakthrough was positively associated. More research is needed to identify PPE features that reduce breakthrough, how targeted changes impact exposures, and how fireground exposures relate to biological absorption of contaminants.

    • Physical Activity
      • INTRODUCTION: Active commuting to work is one way people can be physically active and can be influenced by state-level initiatives. The American Community Survey (ACS) is a potential data source to evaluate changes in active commuting at the state level, but state-level changes have not been well documented. We examined state-level changes in estimates of walking, biking, and taking transit to work (combined and separately) among employed persons between 2006 and 2017. METHODS: Data were from the ACS, a nationally representative annual household survey from the US Census Bureau. We estimated state-level prevalence of walking, bicycling, or taking transit to work (separately and in combination) in 2006 and 2017 and tested differences by year. RESULTS: The prevalence of active commuting to work varied widely among states (2017 range: 1.7% in Alabama and Mississippi to 35.0% in New York). Changes from 2006 to 2017 also varied, with 8 states exhibiting a significant increase (Massachusetts [2.7 percentage points], New York [2.2], Hawaii [1.6], Illinois [1.3], Washington [1.3], New Jersey [1.2], Virginia [0.9], and Michigan [0.4]), and 12 exhibiting a significant decrease (South Dakota [-1.9], Idaho [-1.3], New Hampshire [-1.3], Wisconsin [-1.1], Maryland [-1.0], Nevada [-0.9], Ohio [-0.8], Mississippi [-0.6], Texas [-0.6], Florida [-0.5], Georgia [-0.4], and Indiana [-0.4]). The contributions of walking, bicycling, and taking transit also varied by state. CONCLUSION: Active commuting remains relatively rare across states. States pursuing initiatives to support active transportation may consider using ACS to monitor and evaluate changes in active commuting.

    • Substance Use and Abuse

  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. Breast cancer survival among males by race, ethnicity, age, geographic region, and stage - United States, 2007-2016external icon
        Ellington TD, Henley SJ, Wilson RJ, Miller JW.
        MMWR Morb Mortal Wkly Rep. 2020 Oct 16;69(41):1481-1484.
        Breast cancer among males in the United States is rare; approximately 2,300 new cases and 500 associated deaths were reported in 2017, accounting for approximately 1% of all breast cancers.* Risk for male breast cancer increases with increasing age (1), and compared with women, men receive diagnoses later in life and often at a later stage of disease (1). Gradual improvement in breast cancer survival from 1976-1985 to 1996-2005 has been more evident for women than for men (1). Studies examining survival differences among female breast cancer patients observed that non-Hispanic White (White) females had a higher survival than non-Hispanic Black (Black) females (2), but because of the rarity of breast cancer among males, few studies have examined survival differences by race or other factors such as age, stage, and geographic region. CDC's National Program of Cancer Registries (NPCR)(†) data were used to examine relative survival of males with breast cancer diagnosed during 2007-2016 by race/ethnicity, age group, stage at diagnosis, and U.S. Census region. Among males who received a diagnosis of breast cancer during 2007-2016, 1-year relative survival was 96.1%, and 5-year relative survival was 84.7%. Among characteristics examined, relative survival varied most by stage at diagnosis: the 5-year relative survival for males was higher for cancers diagnosed at localized stage (98.7%) than for those diagnosed at distant stage (25.9%). Evaluation of 1-year and 5-year relative survival among males with breast cancer might help guide health care decisions regarding early detection of male breast cancer and establishing programs to support men at high risk for breast cancer and male breast cancer survivors.

      2. The Longitudinal Epidemiologic Assessment of Diabetes Risk (LEADR): Unique 1.4 M patient electronic health record cohortexternal icon
        Fishbein HA, Birch RJ, Mathew SM, Sawyer HL, Pulver G, Poling J, Kaelber D, Mardon R, Johnson MC, Pace W, Umbel KD, Zhang X, Siegel KR, Imperatore G, Shrestha S, Proia K, Cheng Y, McKeever Bullard K, Gregg EW, Rolka D, Pavkov ME.
        Healthc (Amst). 2020 Oct 1;8(4):100458.
        BACKGROUND: The Longitudinal Epidemiologic Assessment of Diabetes Risk (LEADR) study uses a novel Electronic Health Record (EHR) data approach as a tool to assess the epidemiology of known and new risk factors for type 2 diabetes mellitus (T2DM) and study how prevention interventions affect progression to and onset of T2DM. We created an electronic cohort of 1.4 million patients having had at least 4 encounters with a healthcare organization for at least 24-months; were aged ≥18 years in 2010; and had no diabetes (i.e., T1DM or T2DM) at cohort entry or in the 12 months following entry. EHR data came from patients at nine healthcare organizations across the U.S. between January 1, 2010-December 31, 2016. RESULTS: Approximately 5.9% of the LEADR cohort (82,922 patients) developed T2DM, providing opportunities to explore longitudinal clinical care, medication use, risk factor trajectories, and diagnoses for these patients, compared with patients similarly matched prior to disease onset. CONCLUSIONS: LEADR represents one of the largest EHR databases to have repurposed EHR data to examine patients' T2DM risk. This paper is first in a series demonstrating this novel approach to studying T2DM. IMPLICATIONS: Chronic conditions that often take years to develop can be studied efficiently using EHR data in a retrospective design. LEVEL OF EVIDENCE: While much is already known about T2DM risk, this EHR's cohort's 160 M data points for 1.4 M people over six years, provides opportunities to investigate new unique risk factors and evaluate research hypotheses where results could modify public health practice for preventing T2DM.

      3. Prostate cancer incidence and survival, by stage and race/ethnicity - United States, 2001-2017external icon
        Siegel DA, O'Neil ME, Richards TB, Dowling NF, Weir HK.
        MMWR Morb Mortal Wkly Rep. 2020 Oct 16;69(41):1473-1480.
        Among U.S. men, prostate cancer is the second leading cause of cancer-related death (1). Past studies documented decreasing incidence of prostate cancer overall since 2000 but increasing incidence of distant stage prostate cancer (i.e., signifying spread to parts of the body remote from the primary tumor) starting in 2010 (2,3). Past studies described disparities in prostate cancer survival by stage, age, and race/ethnicity using data covering ≤80% of the U.S. population (4,5). To provide recent data on incidence and survival of prostate cancer in the United States, CDC analyzed data from population-based cancer registries that contribute to U.S. Cancer Statistics (USCS).* Among 3.1 million new cases of prostate cancer recorded during 2003-2017, localized, regional, distant, and unknown stage prostate cancer accounted for 77%, 11%, 5%, and 7% of cases, respectively, but the incidence of distant stage prostate cancer significantly increased during 2010-2017. During 2001-2016, 10-year relative survival for localized stage prostate cancer was 100%. Overall, 5-year survival for distant stage prostate cancer improved from 28.7% during 2001-2005 to 32.3% during 2011-2016; for the period 2001-2016, 5-year survival was highest among Asian/Pacific Islanders (API) (42.0%), followed by Hispanics (37.2%), American Indian/Alaska Natives (AI/AN) (32.2%), Black men (31.6%), and White men (29.1%). Understanding incidence and survival differences by stage, race/ethnicity, and age can guide public health planning related to screening, treatment, and survivor care. Future research into differences by stage, race/ethnicity, and age could inform interventions aimed at improving disparities in outcomes.

    • Communicable Diseases
      1. Antibody responses after classroom exposure to teacher with coronavirus disease, March 2020external icon
        Brown NE, Bryant-Genevier J, Bandy U, Browning CA, Berns AL, Dott M, Gosciminski M, Lester SN, Link-Gelles R, Quilliam DN, Sejvar J, Thornburg NJ, Wolff BJ, Watson J.
        Emerg Infect Dis. 2020 Sep;26(9):2263-5.
        After returning from Europe to the United States, on March 1, 2020, a symptomatic teacher received positive test results for severe acute respiratory syndrome coronavirus 2. Of the 21 students exposed to the teacher in the classroom, serologic results suggested past infection for 2. Classroom contact may result in virus transmission.

