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Volume 12, Issue, 4 February 4, 2020

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CDC Science Clips: Volume 12, Issue 4, February 3, 2020

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

This week Science Clips features journal articles, commentaries, and editorials on a novel (new) coronavirus (named “2019-nCoV”) that was first detected in Wuhan City, Hubei Province, China and continues to expand.

For additional information, please consult:

CDC 2019 Coronavirus Home
World Health Organization Novel coronavirus (2019-nCoV)external icon
PubMed search strategyexternal icon to retrieve citations, including ahead-of-print citations, on the 2019 novel coronavirus:  2019-nCoV OR (wuhan[tiab] AND coronavirus[tiab])
New England Journal of Medicine 2019 Novel Coronavirus (2019-nCoV)external icon A collection of articles and other resources on the outbreak, including clinical reports, management guidelines, and commentary.
The Lancet 2019-nCoV Resource Centreexternal icon Collects 2019-nCoV content from across The Lancet journals as it is published. All content listed on this page is free to access.

The report consists of these components:

  1. Key Scientific Articles in Featured Topic Areas
    Subject matter experts decide what topic to feature, and articles are selected from the last 3 to 6 months of published literature. Key topic coincides monthly with other CDC products (e.g. Vital Signs).
    • Zoonotic and Vectorborne Diseases - 2019 Novel Coronavirus (2019-nCoV)
      1. Potential for global spread of a novel coronavirus from Chinaexternal icon
        Bogoch I, Watts A, Thomas-Bachli A, Huber C, Kraemer MG, Khan K.
        J Travel Med. 2020 .

      2. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family clusterexternal icon
        Chan J, Yuan S, Kok K, To K, Chu H, Yang J, Xing F, Liu J, Yip C, Poon R, Tsoi H, Lo S, Chan K, Poon V, Chan W, Ip J, Cai J, Cheng V, Chen H, Hui C, Yuen K.
        Lancet (London, England). 2020 :S0140-6736(20)30154-9.
        BACKGROUND: An ongoing outbreak of pneumonia associated with a novel coronavirus was reported in Wuhan city, Hubei province, China. Affected patients were geographically linked with a local wet market as a potential source. No data on person-to-person or nosocomial transmission have been published to date. METHODS: In this study, we report the epidemiological, clinical, laboratory, radiological, and microbiological findings of five patients in a family cluster who presented with unexplained pneumonia after returning to Shenzhen, Guangdong province, China, after a visit to Wuhan, and an additional family member who did not travel to Wuhan. Phylogenetic analysis of genetic sequences from these patients were done. FINDINGS: From Jan 10, 2020, we enrolled a family of six patients who travelled to Wuhan from Shenzhen between Dec 29, 2019 and Jan 4, 2020. Of six family members who travelled to Wuhan, five were identified as infected with the novel coronavirus. Additionally, one family member, who did not travel to Wuhan, became infected with the virus after several days of contact with four of the family members. None of the family members had contacts with Wuhan markets or animals, although two had visited a Wuhan hospital. Five family members (aged 36-66 years) presented with fever, upper or lower respiratory tract symptoms, or diarrhoea, or a combination of these 3-6 days after exposure. They presented to our hospital (The University of Hong Kong-Shenzhen Hospital, Shenzhen) 6-10 days after symptom onset. They and one asymptomatic child (aged 10 years) had radiological ground-glass lung opacities. Older patients (aged >60 years) had more systemic symptoms, extensive radiological ground-glass lung changes, lymphopenia, thrombocytopenia, and increased C-reactive protein and lactate dehydrogenase levels. The nasopharyngeal or throat swabs of these six patients were negative for known respiratory microbes by point-of-care multiplex RT-PCR, but five patients (four adults and the child) were RT-PCR positive for genes encoding the internal RNA-dependent RNA polymerase and surface Spike protein of this novel coronavirus, which were confirmed by Sanger sequencing. Phylogenetic analysis of these five patients' RT-PCR amplicons and two full genomes by next-generation sequencing showed that this is a novel coronavirus, which is closest to the bat severe acute respiatory syndrome (SARS)-related coronaviruses found in Chinese horseshoe bats. INTERPRETATION: Our findings are consistent with person-to-person transmission of this novel coronavirus in hospital and family settings, and the reports of infected travellers in other geographical regions. FUNDING: The Shaw Foundation Hong Kong, Michael Seak-Kan Tong, Respiratory Viral Research Foundation Limited, Hui Ming, Hui Hoy and Chow Sin Lan Charity Fund Limited, Marina Man-Wai Lee, the Hong Kong Hainan Commercial Association South China Microbiology Research Fund, Sanming Project of Medicine (Shenzhen), and High Level-Hospital Program (Guangdong Health Commission).

      3. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive studyexternal icon
        Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, Qiu Y, Wang J, Liu Y, Wei Y, Xia J, Yu T, Zhang X, Zhang L.
        Lancet. 2020 Jan 30.
        BACKGROUND: In December, 2019, a pneumonia associated with the 2019 novel coronavirus (2019-nCoV) emerged in Wuhan, China. We aimed to further clarify the epidemiological and clinical characteristics of 2019-nCoV pneumonia. METHODS: In this retrospective, single-centre study, we included all confirmed cases of 2019-nCoV in Wuhan Jinyintan Hospital from Jan 1 to Jan 20, 2020. Cases were confirmed by real-time RT-PCR and were analysed for epidemiological, demographic, clinical, and radiological features and laboratory data. Outcomes were followed up until Jan 25, 2020. FINDINGS: Of the 99 patients with 2019-nCoV pneumonia, 49 (49%) had a history of exposure to the Huanan seafood market. The average age of the patients was 55.5 years (SD 13.1), including 67 men and 32 women. 2019-nCoV was detected in all patients by real-time RT-PCR. 50 (51%) patients had chronic diseases. Patients had clinical manifestations of fever (82 [83%] patients), cough (81 [82%] patients), shortness of breath (31 [31%] patients), muscle ache (11 [11%] patients), confusion (nine [9%] patients), headache (eight [8%] patients), sore throat (five [5%] patients), rhinorrhoea (four [4%] patients), chest pain (two [2%] patients), diarrhoea (two [2%] patients), and nausea and vomiting (one [1%] patient). According to imaging examination, 74 (75%) patients showed bilateral pneumonia, 14 (14%) patients showed multiple mottling and ground-glass opacity, and one (1%) patient had pneumothorax. 17 (17%) patients developed acute respiratory distress syndrome and, among them, 11 (11%) patients worsened in a short period of time and died of multiple organ failure. INTERPRETATION: The 2019-nCoV infection was of clustering onset, is more likely to affect older males with comorbidities, and can result in severe and even fatal respiratory diseases such as acute respiratory distress syndrome. In general, characteristics of patients who died were in line with the MuLBSTA score, an early warning model for predicting mortality in viral pneumonia. Further investigation is needed to explore the applicability of the MuLBSTA score in predicting the risk of mortality in 2019-nCoV infection. FUNDING: National Key R&D Program of China.

      4. Emerging coronaviruses: genome structure, replication, and pathogenesisexternal icon
        Chen Y, Liu Q, Guo D.
        J Med Virol. 2020 :10.1002/jmv.25681.
        The recent emergence of a novel coronavirus (2019-nCoV), which is causing an outbreak of unusual viral pneumonia in patients in Wuhan, a central city in China, is another warning of the risk of coronaviruses posed to public health. In this mini-review, we provide a brief introduction of the general features of coronaviruses and describe diseases caused by different coronaviruses in humans and animals. This review will help understand the biology and potential risk of coronaviruses that exist in richness in wildlife such as bats. This article is protected by copyright. All rights reserved.

      5. Outbreak of a novel coronavirusexternal icon
        Du Toit A.
        Nature reviews. Microbiology. 2020 :10.1038/s41579-020-0332-0.


      7. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, Chinaexternal icon
        Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B.
        Lancet (London, England). 2020 :S0140-6736(20)30183-5.
        BACKGROUND: A recent cluster of pneumonia cases in Wuhan, China, was caused by a novel betacoronavirus, the 2019 novel coronavirus (2019-nCoV). We report the epidemiological, clinical, laboratory, and radiological characteristics and treatment and clinical outcomes of these patients. METHODS: All patients with suspected 2019-nCoV were admitted to a designated hospital in Wuhan. We prospectively collected and analysed data on patients with laboratory-confirmed 2019-nCoV infection by real-time RT-PCR and next-generation sequencing. Data were obtained with standardised data collection forms shared by the International Severe Acute Respiratory and Emerging Infection Consortium from electronic medical records. Researchers also directly communicated with patients or their families to ascertain epidemiological and symptom data. Outcomes were also compared between patients who had been admitted to the intensive care unit (ICU) and those who had not. FINDINGS: By Jan 2, 2020, 41 admitted hospital patients had been identified as having laboratory-confirmed 2019-nCoV infection. Most of the infected patients were men (30 [73%] of 41); less than half had underlying diseases (13 [32%]), including diabetes (eight [20%]), hypertension (six [15%]), and cardiovascular disease (six [15%]). Median age was 49·0 years (IQR 41·0-58·0). 27 (66%) of 41 patients had been exposed to Huanan seafood market. One family cluster was found. Common symptoms at onset of illness were fever (40 [98%] of 41 patients), cough (31 [76%]), and myalgia or fatigue (18 [44%]); less common symptoms were sputum production (11 [28%] of 39), headache (three [8%] of 38), haemoptysis (two [5%] of 39), and diarrhoea (one [3%] of 38). Dyspnoea developed in 22 (55%) of 40 patients (median time from illness onset to dyspnoea 8·0 days [IQR 5·0-13·0]). 26 (63%) of 41 patients had lymphopenia. All 41 patients had pneumonia with abnormal findings on chest CT. Complications included acute respiratory distress syndrome (12 [29%]), RNAaemia (six [15%]), acute cardiac injury (five [12%]) and secondary infection (four [10%]). 13 (32%) patients were admitted to an ICU and six (15%) died. Compared with non-ICU patients, ICU patients had higher plasma levels of IL2, IL7, IL10, GSCF, IP10, MCP1, MIP1A, and TNFα. INTERPRETATION: The 2019-nCoV infection caused clusters of severe respiratory illness similar to severe acute respiratory syndrome coronavirus and was associated with ICU admission and high mortality. Major gaps in our knowledge of the origin, epidemiology, duration of human transmission, and clinical spectrum of disease need fulfilment by future studies. FUNDING: Ministry of Science and Technology, Chinese Academy of Medical Sciences, National Natural Science Foundation of China, and Beijing Municipal Science and Technology Commission.

      8. Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor bindingexternal icon
        Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, Wang W, Song H, Huang B, Zhu N, Bi Y, Ma X, Zhan F, Wang L, Hu T, Zhou H, Hu Z, Zhou W, Zhao L, Chen J, Meng Y, Wang J, Lin Y, Yuan J, Xie Z, Ma J, Liu WJ, Wang D, Xu W, Holmes EC, Gao GF, Wu G, Chen W, Shi W, Tan W.
        Lancet. 2020 Jan 30.
        BACKGROUND: In late December, 2019, patients presenting with viral pneumonia due to an unidentified microbial agent were reported in Wuhan, China. A novel coronavirus was subsequently identified as the causative pathogen, provisionally named 2019 novel coronavirus (2019-nCoV). As of Jan 26, 2020, more than 2000 cases of 2019-nCoV infection have been confirmed, most of which involved people living in or visiting Wuhan, and human-to-human transmission has been confirmed. METHODS: We did next-generation sequencing of samples from bronchoalveolar lavage fluid and cultured isolates from nine inpatients, eight of whom had visited the Huanan seafood market in Wuhan. Complete and partial 2019-nCoV genome sequences were obtained from these individuals. Viral contigs were connected using Sanger sequencing to obtain the full-length genomes, with the terminal regions determined by rapid amplification of cDNA ends. Phylogenetic analysis of these 2019-nCoV genomes and those of other coronaviruses was used to determine the evolutionary history of the virus and help infer its likely origin. Homology modelling was done to explore the likely receptor-binding properties of the virus. FINDINGS: The ten genome sequences of 2019-nCoV obtained from the nine patients were extremely similar, exhibiting more than 99.98% sequence identity. Notably, 2019-nCoV was closely related (with 88% identity) to two bat-derived severe acute respiratory syndrome (SARS)-like coronaviruses, bat-SL-CoVZC45 and bat-SL-CoVZXC21, collected in 2018 in Zhoushan, eastern China, but were more distant from SARS-CoV (about 79%) and MERS-CoV (about 50%). Phylogenetic analysis revealed that 2019-nCoV fell within the subgenus Sarbecovirus of the genus Betacoronavirus, with a relatively long branch length to its closest relatives bat-SL-CoVZC45 and bat-SL-CoVZXC21, and was genetically distinct from SARS-CoV. Notably, homology modelling revealed that 2019-nCoV had a similar receptor-binding domain structure to that of SARS-CoV, despite amino acid variation at some key residues. INTERPRETATION: 2019-nCoV is sufficiently divergent from SARS-CoV to be considered a new human-infecting betacoronavirus. Although our phylogenetic analysis suggests that bats might be the original host of this virus, an animal sold at the seafood market in Wuhan might represent an intermediate host facilitating the emergence of the virus in humans. Importantly, structural analysis suggests that 2019-nCoV might be able to bind to the angiotensin-converting enzyme 2 receptor in humans. The future evolution, adaptation, and spread of this virus warrant urgent investigation. FUNDING: National Key Research and Development Program of China, National Major Project for Control and Prevention of Infectious Disease in China, Chinese Academy of Sciences, Shandong First Medical University.

      9. China coronavirus: what do we know so far?external icon
        Mahase E.
        BMJ (Clinical research ed.). 2020 ;368:m308-m308.

      10. A novel coronavirus emerging in China - key questions for impact assessmentexternal icon
        Munster V, Koopmans M, van Doremalen N, van Riel D, de Wit E.
        N Engl J Med. 2020 :10.1056/NEJMp2000929.


      12. Coronavirus infections-more than just the common coldexternal icon
        Paules C, Marston H, Fauci A.
        JAMA. 2020 :10.1001/jama.2020.0757.

      13. Another decade, another coronavirusexternal icon
        Perlman S.
        N Engl J Med. 2020 :10.1056/NEJMe2001126.

      14. Novel framework for assessing epidemiologic effects of influenza epidemics and pandemicsexternal icon
        Reed C, Biggerstaff M, Finelli L, Koonin LM, Beauvais D, Uzicanin A, Plummer A, Bresee J, Redd SC, Jernigan DB.
        Emerg Infect Dis. 2013 Jan;19(1):85-91.
        The effects of influenza on a population are attributable to the clinical severity of illness and the number of persons infected, which can vary greatly between seasons or pandemics. To create a systematic framework for assessing the public health effects of an emerging pandemic, we reviewed data from past influenza seasons and pandemics to characterize severity and transmissibility (based on ranges of these measures in the United States) and outlined a formal assessment of the potential effects of a novel virus. The assessment was divided into 2 periods. Because early in a pandemic, measurement of severity and transmissibility is uncertain, we used a broad dichotomous scale in the initial assessment to divide the range of historic values. In the refined assessment, as more data became available, we categorized those values more precisely. By organizing and prioritizing data collection, this approach may inform an evidence-based assessment of pandemic effects and guide decision making.

      15. A novel coronavirus outbreak of global health concernexternal icon
        Wang C, Horby P, Hayden F, Gao G.
        Lancet (London, England). 2020 :S0140-6736(20)30185-9.

