Issue 40, November 10, 2020

CDC Science Clips: Volume 12, Issue 40, November 10, 2020

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

  1. 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. Sociodemographic and geographic variation in awareness of stroke signs and symptoms among adults - United States, 2017external icon
        Jackson SL, Legvold B, Vahratian A, Blackwell DL, Fang J, Gillespie C, Hayes D, Loustalot F.
        MMWR Morb Mortal Wkly Rep. 2020 Nov 6;69(44):1617-1621.
        Stroke is the fifth leading cause of death in the United States (1). In 2017, on average, a stroke-related death occurred every 3 minutes and 35 seconds in the United States, and stroke is a leading cause of long-term disability (1). To prevent mortality or long-term disability, strokes require rapid recognition and early medical intervention (2,3). Common stroke signs and symptoms include sudden numbness or weakness of the face, arm, or leg, especially on one side; sudden confusion or trouble speaking; sudden trouble seeing in one or both eyes; sudden trouble walking, dizziness, or loss of balance; and a sudden severe headache with no known cause. Recommended action at the first sign of a suspected stroke is to quickly request emergency services (i.e., calling 9-1-1) (2). Public education campaigns have emphasized recognizing stroke signs and symptoms and the importance of calling 9-1-1, and stroke knowledge increased 14.7 percentage points from 2009 to 2014 (4). However, disparities in stroke awareness have been reported (4,5). Knowledge of the five signs and symptoms of stroke and the immediate need to call emergency medical services (9-1-1), collectively referred to as "recommended stroke knowledge," was assessed among 26,076 adults aged ≥20 years as part of the 2017 National Health Interview Survey (NHIS). The prevalence of recommended stroke knowledge among U.S. adults was 67.5%. Stroke knowledge differed significantly by race and Hispanic origin (p<0.001). The prevalence of recommended stroke knowledge was highest among non-Hispanic White adults (71.3%), followed by non-Hispanic Black adults (64.0%) and Hispanic adults (57.8%). Stroke knowledge also differed significantly by sex, age, education, and urbanicity. After multivariable adjustment, these differences remained significant. Increasing awareness of the signs and symptoms of stroke continues to be a national priority. Estimates from this report can inform public health strategies for increasing awareness of stroke signs and symptoms.

      2. BACKGROUND: The 2017 American College of Cardiology / American Heart Association Guideline for blood pressure (BP) management newly classifies millions of Americans with elevated blood pressure or stage 1 hypertension for recommended lifestyle modification alone (without pharmacotherapy). This study characterized these adults, including their CVD risk factors, barriers to lifestyle modification, and healthcare access. METHODS: This cross-sectional study examined nationally representative National Health and Nutrition Examination Survey data, 2013-2016, on 10,205 US adults aged ≥18, among whom 2,081 had elevated blood pressure or stage 1 hypertension and met 2017 ACC/AHA BP Guideline criteria for lifestyle modification alone. RESULTS: An estimated 22% of US adults (52 million) would be recommended for lifestyle modification alone. Among these, 58% were men, 43% had obesity, 52% had low quality diet, 95% consumed excess sodium, 43% were physically inactive, and 8% consumed excess alcohol. Many reported attempting lifestyle changes (range: 39%-60%). Those who reported receiving health professional advice to lose weight (adjusted prevalence ratio 1.21, 95% confidence interval 1.06-1.38), reduce sodium intake (2.33, 2.00-2.72), or exercise more (1.60, 1.32-1.95) were significantly more likely to report attempting changes. However, potential barriers to lifestyle modification included 28% of adults reporting disability, asthma, or arthritis. Additionally, 20% had no health insurance and 22% had no healthcare visits in the last year. CONCLUSIONS: One fifth of US adults met 2017 ACC/AHA BP Guideline criteria for lifestyle modification alone, and many reported attempting behavior change. However, barriers exist such as insurance gaps, limited access to care, and physical impairment.

    • Communicable Diseases
      1. Sexual history taking in clinical settings: A narrative reviewexternal icon
        Brookmeyer KA, Coor A, Kachur RE, Beltran O, Reno HE, Dittus PJ.
        Sex Transm Dis. 2020 Oct 21.
        OBJECTIVES: To explore gaps between CDC's clinical guidelines for obtaining a sexual history and regular clinical practice. We examine how patient, provider and setting characteristics may influence the likelihood of obtaining comprehensive sexual histories and examine patient outcomes linked to sexual history taking. METHODS: We performed a narrative review to identify studies that examined clinical practice and sexual history taking via eight databases. A two-level inclusion protocol was followed, wherein the abstract and full text of the article were reviewed, respectively. Data was abstracted using a standardized tool developed for this study. RESULTS: The search yielded 2,700 unique studies, of which 2,193 were excluded in level one and 497 were excluded in level 2, leaving ten studies for data abstraction. None of the studies reported comprehensive sexual history taking, and eight studies reported differences in how providers obtain a sexual history when patient and provider demographics are considered. Three studies found a positive link between providers who discuss sexual history and provider STD testing. CONCLUSIONS: When sexual histories are obtained, they are not comprehensive, and providers may discuss sexual history differentially based on patients' demographic characteristics. Providers who discuss patients' sexual history may be more likely to also provide sexual health preventive care.