      2. Erroneous reporting of deaths attributed to pneumonia and influenza at 2 New York city teaching hospitals, 2013-2014external icon
        Brown TS, Dubowski K, Plitt M, Falci L, Lee E, Huynh M, Furuya Y, Vora NM.
        Public Health Rep. 2020 Oct 8.
        OBJECTIVES: Cause-of-death information, reported by frontline clinicians after a patient's death, is an irreplaceable source of public health data. However, systematic bias in cause-of-death reporting can lead to over- or underestimation of deaths attributable to different causes. New York City consistently reports higher rates of deaths attributable to pneumonia and influenza than many other US cities and the country. We investigated systematic erroneous reporting as a possible explanation for this phenomenon. METHODS: We reviewed all deaths from 2 New York City hospitals during 2013-2014 in which pneumonia or influenza was reported as the underlying cause of death (n = 188), and we examined the association between erroneous reporting and multiple extrinsic factors that may influence cause-of-death reporting (patient demographic characteristics and medical comorbidities, time and hospital location of death, type of medical provider reporting the death, and availability of certain diagnostic information). RESULTS: Pneumonia was erroneously reported as the underlying cause of death in 163 (86.7%) reports. We identified heart disease and dementia as the more likely underlying cause of death in 21% and 17% of erroneously reported deaths attributable to pneumonia, respectively. We found no significant association between erroneous reporting and the multiple extrinsic factors examined. CONCLUSIONS: Our results underscore how erroneous reporting of 1 condition can lead to underreporting of other causes of death. Misapplication or misunderstanding of procedures by medical providers, rather than extrinsic factors influencing the reporting process, are key drivers of erroneous cause-of-death reporting.

      3. Demographic characteristics, experiences, and beliefs associated with hand hygiene among adults during the COVID-19 pandemic - United States, June 24-30, 2020external icon
        Czeisler M, Garcia-Williams AG, Molinari NA, Gharpure R, Li Y, Barrett CE, Robbins R, Facer-Childs ER, Barger LK, Czeisler CA, Rajaratnam SM, Howard ME.
        MMWR Morb Mortal Wkly Rep. 2020 Oct 16;69(41):1485-1491.
        Frequent hand hygiene, including handwashing with soap and water or using a hand sanitizer containing ≥60% alcohol when soap and water are not readily available, is one of several critical prevention measures recommended to reduce the spread of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19).* Previous studies identified demographic factors associated with handwashing among U.S. adults during the COVID-19 pandemic (1,2); however, demographic factors associated with hand sanitizing and experiences and beliefs associated with hand hygiene have not been well characterized. To evaluate these factors, an Internet-based survey was conducted among U.S. adults aged ≥18 years during June 24-30, 2020. Overall, 85.2% of respondents reported always or often engaging in hand hygiene following contact with high-touch public surfaces such as shopping carts, gas pumps, and automatic teller machines (ATMs).(†) Respondents who were male (versus female) and of younger age reported lower handwashing and hand sanitizing rates, as did respondents who reported lower concern about their own infection with SARS-CoV-2(§) and respondents without personal experience with COVID-19. Focused health promotion efforts to increase hand hygiene adherence should include increasing visibility and accessibility of handwashing and hand sanitizing materials in public settings, along with targeted communication to males and younger adults with focused messages that address COVID-19 risk perception.

      4. Transmission dynamics by age group in COVID-19 hotspot counties - United States, April-September 2020external icon
        Oster AM, Caruso E, DeVies J, Hartnett KP, Boehmer TK.
        MMWR Morb Mortal Wkly Rep. 2020 Oct 16;69(41):1494-1496.
        CDC works with other federal agencies to identify counties with increasing coronavirus disease 2019 (COVID-19) incidence (hotspots) and offers support to state, tribal, local, and territorial health departments to limit the spread of SARS-CoV-2, the virus that causes COVID-19 (1). Understanding whether increasing incidence in hotspot counties is predominantly occurring in specific age groups is important for identifying opportunities to prevent or reduce transmission. The percentage of positive SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) test results (percent positivity) is an important indicator of community transmission.* CDC analyzed temporal trends in percent positivity by age group in COVID-19 hotspot counties before and after their identification as hotspots. Among 767 hotspot counties identified during June and July 2020, early increases in the percent positivity among persons aged ≤24 years were followed by several weeks of increasing percent positivity in persons aged ≥25 years. Addressing transmission among young adults is an urgent public health priority.

      5. Factors influencing risk for COVID-19 exposure among young adults aged 18-23 years - Winnebago County, Wisconsin, March-July 2020external icon
        Wilson RF, Sharma AJ, Schluechtermann S, Currie DW, Mangan J, Kaplan B, Goffard K, Salomon J, Casteel S, Mukasa A, Euhardy N, Ruiz A, Bautista G, Bailey E, Westergaard R, Gieryn D.
        MMWR Morb Mortal Wkly Rep. 2020 Oct 16;69(41):1497-1502.
        On May 13, 2020, the Wisconsin Supreme Court declared the state's Safer at Home Emergency Order ( "unlawful, invalid, and unenforceable,"* thereby increasing opportunities for social and business interactions. By mid-June, Winnebago County,(†) Wisconsin experienced an increase in the number of infections with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), with the largest increase among persons aged 18-23 years (young adults) (1). This age group(§) accounts for 12.5% of the population in the county. To identify factors that influence exposure to COVID-19 among young adults in Winnebago County, characteristics of COVID-19 cases and drivers of behaviors in this age group were examined. During March 1-July 18, 2020, 240 young adults received positive SARS-CoV-2 test results, accounting for 32% of all Winnebago County cases. In 30 key informant interviews, most interviewees reported exposure to misinformation, conflicting messages, or opposing views about the need for and effectiveness of masks. Thirteen young adults described social or peer pressure to not wear a mask and perceived severity of disease outcome for themselves as low but high for loved ones at risk. Having low perceived severity of disease outcome might partly explain why, when not in physical contact with loved ones at risk, young adults might attend social gatherings or not wear a mask (2). Exposure to misinformation and unclear messages has been identified as a driver of behavior during an outbreak (3,4), underscoring the importance of providing clear and consistent messages about the need for and effectiveness of masks. In addition, framing communication messages that amplify young adults' responsibility to protect others and target perceived social or peer pressure to not adhere to public health guidance might persuade young adults to adhere to public health guidelines that prevent the spread of COVID-19.

    • Disaster Control and Emergency Services
      1. Geospatial analysis in responding to a nuclear detonation scenario in NYC: The Gotham Shield Exerciseexternal icon
        Lowe L, Salame-Alfie A, Neurath B, Quinn C, Ansari A, Whitcomb R, Dopson S.
        J Homel Secur Emerg Manag. 2020 .
        In April 2017, the Centers for Disease Control and Prevention (CDC) participated in the Gotham Shield Exercise, led by the Federal Emergency Management Agency (FEMA) and in collaboration with other federal agencies to test the federal, state and local government's ability to respond to an improvised nuclear device (IND). With active engagement from CDC leadership, 266 scientific and support staff from across the agency participated in the Gotham Shield exercise. The scenario involved a 10-kiloton detonation near the Lincoln Tunnel in New Jersey. This nuclear detonation scenario provided CDC with the opportunity to test some of the all-hazards tools the agency uses during response to other national or international emergencies, such as Geographic Information Systems (GIS) and mapping tools, and apply these tools to a nuclear emergency. Geospatial analysis associated with real time data can provide near real time information for individuals and entities associated with response and recovery activities. This type of analysis can provide timely data in regard to maps and information used to properly place staging areas for Community Reception Centers (CRC), mass care locations, and other medical care and countermeasure related services. Maps showing locations of power loss, such as locations of lost or inoperable main electrical grid and substations, combined with real time data on where power is available provides valuable information for first responders and emergency managers as well as responders engaged in communicating critical public messages to affected populations in these areas. By using real-time information, response officials can direct the response, allocate scarce resources, aid in coordination efforts, and provide a more efficient means of providing critical public health and medical services. The results of the exercise highlight the importance of using geospatial analysis for response planning and effect mitigation before, during, and after a public health event of this magnitude, and the value they represent in informed decision making.