      16. A novel coronavirus from patients with pneumonia in China, 2019external icon
        Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, Huang B, Shi W, Lu R, Niu P, Zhan F, Ma X, Wang D, Xu W, Wu G, Gao G, Tan W.
        N Engl J Med. 2020 :10.1056/NEJMoa2001017.
        In December 2019, a cluster of patients with pneumonia of unknown cause was linked to a seafood wholesale market in Wuhan, China. A previously unknown betacoronavirus was discovered through the use of unbiased sequencing in samples from patients with pneumonia. Human airway epithelial cells were used to isolate a novel coronavirus, named 2019-nCoV, which formed another clade within the subgenus sarbecovirus, Orthocoronavirinae subfamily. Different from both MERS-CoV and SARS-CoV, 2019-nCoV is the seventh member of the family of coronaviruses that infect humans. Enhanced surveillance and further investigation are ongoing. (Funded by the National Key Research and Development Program of China and the National Major Project for Control and Prevention of Infectious Disease in China.).


  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. Comorbid conditions and the transition among states of hip osteoarthritis and symptoms in a community-based study: a multi-state time-to-event model approachexternal icon
        Alvarez C, Cleveland RJ, Schwartz TA, Renner JB, Murphy LB, Jordan JM, Callahan LF, Golightly YM, Nelson AE.
        Arthritis Res Ther. 2020 Jan 20;22(1):12.
        BACKGROUND: We examined the association of three common chronic conditions (obesity, diabetes mellitus [DM], and cardiovascular disease [CVD]) with transitions among states of hip osteoarthritis (HOA). METHODS: This longitudinal analysis used data from the Johnston County Osteoarthritis Project (JoCo OA, n = 3857), a community-based study in North Carolina, USA, with 18.4 +/- 1.5 years of follow-up. Transitions across the following states were modeled: development of radiographic HOA (rHOA; Kellgren-Lawrence grade [KLG] of< 2); development of hip symptoms (self-reported hip pain, aching, or stiffness on most days) or symptomatic HOA (sxHOA; rHOA and symptoms in the same hip), and resolution of symptoms. Obesity (body mass index >/= 30 kg/m(2)) and self-reported DM and CVD were the time-dependent comorbid conditions of interest. Markov multi-state models were used to estimate adjusted hazard ratios and 95% confidence intervals to describe the associations between the conditions and HOA states. RESULTS: The sample included 33% African Americans, 39% men, with a mean (SD) age of 62.2 (9.8) years; the frequencies of the comorbidities increased substantially over time. When considered individually, obesity was associated with incident hip symptoms, while CVD and DM were associated with reduced symptom resolution. For those with > 1 comorbidity, the likelihood of incident sxHOA increased, while that of symptom resolution significantly decreased. When stratified by sex, the association between obesity and incident symptoms was only seen in women; among men with DM versus men without, there was a significant (~ 75%) reduction in symptom resolution in those with rHOA. When stratified by race, African Americans with DM, versus those without, were much more likely to develop sxHOA. CONCLUSIONS: Comorbid chronic conditions are common in individuals with OA, and these conditions have a significant impact on the persistence and progression of HOA. OA management decisions, both pharmacologic and non-pharmacologic, should include considerations of the inter-relationships between OA and common comorbidities such as DM and CVD.


      3. Survivorship objectives in comprehensive cancer control plans: a systematic reviewexternal icon
        Mollica MA, Falisi AL, Geiger AM, Jacobsen PB, Lunsford NB, Pratt-Chapman ML, Townsend JS, Nekhlyudov L.
        J Cancer Surviv. 2020 Jan 17.
        PURPOSE: Over a decade ago, the National Academy of Medicine (NAM) recommended that states develop, implement, and evaluate plans that include consideration of survivorship care. The purpose of this study was to review comprehensive cancer control plans in the USA, specifically to identify the inclusion of cancer survivorship-focused goals and objectives and examine alignment of survivorship-focused objectives with the NAM recommendations. METHODS: Plans from 50 states, 7 territories, 5 tribal organizations, and the District of Columbia were reviewed to assess inclusion of survivorship goals and objectives. One territory plan was excluded because it did not include a survivorship-focused goal or objective (final n = 62). Objectives were assigned to domains based on NAM survivorship recommendations. RESULTS: Plans included between 1 and 19 survivorship-related objectives. Of the 345 survivorship objectives extracted and analyzed, the most prevalent domains addressed were raising awareness, survivorship care plans, healthcare professional capacity, and models of coordinated care. Employment-related concerns, developing and implementing quality measures, and investments in research were not frequently included in objectives. CONCLUSIONS: Comprehensive cancer control plans represent an important strategy that may reduce the impact of cancer and its treatment. State, territorial, and tribal coalitions can use these results to systematically focus future survivorship efforts on areas relevant to their region and population. IMPLICATIONS FOR CANCER SURVIVORS: The growing number of survivors requires broad-ranging policy strategies. Future efforts are needed to assess the implementation and impact of plan strategies to improve the overall wellness of cancer survivors.

      4. Evidence-based interventions for high blood pressure and glycemic control among Illinois health systemsexternal icon
        Price JD, Jayaprakash M, McKay CM, Amerson NL, Jimenez PL, Barbour KE, Cunningham TJ.
        Prev Chronic Dis. 2020 Jan 23;17:E08.
        INTRODUCTION: Evidence-based interventions (referral, team-based care, self-management, and self-monitoring) for chronic disease management are well documented and widely used by Federally Qualified Health Centers (FQHCs). However, how these interventions are implemented varies substantially. METHODS: The Illinois Health Information Systems Survey was deployed to 49 FQHCs. Responses were grouped into 4 distinct policies, systems, and processes (P/S/P) categories: internal policies/workflows, huddles (brief meetings), electronic health record alerts/tracking tools, and case manager/coordinator interaction. Responses were then direct-matched to the 2016 Health Resources and Services and Administration Uniform Data System clinical quality indicator (QI) percent scores. Descriptive statistics were generated and level of significance (P < .05) was tested for hypertension and type 2 diabetes mellitus. RESULTS: The total number of P/S/Ps in place for hypertension ranged from 0 to 13 (mean, 6.9) and 0 to 8 for diabetes (mean, 5.1). Meeting or exceeding the national mean QI percent score for controlled blood pressure (62.4%) was significant among FQHCs with 9 or more P/S/Ps compared with those with 8 or fewer P/S/Ps. A positive association in clinical QI percent score was found among organizations that had 3 or more P/S/Ps (for all 4 intervention areas), although none were significant. CONCLUSION: An assessment of the types of P/S/Ps used to implement evidence-based interventions for hypertension and diabetes management is a first in Illinois. Initial results support some relationship between the number of P/S/Ps implemented and clinical QI percent score for both hypertension and diabetes.

    • Communicable Diseases
      1. Heritage and genealogy travel health concerns in the era of in-home DNA testingexternal icon
        Angelo KM, Breiman J, Wu HM, Nemhauser J, Walker AT.
        J Travel Med. 2020 Jan 14.

      2. Mother-to-child transmission of HIV in adolescents and young women: Findings from a national prospective cohort survey, Zimbabwe, 2013-2014external icon
        Burrage AB, Mushavi A, Shiraishi RW, Barr BT, Shambira G, Nyakura J, Balachandra S, Kilmarx PH, Dinh TH.
        J Adolesc Health. 2020 Jan 18.
        PURPOSE: We assessed 18-month cumulative mother-to-child HIV transmission (MTCT) risk and risk factors for no antiretroviral medication use during pregnancy among adolescent, young women, and adult mothers in Zimbabwe. METHODS: We analyzed data from a prospective survey of 1,171 mother-infant pairs with HIV-exposed infants aged 4-12 weeks who were recruited from 151 immunization clinics from February to August 2013. HIV-exposed infants were followed until diagnosed with HIV, death, or age 18 months. Findings were weighted and adjusted for complex survey design and nonresponse. RESULTS: The 18-month cumulative MTCT risk was highest among adolescent aged </=19 years (12%) followed by young women aged 20-24 years (7.5%) and adult women aged >/=25 years (6.9%). Across these groups, more than 94% had >/=1 antenatal care visit by 21 weeks of gestation, more than 95% had >/=1 HIV test, and more than 98% knew their HIV status. Of known HIV-positive mothers, maternal antiretroviral medication coverage during pregnancy was 76.8% (95% confidence interval: 65.1-85.5), 83.8% (78.6-87.9), and 87.8% (84.6-90.4) among adolescent, young women, and adult mothers, respectively. Among HIV-positive mothers diagnosed prenatally, the adjusted odds ratio of no ARV use during pregnancy was increased among those who had no antenatal care attendance (adjusted odds ratio: 7.7 [3.7-16.0]), no HIV testing (7.3 [2.3-23.5]), no prepartum CD4 count testing (2.1 [1.3-3.4]), and maternal HIV identification during pregnancy (2.9 [1.8-4.8]). Age was not a risk factor. CONCLUSIONS: With similar coverage of prevention of MTCT services, the 18-month cumulative MTCT risk was higher among adolescents and young women, compared with adults. Additional research should examine the causes to develop targeted interventions.

      3. BACKGROUND: This study examined condom use and sexually transmitted infection (STI) testing among unmarried, non-cohabiting women and men who had multiple past-year partnerships or perceived their partner's involvement in another sexual relationship. METHODS: We identified 5868 and 5330 unmarried, non-cohabiting sexually active women and men aged 15 to 44 years using National Survey of Family Growth data for 2011 to 2017. To measure multiple partnerships, we created 4 dichotomous variables that included both past-year number of opposite-sex sex partners (1, 2 or more) and perceived partner nonmonogamy (PPNM) (yes, no). Results were stratified by relationship type at last sex ("steady" vs "casual"). RESULTS: Overall, 39.4% of women and 48.3% of men reported multiple partnerships and 23.4% and 24.0% reported PPNM. Lower condom use was seen for women and men who had 2 or more partners in the past year and PPNM than those with only 1 partner and no PPNM (women, 28.5%; 95% confidence interval [CI], 24.1-32.9 vs 39.3%; 95% CI, 36.6-41.9) (men, 37.7%; 33.5-41.8 vs 54.9%; 51.9-57.9). STI testing was higher for groups with PPNM. Men with a steady sex partner had higher prevalence of past-year STI testing if they reported PPNM than not (adjusted prevalence ratio, 2.00; 95% CI, 1.63-2.45). CONCLUSIONS: Screening practices that include a standardized sexual risk assessment could identify those with multiple sex partners or PPNM and improve linkage to STI services. Availability of point-of-care tests and expedited partner therapy could provide targeted strategies that prioritize rapid diagnosis and effective partner treatment which may prevent further STI spread.

      4. Humoral and mucosal immune responses to human norovirus in the elderlyexternal icon
        Costantini VP, Cooper EM, Hardaker HL, Lee LE, DeBess EE, Cieslak PR, Hall AJ, Vinje J.
        J Infect Dis. 2020 Jan 20.
        BACKGROUND: Most information on mucosal and systemic immune response to norovirus infection is derived from human challenge studies, birth cohort studies, or vaccine trials in healthy adults. However, few data are available on immune responses to norovirus in the elderly. MATERIALS: To study the mucosal and systemic immune response against norovirus, 43 long-term care facilities (LTCFs) were enrolled prospectively in 2010-2014. Baseline saliva samples were collected from 17 facilities and from cases and controls up to day 84 from 10 outbreaks as well as acute and convalescent sera. RESULTS: Norovirus-specific IgA levels in baseline saliva samples were low and increased in both symptomatic patients and asymptomatic shedders at day 5 after onset. ROC analysis correctly assigned prior norovirus infection in 23 (92%) of 25 participants. Cases and asymptomatic shedders showed seroconversion for IgG (80%), IgA (78%) and blockade antibodies (87%). Salivary IgA levels strongly correlated with increased convalescent serum IgA titers and blockade antibodies. CONCLUSIONS: Salivary IgA levels strongly correlated with serum IgA titers and blockade antibodies and remained elevated 3 months after a norovirus outbreak. A single salivary sample collected on day 14 could be used to identify recent infection in a suspected outbreak or to monitor population salivary IgA.

      5. Human parainfluenza virus circulation, United States, 2011-2019external icon
        DeGroote NP, Haynes AK, Taylor C, Killerby ME, Dahl RM, Mustaquim D, Gerber SI, Watson JT.
        J Clin Virol. 2020 Jan 9;124:104261.
        BACKGROUND: Human parainfluenza viruses (HPIVs) cause upper and lower respiratory tract illnesses, most frequently among infants and young children, but also in the elderly. While seasonal patterns of HPIV types 1-3 have been described, less is known about national patterns of HPIV-4 circulation. OBJECTIVES: To describe patterns of HPIVs circulation in the United States (US). STUDY DESIGN: We used data from the National Respiratory and Enteric Virus Surveillance System (NREVSS), a voluntary passive laboratory-based surveillance system, to characterize the epidemiology and circulation patterns of HPIVs in the US during 2011-2019. We summarized the number of weekly aggregated HPIV detections nationally and by US census region, and used a subset of data submitted to NREVSS from public health laboratories and several clinical laboratories during 2015-2019 to analyze differences in patient demographics. RESULTS: During July 2011 - June 2019, 2,700,135 HPIV tests were reported; 122,852 (5 %) were positive for any HPIV including 22,446 for HPIV-1 (18 %), 17,474 for HPIV-2 (14 %), 67,649 for HPIV-3 (55 %), and 15,283 for HPIV-4 (13 %). HPIV testing increased substantially each year. The majority of detections occurred in children aged </= 2 years (36 %) with fluctuations in the distribution of age by type. CONCLUSIONS: HPIVs were detected year-round during 2011-2019, with type-specific year-to-year variations in circulation patterns. Among HPIV detections where age was known, the majority were aged </= 2 years. HPIV-4 exhibited an annual fall-winter seasonality, both nationally and regionally. Continued surveillance is needed to better understand national patterns of HPIV circulation.

      6. Associations between neighborhood problems and sexual behaviors among black men who have sex with men in the deep south: The MARI Studyexternal icon
        Duncan DT, Sutton MY, Park SH, Callander D, Kim B, Jeffries WL, Henny KD, Harry-Hernandez S, Barber S, Hickson DA.
        Arch Sex Behav. 2020 Jan 16.
        There is a disproportionately high HIV incidence among Black men who have sex with men (MSM) despite equal or lower levels of HIV risk behaviors compared to White MSM. Due to high levels of racial segregation in the U.S., Black MSM have an elevated likelihood of living in neighborhoods that contain psychosocial stressors, which, in turn, may increase behaviors promoting HIV infection. We examined associations between perceived neighborhood problems and sexual behaviors among Black MSM in the Deep South, a population at highest risk of HIV. Data came from the MARI Study, which included Black MSM ages 18-66 years recruited from the Jackson, MS, and Atlanta, GA, metropolitan areas (n = 377). Participants completed questions about neighborhood problems (e.g., excessive noise, heavy traffic/speeding cars and trash/litter) and sexual behaviors (e.g., condomless sex and drug use before or during sex). We used Poisson's regression model with robust standard errors to estimate the adjusted prevalence ratio (aPR; 95% confidence intervals [CI]) of neighborhood problems (coded as tertiles [tertile 1 = low neighborhood problems, tertile 2 = medium neighborhood problems, tertile 3 = high neighborhood problems] as well as continuously) with sexual behaviors, after adjustment for sociodemographic characteristics and other variables. About one-fourth of the sample reported at least one neighborhood problem, with the most common (31.6%) being no/poorly maintained sidewalks, which indicates an infrastructural problem. In multivariable models, compared to those in the lowest tertile, those reporting more neighborhood problems (tertile 2: aPR = 1.49, 95% CI = 1.04, 2.14 and tertile 3: aPR = 1.53, 95% CI = 1.05, 2.24) reported more drug use before or during sex (p for trend = .027). Neighborhood problems may promote behaviors (e.g., drug use before or during sex) conducive to HIV infection. Structural interventions could improve community infrastructure to reduce neighborhood problems (e.g., no/poorly maintained sidewalks and litter). These interventions may help to reduce HIV incidence among Black MSM in the Deep South.

      7. Evaluating DREAMS HIV prevention interventions targeting adolescent girls and young women in high HIV prevalence districts in South Africa: protocol for a cross-sectional studyexternal icon
        George G, Cawood C, Puren A, Khanyile D, Gerritsen A, Govender K, Beckett S, Glenshaw M, Diallo K, Ayalew K, Gibbs A, Reddy T, Madurai L, Kufa-Chakezha T, Kharsany AB.
        BMC Womens Health. 2020 Jan 16;20(1):7.
        BACKGROUND: Young women in sub-Saharan Africa remain at the epicentre of the HIV epidemic, with surveillance data indicating persistent high levels of HIV incidence. In South Africa, adolescent girls and young women (AGYW) account for a quarter of all new HIV infections. Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) is a strategy introduced by the United States President's Emergency Plan for AIDS Relief (PEPFAR) aimed at reducing HIV incidence among AGYW in 10 countries in sub-Saharan Africa by 25% in the programme's first year, and by 40% in the second year. This study will assess the change in HIV incidence and reduction in risk associated behaviours that can be attributed to the DREAMS initiative in South Africa, using a population-based cross-sectional survey. METHODS: Data will be collected from a household-based representative sample of AGYW (between the ages 12-24 years) in four high prevalence districts (more than 10% of the population have HIV in these districts) in South Africa in which DREAMS has been implemented. A stratified cluster-based sampling approach will be used to select eligible participants for a cross-sectional survey with 18,500, to be conducted over 2017/2018. A questionnaire will be administered containing questions on sexual risk behaviour, selected academic and developmental milestones, prevalence of gender based violence, whilst examining exposure to DREAMS programmes. Biological samples, including two micro-containers of blood and self-collected vulvovaginal swab samples, are collected in each survey to test for HIV infection, HIV incidence, sexually transmitted infections (STIs) and pregnancy. This study will measure trends in population level HIV incidence using the Limiting antigen (LAg) Avidity Enzyme Immuno-Assay (EIA) and monitor changes in HIV incidence. DISCUSSION: Ending the HIV/AIDS pandemic by 2030 requires the continual monitoring and evaluation of prevention programmes, with the aim of optimising efforts and ensuring the achievement of epidemic control. This study will determine the impact DREAMS interventions have had on HIV incidence among AGYW in a 'real world, non-trial setting'.

      8. Persistence with HIV preexposure prophylaxis in the United States, 2012-2017external icon
        Huang YA, Tao G, Smith DK, Hoover KW.
        Clin Infect Dis. 2020 Jan 14.
        BACKGROUND: Daily oral preexposure prophylaxis (PrEP) is highly effective in preventing HIV infection if used adherently throughout periods of HIV risk. We estimated PrEP persistence among cohorts of persons with commercial or Medicaid insurance. METHODS: We analyzed data from the IBM MarketScan Research Database to identify persons aged 18-64 years who initiated PrEP between 2012-2017. We assessed PrEP persistence by calculating the time period that each person continued filling PrEP prescriptions until there was a gap in prescription fills >30 days. We used Kaplan-Meier time-to-event methods to estimate the proportion of PrEP users who persisted with PrEP at 3, 6, and 12 months after initiation, and constructed Cox proportional hazards models to determine patient characteristics associated with non-persistence. RESULTS: We studied 11,807 commercially insured and 647 Medicaid insured persons with PrEP prescriptions. Commercially insured patients persisted for median time of 13.7 months (95% CI 13.3-14.1), compared to 6.8 months (95% CI 6.1-7.6) among Medicaid patients. Additionally, female sex, younger age, residence in rural location, and black race were associated with shorter persistence. After adjusting for covariates, we found that female sex (Hazard Ratio [HR]=1.81; 95% CI 1.56-2.11) and younger age (18-24 years: HR=2.38; 95% CI 2.11-2.69) predicted non-persistence. CONCLUSIONS: More than half of commercially insured persons who initiated PrEP persisted with it for 12 months, compared to a third of those with Medicaid. A better understanding of reasons for non-persistence is important to support persistent PrEP use, and to develop interventions designed for the diverse needs of at-risk populations.

      9. Global transmission of live polioviruses: Updated dynamic modeling of the polio endgameexternal icon
        Kalkowska DA, Pallansch MA, Wassilak SG, Cochi SL, Thompson KM.
        Risk Anal. 2020 Jan 20.
        Nearly 20 years after the year 2000 target for global wild poliovirus (WPV) eradication, live polioviruses continue to circulate with all three serotypes posing challenges for the polio endgame. We updated a global differential equation-based poliovirus transmission and stochastic risk model to include programmatic and epidemiological experience through January 2020. We used the model to explore the likely dynamics of poliovirus transmission for 2019-2023, which coincides with a new Global Polio Eradication Initiative Strategic Plan. The model stratifies the global population into 72 blocks, each containing 10 subpopulations of approximately 10.7 million people. Exported viruses go into subpopulations within the same block and within groups of blocks that represent large preferentially mixing geographical areas (e.g., continents). We assign representative World Bank income levels to the blocks along with polio immunization and transmission assumptions, which capture some of the heterogeneity across countries while still focusing on global poliovirus transmission dynamics. We also updated estimates of reintroduction risks using available evidence. The updated model characterizes transmission dynamics and resulting polio cases consistent with the evidence through 2019. Based on recent epidemiological experience and prospective immunization assumptions for the 2019-2023 Strategic Plan, the updated model does not show successful eradication of serotype 1 WPV by 2023 or successful cessation of oral poliovirus vaccine serotype 2-related viruses.

      10. The impact of human immunodeficiency virus exposure on respiratory syncytial virus-associated severe respiratory illness in South African infants, 2011-2016external icon
        McMorrow ML, Tempia S, Walaza S, Treurnicht FK, Moyes J, Cohen AL, Pretorius M, Hellferscee O, Wolter N, von Gottberg A, Nguweneza A, McAnerney JM, Naby F, Mekgoe O, Venter M, Madhi SA, Cohen C.
        Clin Infect Dis. 2019 Nov 27;69(12):2208-2211.
        From 2011 through 2016, we conducted surveillance for severe respiratory illness in infants. Human immunodeficiency virus exposure significantly increased the risk of respiratory syncytial virus (RSV)-associated hospitalization in infants aged <5 months. More than 60% of RSV-associated hospitalizations occurred in the first 4 months of life and may be preventable through maternal vaccination or birth-dose monoclonal antibody.

      11. Overcoming the challenges of studying expedited partner therapy in the real worldexternal icon
        Nemeth SV, Schillinger JA.
        Sex Transm Dis. 2019 Oct;46(10):693-696.

      12. Low levels of HIV-1 drug resistance mutations in patients who achieved viral re-suppression without regimen switch: a retrospective studyexternal icon
        Onwuamah CK, Okpokwu J, Audu R, Imade G, Meloni ST, Okwuraiwe A, Chebu P, Musa AZ, Chaplin B, Dalhatu I, Agbaji O, Samuels J, Ezechi O, Ahmed M, Odaibo G, Olaleye DO, Okonkwo P, Salako BL, Raizes E, Yang C, Kanki PJ, Idigbe EO.
        BMC Microbiol. 2020 Jan 20;20(1):17.
        BACKGROUND: We identified a HIV-positive cohort in virologic failure (VF) who re-suppressed without drug switch. We characterized their drug resistance mutations (DRM) and adherence profiles to learn how to better manage HIV drug resistance. A retrospective cohort study utilizing clinical data and stored samples. Patients received ART at three Nigerian treatment centres. Plasma samples stored when they were in VF were genotyped. RESULT: Of 126 patients with samples available, 57 were successfully genotyped. From ART initiation, the proportion of patients with adherence >/=90% increased steadily from 54% at first high viral load (VL) to 67% at confirmed VF, and 81% at time of re-suppressed VL. Sixteen (28%) patients had at least one DRM. Forty-six (81%) patients had full susceptibility to the three drugs in their first-line (1 L) regimen. Thirteen (23%) were resistant to at least one antiretroviral drug but three were resistant to drugs not used in Nigeria. Ten patients had resistance to their 1 L drug(s) and six were fully susceptible to the three drugs in the recommended second-line regimen. CONCLUSION: This cohort had little drug resistance mutations. We conclude that if adherence is not assured, patients could exhibit virologic failure without having developed mutations associated with drug resistance.

      13. Genetic characterization of influenza A(H3N2) viruses circulating in coastal Kenya, 2009-2017external icon
        Owuor DC, Ngoi JM, Otieno JR, Otieno GP, Nyasimi FM, Nyiro JU, Agoti CN, Chaves SS, Nokes DJ.
        Influenza Other Respir Viruses. 2020 Jan 13.
        BACKGROUND: Influenza viruses evolve rapidly and undergo immune driven selection, especially in the hemagglutinin (HA) protein. We report amino acid changes affecting antigenic epitopes and receptor-binding sites of A(H3N2) viruses circulating in Kilifi, Kenya, from 2009 to 2017. METHODS: Next-generation sequencing (NGS) was used to generate A(H3N2) virus genomic data from influenza-positive specimens collected from hospital admissions and health facility outpatients presenting with acute respiratory illness to health facilities within the Kilifi Health and Demographic Surveillance System. Full-length HA sequences were utilized to characterize A(H3N2) virus genetic and antigenic changes. RESULTS: From 186 (90 inpatient and 96 outpatient) influenza A virus-positive specimens processed, 101 A(H3N2) virus whole genomes were obtained. Among viruses identified in inpatient specimens from 2009 to 2015, divergence of circulating A(H3N2) viruses from the vaccine strains A/Perth/16/2009, A/Texas/50/2012, and A/Switzerland/9715293/2013 formed 6 genetic clades (A/Victoria/208/2009-like, 3B, 3C, 3C.2a, 4, and 7). Among viruses identified in outpatient specimens from 2015 to 2017, divergence of circulating A(H3N2) viruses from vaccine strain A/Hong Kong/4801/2014 formed clade 3C.2a, subclades 3C.2a2 and 3C.2a3, and subgroup 3C.2a1b. Several amino acid substitutions were associated with the continued genetic evolution of A(H3N2) strains in circulation. CONCLUSIONS: Our results suggest continuing evolution of currently circulating A(H3N2) viruses in Kilifi, coastal Kenya and suggest the need for continuous genetic and antigenic viral surveillance of circulating seasonal influenza viruses with broad geographic representation to facilitate prompt and efficient selection of influenza strains for inclusion in future influenza vaccines.

      14. Hepatitis E as a cause of adult hospitalization in Bangladesh: Results from an acute jaundice surveillance study in six tertiary hospitals, 2014-2017external icon
        Paul RC, Nazneen A, Banik KC, Sumon SA, Paul KK, Akram A, Uzzaman MS, Iqbal T, Tejada-Strop A, Kamili S, Luby SP, Gidding HF, Hayen A, Gurley ES.
        PLoS Negl Trop Dis. 2020 Jan 21;14(1):e0007586.
        In the absence of reliable data on the burden of hepatitis E virus (HEV) in high endemic countries, we established a hospital-based acute jaundice surveillance program in six tertiary hospitals in Bangladesh to estimate the burden of HEV infection among hospitalized acute jaundice patients aged >/=14 years, identify seasonal and geographic patterns in the prevalence of hepatitis E, and examine factors associated with death. We collected blood specimens from enrolled acute jaundice patients, defined as new onset of either yellow eyes or skin during the past three months of hospital admission, and tested for immunoglobulin M (IgM) antibodies against HEV, HBV and HAV. The enrolled patients were followed up three months after hospital discharge to assess their survival status; pregnant women were followed up three months after their delivery to assess pregnancy outcomes. From December'2014 to September'2017, 1925 patients with acute jaundice were enrolled; 661 (34%) had acute hepatitis E, 48 (8%) had hepatitis A, and 293 (15%) had acute hepatitis B infection. Case fatality among hepatitis E patients was 5% (28/589). Most of the hepatitis E cases were males (74%; 486/661), but case fatality was higher among females-12% (8/68) among pregnant and 8% (7/91) among non-pregnant women. Half of the patients who died with acute hepatitis E had co-infection with HAV or HBV. Of the 62 HEV infected mothers who were alive until the delivery, 9 (15%) had miscarriage/stillbirth, and of those children who were born alive, 19% (10/53) died, all within one week of birth. This study confirms that hepatitis E is the leading cause of acute jaundice, leads to hospitalizations in all regions in Bangladesh, occurs throughout the year, and is associated with considerable morbidity and mortality. Effective control measures should be taken to reduce the risk of HEV infections including improvements in water quality, sanitation and hygiene practices and the introduction of HEV vaccine to high-risk groups.

      15. Oropharyngeal microbiome of a college population following a meningococcal disease outbreakexternal icon
        Retchless AC, Kretz CB, Rodriguez-Rivera LD, Chen A, Soeters HM, Whaley MJ, Wang X.
        Sci Rep. 2020 Jan 20;10(1):632.
        Asymptomatic oropharyngeal carriage of Neisseria meningitidis peaks in adolescence and young adulthood. Following a meningococcal disease outbreak at a U.S. college, we profiled the oropharyngeal microbiomes of 158 students to identify associations between bacterial community composition and meningococcal carriage or risk factors for carriage, including male gender, smoking, and frequent social mixing. Metagenomic shotgun sequencing identified 268 bacterial taxa at the genus or species level, with Streptococcus, Veillonella, and Rothia species being most abundant. Microbiome composition showed weak associations with meningococcal carriage and risk factors for carriage. N. meningitidis abundance was positively correlated with that of Fusobacterium nucleatum, consistent with hypothesized propionic acid cross-feeding. Additional species had positive abundance correlations with N. meningitidis, including Aggregatibacter aphrophilus, Campylobacter rectus, Catonella morbi, Haemophilus haemolyticus, and Parvimonas micra. N. meningitidis abundance was negatively correlated with unidentified Veillonella species. Several of these species are commonly found in dental plaque, while N. meningitidis is primarily found in the pharynx, suggesting that ecological interactions extend throughout the oral cavity. Although risk factors for meningococcal carriage do not strongly impact most bacterial species in the oropharynx, variation in the upper respiratory tract microbiome may create conditions that are more or less favorable for N. meningitidis carriage.

      16. HIV outbreak control with effective access to care and harm reduction in North Carolina, 2017-2018external icon
        Samoff E, Mobley V, Hudgins M, Cope AB, Adams ND, Caputo CR, Dennis AM, Billock RM, Crowley CA, Clymore JM, Foust E.
        Am J Public Health. 2020 Jan 16:e1-e7.
        Objectives. To assess and control a potential outbreak of HIV among people who inject drugs in Western North Carolina.Methods. Disease intervention specialists offered testing for hepatitis B and hepatitis C, harm reduction materials, and linkage to care to 7 linked people recently diagnosed with HIV who also injected drugs. Contacts were offered the same services and HIV testing. HIV genotype analysis was used to characterize HIV spread. We assessed testing and care outcomes by using state surveillance information.Results. Disease intervention specialists contacted 6 of 7 linked group members and received information on 177 contacts; among 96 prioritized contacts, 42 of 96 (44%) were exposed to or diagnosed with hepatitis C, 4 of 96 (4%) had hepatitis B, and 14 of 96 (15%) had HIV (2 newly diagnosed during the investigation). HIV genotype analysis suggested recent transmission to linked group members and 1 contact. Eleven of 14 with HIV were virally suppressed following the outbreak response.Conclusions. North Carolina identified and rapidly responded to an HIV outbreak among people reporting injecting drugs. Effective HIV care, the availability of syringe exchange services, and the rapid response likely contributed to controlling this outbreak. (Am J Public Health. Published online ahead of print January 16, 2020: e1-e7. doi:10.2105/AJPH.2019.305490).