    • Disease Reservoirs and Vectors
      1. The TIRS trial: protocol for a cluster randomized controlled trial assessing the efficacy of preventive targeted indoor residual spraying to reduce Aedes-borne viral illnesses in Merida, Mexicoexternal icon
        Manrique-Saide P, Dean NE, Halloran ME, Longini IM, Collins MH, Waller LA, Gomez-Dantes H, Lenhart A, Hladish TJ, Che-Mendoza A, Kirstein OD, Romer Y, Correa-Morales F, Palacio-Vargas J, Mendez-Vales R, Pérez PG, Pavia-Ruz N, Ayora-Talavera G, Vazquez-Prokopec GM.
        Trials. 2020 Oct 8;21(1):839.
        BACKGROUND: Current urban vector control strategies have failed to contain dengue epidemics and to prevent the global expansion of Aedes-borne viruses (ABVs: dengue, chikungunya, Zika). Part of the challenge in sustaining effective ABV control emerges from the paucity of evidence regarding the epidemiological impact of any Aedes control method. A strategy for which there is limited epidemiological evidence is targeted indoor residual spraying (TIRS). TIRS is a modification of classic malaria indoor residual spraying that accounts for Aedes aegypti resting behavior by applying residual insecticides on exposed lower sections of walls (< 1.5 m), under furniture, and on dark surfaces. METHODS/DESIGN: We are pursuing a two-arm, parallel, unblinded, cluster randomized controlled trial to quantify the overall efficacy of TIRS in reducing the burden of laboratory-confirmed ABV clinical disease (primary endpoint). The trial will be conducted in the city of Merida, Yucatan State, Mexico (population ~ 1million), where we will prospectively follow 4600 children aged 2-15 years at enrollment, distributed in 50 clusters of 5 × 5 city blocks each. Clusters will be randomly allocated (n = 25 per arm) using covariate-constrained randomization. A "fried egg" design will be followed, in which all blocks of the 5 × 5 cluster receive the intervention, but all sampling to evaluate the epidemiological and entomological endpoints will occur in the "yolk," the center 3 × 3 city blocks of each cluster. TIRS will be implemented as a preventive application (~ 1-2 months prior to the beginning of the ABV season). Active monitoring for symptomatic ABV illness will occur through weekly household visits and enhanced surveillance. Annual sero-surveys will be performed after each transmission season and entomological evaluations of Ae. aegypti indoor abundance and ABV infection rates monthly during the period of active surveillance. Epidemiological and entomological evaluation will continue for up to three transmission seasons. DISCUSSION: The findings from this study will provide robust epidemiological evidence of the efficacy of TIRS in reducing ABV illness and infection. If efficacious, TIRS could drive a paradigm shift in Aedes control by considering Ae. aegypti behavior to guide residual insecticide applications and changing deployment to preemptive control (rather than in response to symptomatic cases), two major enhancements to existing practice. TRIAL REGISTRATION: NCT04343521 . Registered on 13 April 2020. The protocol also complies with the WHO International Clinical Trials Registry Platform (ICTRP) (Additional file 1). PRIMARY SPONSOR: National Institutes of Health, National Institute of Allergy and Infectious Diseases (NIH/NIAID).

      2. Mechanisms associated with pyrethroid resistance in populations of Aedes aegypti (Diptera: Culicidae) from the Caribbean coast of Colombiaexternal icon
        Pareja-Loaiza PX, Santacoloma Varon L, Rey Vega G, Gómez-Camargo D, Maestre-Serrano R, Lenhart A.
        PLoS One. 2020 ;15(10):e0228695.
        Aedes aegypti is the main vector of dengue, chikungunya, and Zika viruses, which are of great public health importance in Colombia. Aedes control strategies in Colombia rely heavily on the use of organophosphate and pyrethroid insecticides, providing constant selection pressure and the emergence of resistant populations. In recent years, insecticide use has increased due to the increased incidence of dengue and recent introductions of chikungunya and Zika. In the present study, pyrethroid resistance was studied across six populations of Ae. aegypti from the Caribbean coast of Colombia. Susceptibility to λ-cyhalothrin, deltamethrin, and permethrin was assessed, and resistance intensity was determined. Activity levels of enzymes associated with resistance were measured, and the frequencies of three kdr alleles (V1016I, F1534C, V410L) were calculated. Results showed variations in pyrethroid susceptibility across Ae. aegypti populations and altered enzyme activity levels were detected. The kdr alleles were detected in all populations, with high variations in frequencies: V1016I (frequency ranging from 0.15-0.70), F1534C (range 0.94-1.00), and V410L (range 0.05-0.72). In assays of phenotyped individuals, associations were observed between the presence of V1016I, F1534C, and V410L alleles and resistance to the evaluated pyrethroids, as well as between the VI1016/CC1534/VL410 tri-locus genotype and λ-cyhalothrin and permethrin resistance. The results of the present study contribute to the knowledge of the mechanisms underlying the resistance to key pyrethroids used to control Ae. aegypti along the Caribbean coast of Colombia.

      3. Koala retrovirus diversity, transmissibility, and disease associationsexternal icon
        Zheng H, Pan Y, Tang S, Pye GW, Stadler CK, Vogelnest L, Herrin KV, Rideout BA, Switzer WM.
        Retrovirology. 2020 Oct 2;17(1):34.
        BACKGROUND: Koalas are infected with the koala retrovirus (KoRV) that exists as exogenous or endogenous viruses. KoRV is genetically diverse with co-infection with up to ten envelope subtypes (A-J) possible; KoRV-A is the prototype endogenous form. KoRV-B, first found in a small number of koalas with an increased leukemia prevalence at one US zoo, has been associated with other cancers and increased chlamydial disease. To better understand the molecular epidemiology of KoRV variants and the effect of increased viral loads (VLs) on transmissibility and pathogenicity we developed subtype-specific quantitative PCR (qPCR) assays and tested blood and tissue samples from koalas at US zoos (n = 78), two Australian zoos (n = 27) and wild-caught (n = 21) in Australia. We analyzed PCR results with available clinical, demographic, and pedigree data. RESULTS: All koalas were KoRV-A-infected. A small number of koalas (10.3%) at one US zoo were also infected with non-A subtypes, while a higher non-A subtype prevalence (59.3%) was found in koalas at Australian zoos. Wild koalas from one location were only infected with KoRV-A. We observed a significant association of infection and plasma VLs of non-A subtypes in koalas that died of leukemia/lymphoma and other neoplasias and report cancer diagnoses in KoRV-A-positive animals. Infection and VLs of non-A subtypes was not associated with age or sex. Transmission of non-A subtypes occurred from dam-to-offspring and likely following adult-to-adult contact, but associations with contact type were not evaluated. Brief antiretroviral treatment of one leukemic koala infected with high plasma levels of KoRV-A, -B, and -F did not affect VL or disease progression. CONCLUSIONS: Our results show a significant association of non-A KoRV infection and plasma VLs with leukemia and other cancers. Although we confirm dam-to-offspring transmission of these variants, we also show other routes are possible. Our validated qPCR assays will be useful to further understand KoRV epidemiology and its zoonotic transmission potential for humans exposed to koalas because KoRV can infect human cells.

    • Healthcare Associated Infections
      1. Infiltrating Kaposi sarcoma presenting as acute kidney injury: An unexpected consequence of deliberate hepatitis C positive organ transplantationexternal icon
        Story M, Sanders ML, Bashir A, Longo J, Abel S, Dollard S, Grodstein E, Thomas C, Katz D.
        Transpl Infect Dis. 2020 Oct 3.
        Kaposi sarcoma (KS) following kidney transplantation can result from recipient reactivation of latent human herpesvirus 8 (HHV-8) infection or activation of donor acquired HHV-8 infection. Post-transplant KS typically manifests with cutaneous pathology, but rare cases of renal allograft involvement have been reported. We describe two cases of donor derived HHV-8 infection in two hepatitis C (HCV) viremia negative transplant recipients who each received a kidney from a donor with HCV viremia. One recipient did not develop KS while the other presented with acute kidney injury due to extensive KS infiltration of the renal parenchyma and metastatic disease. This report reviews the literature for cases of KS involving the renal allograft and highlights an unexpected consequence of deliberate HCV positive organ transplantation.