      17. More screening or more disease? Gonorrhea testing and positivity patterns among men in three large clinical practices in Massachusetts, 2010-2017external icon
        Willis SJ, Elder H, Cocoros N, Young J, Marcus JL, Eberhardt K, Callahan M, Herrick B, Weiss M, Hafer E, Erani D, Josephson M, Llata E, Flagg EW, Hsu KK, Klompas M.
        Clin Infect Dis. 2020 Jan 22.
        BACKGROUND: Gonorrhea diagnosis rates in the U.S. increased by 75% during 2009-2017, predominantly in men. It is unclear whether the increase among men is being driven by more screening, an increase in the prevalence of disease, or both. We sought to evaluate changes in gonorrhea testing patterns and positivity among men in Massachusetts. METHODS: The analysis included men >/=15 years who received care during 2010-2017 in three clinical practice groups. We calculated annual percentages of men who received a gonorrhea test and men with at least one positive result, among men tested. Log-binomial regression models were used to examine trends in these outcomes. We adjusted for clinical and demographic characteristics that may influence predilection to test and probability of gonorrhea disease. RESULTS: On average 306,348 men had encounters each year. There was a significant increase in men with at least one gonorrhea test from 2010 (3.1%) to 2017 (6.4%; adjusted annual RR: 1.12, 95% CI 1.12,1.13). There was a significant, albeit lesser, increase in the percentage of tested men with at least one positive result (1.0% in 2010 to 1.5% in 2017; adjusted annual RR: 1.07, 95% CI 1.04,1.09). CONCLUSIONS: We estimated significant increases in the proportion of men tested at least once in a year for gonorrhea and the proportion of tested men with at least one positive gonorrhea result between 2010 and 2017. These results suggest that observed increases in gonorrhea rates could be explained by both increases in screening and the prevalence of gonorrhea.

    • Environmental Health
      1. Blood lead levels in U.S. women of childbearing age, 1976-2016external icon
        Ettinger AS, Egan KB, Homa DM, Brown MJ.
        Environ Health Perspect. 2020 Jan;128(1):17012.
        BACKGROUND: Lead can adversely affect maternal and child health across a wide range of exposures; developing fetuses and breastfeeding infants may be particularly vulnerable. We describe the distribution of blood lead levels (BLLs) in U.S. women of childbearing age and associations with sociodemographic, reproductive, smoking, and housing characteristics over a 40-y period. METHODS: Data from the National Health and Nutrition Examination Survey (NHANES) II, NHANES III Phase I and Phase II, and 1999-2016 continuous NHANES were used to describe the distribution of BLLs (given in micrograms per deciliter; 1mug/dL=0.0483mumol/L) in U.S. women 15-49 years of age between 1976 and 2016. For all women with valid BLLs (n=22,408), geometric mean (GM) BLLs and estimated prevalence of BLLs >/=5mug/dL were calculated overall and by selected demographic characteristics. For NHANES II, estimated prevalence of BLLs >/=10 and >/=20mug/dL were also calculated. RESULTS: The most recent GM BLLs (2007-2010 and 2011-2016, respectively) were 0.81mug/dL [95% confidence interval (CI): 0.79, 0.84] and 0.61mug/dL (95% CI: 0.59, 0.64). In comparison, GM BLLs in earlier periods (1976-1980, 1988-1991, and 1991-1994) were 10.37mug/dL (95% CI: 9.95, 10.79), 1.85mug/dL (95% CI: 1.75, 1.94), and 1.53mug/dL (95% CI: 1.45, 1.60), respectively. In 2011-2016, 0.7% of women of childbearing age had BLLs >/=5mug/dL, and higher BLLs were associated with older age, other race/ethnicity, birthplace outside the United States, four or more live births, exposure to secondhand tobacco smoke, and ever pregnant or not currently pregnant. DISCUSSION: Lead exposure in U.S. women of childbearing age is generally low and has substantially decreased over this 40-y period. However, based on these estimates, there are still at least 500,000 U.S. women being exposed to lead at levels that may harm developing fetuses or breastfeeding infants. Identifying high-risk women who are or intend to become pregnant remains an important public health issue. https://doi.org/10.1289/EHP5925.

      2. Identifying needs for advancing the profession and workforce in environmental healthexternal icon
        Gerding JA, Brooks BW, Landeen E, Whitehead S, Kelly KR, Allen A, Banaszynski D, Dorshorst M, Drager L, Eshenaur T, Freund J, Inman A, Long S, Maloney J, McKeever T, Pigman T, Rising N, Scanlan S, Scott J, Shukie C, Stewart G, Tamekazu D, Wade V, White C, Sarisky J.
        Am J Public Health. 2020 Jan 16:e1-e7.
        An ever-changing landscape for environmental health (EH) requires in-depth assessment and analysis of the current challenges and emerging issues faced by EH professionals. The Understanding the Needs, Challenges, Opportunities, Vision, and Emerging Roles in Environmental Health initiative addressed this need.After receiving responses from more than 1700 practitioners, during an in-person workshop, focus groups identified and described priority problems and supplied context on addressing the significant challenges facing EH professionals with state health agencies and local health departments. The focus groups developed specific problem statements detailing the EH profession and workforce's prevailing challenges and needs according to 6 themes, including effective leadership, workforce development, equipment and technology, information systems and data, garnering support, and partnerships and collaboration.We describe the identified priority problems and needs and provide recommendations for ensuring a strong and robust EH profession and workforce ready to address tomorrow's challenges. (Am J Public Health. Published online ahead of print January 16, 2020: e1-e7. doi:10.2105/AJPH.2019.305441).

      3. Ten questions concerning the implications of carpet on indoor chemistry and microbiologyexternal icon
        Haines SR, Adams RI, Boor BE, Bruton TA, Downey J, Ferro AR, Gall E, Green BJ, Hegarty B, Horner E, Jacobs DE, Lemieux P, Misztal PK, Morrison G, Perzanowski M, Reponen T, Rush RE, Virgo T, Alkhayri C, Bope A, Cochran S, Cox J, Donohue A, May AA, Nastasi N, Nishioka M, Renninger N, Tian Y, Uebel-Niemeier C, Wilkinson D, Wu T, Zambrana J, Dannemiller KC.
        Build Environ. 2020 ;170.
        Carpet and rugs currently represent about half of the United States flooring market and offer many benefits as a flooring type. How carpets influence our exposure to both microorganisms and chemicals in indoor environments has important health implications but is not well understood. The goal of this manuscript is to consolidate what is known about how carpet impacts indoor chemistry and microbiology, as well as to identify the important research gaps that remain. After describing the current use of carpet indoors, questions focus on five specific areas: 1) indoor chemistry, 2) indoor microbiology, 3) resuspension and exposure, 4) current practices and future needs, and 5) sustainability. Overall, it is clear that carpet can influence our exposures to particles and volatile compounds in the indoor environment by acting as a direct source, as a reservoir of environmental contaminants, and as a surface supporting chemical and biological transformations. However, the health implications of these processes are not well known, nor how cleaning practices could be optimized to minimize potential negative impacts. Current standards and recommendations focus largely on carpets as a primary source of chemicals and on limiting moisture that would support microbial growth. Future research should consider enhancing knowledge related to the impact of carpet in the indoor environment and how we might improve the design and maintenance of this common material to reduce our exposure to harmful contaminants while retaining the benefits to consumers.


      5. Association between maternal occupational exposure to polycyclic aromatic hydrocarbons and rare birth defects of the face and central nervous systemexternal icon
        Santiago-Colon A, Rocheleau CM, Chen IC, Sanderson W, Waters MA, Lawson CC, Langlois PH, Cragan JD, Reefhuis J.
        Birth Defects Res. 2020 Jan 14.
        BACKGROUND: Previous studies suggested associations between maternal smoking, a source of exposure to polycyclic aromatic hydrocarbons (PAHs) and other chemicals, and central nervous system and face birth defects; however, no previous studies have evaluated maternal occupational PAH exposure itself. METHODS: Jobs held in the periconceptional period were retrospectively assigned for occupational PAH exposures. Associations between maternal occupational PAH exposure and selected rare defects of the face (cataracts, microphthalmia, glaucoma, microtia, and choanal atresia) and central nervous system (holoprosencephaly, hydrocephaly, cerebellar hypoplasia, and Dandy-Walker malformation) were evaluated using data from the National Birth Defects Prevention Study, a population-based case-control study in the United States. Crude and adjusted odds ratios (ORs) with 95% confidence intervals were calculated to estimate associations between each evaluated defect and PAH exposure using multivariable logistic regression. RESULTS: Food and beverage serving, as well as cooks and food preparation occupations, were among the most frequent jobs held by exposed mothers. Cataracts, microtia, microphthalmia, and holoprosencephaly were significantly associated with PAH exposure with evidence of dose-response (P-values for trend </=.05). Hydrocephaly was associated with any PAH exposure, but not significant for trend. Sensitivity analyses that reduced possible sources of exposure misclassification tended to strengthen associations. CONCLUSIONS: This is the first population-based case-control study to evaluate associations between maternal occupational PAH exposures and these rare birth defects of the central nervous system and face.

      6. Maternal occupational exposure to solvents and gastroschisis in offspring - National Birth Defects Prevention Study 1997-2011external icon
        Spinder N, Almli LM, Desrosiers TA, Arnold KE, Bergman JE, Kromhout H, Boezen HM, de Walle HE, Rocheleau C, Reefhuis J.
        Occup Environ Med. 2020 Jan 16.
        OBJECTIVES: The aim of this study was to assess the association between maternal occupational exposure to solvents and gastroschisis in offspring. METHODS: We used data from the National Birth Defects Prevention Study, a large population-based case-control study of major birth defects conducted in 10 US states from 1997 to 2011. Infants with gastroschisis were ascertained by active birth defects surveillance systems. Control infants without major birth defects were selected from vital records or birth hospital records. Self-reported maternal occupational histories were collected by telephone interview. Industrial hygienists reviewed this information to estimate exposure to aromatic, chlorinated and petroleum-based solvents from 1 month before conception through the first trimester of pregnancy. Cumulative exposure to solvents was estimated for the same period accounting for estimated exposure intensity and frequency, job duration and hours worked per week. ORs and 95% CIs were estimated to assess the association between exposure to any solvents or solvent classes, and gastroschisis risk. RESULTS: Among 879 cases and 7817 controls, the overall prevalence of periconceptional solvent exposure was 7.3% and 7.4%, respectively. Exposure to any solvent versus no exposure to solvents was not associated with gastroschisis after adjusting for maternal age (OR 1.00, 95% CI 0.75 to 1.32), nor was an association noted for solvent classes. There was no exposure-response relationship between estimated cumulative solvent exposure and gastroschisis after adjusting for maternal age. CONCLUSION: Our study found no association between maternal occupational solvent exposure and gastroschisis in offspring. Further research is needed to understand risk factors for gastroschisis.

      7. A cluster, randomized control trial was conducted to assess the effects of social marketing approach on purchase rates and water treatment behavior of Klorfasil, a chlorine-based household water treatment product among seven villages in Thomassique, Haiti, from May to December 2016. Villages were randomized to the free-trial (257 households) or cost-sharing (240 households) group. Households in the free-trial group were allowed 30 days of free Klorfasil use before purchase decision. Households who purchased Klorfasil were then followed up for 30, 60, and 180 days. At the last follow-up, respondents were asked if they would like to repurchase Klorfasil. Questionnaire survey and water quality assessment by residual-free chlorine were conducted in each survey. Chi-square test, t-test, and logistic regression were applied. The first purchase rate of the cost-sharing group was significantly higher than that of the free-trial group (79.2% versus 67.3%). By contrast, the repurchase rate of the free-trial group was higher (82.9% versus 66.3%). However, the overall repurchase rate was 71.6% and the proportion of long-term users was significantly higher in the cost-sharing group (56% versus 47%). Water treatment rates in the cost-sharing group were significantly higher than those in the free-trial group in the first and final surveys (odds ratio [OR] = 0.15, OR = 0.32). Households with high and medium economic status both had significantly higher purchase rates than low economic status households (OR = 4.40, OR = 1.94). Households with higher educated respondents had significantly better water treatment practices (OR = 2.15). The free-trial approach did not increase the first purchase rate but increased the repurchase rate later. The cost-sharing approach significantly encouraged long-term usage.

    • Food Safety
      1. Cyclosporiasis epidemiologically linked to consumption of green onions: Houston Metropolitan Area, August 2017external icon
        Hall NB, Chancey RJ, Keaton AA, Heines V, Cantu V, Vakil V, Long S, Short K, Franciscus E, Wahab N, Gieraltowski L, Straily A.
        J Food Prot. 2020 Jan 21:326-330.
        During July 2017, Texas public health officials noted an increase in the number of reported cyclosporiasis cases. They detected a cluster in the Houston metropolitan area that involved four locations of a Mediterranean restaurant chain, restaurant A. A case-control study was conducted among patrons of restaurant A to identify a common food vehicle among items containing fresh produce. In matched case-control ingredient-level analyses that included both probable and confirmed cases, consumption of green onions, red onions, tomatoes, and cabbage was significantly associated with illness. A substantial percentage of case patients reported consumption of green onions, and only green onions remained statistically significantly associated with illness, whether probable and confirmed cases were included in analyses (matched odds ratio: 11.3; 95% confidence interval: 2.5 to 104.7), or only confirmed cases were included in analyses (matched odds ratio: 17.6; 95% confidence interval: 2.5 to 775.7). These results provide evidence that green onions were the likely vehicle of infection. It was not possible to trace the green onions to their source due to the need to redirect public health resources to Hurricane Harvey response efforts in Texas.

    • Health Disparities
      1. 'Home is where the health is': Housing quality and adult health outcomes in the survey of income and program participationexternal icon
        Boch SJ, Taylor DM, Danielson ML, Chisolm DJ, Kelleher KJ.
        Prev Med. 2020 Jan 15;132:105990.
        Nearly a quarter of the homes in the United States were considered unhealthy or inadequate, but whether these housing characteristics have direct effects on health or whether they are driven by other contextual housing and neighborhood characteristics remains unclear. The purpose of this study was to quantify the independent associations between poor housing quality and adult health outcomes, adjusting for socioeconomic factors (e.g. income to poverty ratio, food insecurity) and other contextual housing characteristics (e.g. rental status, number of people per household, unsafe neighborhood). Using in-person household interview data from wave 1 of the 2014 Survey of Income and Program Participation (SIPP), a secondary analysis was performed using a series of logistic regression models. The 2014 SIPP sample is a multistage stratified sample of 53,070 housing units designed to represent the civilian, noninstitutionalized population of the United States (N = 55,281 adults ages 18 and older). Our results indicate that each additional poor housing characteristic was associated with poorer health status (OR: 1.17, CI [1.11, 1.23]), higher medical utilization (OR: 1.11 CI: [1.06, 1.16]), and a higher likelihood of hospitalization (OR: 1.07, CI [1.02, 1.12]). Non-housing-related government assistance, food security, and safe neighborhoods only partially explained associations between housing quality and health outcomes. Evaluating current local, state, and federal policy on housing quality standards may help determine if these standards decrease the number of Americans residing in inadequate homes or result in improvements in health and reductions in healthcare costs. Simply put, the home is where [we suggest] the health is.

      2. Bridging the gap in potentially excess deaths between rural and urban counties in the United Statesexternal icon
        Garcia MC, Faul M, Dowling NF, Thomas CC, Iademarco MF.
        Public Health Rep. 2020 Jan 22:33354919900890.

    • Health Economics
      1. Stunting: an overlooked problem in Myanmar - an economic evaluationexternal icon
        Aye SK, Mar SL, Lwin NN, Hnin ZL, Hlaing LM, Washington ML, Harris JR.
        Int J Technol Assess Health Care. 2020 Jan 20:1-6.
        OBJECTIVES: Stunting increases a child's susceptibility to diseases, increases mortality, and is associated over long term with reduced cognitive abilities, educational achievement, and productivity. We aimed to assess the most effective public health nutritional intervention to reduce stunting in Myanmar. METHODS: We searched the literature and developed a conceptual framework for interventions known to reduce stunting. We focused on the highest impact and most feasible interventions to reduce stunting in Myanmar, described policies to implement them, and compared their costs and projected effect on stunting using data-based decision trees. We estimated costs from the government perspective and calculated total projected cases of stunting prevented and cost per case prevented (cost-effectiveness). All interventions were compared to projected cases of stunting resulting from the current situation (e.g., no additional interventions). RESULTS: Three new policy options were identified. Operational feasibility for all three options ranged from medium to high. Compared to the current situation, two were similarly cost-effective, at an additional USD 598 and USD 667 per case of stunting averted. The third option was much less cost-effective, at an additional USD 27,741 per case averted. However, if donor agencies were to expand their support in option three to the entire country, the prevalence of 22.5 percent would be reached by 2025 at an additional USD 667 per case averted. CONCLUSIONS: A policy option involving immediate expansion of the current implementation of proven nutrition-specific interventions is feasible. It would have the highest impact on stunting and would approach the WHO 2025 target.

      2. Despite the elimination of measles in the US in the year 2000, cases continue to occur with measles outbreaks having occurred in various jurisdictions in the US in 2018 and 2019. Understanding the cost associated to measles outbreaks can inform cost-of-illness and cost-effectiveness studies of measles and measles prevention. We performed a literature review and identified 10 published studies from 2001-2018 that presented cost estimates from 11 measles outbreaks. Median total costs per measles outbreak were $152,308 (range, $9,862-$1,063,936); median cost per case was $32,805 (range, $7,396-$76,154) and median cost per contact was $223 (range, $81-$746). There was limited data on direct and indirect costs associated with measles. These findings highlight how costly measles outbreaks can be, the value of this information for public health department budgeting, and the importance of more broadly documenting the cost of measles outbreaks.

      3. Estimating the costs and cost-effectiveness of HIV self-testing among men who have sex with men, United Statesexternal icon
        Shrestha RK, Chavez PR, Noble M, Sansom SL, Sullivan PS, Mermin JH, MacGowan RJ.
        J Int AIDS Soc. 2020 Jan;23(1):e25445.
        INTRODUCTION: HIV testing is an essential prerequisite for accessing treatment with antiretroviral therapy or prevention using pre-exposure prophylaxis. Internet distribution of HIV self-tests is a novel approach, and data on the programmatic cost of this approach are limited. We analyse the costs and cost-effectiveness of a self-testing programme. METHODS: Men who have sex with men (MSM) reporting unknown or negative HIV status were enrolled from March to August 2015 into a 12-month trial of HIV self-testing in the United States. Participants were randomly assigned either to the self-testing arm or the control arm. All participants received information on HIV testing services and locations in their community. Self-testing participants received up to four self-tests each quarter, which they could use themselves or distribute to their social network associates. Quarterly follow-up surveys collected testing outcomes, including number of tests used and new HIV diagnoses. Using trial expenditure data, we estimated the cost of implementing a self-testing programme. Primary outcomes of this analysis included total programme implementation costs, cost per self-test completed, cost per person tested, cost per new HIV diagnosis among those self-tested and cost per quality adjusted life year (QALY) saved. RESULTS: A total of 2665 men were assigned either to the self-testing arm (n = 1325) or the control arm (n = 1340). HIV testing was reported by 971 self-testing participants who completed a total of 5368 tests. In the control arm, 619 participants completed 1463 HIV tests. The self-testing participants additionally distributed 2864 self-tests to 2152 social network associates. Testing during the trial identified 59 participants and social network associates with newly diagnosed HIV infection in the self-testing arm; 11 control participants were newly diagnosed with HIV. The implementation cost of the HIV self-testing programme was $449,510. The cost per self-test completed, cost per person tested at least once, and incremental cost per new HIV diagnosis was $61, $145 and $9365 respectively. We estimated that self-testing programme potentially averted 3.34 transmissions, saved 14.86 QALYs and nearly $1.6 million lifetime HIV treatment costs. CONCLUSIONS: The HIV self-testing programme identified persons with newly diagnosed HIV infection at low cost, and the programme is cost saving.

    • Immunity and Immunization
      1. Delayed dosing intervals for quadrivalent human papillomavirus vaccine do not reduce antibody avidityexternal icon
        Brady AM, Walter EB, Markowitz LE, Unger ER, Panicker G.
        Hum Vaccin Immunother. 2020 Jan 22:1-6.
        The quadrivalent HPV vaccine (4vHPV) was originally recommended as a three-dose series (0/2/6 months), though delays in completing the series frequently occur. We previously found delayed dosing in girls resulted in similar or higher antibody titers compared to on-time dosing. Archived sera from 262 healthy females aged 9-18 recruited from pediatric clinics were tested to determine if delayed dosing intervals affected antibody avidity. Avidity index (AI; ratio of IgG Ab bound in the treated and untreated sample) was determined pre- and post-dose 3 4vHPV for each participant using a modified multiplex ELISA. Data were grouped by dosing intervals: (1) on-time dose 2 and 3, (2) delayed dose 2 and on-time dose 3, (3) on-time dose 2 and delayed dose 3, (4) delayed dose 2 and 3. Overall, mean AI was highest for HPV16 and lowest for HPV6. As expected, AI did not differ between groups 1 & 3 or groups 2 & 4 pre-dose 3, however, for most types mean AI was significantly higher both pre- and post-dose 3 for groups with delayed dose 2. For all types, mean AI was higher post-dose 3 in all delayed dosing groups compared to group 1. One month post-dose 3, there was a positive but weak correlation between AIs and antibody titer for HPV 6 (rho = 0.25, p = .0001), HPV 11 (rho = 0.14, p = .0370), HPV 16 (rho = 0.11, p = .0934), and HPV 18 (rho = 0.37, p < .0001). Our findings suggest longer intervals between doses result in higher antibody avidity, providing further evidence that delayed dosing of 4vHPV does not hinder the immune response.

      2. Rotavirus vaccination and type 1 diabetes risk among US children with commercial insuranceexternal icon
        Burke RM, Tate JE, Dahl RM, Saydah S, Imperatore G, Gregg EW, Parashar UD.
        JAMA Pediatr. 2020 Jan 21.

      3. Specificity, kinetics and longevity of antibody responses to avian influenza A(H7N9) virus infection in humansexternal icon
        Chen J, Zhu H, Horby PW, Wang Q, Zhou J, Jiang H, Liu L, Zhang T, Zhang Y, Chen X, Deng X, Nikolay B, Wang W, Cauchemez S, Guan Y, Uyeki TM, Yu H.
        J Infect. 2020 Jan 16.
        OBJECTIVES: The long-term dynamics of antibody responses in patients with influenza A(H7N9) virus infection are not well understood. METHODS: We conducted a longitudinal serological follow-up study in patients who were hospitalized with A(H7N9) virus infection, during 2013-2018. A(H7N9) virus-specific antibody responses were assessed by hemagglutination inhibition (HAI) and neutralization (NT) assays. A random intercept model was used to fit a curve to HAI antibody responses over time. HAI antibody responses were compared by clinical severity. RESULTS: Of 67 patients with A(H7N9) virus infection, HAI antibody titers reached 40 on average 11 days after illness onset and peaked at a titer of 290 after three months, and average titers of >/=80 and >/=40 were present until 11 months and 22 months respectively. HAI antibody responses were significantly higher in patients who experienced severe disease, including respiratory failure and acute respiratory distress syndrome, compared with patients who experienced less severe illness. CONCLUSIONS: Patients with A(H7N9) virus infection who survived severe disease mounted higher antibody responses that persisted for longer periods compared with those that experienced moderate disease. Studies of convalescent plasma treatment for A(H7N9) patients should consider collection of donor plasma from survivors of severe disease between 1-11 months after illness onset.

      4. The American Committee on Immunization Practices recommends the use of the oral cholera vaccine (OCV) in international travelers aged 18-64 years who visit areas of active cholera transmission. CDC Travelers' Health Branch currently tracks areas of active cholera transmission and posts this information on their country-specific destination web pages at https://wwwnc.cdc.gov/travel/destinations/list. Lessons learned from a webinar conducted among health care providers have led to improvements in how CDC shares information on the OCV. Here, we summarize the major considerations for providers offering the OCV to U.S. travelers and indicate where they can find more information.

      5. Since 2005, a single dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine has been recommended by the Advisory Committee on Immunization Practices (ACIP) for adolescents and adults (1,2). After receipt of Tdap, booster doses of tetanus and diphtheria toxoids (Td) vaccine are recommended every 10 years or when indicated for wound management. During the October 2019 meeting of ACIP, the organization updated its recommendations to allow use of either Td or Tdap where previously only Td was recommended. These situations include decennial Td booster doses, tetanus prophylaxis when indicated for wound management in persons who had previously received Tdap, and for multiple doses in the catch-up immunization schedule for persons aged >/=7 years with incomplete or unknown vaccination history. Allowing either Tdap or Td to be used in situations where Td only was previously recommended increases provider point-of-care flexibility. This report updates ACIP recommendations and guidance regarding the use of Tdap vaccines (3).

      6. Thin silk fibroin films as a dried format for temperature stabilization of inactivated polio vaccineexternal icon
        Stinson JA, Palmer CR, Miller DP, Li AB, Lightner K, Jost H, Weldon WC, Oberste MS, Kluge JA, Kosuda KM.
        Vaccine. 2020 Jan 17.
        Current inactivated polio vaccine (IPV) products are sensitive to both freezing and elevated temperatures and therefore must be shipped and stored between 2 degrees C and 8 degrees C, a requirement that imposes financial and logistical challenges for global distribution. As such, there is a critical need for a robust, thermally stable IPV to support global polio eradication and post-eradication immunization needs. Here, we present the development of air-dried thin films for temperature stabilization of IPV using the biomaterial silk fibroin. Thin-film product compositions were optimized for physical properties as well as poliovirus D-antigen recovery and were tested under accelerated and real-time stability storage conditions. Silk fibroin IPV films maintained 70% D-antigen potency after storage for nearly three years at room temperature, and greater than 50% potency for IPV-2 and IPV-3 serotypes at 45 degrees C for one year. The immunogenicity of silk fibroin IPV films after 2-week storage at 45 degrees C was assessed in Wistar rats and the stressed films generated equivalent neutralizing antibody responses to commercial vaccine for IPV-1 and IPV-2. However, the absence of IPV-3 responses warrants further investigation into the specificity of ELISA for intact IPV-3 D-antigen. By demonstrating immunogenicity post-storage, we offer the air-dried silk film format as a means to increase IPV vaccine access through innovative delivery systems such as microneedles.

    • Injury and Violence
      1. Chronic diseases, health conditions, and other impacts associated with rape victimization of U.S. womenexternal icon
        Basile KC, Smith SG, Chen J, Zwald M.
        J Interpers Violence. 2020 Jan 23:886260519900335.
        Sexual violence (SV) is an urgent public health issue that is common and has lifelong effects on health. Previous scholarship has documented the association of SV victimization with numerous health conditions and impacts, but much of this past work has focused on negative health outcomes associated with child sexual abuse using non-nationally representative samples. This article used a nationally representative female sample to examine health conditions associated with any lifetime experience of rape. We also examined injury and health outcomes (e.g., fear, injury) resulting from any violence by a perpetrator of rape. About two in five rape victims (39.1%) reported injury (e.g., bruises, vaginal tears), and 12.3% reported a sexually transmitted disease as a result of the rape victimization. Approximately 71.3% of rape victims (an estimated 16.4 million women) experienced some form of impact as a result of violence by a rape perpetrator. Among U.S. women, the adjusted odds of experiencing asthma, irritable bowel syndrome, frequent headaches, chronic pain, difficulty sleeping, activity limitations, poor physical or mental health, and use of special equipment (e.g., wheelchair) were significantly higher for lifetime rape victims compared with non-victims. This article fills gaps in our understanding of health impacts associated with rape of women and is the only nationally representative source of this information to our knowledge. Primary prevention efforts in youth that seek to prevent the first occurrence of rape and other forms of SV may be most effective for reducing the long-term health effects of this violence.

      2. Factors that protect children from community violence: Applying the INSPIRE model to a sample of South African childrenexternal icon
        Falconer NS, Casale M, Kuo C, Nyberg BJ, Hillis SD, Cluver LD.
        J Interpers Violence. 2020 Jan 16:886260519898425.
        Community violence is a prevalent form of interpersonal violence in South Africa for children living in low-income areas. Trauma arising from violence exposure is of concern in contexts where access to treatment is often unattainable. As simultaneous multisectoral strategies show higher potential to counter interpersonal violence than single interventions, the World Health Organization with partners created INSPIRE. INSPIRE takes an integrated approach coordinated across formal and informal settings of civil and private society. Responding to research paucity on methods that counter community violence in LMIC settings, this study employed a cross-sectional correlational design consisting of a sample of 2,477 children aged 10 to 17 years from the Young Carers 2009-2010 study conducted in a low-income, HIV-endemic province of South Africa highly affected by community violence. Multiple logistic regressions assessed individual and dose associations between four INSPIRE-based violence prevention strategies-positive parenting, basic necessities, formal social support, and school structural support-and direct and indirect community violence outcomes. Three strategies had significant associations with community violence outcomes: necessities (direct p < .001; adjusted odds ratio [AOR] = .57; indirect p < .01; AOR = .62), formal support (direct p < .05; AOR = .83; indirect p < .05; AOR = .73), and school support (direct p < .001; AOR = .53; indirect p < .001; AOR = .49). Combined interventions in direct and indirect community violence analyses demonstrated that children reporting a higher number of strategies were less likely to have experienced community violence. This outcome extends the results of longitudinal studies in South Africa highlighting social protection with care as a means to overcome structural deprivation strains, thereby reducing the likelihood of children's exposure to community violence. Moreover, these findings uphold the INSPIRE model as an effective cross-sectoral approach to prevent and reduce the community violence that children experience.