    • Immunity and Immunization
      1. Strengthening National Immunization Technical Advisory Groups in resource-limited settings: current and potential linkages with polio national certification committeesexternal icon
        Greene SA, Anya BM, Asghar H, Chaudhri IA, Datta SD, Donadel ME, Kouadio KI, Shefer AM, Cavallaro KF.
        Health Res Policy Syst. 2020 Oct 6;18(1):116.
        BACKGROUND: Countries are transitioning assets and functions from polio eradication to integrated immunization and surveillance activities. We assessed the extent of linkages between and perceptions of National Immunization Technical Advisory Groups (NITAGs) and National Certification Committees (NCCs) for polio eradication to understand how linkages can be leveraged to improve efficiencies of these expert bodies. METHODS: During May 2017 to May 2018, we administered a 15-question survey to a NITAG chair or member and an NCC counterpart in all countries of the WHO Regions for Africa (AFR) and for the Eastern Mediterranean (EMR) that had both a NITAG and an NCC. Data were analysed using frequency distributions. RESULTS: Of countries with both a NITAG and an NCC (n = 44), the response rate was 92% (22/24) in AFR and 75% (15/20) in EMR. Some respondents reported being very familiar with the functions of the other technical bodies, 36% (8/22) for NITAG members and 38% (14/37) for NCC members. Over 85% (51/59) of respondents felt it was somewhat useful or very useful to strengthen ties between bodies. Nearly all respondents (98%, 58/59) felt that NCC expertise could inform measles and rubella elimination programmes. CONCLUSIONS: We observed a broad consensus that human resource assets of NCCs may serve an important technical role to support national immunization policy-making. At this stage of the polio eradication initiative, countries should consider how to integrate the technical expertise of NCC members to reinforce NITAGs and maintain the polio essential functions, beginning in countries that have been polio-free for several years.

      2. Quality improvement coaching for human papillomavirus vaccination coverage: A process evaluation in 3 states, 2018-2019external icon
        Leeman J, Petermann V, Heisler-MacKinnon J, Bjork A, Brewer NT, Grabert BK, Gilkey MB.
        Prev Chronic Dis. 2020 Oct 8;17:E120.
        PURPOSE AND OBJECTIVES: Quality improvement (QI) coaching improves human papillomavirus (HPV) vaccination coverage, but effects of coaching have been small, and little is known about how and when QI coaching works. To assess implementation outcomes and explore factors that might explain variation in outcomes, we conducted a process evaluation of a QI coaching intervention for HPV vaccination. INTERVENTION APPROACH: QI coaches received tools and training to support 4 core coaching competencies: 1) expertise in using clinic-level adolescent vaccination data to drive change, 2) knowledge of the evidence base to support change in HPV vaccination practice, 3) familiarity with improvement strategies and action planning, and 4) skill in building relationships. EVALUATION METHODS: Our mixed methods evaluation involved collecting quantitative data through effort-tracking logs and gathering qualitative data through in-depth interviews with QI coaches (N = 11) who worked with 89 clinics in 3 US states. Data were collected on implementation outcomes and on contextual factors that might explain variations in those outcomes. Implementation outcomes included adoption by clinics, reach to providers and staff (ie, participation in the coaching visit), and implementation fidelity. RESULTS: States achieved either high adoption or high reach, but not both. For example, state A had high adoption with 94% of clinics accepting a coaching visit, but low reach with a median of 1 participant per clinic. In contrast, state C had lower adoption (29%, P < .01) than state A but higher reach (median of 4 participants per clinic, P < .01). Generally, states had high coaching protocol fidelity with the exception of advising on strategies and action planning. QI coaches described factors that might explain these variations, including strength of relationships with clinic staff and whether they recruited clinics directly or through large clinic networks. IMPLICATIONS FOR PUBLIC HEALTH: Our findings have implications for the design of future QI coaching initiatives, including how coaches recruit clinics to ensure full clinic engagement, refinements to coaching visits, and how QI coaches can effectively engage with clinic networks. Findings could inform future QI coaching interventions to strengthen their impact on public health.

      3. Immunogenicity of seasonal inactivated influenza and inactivated polio vaccines among children in Senegal: Results from a cluster-randomized trialexternal icon
        Niang M, Deming ME, Goudiaby D, Diop OM, Dia N, Diallo A, Ortiz JR, Diop D, Lewis KD, Lafond KE, Widdowson MA, Victor JC, Neuzil KM.
        Vaccine. 2020 Oct 1.
        Data on influenza vaccine immunogenicity in children are limited from tropical developing countries. We recently reported significant, moderate effectiveness of a trivalent inactivated influenza vaccine (IIV) in a controlled, cluster-randomized trial in children in rural Senegal during 2009, a year of H3N2 vaccine mismatch (NCT00893906). We report immunogenicity of IIV3 and inactivated polio vaccine (IPV) from that trial. We evaluated hemagglutination inhibition (HAI) and polio antibody titers in response to vaccination of three age groups (6 through 35 months, 3 through 5 years, and 6 through 8 years). As all children were IIV naïve, each received two vaccine doses, although titers were assessed after only the first dose for subjects aged 6 through 8 years. Seroconversion rates (4-fold titer rise or increase from <1:10 to ≥1:40) were 74-87% for A/H1N1, 76-87% for A/H3N2, and 54-79% for B/Yamagata. Seroprotection rates (HAI titer ≥ 1:40) were 79-88% for A/H1N1, 88-96% for A/H3N2, and 52-74% for B/Yamagata. IIV responses were lowest in the youngest age group, and they were comparable between ages 3 through 5 years after two doses and 6 through 8 years after one dose. We found that baseline seropositivity (HAI titer ≥ 1:10) was an effect modifier of IIV response. Using a seroprotective titer (HAI titer ≥ 1:160) recommended for IIV evaluation in children, we found that among subjects who were seropositive at baseline, 69% achieved seroprotection for both A/H1N1 and A/H3N2, while among those who were seronegative at baseline, seroprotection was achieved in 11% for A/H1N1 and 22% for A/H3N2. The IPV group had high baseline polio antibody seropositivity and appropriate responses to vaccination. Our data emphasize the importance of a two-dose IIV3 series in vaccine naïve children. IIV and IPV vaccines were immunogenic in Senegalese children.

      4. Adenoviral vector-based vaccine platforms for developing the next generation of influenza vaccinesexternal icon
        Sayedahmed EE, Elkashif A, Alhashimi M, Sambhara S, Mittal SK.
        Vaccines (Basel). 2020 Oct 1;8(4).
        Ever since the discovery of vaccines, many deadly diseases have been contained worldwide, ultimately culminating in the eradication of smallpox and polio, which represented significant medical achievements in human health. However, this does not account for the threat influenza poses on public health. The currently licensed seasonal influenza vaccines primarily confer excellent strain-specific protection. In addition to the seasonal influenza viruses, the emergence and spread of avian influenza pandemic viruses such as H5N1, H7N9, H7N7, and H9N2 to humans have highlighted the urgent need to adopt a new global preparedness for an influenza pandemic. It is vital to explore new strategies for the development of effective vaccines for pandemic and seasonal influenza viruses. The new vaccine approaches should provide durable and broad protection with the capability of large-scale vaccine production within a short time. The adenoviral (Ad) vector-based vaccine platform offers a robust egg-independent production system for manufacturing large numbers of influenza vaccines inexpensively in a short timeframe. In this review, we discuss the progress in the development of Ad vector-based influenza vaccines and their potential in designing a universal influenza vaccine.