      3. Suicide rates by industry and occupation - National Violent Death Reporting System, 32 States, 2016external icon
        Peterson C, Sussell A, Li J, Schumacher PK, Yeoman K, Stone DM.
        MMWR Morb Mortal Wkly Rep. 2020 Jan 24;69(3):57-62.
        In 2017, nearly 38,000 persons of working age (16-64 years) in the United States died by suicide, which represents a 40% rate increase (12.9 per 100,000 population in 2000 to 18.0 in 2017) in less than 2 decades.* To inform suicide prevention, CDC analyzed suicide data by industry and occupation among working-age decedents presumed to be employed at the time of death from the 32 states participating in the 2016 National Violent Death Reporting System (NVDRS).(dagger)(,)( section sign) Compared with rates in the total study population, suicide rates were significantly higher in five major industry groups: 1) Mining, Quarrying, and Oil and Gas Extraction (males); 2) Construction (males); 3) Other Services (e.g., automotive repair) (males); 4) Agriculture, Forestry, Fishing, and Hunting (males); and 5) Transportation and Warehousing (males and females). Rates were also significantly higher in six major occupational groups: 1) Construction and Extraction (males and females); 2) Installation, Maintenance, and Repair (males); 3) Arts, Design, Entertainment, Sports, and Media (males); 4) Transportation and Material Moving (males and females); 5) Protective Service (females); and 6) Healthcare Support (females). Rates for detailed occupational groups (e.g., Electricians or Carpenters within the Construction and Extraction major group) are presented and provide insight into the differences in suicide rates within major occupational groups. CDC's Preventing Suicide: A Technical Package of Policy, Programs, and Practices (1) contains strategies to prevent suicide and is a resource for communities, including workplace settings.

    • Laboratory Sciences
      1. Identification of Entamoeba histolytica in patients with suspected amebiasis in Jordan using PCR-based assaysexternal icon
        Al-Dalabeeh EA, Irshaid FI, Roy S, Ali IK, Al-Shudifat AM.
        Pak J Biol Sci. 2020 Jan;23(2):166-172.
        BACKGROUND AND OBJECTIVE: Identification of Entamoeba histolytica (E. histolytica) by microscopy alone can be problematic because E. dispar and E. moshkovskii are morphologically similar to E. histolytica. Therefore, this study aimed to assess the performance of microscopy in the detection of E. histolytica in stool specimens with the help of PCR-based assays and enzyme-linked immunosorbent assay (ELISA). MATERIALS AND METHODS: Between September, 2017 and September, 2018, 200 stool specimens were obtained from Jordanian patients with suspected amebiasis. All specimens were subjected to microscopic analysis. DNA was extracted from the microscopy-positive stool samples. A conventional PCR and a duplex real-time PCR were performed to detect E. histolytica and E. dispar. RESULTS: By microscopy, 35% (70/200) of specimens were tested positive for Entamoeba complex. All 70 microscopic-positive Entamoeba complex samples were negative for the presence of E. histolytica by the NOVITEC(R) E. histolytica ELISA assay. All 70 samples positive by microscopy were negative for the presence of E. histolytica and E. dispar by PCR-based assays. CONCLUSION: We suspect some of these microscopy-positive stool specimens might contain a potentially novel species of Entamoeba that could not be detected by ELISA or PCR-based assays specific for E. histolytica and E. dispar. Diagnosis of amebiasis remains challenging here in Jordan and hence highlighting the need for improved diagnostic method.

      2. Using the LN34 Pan-Lyssavirus Real-Time RT-PCR Assay for rabies diagnosis and rapid genetic typing from formalin-fixed human brain tissueexternal icon
        Condori RE, Niezgoda M, Lopez G, Matos CA, Mateo ED, Gigante C, Hartloge C, Filpo AP, Haim J, Satheshkumar PS, Petersen B, Wallace R, Olson V, Li Y.
        Viruses. 2020 Jan 18;12(1).
        Human rabies post mortem diagnostic samples are often preserved in formalin. While immunohistochemistry (IHC) has been routinely used for rabies antigen detection in formalin-fixed tissue, the formalin fixation process causes nucleic acid fragmentation that may affect PCR amplification. This study reports the diagnosis of rabies in an individual from the Dominican Republic using both IHC and the LN34 pan-lyssavirus real-time RT-PCR assay on formalin-fixed brain tissue. The LN34 assay generates a 165 bp amplicon and demonstrated higher sensitivity than traditional PCR. Multiple efforts to amplify nucleic acid fragments larger than 300 bp using conventional PCR were unsuccessful, probably due to RNA fragmentation. Sequences generated from the LN34 amplicon linked the case to the rabies virus (RABV) strain circulating in the Ouest Department of Haiti to the border region between Haiti and the Dominican Republic. Direct sequencing of the LN34 amplicon allowed rapid and low-cost rabies genetic typing.

      3. EGFR and TGF-beta signaling pathways cooperate to mediate Chlamydia pathogenesisexternal icon
        Igietseme JU, Partin J, George Z, Omosun Y, Goldstein J, Joseph K, Ellerson D, Eko FO, Pohl J, Bandea C, Black CM.
        Infect Immun. 2020 Jan 21.
        Human genital Chlamydia infection is a major public health concern due to the serious reproductive system complications. Chlamydia binds several receptor tyrosine kinases (RTKs) on host cells, including the epidermal growth factor receptor (EGFR) and activates cellular signaling cascades for host invasion, cytoskeletal remodeling, optimal inclusion development, and induction of pathogenic epithelial-mesenchyme transition (EMT). Chlamydia also upregulates TGF-beta expression whose signaling pathway synergizes with the EGFR cascade, but its role in infectivity, inclusions and EMT induction is unknown. We hypothesized that the EGFR and TGF-beta signaling pathways cooperate during chlamydial infection for optimal inclusion development and stable EMT induction. The results revealed that Chlamydia upregulated TGF-beta expression as early as 6 h post-infection of epithelial cells and stimulated both the EGFR and TGF-beta signaling pathways. Inhibition of either the EGFR or TGF-betaR1 signaling substantially reduced inclusions development; however, the combined inhibition of both EGFR and TGF-betaR1 signaling reduced inclusions by over 90% and prevented EMT induction. Importantly, EGFR inhibition suppressed TGF-beta expression, and an inhibitory thrombospondin-1 (Tsp1)-based peptide inhibited chlamydia-induced EMT, revealing a major source of active TGF-betaduring infection. Finally, TGF-betaR signaling inhibition suppressed the expression of transforming acidic coiled-coil protein-3 (TACC3) that stabilizes EGFR signaling, suggesting a reciprocal regulation between TGF-beta and EGFR signaling during chlamydial infection. Thus, RTK-mediated host invasion by chlamydia upregulated TGF-beta expression and signaling, which cooperated with other cellular signaling cascades and cytoskeletal remodeling to support optimal inclusion development and EMT induction. The finding may provide new targets for chlamydial disease biomarkers and prevention.

      4. Culture-independent tracking of Vibrio cholerae lineages reveals complex spatiotemporal dynamics in a natural populationexternal icon
        Kirchberger PC, Orata FD, Nasreen T, Kauffman KM, Tarr CL, Case RJ, Polz MF, Boucher YF.
        Environ Microbiol. 2020 Jan 22.
        Populations of the bacterium Vibrio cholerae consist of dozens of distinct lineages, with primarily (but not exclusively) members of the pandemic generating (PG) lineage capable of causing the diarrheal disease cholera. Assessing composition and temporal dynamics of such populations requires extensive isolation efforts and thus only rarely covers large geographic areas or timeframes exhaustively. We developed a culture-independent amplicon sequencing strategy based on the protein-coding gene viuB (vibriobactin utilization) to study the structure of a V. cholerae population over the course of a summer. We show that the 26 co-occurring V. cholerae lineages continuously compete for limited space on nutrient-rich particles where only few of them can grow to large numbers. Differential abundance of lineages between locations and size-fractions associated with a particle-attached or free-swimming lifestyle could reflect adaptation to various environmental niches. In particular, a major V. cholerae lineage occasionally grow to large numbers on particles but remain undetectable using isolation-based methods, indicating selective culturability for some members of the species. We thus demonstrate that isolation-based studies may not accurately reflect the structure and complex dynamics of V. cholerae populations and provide a scalable high-throughput method for both epidemiological and ecological approaches to studying this species. This article is protected by copyright. All rights reserved.

      5. Regular use of vibrating hand tools results in cold-induced vasoconstriction, finger blanching, and a reduction in tactile sensitivity and manual dexterity. Depending upon the length and frequency, vibration induces regeneration, or dysfunction and apoptosis, inflammation and an increase in reactive oxygen species (ROS) levels. These changes may be associated with mitochondria, this study examined the effects of vibration on total and functional mitochondria number. Male rats were exposed to restraint or tail vibration at 62.5, 125, or 250 Hz. The frequency-dependent effects of vibration on mitochondrial number and generation of oxidative stress were examined. After 10 days of exposure at 125 Hz, ventral tail arteries (VTA) were constricted and there was an increase in mitochondrial number and intensity of ROS staining. In the skin, the influence of vibration on arterioles displayed a similar but insignificant response in VTA. There was also a reduction in the number of small nerves with exposure to vibration at 250 Hz, and a reduction in mitochondrial number in nerves in restrained and all vibrated conditions. There was a significant rise in the size of the sensory receptors with vibration at 125 Hz, and an elevation in ROS levels. Based upon these results, mitochondria number and activity are affected by vibration, especially at frequencies at or near resonance. The influence of vibration on the vascular system may either be adaptive or maladaptive. However, the effects on cutaneous nerves might be a precursor to loss of innervation and sensory function noted in workers exposed to vibration.

      6. Use of pre-ART laboratory screening to identify renal, hepatic and haematological abnormalities in Cote d'Ivoireexternal icon
        Minchella PA, Adje-Toure C, Zhang G, Tehe A, Hedje J, Rottinghaus ER, Natacha K, Diallo K, Ouedraogo GL, Nkengasong JN.
        Trop Med Int Health. 2020 Jan 20.
        BACKGROUND: High demand for HIV-services and extensive clinical guidelines force health systems in low-resource settings to dedicate resources to service delivery at the expense of other priorities. Simplifying services may reduce the burden on health systems and pre-antiretroviral therapy (ART) laboratory screening is among the services under consideration for simplification. METHODS: We assessed the frequencies of conditions linked to ART toxicities among 34,994 adult, ART-naive patients with specimens referred to the RETRO-CI laboratory in Abidjan, Cote d'Ivoire between 1998 and 2017. Screening included tests for serum creatinine, alanine aminotransferase (ALT) and haemoglobin (Hb) to identify renal dysfunction (estimated glomerular filtration rate < 50 mL/min), hepatic abnormalities (ALT > 5x upper limit of normal) and severe anaemia (Hb < 6.5 g/dL), respectively. We considered screening results across four eras and identified factors associated with the conditions in question. RESULTS: The prevalence of renal dysfunction, hepatic abnormalities and severe anaemia were largely unchanged over time and just 8.4% of patients had any of the three conditions. Key factors associated with renal dysfunction and severe anaemia were age > 50 years (adjusted odds ratio (aOR): 2.53; 95% confidence interval (CI): 2.19-2.92; P < 0.001) and CD4 < 100 cells/microl (aOR: 2.57; 95% CI: 2.30-2.88; P < 0.001). CONCLUSION: The relative infrequency of conditions linked to toxicity in Cote d'Ivoire supports the notion that simplification of pre-ART laboratory screening may be undertaken with limited negative impact on identification of adverse events. Targeted screening may be a feasible strategy to balance detection of conditions associated with ART toxicities with simplification of services.

      7. Composition-function analysis of HDL subpopulations: Influence of lipid composition on particle functionalityexternal icon
        Niisuke K, Kuklenyik Z, Horvath KV, Gardner MS, Toth CA, Asztalos BF.
        J Lipid Res. 2020 Jan 17.
        The composition-function relationship of HDL particles and its effects on the mechanisms driving coronary heart disease (CHD) is poorly understood. We tested the hypothesis that the functionality of HDL particles is significantly influenced by their lipid composition. Using a novel 3D-separation method, we isolated five different-sized HDL subpopulations from CHD patients who had low prebeta-1 functionality (ABCA1-dependent cholesterol-efflux normalized for prebeta-1 concentration) and controls who had either low or high prebeta-1 functionality. Molecular numbers of apoA-I, apoA-II, and eight major lipid classes were determined in each subpopulation by LC/MS. The average number of lipid molecules decreased from 422 in the large spherical alpha-1 particles to 57 in the small discoid prebeta-1 particles. With decreasing particle size, the relative concentration of free cholesterol (FC) decreased in alpha-mobility but not in prebeta-1 particles. Prebeta-1 particles contained more lipids than predicted; 30% of which were neutral lipids (cholesteryl ester and TG) indicating that these particles were mainly remodeled from larger particles not newly synthesized. There were significant correlations between HDL-particle functionality and the concentrations of several lipids. Unexpectedly, the phospholipid:FC ratio was significantly correlated with large-HDL-particle functionality but not with prebeta-1 functionality. There was significant positive correlation between particle functionality and total lipids in high-F controls indicating that the lipid-binding capacity of apoA-I plays a major role in the cholesterol efflux capacity of HDL particles. Functionality and lipid composition of HDL particles are significantly correlated and probably both are influenced by the lipid-binding capacity of apoA-I.

      8. Trends in HIV-2 diagnoses and use of the HIV-1/HIV-2 differentiation test - United States, 2010-2017external icon
        Peruski AH, Wesolowski LG, Delaney KP, Chavez PR, Owen SM, Granade TC, Sullivan V, Switzer WM, Dong X, Brooks JT, Joyce MP.
        MMWR Morb Mortal Wkly Rep. 2020 Jan 24;69(3):63-66.
        Since 2014, the recommended laboratory testing algorithm for diagnosing human immunodeficiency virus (HIV) infection has included a supplemental HIV-1/HIV-2 differentiation test to confirm infection type on the basis of the presence of type-specific antibodies (1). Correctly identifying HIV-1 and HIV-2 infections is vital because their epidemiology and clinical management differ. To describe the percentage of diagnoses for which an HIV-1/HIV-2 differentiation test result was reported and to categorize HIV type based on laboratory test results, 2010-2017 data from CDC's National HIV Surveillance System (NHSS) were analyzed. During 2010-2017, a substantial increase in the number of HIV-1/HIV-2 differentiation test results were reported to NHSS, consistent with implementation of the HIV laboratory-based testing algorithm recommended in 2014. However, >99.9% of all HIV infections identified in the United States were categorized as HIV-1, and the number of HIV-2 diagnoses (mono-infection or dual-infection) remained extremely low (<0.03% of all HIV infections). In addition, the overall number of false positive HIV-2 test results produced by the HIV-1/HIV-2 differentiation increased. The diagnostic value of a confirmatory antibody differentiation test in a setting with sensitive and specific screening tests and few HIV-2 infections might be limited. Evaluation and consideration of other HIV tests approved by the Food and Drug Administration (FDA) that might increase efficiencies in the CDC and Association of Public Health Laboratories-recommended HIV testing algorithm are warranted.

      9. Biomarker profile in stable Fontan patientsexternal icon
        Saraf A, De Staercke C, Everitt I, Haouzi A, Ko YA, Jennings S, Kim JH, Rodriguez FH, Kalogeropoulos AP, Quyyumi A, Book W.
        Int J Cardiol. 2020 Jan 9.
        BACKGROUND: As the population of adults with congenital heart disease (CHD) grows, cardiologists continue to encounter patients with complex anatomies that challenge the standard treatment of care. Single ventricle Fontan palliated patients are the most complex within CHD, with a high morbidity and mortality burden. Factors driving this early demise are largely unknown. METHODS AND RESULTS: We analyzed biomarker expression in 44 stable Fontan outpatients (29.2 +/- 10.7 years, 68.2% female) seen in the outpatient Emory Adult Congenital Heart Center and compared them to 32 age, gender and race matched controls. In comparison to controls, Fontan patients had elevated levels of multiple cytokines within the inflammatory pathway including Tumor Necrosis Factor-alpha (TNF-alpha) (p < 0.001), Interleukin-6 (IL-6) (p < 0.011), Growth Derived Factor-15 (GDF-15) (p < 0.0001), beta2-macroglobulin, (p = 0.0006), stem cell mobilization: Stromal Derived Factor-1 proportional, variant (SDF-1alpha) (p = 0.006), extracellular matrix turnover: Collagen IV (p < 0.0001), neurohormonal activation: Renin (p < 0.0001), renal dysfunction: Cystatin C (p < 0.0001) and Urokinase Receptor (uPAR) (p = 0.022), cardiac injury: Troponin-I (p < 0.0004) and metabolism: Adiponectin (p = 0.0037). Within 1 year of enrollment 50% of Fontan patients had hospitalizations, arrhythmias or worsening hepatic function. GDF-15 was significantly increased in Fontan patients with clinical events (p < 0.0001). In addition, GDF-15 moderately correlated with longer duration of Fontan (r = 0.55, p = 0.01) and was elevated in atriopulmonary (AP) Fontan circulation. Finally, in a multivariate model, VEGF-D and Collagen IV levels were found to be associated with a change in MELDXI, a marker of liver dysfunction. CONCLUSION: Multiple clinical and molecular biomarkers are upregulated in Fontan patients, suggesting a state of chronic systemic dysregulation.

      10. BACKGROUND: Recognition of rickettsialpox infection on skin biopsy can be challenging. The histopathology is nonspecific and inconsistently described. We assess classic histopathologic features in confirmed cases and review the literature. METHODS: We searched for cases of "rickettsialpox" diagnosed between 2006-2018 with positive immunostaining for Spotted Fever Group Rickettsia species. Original slides were evaluated for vacuolar alterations, granulomatous inflammation, vasculitis, necrosis, fibrin thrombi, microvesiculation, papillary dermal edema and extravasated red blood cells. All biopsies were stained with CD3, CD20, CD68 and myeloperoxidase. RESULTS: Six biopsies were compiled, 3 of which were sampled from vesiculopapules, 1 from a maculopapule, and 2 from eschars. Vacuolar alterations and vasculitis were present in all biopsies (6/6; 100%). Granulomatous inflammation was present in 5 biopsies (5/6; 83.3%). Fibrin thrombi and red blood cells were seen in 3/6 (50%) of biopsies. The eschars showed necrosis of the epidermis and superficial dermis (2/6, 33.3%). Only 1 biopsy showed intraepidermal vesiculation and papillary dermal edema (1/6; 16.7%). All six biopsies showed perivascular infiltration with CD3+ T-cells, and low amounts of CD20+ B-cells and neutrophils. Five of the six biopsies (83.3%) showed significant levels of CD68+ histiocytes. CONCLUSION: The histopathology of rickettsialpox infection is septic lymphocytic and granulomatous vasculitis. This article is protected by copyright. All rights reserved.

    • Maternal and Child Health
      1. Geographical distribution of Anopheles stephensi in eastern Ethiopiaexternal icon
        Balkew M, Mumba P, Dengela D, Yohannes G, Getachew D, Yared S, Chibsa S, Murphy M, George K, Lopez K, Janies D, Choi SH, Spear J, Irish SR, Carter TE.
        Parasit Vectors. 2020 Jan 20;13(1):35.
        BACKGROUND: The recent detection of the South Asian malaria vector Anopheles stephensi in Ethiopia and other regions in the Horn of Africa has raised concerns about its potential impact on malaria transmission. We report here the findings of a survey for this species in eastern Ethiopia using both morphological and molecular methods for species identification. METHODS: Adult and larval/pupal collections were conducted at ten sites in eastern Ethiopia and Anopheles specimens were identified using standard morphological keys and genetic analysis. RESULTS: In total, 2231 morphologically identified An. stephensi were collected. A molecular approach incorporating both PCR endpoint assay and sequencing of portions of the internal transcribed spacer 2 (ITS2) and cytochrome c oxidase subunit 1 (cox1) loci confirmed the identity of the An. stephensi in most cases (119/124 of the morphologically identified An. stephensi confirmed molecularly). Additionally, we observed Aedes aegypti larvae and pupae at many of the An. stephensi larval habitats. CONCLUSIONS: Our findings show that An. stephensi is widely distributed in eastern Ethiopia and highlight the need for further surveillance in the southern, western and northern parts of the country and throughout the Horn of Africa.

      2. Left ventricular dysfunction in Duchenne muscular dystrophyexternal icon
        James KA, Gralla J, Ridall LA, Do TN, Czaja AS, Mourani PM, Ciafaloni E, Cunniff C, Donnelly J, Oleszek J, Pandya S, Price E, Yang ML, Auerbach SR.
        Cardiol Young. 2020 Jan 22:1-6.
        BACKGROUND: Duchenne muscular dystrophy is associated with progressive cardiorespiratory failure, including left ventricular dysfunction. METHODS AND RESULTS: Males with probable or definite diagnosis of Duchenne muscular dystrophy, diagnosed between 1 January, 1982 and 31 December, 2011, were identified from the Muscular Dystrophy Surveillance Tracking and Research Network database. Two non-mutually exclusive groups were created: patients with >/=2 echocardiograms and non-invasive positive pressure ventilation-compliant patients with >/=1 recorded ejection fraction. Quantitative left ventricular dysfunction was defined as an ejection fraction <55%. Qualitative dysfunction was defined as mild, moderate, or severe. Progression of quantitative left ventricular dysfunction was modelled as a continuous time-varying outcome. Change in qualitative left ventricle function was assessed by the percentage of patients within each category at each age. Forty-one percent (n = 403) had >/=2 ejection fractions containing 998 qualitative assessments with a mean age at first echo of 10.8 +/- 4.6 years, with an average first ejection fraction of 63.1 +/- 12.6%. Mean age at first echo with an ejection fraction <55 was 15.2 +/- 3.9 years. Thirty-five percent (140/403) were non-invasive positive pressure ventilation-compliant and had ejection fraction information. The estimated rate of decline in ejection fraction from first ejection fraction was 1.6% per year and initiation of non-invasive positive pressure ventilation did not change this rate. CONCLUSIONS: In our cohort, we observed that left ventricle function in patients with Duchenne muscular dystrophy declined over time, independent of non-invasive positive pressure ventilation use. Future studies are needed to examine the impact of respiratory support on cardiac function.

    • Nutritional Sciences
      1. The objective of this study was to describe the prevalence of sugar-sweetened beverage (SSB) intake among US adults (n = 68,896) residing in metropolitan and nonmetropolitan counties, by state, using data from the Behavioral Risk Factor Surveillance System. We used multinomial logistic regression to calculate adjusted prevalence ratios for daily (>/=1 time per day) SSB intake. Overall, 26.0% of respondents reported daily SSB intake, with significantly higher prevalence in nonmetropolitan counties (30.9%) than in metropolitan counties (24.8%) (adjusted prevalence ratio = 1.32, 95% confidence interval, 1.26-1.39). This same pattern was significant in 5 of 11 states with metropolitan and nonmetropolitan counties. These findings could inform efforts to reduce frequent SSB intake in nonmetropolitan areas.

      2. Mean dietary salt intake in Nepal: A population survey with 24-hour urine collectionsexternal icon
        Neupane D, Rijal A, Henry ME, Kallestrup P, Koirala B, McLachlan CS, Ghimire K, Zhao D, Sharma S, Pokharel Y, Joseph K, Olsen MH, Schutte AE, Appel LJ.
        J Clin Hypertens (Greenwich). 2020 Jan 22.
        High salt (sodium chloride) intake raises blood pressure and increases the risk of developing hypertension, a major risk factor for cardiovascular disease. Little is known about salt intake in Nepal, and no study has estimated salt consumption from 24-hour urinary sodium excretion. Participants (n = 451) were recruited from the Community-Based Management of Non-Communicable Diseases in Nepal (COBIN) cohort in 2018. Salt intake was estimated by analyzing 24-hour urinary sodium excretion. Multivariate linear regression was used to estimate differences in salt intake. The mean (+/-SD) age and salt intake were 49.6 (+/-9.8) years and 13.3 (+/-4.7) g/person/d, respectively. Higher salt intake was significantly associated with male gender (beta for female = -2.4; 95% CI: -3.3, -1.4) and younger age (beta10 years = -1.4; 95% CI: -1.4, -0.5) and higher BMI (beta = 0.1; 95% CI: 0.0, 0.2). A significant association was also found between increase in systolic blood pressure and higher salt intake (beta = 0.3; 95% CI: 0.0, 0.7). While 55% reported that they consumed just the right amount of salt, 98% were consuming more than the WHO recommended salt amount (<5 g/person/d). Daily salt intake in this population was over twice the limit recommended by the WHO, suggesting a substantial need to reduce salt intake in this population. It also supports the need of global initiatives such as WHO's Global Hearts Initiative SHAKE technical package and Resolves to Save Lives for sodium reduction in low- and middle-income countries like Nepal.

    • Occupational Safety and Health
      1. Mild steel and stainless steel welding fumes elicit pro-inflammatory and pro-oxidant effects in first trimester trophoblast cellsexternal icon
        Olgun NS, Morris AM, Bowers LN, Stefaniak AB, Friend SA, Reznik SE, Leonard SS.
        Am J Reprod Immunol. 2020 Jan 13:e13221.
        PROBLEM: As more women join the skilled-trade workforce, the effects of workplace exposures on pregnancy need to be explored. This study aims to identify the effects of mild steel and stainless steel welding fume exposures on cultured placental trophoblast cells. METHOD OF STUDY: Welding fumes (mild steel and stainless steel) were generously donated by Lincoln Electric. Electron microscopy was used to characterize welding fume particle size and the ability of particles to enter extravillous trophoblast cells (HTR-8/SVneo). Cellular viability, free radical production, cytokine production, and ability of cells to maintain invasive properties were analyzed, respectively, by WST-1, electron paramagnetic resonance, DCFH-DA, V-plex MULTI-SPOT assay system, and a matrix gel invasion assay. RESULTS: For all three welding fume types, average particle size was < 210 nm. HTR-8/SVneo cells internalized welding particles, and nuclear condensation was observed. Cellular viability was significantly decreased at the high dose of 100 microg/ml for all three welding fumes, and stainless steel generated the greatest production of the hydroxyl radical, and intracellular reactive oxygen species. Production of the cytokines IL-1beta and TNFalpha were not observed in response to welding fume exposure, but IL-6 and IL-8 were. Finally, the invasive capability of cells was decreased upon exposure to both mild steel and stainless steel welding fumes. CONCLUSION: Welding fumes are cytotoxic to extravillous trophoblasts, as is evident by the production of free radicals, pro-inflammatory cytokines, and the observed decrease in invasive capabilities.

    • Parasitic Diseases
      1. Trachoma, anti-Pgp3 serology and ocular Chlamydia trachomatis infection in Papua New Guineaexternal icon
        Macleod CK, Butcher R, Javati S, Gwyn S, Jonduo M, Abdad MY, Roberts CH, Keys D, Koim SP, Ko R, Garap J, Pahau D, Houinei W, Martin DL, Pomat WS, Solomon AW.
        Clin Infect Dis. 2020 Jan 22.
        BACKGROUND: In Melanesia, the prevalence of trachomatous inflammation-follicular (TF) suggests public health-level interventions against active trachoma are needed. However, the prevalence of trachomatous trichiasis (TT) is below the threshold for elimination as a public health problem and evidence of conjunctival infection with trachoma's causative organism (Chlamydia trachomatis, Ct) is rare. Here, we examine the prevalence of ocular infection with Ct and previous exposure to Ct in three districts of Papua New Guinea. METHODS: All individuals aged 1-9 years who were examined for clinical signs of trachoma in three Global Trachoma Mapping Project evaluation units (EUs) were eligble to take part in this study (n=3181). Conjuntival swabs were collected from 349 children with TF and tested by PCR to assess for ocular Ct infection. Dried blood spots were collected from 2572 children and tested for anti-Pgp3 antibodies using a multiplex assay. RESULTS: The proportion of children with TF who had Ct infection was low across all three EUs (overall 2%). Anti-Pgp3 seroprevalence was 5.2% overall and there was no association between anti-Pgp3 antibody level and presence of TF. In two EUs, age-specific seroprevalence did not increase significantly with increasing age in the 1-9-year-old population. In the third EU, there was a statistically significant change with age but the overall seroprevalence and peak age-secific seroprevalence was very low. CONCLUSION: Based on these results, together with similar findings from the Solomon Islands and Vanuatu, the use of TF to guide antibiotic mass drug administration decisions in Melanesia should be reviewed.

    • Physical Activity
      1. Physical activity surveillance using wearable activity monitors: Are US adults willing to share their data?external icon
        Hyde ET, Omura JD, Fulton JE, Weldy A, Carlson SA.
        Am J Health Promot. 2020 Jan 20:890117119900587.
        PURPOSE: Wearable activity monitors (wearables) have generated interest for national physical activity (PA) surveillance; however, concerns exist related to estimates obtained from current users willing to share data. We examined how limiting data to current users who are willing to share data associated with PA estimates in a nationwide sample. DESIGN: Cross-sectional web-based survey. SETTING: US adults. SUBJECTS: In total, 942 respondents. MEASURES: The 2018 Government & Academic Omnibus Survey assessing current wearable use, willingness to share data with various people or organizations, and PA levels. ANALYSIS: Estimated the prevalence of current wearable use; current users' willingness to share data with various people or organizations; and PA levels overall, among current users, and among current users willing to share their data. RESULTS: Overall, 21.7% (95% confidence interval [CI]: 19.1-24.5) of US adults reported currently using a wearable. Among current users, willingness to share ranged from 40.1% with a public health agency to 76.3% with their health-care provider. Overall, 62.2% (95% CI: 58.9-65.3) of adults were physically active. These levels were similar between current users (75.0%, 95% CI: 68.3-80.7) and current users willing to share their data (75.3%, 95% CI: 67.9-81.5). CONCLUSION: Our findings suggest that using data from wearable users may overestimate PA levels, although reported willingness to share the data may not compound this issue.

    • Reproductive Health
      1. An evaluation of infertility among women in the Republic of Palau, 2016external icon
        Kreisel KM, Ikerdeu E, Cash HL, De Jesus SL, Kamb ML, Anderson T, Barrow RY, Sugiyama MS, Basilius K, Madraisau S.
        Hawaii J Health Soc Welf. 2020 Jan;79(1):7-15.
        Fertility challenges are a personal and important part of a woman's reproductive health and are associated with health and lifestyle factors. Limited data exist on infertility among women in Palau. We describe the lifetime prevalence of self-reported infertility in a nationally representative sample of women in Palau and investigate the association between tobacco and/or betel nut use and infertility. During May-December 2016, a population-based survey of noncommunicable diseases was conducted in Palau using a geographically stratified random sample of households (N=2409). Men and women >/=18 years of age were chosen randomly from each selected household. The prevalence of a self-reported lifetime episode of infertility (having tried unsuccessfully to become pregnant for >/=12 months) was evaluated among 874 women aged >/=18 years by key health and lifestyle factors. Prevalence ratios (PR) and 95% confidence intervals (CI) were calculated. Of 315 women who ever tried to become pregnant, 39.7% (95% CI: 34.2%, 45.3%) reported a lifetime episode of infertility. Prevalence was higher in women of Palauan vs other ethnicity (PR=1.6, 95% CI: 1.1, 2.3), those who self-reported poor/not good vs. excellent/ very good health status (PR=2.1, 95% CI: 1.4, 3.3), and those with a body mass index (BMI) >/=30 vs <30 (PR=1.7, 95% CI: 1.3, 2.2). Adjusted models showed that tobacco and/or betel nut users were almost twice as likely to report infertility versus non-users (PR=1.8, 95% CI: 1.3, 2.5). More research is needed to understand the infertility experiences of women in Palau and to promote lifestyle factors contributing to optimal reproductive health.