    • Laboratory Sciences
      1. Comparison of participant-collected nasal and staff-collected oropharyngeal specimens for human ribonuclease P detection with RT-PCR during a community-based studyexternal icon
        Arnold MT, Temte JL, Barlow SK, Bell CJ, Goss MD, Temte EG, Checovich MM, Reisdorf E, Scott S, Guenther K, Wedig M, Shult P, Uzicanin A.
        PLoS One. 2020 ;15(10):e0239000.
        We analyzed 4,352 participant- and staff-collected respiratory specimens from 2,796 subjects in the Oregon Child Absenteeism due to Respiratory Disease Study. Trained staff collected oropharyngeal specimens from school-aged children with acute respiratory illness while household participants of all ages collected their own midturbinate nasal specimens in year one and anterior nasal specimens in year two. Human ribonuclease P levels were measured using RT-PCR for all staff- and participant-collected specimens to determine adequacy, defined as Cycle threshold less than 38. Overall, staff- and participant-collected specimens were 99.9% and 96.4% adequate, respectively. Participant-collected midturbinate specimens were 95.2% adequate in year one, increasing to 97.2% in year two with anterior nasal collection. The mean human ribonuclease P Cycle threshold for participant-collected specimens was 31.18 in year one and 28.48 in year two. The results from this study suggest that community-based participant collection of respiratory specimens is comparable to staff-collected oropharyngeal specimens, is feasible, and may be optimal with anterior nasal collection.

      2. Identification of Streptococcus suis meningitis by direct triplex real-time PCR, Burkina Fasoexternal icon
        Ouattara M, Tamboura M, Kambire D, Sanou M, Ouattara K, Congo M, Kaboré A, Sanou S, Kabré E, Sharpley S, Tran T, Schwartz S, Ouangraoua S, Ouedraogo AS, Sangaré L, Ouedraogo-Traore R, Whitney CG, Beall B.
        Emerg Infect Dis. 2020 Sep;26(9):2223-2226.
        Meningitis confirmation in Burkina Faso uses PCR for detecting Streptococcus pneumoniae, Neisseria meningitidis, or Hemophilus influenzae. We identified 38 cases of meningitis among 590 that were PCR-positive for 3 nonpneumococcal streptococcal pathogens, including 21 cases of Streptococcus suis. Among the country's 13 regions, 10 had S. suis-positive cases.

      3. BACKGROUND: In biomarker-based studies, collecting repeated biospecimens per participant can decrease measurement error, particularly for biomarkers displaying high within-subject variability. Guidelines to combine such repeated biospecimens do not exist. AIMS: To compare the efficiency of several designs relying on repeated biospecimens to estimate exposure over 7 days. METHODS: We quantified triclosan and bisphenol A (BPA) in all urine voids (N=427) collected over seven days from eight individuals. We estimated the volume-weighted concentrations for all urine samples collected during a week and compared these gold standards with the concentrations obtained for equal-volume pools (standardized or not for urine dilution), unequal-volume pools (based on sample volume or creatinine concentration), and for the mean of the creatinine-standardized concentrations measured in each spot sample. RESULTS: For both chemicals, correlations with gold standards were similar for equal- and unequal-volume pooling designs. Only for BPA, correlation coefficients were markedly lower after standardization for specific gravity or creatinine of concentrations estimated in equal-volume pools. Averaging BPA creatinine-standardized concentrations measured in each spot sample led also to lower correlations with gold standards compared to those obtained for unstandardized pooling designs. CONCLUSION: For BPA and triclosan, considering individual urine sample volume or creatinine concentrations when pooling is unnecessary because equal-volume pool adequately estimates concentrations in gold standards. Standardization for specific gravity or creatinine of the concentrations assessed in equal-volume pool as well as averaging creatinine-standardized concentrations measured in each individual spot sample are not suitable for BPA. These results provide a practical framework on how to combine repeated biospecimens in epidemiological studies.

      4. Comprehensive laboratory evaluation of a specific lateral flow assay for the presumptive identification of Francisella tularensis in suspicious white powders and aerosol samplesexternal icon
        Pillai SP, DePalma L, Prentice KW, Ramage JG, Chapman C, Sarwar J, Parameswaran N, Petersen J, Yockey B, Young J, Singh A, Pillai CA, Manickam G, Thirunavkkarasu N, Avila JR, Sharma S, Morse SA, Venkateswaran K, Anderson K, Hodge DR.
        Health Secur. 2020 Mar/Apr;18(2):83-95.
        We conducted a comprehensive, multi-phase laboratory evaluation of the Tularemia BioThreat Alert(®) (BTA) test, a lateral flow assay (LFA) for the rapid detection of Francisella tularensis. The study, conducted at 2 sites, evaluated the limit of detection (LOD) of this assay using the virulent SchuS4 strain and the avirulent LVS strain of F. tularensis. In 6-phase evaluation (linear dynamic range and reproducibility, inclusivity, near-neighbor, environmental background, white powder, and environmental filter extract), 13 diverse strains of F. tularensis, 8 Francisella near neighbors, 61 environmental background organisms, 26 white powders, and a pooled aerosol extract were tested. In the 937 tests performed, the Tularemia BTA demonstrated an LOD of 10(7) to 10(8) cfu/mL, with a sensitivity of 100.00%, specificity of 98.08%, and accuracy of 98.84%. These performance data are important for accurate interpretation of qualitative results arising from screening suspicious white powders in the field.

      5. Large differences in urinary benzene metabolite s-phenylmercapturic acid quantitation: A comparison of five LC-MS-MS methodsexternal icon
        Tevis DS, Willmore A, Bhandari D, Bowman B, Biren C, Kenwood BM, Jacob P, Liu J, Bello K, Hecht SS, Carmella SG, Chen M, Gaudreau E, Bienvenu JF, Blount BC, De Jesús VR.
        J Anal Toxicol. 2020 Oct 7.
        Benzene is a known genotoxic carcinogen linked to many hematological abnormalities. S-phenylmercapturic acid (PHMA, N-Acetyl-S-(phenyl)-L-cysteine, CAS# 4775-80-8) is a urinary metabolite of benzene and is used as a biomarker to assess benzene exposure. Pre-S-phenylmercapturic acid (pre-PHMA) is a PHMA precursor that dehydrates to PHMA at acidic pH. Published analytical methods that measure urinary PHMA adjust urine samples to a wide range of pH values using several types of acid, potentially leading to highly variable results depending on the concentration of pre-PHMA in a sample. Information is lacking on the variation in sample preparation among laboratories regularly measuring PHMA and the effect of those differences on PHMA quantitation in human urine samples. To investigate the differences in PHMA quantitation, we conducted an inter-laboratory comparison that included the analysis of 50 anonymous human urine samples (25 self-identified smokers, 25 self-identified non-smokers), quality control samples, and commercially available reference samples in five laboratories using different analytical methods to determine which sample preparation methods are currently in use and compare PHMA results. Observed urinary PHMA concentrations were proportionally higher at lower pH and results for anonymous urine samples varied widely among the methods. The method with the neutral preparation pH yielded results about 60% lower than the method using the most acidic conditions. Samples spiked with PHMA showed little variation, suggesting that the variability in results in human urine samples across methods is driven by the acid-mediated conversion of pre-PHMA to PHMA.

      6. Detection and characterization of diphtheria toxin gene-bearing corynebacterium species through a new real-time PCR assayexternal icon
        Williams MM, Waller JL, Aneke JS, Weigand MR, Diaz MH, Bowden KE, Simon AK, Peng Y, Xiaoli L, Cassiday PK, Winchell J, Tondella ML.
        J Clin Microbiol. 2020 Sep 22;58(10).
        Respiratory diphtheria, characterized by a firmly adherent pseudomembrane, is caused by toxin-producing strains of Corynebacterium diphtheriae, with similar illness produced occasionally by toxigenic Corynebacterium ulcerans or, rarely, Corynebacterium pseudotuberculosis While diphtheria laboratory confirmation requires culture methods to determine toxigenicity, real-time PCR (RT-PCR) provides a faster method to detect the toxin gene (tox). Nontoxigenic tox-bearing (NTTB) Corynebacterium isolates have been described, but impact of these isolates on the accuracy of molecular diagnostics is not well characterized. Here, we describe a new triplex RT-PCR assay to detect tox and distinguish C. diphtheriae from the closely related species C. ulcerans and C. pseudotuberculosis Analytical sensitivity and specificity of the assay were assessed in comparison to culture using 690 previously characterized microbial isolates. The new triplex assay characterized Corynebacterium isolates accurately, with 100% analytical sensitivity for all targets. Analytical specificity with isolates was 94.1%, 100%, and 99.5% for tox, Diph_rpoB, and CUP_rpoB targets, respectively. Twenty-nine NTTB Corynebacterium isolates, representing 5.9% of 494 nontoxigenic isolates tested, were detected by RT-PCR. Whole-genome sequencing of NTTB isolates revealed varied mutations putatively underlying their lack of toxin production, as well as eight isolates with no mutation in tox or the promoter region. This new Corynebacterium RT-PCR method provides a rapid tool to screen isolates and identify probable diphtheria cases directly from specimens. However, the sporadic occurrence of NTTB isolates reinforces the viewpoint that diphtheria culture diagnostics continue to provide the most accurate case confirmation.

    • Nutritional Sciences
      1. BACKGROUND: Higher intake of ultraprocessed foods (UPFs) might be associated with increased risk of cardiovascular disease. OBJECTIVES: Our objective was to examine the association between usual percentage of calories (%kcal) from UPFs and the American Heart Association's "Life's Simple 7" cardiovascular health (CVH) metrics in US adults. METHODS: We analyzed data from 11,246 adults aged ≥20 y from the NHANES 2011-2016 (a cross-sectional, nationally representative survey). UPF designation was assigned on the basis of the NOVA classification system, according to the extent and purpose of food processing. Each CVH metric was given a score of 0, 1, or 2 representing poor, intermediate, or ideal health, respectively. Scores of the 6 metrics (excluding diet) were summed, and CVH was categorized as inadequate (0-4), average (5-8), or optimum (9-12). We used the National Cancer Institute's methods to estimate the usual %kcal from UPFs, and multivariable linear and multinomial logistic regression to assess the association between UPFs and CVH, adjusted for age, sex, race and Hispanic origin, education, and poverty. RESULTS: The weighted prevalence of inadequate, average, and optimum CVH was 8.0%, 51.7%, and 40.3%, respectively. The mean usual %kcal from UPFs was 55.4%, and midpoint of quartiles of intake ranged from 40.4% (quartile 1) to 70.5% (quartile 4). Every 5% increase in calories from UPFs was associated with 0.14 points lower CVH score (P < 0.001). The adjusted ORs for inadequate CVH were 1.40 (95% CI: 1.23, 1.60), 1.82 (1.45, 2.29), and 2.57 (1.79, 3.70), respectively, comparing quartiles 2, 3, and 4 with quartile 1 of UPF intake. The pattern of association was largely consistent across subgroups. CONCLUSIONS: Usual %kcal from UPFs represented more than half of total calorie intake in US adults. A graded inverse association between %kcal from UPFs and CVH was observed.

    • Obituary
      1. In memoriam: Francis E. Johnston (1931-2020)external icon
        Schell LM, Gordon-Larsen P, Valleroy LA.
        Am J Hum Biol. 2020 Oct 7:e23514.

    • Occupational Safety and Health
      1. Development of job exposure matrices to estimate occupational exposure to solar and artificial ultraviolet radiationexternal icon
        Boiano JM, Silver SR, Tsai RJ, Sanderson WT, Liu S, Whitehead LW.
        Ann Work Expo Health. 2020 Oct 3.
        OBJECTIVES: Job exposure matrices (JEMs) are important tools for estimating occupational exposures in study populations where only information on industry and occupation (I&O) are available. JEMs The objective of this work was to create JEMs for solar and artificial ultraviolet radiation (UVR) using a US standardized coding scheme. METHODS: Using U.S. Census Bureau industry and occupation codes, separate lists of I&O pairs were developed for solar and artificial UVR by a panel of Certified Industrial Hygienists who assigned exposure ratings to I&O pairs with potential exposure. Parameters for exposure included prevalence (P) and frequency (F) for solar UVR and P, F, and intensity (I) for artificial UVR. Prevalence, or percent of all workers employed in an I&O pair who were exposed, was categorically rated: 0 to <1, 1 to <20; 20 to <80, and ≥80. Frequency of exposure, defined by the number of hours per week workers were exposed, was categorically rated: 0 to <5, 5 to <20, 20 to <35, and ≥35 h per week. For artificial UVR only, intensity of exposure was assigned three ratings: low, low with rare excursions, and >low under normal conditions. Discrepant ratings were resolved via consensus. RESULTS: After excluding I&O pairs assigned P and F ratings of 0 (solar UVR) and P, F, and I ratings of 0 (artificial UVR) from the JEM, 9206 I&O pairs were rated for solar UVR and 2010 I&O pairs for artificial UVR. For solar UVR, 723 (7.9% of all rated pairs) had ratings in the highest category for P and F; this group included 45 occupations in varied industries. Construction and extraction occupations represented most of the occupations (n = 20; 44%), followed by farming, fishing, and forestry occupations (n = 6; 13%). For artificial UVR, 87 I&O pairs (4.3% of all rated pairs) had maximum ratings for P, F, and I; these comprised a single occupation (welding, soldering, and brazing workers) in diverse industries. CONCLUSIONS: JEMs for solar and artificial UVR were developed for a broad range of I&O pairs in the US population and are available for use by researchers conducting occupational epidemiological studies.

      2. How will the future of work shape the OSH professional of the future? A workshop summaryexternal icon
        Felknor SA, Streit JM, Chosewood LC, McDaniel M, Schulte PA, Delclos GL.
        Int J Environ Res Public Health. 2020 Sep 30;17(19).
        Rapid and profound changes anticipated in the future of work will have significant implications for the education and training of occupational safety and health (OSH) professionals and the workforce. As the nature of the workplace, work, and the workforce change, the OSH field must expand its focus to include existing and new hazards (some yet unknown), consider how to protect the health and well-being of a diverse workforce, and understand and mitigate the safety implications of new work arrangements. Preparing for these changes is critical to developing proactive systems that can protect workers, prevent injury and illness, and promote worker well-being. An in-person workshop held on February 3-4, 2020 at The University of Texas Health Science Center (UTHealth) School of Public Health in Houston, Texas, USA, examined some of the challenges and opportunities OSH education will face in both academic and industry settings. The onslaught of the COVID-19 global pandemic reached the United States one month after this workshop and greatly accelerated the pace of change. This article summarizes presentations from national experts and thought leaders across the spectrum of OSH and professionals in the fields of strategic foresight, systems thinking, and industry, and provides recommendations for the field.

      3. Application of air-bubble cushioning to improve the shock absorption performance of type I industrial helmetsexternal icon
        Wu JZ, Pan CS, Ronaghi M, Wimer BM, Reischl U.
        Eng Fail Anal. 2020 Nov;117:104921.
        The industrial helmet is the most used and effective personal protective equipment to reduce work-related traumatic brain injuries. The Type I industrial helmet is a basic helmet model that is commonly used in construction sites and manufacturers. The purpose of the current study was to investigate if shock absorption performance of these helmets could be improved by using an air-bubble cushioning liner to augment the helmet's suspension system. Drop impact tests were performed using a commercial drop tower test machine according to the ANSI Z89.1 Type I drop impact protocol. Typical off-the-shelf Type I industrial helmets were utilized in the study. The effects of the air-bubble cushioning on the helmets' shock absorption performance were evaluated by comparing the original off-the-shelf helmet samples to the helmets equipped with an air-bubble cushioning liner. The air-bubble cushioning liner (thickness 5 mm) was placed between the headform and the helmet when being tested. The impactor had a mass of 3.6 kg and was free-dropped from different heights. The maximal peak transmitted forces for each of the tests have been evaluated and compared. Our results show that the shock absorption effectiveness of the air-bubble cushioning is dependent on the magnitude of the impact force. At lower drop heights (h &lt; 1.63 m), the air-bubble cushioning liner has little effect on the transmitted impact forces, however, at higher drop heights (h&gt;/= 1.73 m) the air-bubble cushioning liner effectively reduced the peak transmitted forces. At a drop height of 1.93 m (the highest drop height tested), the air-bubble cushioning liner reduced the peak transmitted force by over 80%. Our results indicate that adding an air-bubble cushioning liner into a basic Type I industrial helmet will substantially increase shock absorption performance for large impact forces.