      2. Effectiveness and safety of extending intrauterine device duration: A systematic reviewexternal icon
        Ti AJ, Roe AH, Whitehouse KC, Smith RA, Gaffield ME, Curtis KM.
        Am J Obstet Gynecol. 2020 Jan 15.
        OBJECTIVE: To systematically review the literature to determine if extended use of intrauterine devices including the copper or levonorgestrel intrauterine device beyond approved durations is effective and safe for preventing pregnancy. DATA SOURCES: We searched PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and Global Index Medicus from inception through June 2019. STUDY ELIGIBILITY CRITERIA: We considered primary studies of women using the T380A Copper or currently available levonorgestrel intrauterine devices past their approved duration (extended use). The primary outcome was pregnancy. Safety outcomes included adverse events and side effects that led to discontinuation. STUDY APPRAISAL AND SYNTHESIS METHODS: We abstracted study data into evidence tables and assessed study quality as related to the risk of bias, precision, and external validity. For each intrauterine device type, we calculated a pooled pregnancy rate during the first two years of extended use using the Poisson inverse variance method. RESULTS: Of 4,068 studies identified by our search, four good to poor quality studies of the 52 mg levonorgestrel intrauterine device (approved for five years) with a total of 2098 women starting extended use, and two good to fair quality studies of the T380A copper intrauterine device (approved for 10 years) with 245 women starting extended use met inclusion criteria. For the levonorgestrel intrauterine device, the pooled pregnancy rate was 0.02 per 100 person-years (95% confidence interval 0.00-0.45) in year six, 0.03 per 100 person-years (95% confidence interval 0.00-0.71) in year 7, and 0.02 per 100 person-years (95% confidence interval 0.00-0.29) in years six and seven combined. During this same time, annual rates of adverse events or discontinuation due to side effects ranged from 0-3.7 per 100 participants. For the copper intrauterine device, the pooled pregnancy rate for years 11 and 12 was 0.0 per 100 person-years (95% confidence interval 0.0-0.8), and annual rates of adverse events and discontinuation due to side effects during extended use ranged from 0-4.6 per 100 participants. CONCLUSION: The available evidence suggests that rates of pregnancy, adverse events, and discontinuation due to side effects during the first two years of extended use of the 52 mg levonorgestrel intrauterine device and the T380A copper intrauterine device are low and comparable to rates during approved duration of use. Data were limited in quantity and quality, and may not be generalizable to all intrauterine device users.

    • Substance Use and Abuse
      1. Onset of regular smoking before age 21 and subsequent nicotine dependence and cessation behavior among US adult smokersexternal icon
        Ali FR, Agaku IT, Sharapova SR, Reimels EA, Homa DM.
        Prev Chronic Dis. 2020 Jan 16;17:E06.
        This study assessed the association of regular smoking initiation before age 21 years with nicotine dependence and cessation behaviors among US adult smokers. Data came from the 2014-2015 Tobacco Use Supplement to the Current Population Survey. We found that onset of regular smoking at age 18 to 20 years was associated with higher odds of nicotine dependence and lower odds of attempting and intending to quit. These outcomes were observed with regular smoking initiation at age 18 to 20 as well as before age 18, suggesting that efforts to prevent access to tobacco products before age 21 could reduce nicotine addiction and promote cessation later in life.

      2. Characteristics of persons who report using only nicotine-containing products among interviewed patients with e-cigarette, or vaping, product use-associated lung injury - Illinois, August-December 2019external icon
        Ghinai I, Navon L, Gunn JK, Duca LM, Brister S, Love S, Brink R, Fajardo G, Johnson J, Saathoff-Huber L, King BA, Jones CM, Krishnasamy VP, Layden JE.
        MMWR Morb Mortal Wkly Rep. 2020 Jan 24;69(3):84-89.
        In 2019, the United States experienced an outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) (1). Most EVALI patients have reported using tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, products obtained from informal sources (2,3), and vitamin E acetate in these products has been closely linked with EVALI (4,5). However, some EVALI patients report using only nicotine-containing products. This study compared demographic, product use, and clinical characteristics of EVALI patients in Illinois who reported using only nicotine-containing e-cigarette, or vaping, products with those of patients who reported using any THC-containing products. Among 121 interviewed Illinois EVALI patients, 17 (14%) reported using only nicotine-containing products, including nine (7%) patients who had no indication of any THC use, based on self-report or toxicology testing. Compared with patients who used any THC-containing products, these nine patients were significantly more likely to be older and female and were less likely to experience constitutional symptoms or to have leukocytosis on initial evaluation. Although vitamin E acetate has been strongly linked with EVALI, evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC- or non-THC-containing products, in some reported EVALI cases. The contributing cause or causes of EVALI for patients reporting use of only nicotine-containing products warrants further investigation.

      3. The EVALI and youth vaping epidemics - implications for public healthexternal icon
        King BA, Jones CM, Baldwin GT, Briss PA.
        N Engl J Med. 2020 Jan 17.

      4. Update: Characteristics of a nationwide outbreak of e-cigarette, or vaping, product use-associated lung injury - United States, August 2019-January 2020external icon
        Krishnasamy VP, Hallowell BD, Ko JY, Board A, Hartnett KP, Salvatore PP, Danielson M, Kite-Powell A, Twentyman E, Kim L, Cyrus A, Wallace M, Melstrom P, Haag B, King BA, Briss P, Jones CM, Pollack LA, Ellington S.
        MMWR Morb Mortal Wkly Rep. 2020 Jan 24;69(3):90-94.
        Since August 2019, CDC, the Food and Drug Administration (FDA), state and local health departments, and public health and clinical stakeholders have been investigating a nationwide outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) (1). This report updates patient demographic characteristics, self-reported substance use, and hospitalization dates for EVALI patients reported to CDC by states, as well as the distribution of emergency department (ED) visits related to e-cigarette, or vaping, products analyzed through the National Syndromic Surveillance Program (NSSP). As of January 14, 2020, a total of 2,668 hospitalized EVALI cases had been reported to CDC. Median patient age was 24 years, and 66% were male. Overall, 82% of EVALI patients reported using any tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, product (including 33% with exclusive THC-containing product use), and 57% of EVALI patients reported using any nicotine-containing product (including 14% with exclusive nicotine-containing product use). Syndromic surveillance indicates that ED visits related to e-cigarette, or vaping, products continue to decline after sharply increasing in August 2019 and peaking in September 2019. Clinicians and public health practitioners should remain vigilant for new EVALI cases. CDC recommends that persons not use THC-containing e-cigarette, or vaping, products, especially those acquired from informal sources such as friends, family members, or from in-person or online dealers. Vitamin E acetate is strongly linked to the EVALI outbreak and should not be added to any e-cigarette, or vaping, products (2). However, evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC- or non-THC-containing products, in some reported EVALI cases.

    • Zoonotic and Vectorborne Diseases
      1. Further evidence of inadequate quality in lateral flow devices commercially offered for the diagnosis of rabiesexternal icon
        Klein A, Fahrion A, Finke S, Eyngor M, Novak S, Yakobson B, Ngoepe E, Phahladira B, Sabeta C, De Benedictis P, Gourlaouen M, Orciari LA, Yager PA, Gigante CM, Knowles MK, Fehlner-Gardiner C, Servat A, Cliquet F, Marston D, McElhinney LM, Johnson T, Fooks AR, Muller T, Freuling CM.
        Trop Med Infect Dis. 2020 Jan 18;5(1).
        As a neglected zoonotic disease, rabies causes approximately 5.9 x 10(4) human deaths annually, primarily affecting low- and middle-income countries in Asia and Africa. In those regions, insufficient surveillance is hampering adequate medical intervention and is driving the vicious cycle of neglect. Where resources to provide laboratory disease confirmation are limited, there is a need for user-friendly and low-cost reliable diagnostic tools that do not rely on specialized laboratory facilities. Lateral flow devices (LFD) offer an alternative to conventional diagnostic methods and may strengthen control efforts in low-resource settings. Five different commercially available LFDs were compared in a multi-centered study with respect to their diagnostic sensitivity and their agreement with standard rabies diagnostic techniques. Our evaluation was conducted by several international reference laboratories using a broad panel of samples. The overall sensitivities ranged from 0% up to 62%, depending on the LFD manufacturer, with substantial variation between the different laboratories. Samples with high antigen content and high relative viral load tended to test positive more often in the Anigen/Bionote test, the latter being the one with the best performance. Still, the overall unsatisfactory findings corroborate a previous study and indicate a persistent lack of appropriate test validation and quality control. At present, the tested kits are not suitable for in-field use for rabies diagnosis, especially not for suspect animals where human contact has been identified, as an incorrect negative diagnosis may result in human casualties. This study points out the discrepancy between the enormous need for such a diagnostic tool on the one hand, and on the other hand, a number of already existing tests that are not yet ready for use.


      3. Zika virus detection in amniotic fluid and Zika-associated birth defectsexternal icon
        Reyes MM, Ailes EC, Daza M, Tong VT, Osorio J, Valencia D, Turca AR, Galang RR, Gonzalez Duarte M, Ricaldi JN, Anderson KN, Kamal N, Thomas JD, Villanueva J, Burkel VK, Meaney-Delman D, Gilboa SM, Honein MA, Jamieson DJ, Martinez MO.
        Am J Obstet Gynecol. 2020 Jan 15.
        BACKGROUND: Zika virus (ZIKV) infection during pregnancy can cause serious birth defects, including brain and eye abnormalities. The clinical importance of detection of ZIKV ribonucleic acid (RNA) in amniotic fluid is unknown. OBJECTIVES: To describe patterns of ZIKV RNA testing of amniotic fluid relative to other clinical specimens and to examine the association between ZIKV detection in amniotic fluid and Zika-associated birth defects. Our null hypothesis was that ZIKV detection in amniotic fluid was not associated with Zika-associated birth defects. STUDY DESIGN: We conducted a retrospective cohort analysis of women with amniotic fluid specimens submitted to Colombia's National Institute of Health as part of national ZIKV surveillance from January 2016 to January 2017. Specimens (maternal serum, amniotic fluid, cord blood, umbilical cord tissue, and placental tissue) were tested for the presence of ZIKV RNA using a singleplex or multiplex real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) assay. Birth defect information was abstracted from maternal prenatal and infant birth records and reviewed by expert clinicians. Chi-square and Fisher's exact tests were used to compare the frequency of Zika-associated birth defects (defined as brain abnormalities [with or without microcephaly, but excluding neural tube defects and their associated findings] or eye abnormalities) by frequency of detection of ZIKV RNA in amniotic fluid. RESULTS: Our analysis included 128 women with amniotic fluid specimens. Seventy-five women (58%) had prenatally-collected amniotic fluid, 42 (33%) at delivery, and 11 (9%) had missing collection dates. Ninety-one women had both amniotic fluid and other clinical specimens submitted for testing, allowing for comparison across specimen types. Of those 91 women, 68 had evidence of ZIKV infection based on detection of ZIKV RNA (ZIKV+) in >1 specimen. Testing of amniotic fluid collected prenatally or at delivery identified 39 (57%) of these ZIKV infections (15 [22%] identified only in amniotic fluid), and 29 (43%) infections were identified in other specimen types and not amniotic fluid. Among women included in the analysis, 89 had pregnancy outcome information available, allowing for assessment of the presence of Zika-associated birth defects. Zika-associated birth defects were significantly (p<0.05) more common among pregnancies with ZIKV+ amniotic fluid specimens collected prenatally (19/32, 59%) than for those with no laboratory evidence of ZIKV infection in any specimen (6/23, 26%), but the proportion was similar in pregnancies with only ZIKV+ specimens other than amniotic fluid (10/23, 43%). Though Zika-associated birth defects were more common among women with any ZIKV+ amniotic fluid specimen (i.e., collected prenatally or at delivery; 21/43, 49%) than those with no laboratory evidence of ZIKV infection (6/23, 26%), this comparison did not reach statistical significance (p=0.07). CONCLUSIONS: Testing of amniotic fluid provided additional evidence for maternal diagnosis of ZIKV infection. Zika-associated birth defects were more common among women with ZIKV RNA detected in prenatal amniotic fluid specimens than women with no laboratory evidence of ZIKV infection, but similar to women with ZIKV RNA detected in other, non-amniotic fluid specimen types.

      4. Population-based surveillance for birth defects potentially related to Zika virus infection - 22 states and territories, January 2016-June 2017external icon
        Smoots AN, Olson SM, Cragan J, Delaney A, Roth NM, Godfred-Cato S, Jones AM, Nahabedian JF, Fornoff J, Sandidge T, Yazdy MM, Higgins C, Olney RS, Eckert V, Forkner A, Fox DJ, Stolz A, Crawford K, Cho SJ, Knapp M, Ahmed MF, Lake-Burger H, Elmore AL, Langlois P, Breidenbach R, Nance A, Denson L, Caton L, Forestieri N, Bergman K, Humphries BK, Leedom VO, Tran T, Johnston J, Valencia-Prado M, Perez-Gonzalez S, Romitti PA, Fall C, Bryan JM, Barton J, Arias W, St John K, Mann S, Kimura J, Orantes L, Martin B, de Wilde L, Ellis EM, Song Z, Akosa A, Goodroe C, Ellington SR, Tong VT, Gilboa SM, Moore CA, Honein MA.
        MMWR Morb Mortal Wkly Rep. 2020 Jan 24;69(3):67-71.
        Zika virus infection during pregnancy can cause congenital brain and eye abnormalities and is associated with neurodevelopmental abnormalities (1-3). In areas of the United States that experienced local Zika virus transmission, the prevalence of birth defects potentially related to Zika virus infection during pregnancy increased in the second half of 2016 compared with the first half (4). To update the previous report, CDC analyzed population-based surveillance data from 22 states and territories to estimate the prevalence of birth defects potentially related to Zika virus infection, regardless of laboratory evidence of or exposure to Zika virus, among pregnancies completed during January 1, 2016-June 30, 2017. Jurisdictions were categorized as those 1) with widespread local transmission of Zika virus; 2) with limited local transmission of Zika virus; and 3) without local transmission of Zika virus. Among 2,004,630 live births, 3,359 infants and fetuses with birth defects potentially related to Zika virus infection during pregnancy were identified (1.7 per 1,000 live births, 95% confidence interval [CI] = 1.6-1.7). In areas with widespread local Zika virus transmission, the prevalence of birth defects potentially related to Zika virus infection during pregnancy was significantly higher during the quarters comprising July 2016-March 2017 (July-September 2016 = 3.0; October-December 2016 = 4.0; and January-March 2017 = 5.6 per 1,000 live births) compared with the reference period (January-March 2016) (1.3 per 1,000). These findings suggest a fourfold increase (prevalence ratio [PR] = 4.1, 95% CI = 2.1-8.4) in birth defects potentially related to Zika virus in widespread local transmission areas during January-March 2017 compared with that during January-March 2016, with the highest prevalence (7.0 per 1,000 live births) in February 2017. Population-based birth defects surveillance is critical for identifying infants and fetuses with birth defects potentially related to Zika virus regardless of whether Zika virus testing was conducted, especially given the high prevalence of asymptomatic disease. These data can be used to inform follow-up care and services as well as strengthen surveillance.


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