    • Occupational Safety and Health - Mining
      1. Biological effects of inhaled hydraulic fracturing sand dust. VIII. Immunotoxicityexternal icon
        Anderson SE, Shane H, Long C, Marrocco A, Lukomska E, Roberts JR, Marshall N, Fedan JS.
        Toxicol Appl Pharmacol. 2020 Sep 29:115256.
        Hydraulic fracturing ("fracking") is a process used to enhance retrieval of gas from subterranean natural gas-laden rock by fracturing it under pressure. Sand used to stabilize fissures and facilitate gas flow creates a potential occupational hazard from respirable fracking sand dust (FSD). As studies of the immunotoxicity of FSD are lacking, the effects of whole-body inhalation (6 h/d for 4 d) of a FSD, i.e., FSD 8, was investigated at 1, 7, and 27 d post-exposure in rats. Exposure to 10 mg/m(3) FSD 8 resulted in decreased lung-associated lymph node (LLN) cellularity, total B-cells, CD4+ T-cells, CD8+ T-cells and total natural killer (NK) cells at 7-d post exposure. The frequency of CD4+ T-cells decreased while the frequency of B-cells increased (7 and 27 d) in the LLN. In contrast, increases in LLN cellularity and increases in total CD4+ and CD8+ T-cells were observed in rats following 30 mg/m(3) FSD 8 at 1 d post-exposure. Increases in the frequency and number of CD4+ T-cells and NK cells were observed in bronchial alveolar lavage fluid at 7-d post-exposure (10 mg/m(3)) along with an increase in total CD4+ T-cells, CD11b + cells, and NK cells at 1-day post-exposure (30 mg/m(3)). Increases in the numbers of B-cells and CD8+ T-cells were observed in the spleen at 1-day post 30 mg/m(3) FSD 8 exposure. In addition, NK cell activity was suppressed at 1 d (30 mg/m(3)) and 27 d post-exposure (10 mg/m(3)). No change in the IgM response to sheep red blood cells was observed. The findings indicate that FSD 8 caused alterations in cellularity, phenotypic subsets, and impairment of immune function.

      2. Field verification of an improved mine fire location modelexternal icon
        Bahrami D, Zhou L, Yuan L.
        Min Metall Explor. 2020 .
        Underground mine fires remain a concern for mine operators, posing a health and safety risk to mineworkers. In the last decade, the number of mine fires has decreased significantly; however, dealing with an unknown fire in underground mines can be a challenging task, which could lead to a hazardous condition for miners during an evacuation and rescue operation. A timely detection of a mine fire and monitoring its characteristics, namely size and location, are of great importance in reducing the risk of mine fire injuries. A new improved fire location algorithm has been developed and integrated into an Atmospheric Monitoring System (AMS) program by researchers from the National Institute for Occupational Safety and Health (NIOSH). This paper describes the new fire location model and presents the results of verification fire tests conducted at the Safety Research Coal Mine (SRCM) facility of the Pittsburgh Mining Research Division (PMRD) using the collected AMS data. NIOSH is endeavoring to develop workplace solutions to improve detection of and reduce the risk of hazardous conditions in mines. The results demonstrate successful application of the improved fire location model and provide a useful tool for solving the problem of unknown fire location and reducing the risk of hazardous conditions.

      3. Insights into the relationships among the roof, rib, floor, and pillars of underground coal minesexternal icon
        Klemetti TM, Van Dyke MA, Evanek N, Compton CC, Tulu IB.
        Min Metall Explor. 2020 .
        Ground control failures continue to be one of the leading causes of injuries and fatalities in underground coal mining. The roof, rib, floor, and pillars are four areas of potential ground failures that miners, engineers, and consultants are continually evaluating. Quite often, these four underground structures are evaluated independently. A recent push to consider them as a system and in a similar manner as design engineers evaluate mechanical systems has highlighted the need to fully understand the interrelationship among the roof, rib, floor, and pillar. This relationship combines the geometry of the mine layout, geological environment, installed support, and even the timing of the coal extraction. Several studies using field observations and instrumentation show that these relationships can be independent at times, while being dependent in other scenarios. Cases with good roof conditions while the rib and floor deteriorate are contrasted with cases where the roof, rib, and floor deteriorate at the same time. The presented cases in this study demonstrate the importance of understanding the geological environment and mine design to ensure that the proper support is installed.

      4. The exposure of mining workers to crystalline particles, e.g., alpha quartz in respirable dust is a ubiquitous global problem in occupational safety and health at surface and underground operations. The challenge of rapid in-field monitoring for direct assessment and adoption of intervention has not been solved satisfactorily to date, as conventional analytical methods such as X-ray diffraction (XRD) and infrared (IR) spectroscopy require laboratory environments, complex system handling, tedious sample preparation, and are limited by, e.g., addressable particle size. A novel monitoring approach was developed for potential in-field application enabling the quantification of crystalline particles in the respirable regime based on transmission IR spectroscopy. This on-site approach analyzes samples of dust in ambient air collected onto PVC filters using respirable dust sampling devices. In the present study, we demonstrate that portable Fourier transform infrared (FT-IR) spectroscopy in combination with multivariate data analysis provides a versatile tool for the identification and quantification of minerals in complex real-world matrices. Without further sample preparation, the loaded filters are immediately analyzed via transmission IR spectroscopy, and the mineral amount is quantified in real-time using a partial least squares regression (PLSR) algorithm. Due to the inherent molecular selectivity for crystalline as well as organic matrix components, IR spectroscopy uniquely allows to precisely determine the particle composition even in complex samples such as dust from coal mines or clay-rich environments. For establishing a robust PLSR model, a method was developed for generating calibration samples representative in size and composition for respirable mine dust via aerodynamic size separation. Combined with experimental design strategies, this allows tailoring the calibration set to the demands of air quality management in underground mining scenarios, i.e., the respirable particle size regime and the matrix of the target analyte.

    • Parasitic Diseases
      1. Identification of cross-reactive markers to strengthen the development of immunodiagnostic methods for angiostrongyliasis and other parasitic infectionsexternal icon
        Cognato BB, Handali S, de Mattos Pereira L, Barradas JR, Januário da Silva A, Graeff-Teixeira C, Morassutti AL.
        Exp Parasitol. 2020 Sep 18;218:107999.
        Angiostrongylus cantonensis is the main causative agent of eosinophilic meningoencephalitis (EoM) in humans. Molecular diagnostic methods are essential since the identification of larvae in cerebrospinal fluid (CSF) is extremely rare. To date, the detection of a 31 kDa antigen by Western blotting has been the primary immunodiagnostic method for EoM caused by A. cantonensis. However, cross-reactivity with other parasites has been observed. Therefore, we conducted a comparative analysis using sera from individuals with angiostrongyliasis. We also characterized proteins isolated from different cellular sources of A. cantonensis, Toxocara canis, Schistosoma mansoni, and Strongyloides stercoralis with mass spectrometry. A total of 115 cross-reactive proteins were identified. Three of these proteins, heat shock protein, an intermediate filament protein, and galectin 1, represent potential markers for cross-reactivity. In addition, synthetic peptides were generated from previously identified diagnostic targets and tested against sera from individuals infected with several other parasites. As a result, two other markers of cross-reactivity were identified: peptide #4 derived from the 14-3-3 protein and peptide #12 derived from the Lec-5 protein. In contrast, 34 proteins were exclusively present in the Angiostrongylus extracts and represent promising diagnostic molecules for specific identification of A. cantonensis infection. In particular, cytochrome oxidase subunit I is of great interest as a possible immunodiagnostic target for angiostrongyliasis.

    • Physical Activity
      1. Physical activity occurs in 4 domains (leisure, occupational, household, and transportation), but US surveillance often focuses on leisure-time only. We compared estimates of self-reported leisure-time physical activity and estimates of all-domain activity among adults in the National Health and Nutrition Examination Survey for 2011-2016. During the study period, 38.6% met the aerobic physical activity guideline in leisure-time, 58.5% in leisure-time and occupational/household activity, and 63.7% in all domains. Differences within most subgroups when using all domains were similar to differences when using leisure-time activity only, except that we observed no urban/rural differences in the multidomain assessment. Assessment of multiple domains of activity instead of leisure-time-only activity affects prevalence estimates to a greater extent than it affects subgroup differences.

    • Public Health, General
      1. Living systematic reviews and other approaches for updating evidenceexternal icon
        Lansky A, Wethington HR.
        Am J Public Health. 2020 Nov;110(11):1687-1688.

    • Substance Use and Abuse
      1. Recent trends and associated factors of amphetamine-type stimulant overdoses in emergency departmentsexternal icon
        Vivolo-Kantor AM, Hoots BE, Seth P, Jones CM.
        Drug Alcohol Depend. 2020 Sep 25;216:108323.
        BACKGROUND: Emerging data indicate a resurgence of availability and harms of amphetamine-type stimulant (ATS) use. This study examined ATS overdose-involved emergency department (ED) visit trends and visit characteristics associated with ATS overdose. METHODS: Data from the Healthcare Cost and Utilization Project's (HCUP) 2010-2017 Nationwide Emergency Department Sample identified ATS overdose-involved visits. Predicted trend lines from 2010 to 2015 were fit using weighted logistic regression forany or only ATS-involved overdose using ICD-9-CM discharge diagnosis codes; percentage change from 2016 to 2017 used ICD-10-CM. Multivariable logistic regression examined characteristics in 2017 associated with only ATS-involved overdoses compared to drug overdoses not involving ATS. RESULTS: Every year from 2010 to 2015 the odds of any ATS overdose-involved ED visits increased 11 % (odds ratio [OR]: 1.11, 95 % CI: 1.09, 1.14) and 7 % for only ATS overdose-involved visits (OR: 1.07, 95 % CI: 1.04, 1.10). From 2016 to 2017, any and only ATS overdose-involved visit rates increased 19.1 % and 20.5 %, respectively (P < .05). In 2017, ATS overdose-involved visits (N = 42,428) accounted for 4.4 % of all drug overdose visits (N = 956,266). In adjusted regression models, characteristics more prevalent among patients with only ATS overdose included Western region; micropolitan and noncore urbanization levels; unintentional, undetermined, and assault intents; and cardiovascular effects. CONCLUSIONS: Our findings, coupled with the rising availability of ATS and related harms, underscore the expansion of current substance use and overdose prevention and response efforts to address stimulant use, particularly among groups at risk. Research to identify additional individual and community-level risk factors for increasing ATS overdose is warranted.

    • Zoonotic and Vectorborne Diseases
      1. Seoul virus infection and spread in United States home-based ratteries: Rat and human testing results from a multistate outbreak investigationexternal icon
        Knust B, Brown S, de St Maurice A, Whitmer S, Koske SE, Ervin E, Patel K, Graziano J, Morales-Betoulle ME, House J, Cannon D, Kerins J, Holzbauer S, Austin C, Gibbons-Burgener S, Colton L, Dunn J, Zufan S, Choi MJ, Davis WR, Chiang CF, Manning CR, Roesch L, Shoemaker T, Purpura L, McQuiston J, Peterson D, Radcliffe R, Garvey A, Christel E, Morgan L, Scheftel J, Kazmierczak J, Klena JD, Nichol ST, Rollin PE.
        J Infect Dis. 2020 Sep 14;222(8):1311-1319.
        BACKGROUND: During 2017, a multistate outbreak investigation occurred after the confirmation of Seoul virus (SEOV) infections in people and pet rats. A total of 147 humans and 897 rats were tested. METHODS: In addition to immunoglobulin (Ig)G and IgM serology and traditional reverse-transcription polymerase chain reaction (RT-PCR), novel quantitative RT-PCR primers/probe were developed, and whole genome sequencing was performed. RESULTS: Seventeen people had SEOV IgM, indicating recent infection; 7 reported symptoms and 3 were hospitalized. All patients recovered. Thirty-one facilities in 11 US states had SEOV infection, and among those with ≥10 rats tested, rat IgG prevalence ranged 2%-70% and SEOV RT-PCR positivity ranged 0%-70%. Human laboratory-confirmed cases were significantly associated with rat IgG positivity and RT-PCR positivity (P = .03 and P = .006, respectively). Genomic sequencing identified >99.5% homology between SEOV sequences in this outbreak, and these were >99% identical to SEOV associated with previous pet rat infections in England, the Netherlands, and France. Frequent trade of rats between home-based ratteries contributed to transmission of SEOV between facilities. CONCLUSIONS: Pet rat owners, breeders, and the healthcare and public health community should be aware and take steps to prevent SEOV transmission in pet rats and to humans. Biosecurity measures and diagnostic testing can prevent further infections.

      2. Early growth parameters as predictors of developmental delay among children conceived during the 2015-2016 Zika virus outbreak in northeastern Brazilexternal icon
        Rose CE, Bertolli J, Attell JE, Moore CA, Melo F, Kotzky K, Krishna N, Satterfield-Nash A, Pereira IO, Pessoa A, Smith DC, Santelli A, Peacock G.
        Trop Med Infect Dis. 2020 Oct 1;5(4).
        BACKGROUND: Identifying infants with congenital infection for early intervention will likely be challenging in future Zika virus outbreaks. We investigated indicators of risk for developmental delay among children born with and without obvious manifestations of congenital Zika virus infection. METHODS: We evaluated 120 children conceived during the 2015-2016 Zika virus outbreak in Paraíba, Brazil. We analyzed data from children at birth; ages 1-7 months and approximately 24 months, using medical records (i.e., anthropometric measurements diagnoses), medical evaluation (i.e., Zika/other laboratory tests, dysmorphic features), and parent report (seizures, developmental delay). We used a Bayesian modeling approach to identify predictors of developmental delay. RESULTS: Head circumference (HC) and length at birth and rates of growth for HC and length at follow-up were consistent across domains of developmental delay; (e.g., for every 1 cm per month decrease in HC growth rate; there was a corresponding decrease in the gross motor z-score). Modeling results indicated that HC and length at birth, and follow-up HC and length rates of growth, were predictive of developmental delay. CONCLUSION: These findings suggest that accurate measurement and frequent monitoring of HC and length, especially in the first few months of life, may be useful for identifying children possibly congenitally exposed to Zika virus who could benefit from early intervention services.

      3. A fatal case of Powassan virus encephalitisexternal icon
        Yu Q, Matkovic E, Reagan-Steiner S, Denison AM, Osborn R, Salamat SM.
        J Neuropathol Exp Neurol. 2020 Oct 5.
        Powassan virus (POWV) is a flavivirus of the tick-borne encephalitis serogroup that causes a rare and potentially life-threatening neuroinvasive disease. Viral transmission occurs during zoonotic spillover from mammals by the bite of an infected tick in endemic regions of North America. The number of reported POWV cases has recently increased in the United States. We report a fatal case of POWV meningoencephalomyelitis in Northern Wisconsin following a documented tick bite. Histologic examination of the brain demonstrated widespread intraparenchymal and perivascular lymphohistocytic infiltration, microglial nodule formation, and marked neuronal degeneration, most severely involving the substantia nigra, anterior horn of spinal cord and cerebellum. Although no viral inclusions were seen in routine light microscopy, electron microscopy identified multiple neurons containing cytoplasmic clusters of virus particles ∼50 nm in diameter. POWV infection was confirmed using immunohistochemical analysis and reverse transcription-polymerase chain reaction. This report demonstrates in detail regional central nervous system involvement and ultrastructural characteristics of Powassan viral particles by transmission electron microscopy, while highlighting the utility of evaluating fixed autopsy tissues in cases of unexplained meningoencephalomyelitis.

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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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