      2. Patch dynamics modeling framework from pathogens' perspective: Unified and standardized approach for complicated epidemic systemsexternal icon
        Chen S, Owolabi Y, Li A, Lo E, Robinson P, Janies D, Lee C, Dulin M.
        PLoS One. 2020 ;15(10):e0238186.
        Mathematical models are powerful tools to investigate, simulate, and evaluate potential interventions for infectious diseases dynamics. Much effort has focused on the Susceptible-Infected-Recovered (SIR)-type compartment models. These models consider host populations and measure change of each compartment. In this study, we propose an alternative patch dynamic modeling framework from pathogens' perspective. Each patch, the basic module of this modeling framework, has four standard mechanisms of pathogen population size change: birth (replication), death, inflow, and outflow. This framework naturally distinguishes between-host transmission process (inflow and outflow) and within-host infection process (replication) during the entire transmission-infection cycle. We demonstrate that the SIR-type model is actually a special cross-sectional and discretized case of our patch dynamics model in pathogens' viewpoint. In addition, this patch dynamics modeling framework is also an agent-based model from hosts' perspective by incorporating individual host's specific traits. We provide an operational standard to formulate this modular-designed patch dynamics model. Model parameterization is feasible with a wide range of sources, including genomics data, surveillance data, electronic health record, and from other emerging technologies such as multiomics. We then provide two proof-of-concept case studies to tackle some of the existing challenges of SIR-type models: sexually transmitted disease and healthcare acquired infections. This patch dynamics modeling framework not only provides theoretical explanations to known phenomena, but also generates novel insights of disease dynamics from a more holistic viewpoint. It is also able to simulate and handle more complicated scenarios across biological scales such as the current COVID-19 pandemic.

      3. Telework before illness onset among symptomatic adults aged >/= 18 years with and without COVID-19 in 11 outpatient health care facilities - United States, July 2020external icon
        Fisher KA, Olson SM, Tenforde MW, Feldstein LR, Lindsell CJ, Shapiro NI, Files DC, Gibbs KW, Erickson HL, Prekker ME, Steingrub JS, Exline MC, Henning DJ, Wilson JG, Brown SM, Peltan ID, Rice TW, Hager DN, Ginde AA, Talbot HK, Casey JD, Grijalva CG, Flannery B, Patel MM, Self WH.
        MMWR Morb Mortal Wkly Rep. 2020 Nov 6;69(44):1648-1653.
        Since March 2020, large-scale efforts to reduce transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), have continued. Mitigation measures to reduce workplace exposures have included work site policies to support flexible work site options, including telework, whereby employees work remotely without commuting to a central place of work.* Opportunities to telework have varied across industries among U.S. jobs where telework options are feasible (1). However, little is known about the impact of telework on risk for SARS-CoV-2 infection. A case-control investigation was conducted to compare telework between eligible symptomatic persons who received positive SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) test results (case-patients, 153) and symptomatic persons with negative test results (control-participants, 161). Eligible participants were identified in outpatient health care facilities during July 2020. Among employed participants who reported on their telework status during the 2 weeks preceding illness onset (248), the percentage who were able to telework on a full- or part-time basis was lower among case-patients (35%; 42 of 120) than among control-participants (53%; 68 of 128) (p<0.01). Case-patients were more likely than were control-participants to have reported going exclusively to an office or school setting (adjusted odds ratio [aOR] = 1.8; 95% confidence interval [CI] = 1.2-2.7) in the 2 weeks before illness onset. The association was also observed when further restricting to the 175 participants who reported working in a profession outside the critical infrastructure(†) (aOR = 2.1; 95% CI = 1.3-3.6). Providing the option to work from home or telework when possible, is an important consideration for reducing the risk for SARS-CoV-2 infection. In industries where telework options are not available, worker safety measures should continue to be scaled up to reduce possible worksite exposures.

      4. Global reports of intussusception in infants with SARS-CoV-2 infectionexternal icon
        Giovanni JE, Hrapcak S, Melgar M, Godfred-Cato S.
        Pediatr Infect Dis J. 2020 Oct 22.
        Idiopathic intussusception is a common cause of bowel obstruction in infants, presenting as refractory abdominal pain or mass, vomiting, lethargy, and currant jelly stool. Coronavirus disease 2019 is not well characterized in children, especially infants, but symptoms in children have included nausea, vomiting, diarrhea, and abdominal pain. From January to July 2020, intussusception was reported in 5 infants 4-10 months of age who had laboratory-confirmed SARS-CoV-2 infection. All 5 infants presented with currant jelly stool and at least 1 other abdominal symptom, and none presented with respiratory symptoms. Four infants recovered but the fifth infant progressed to a critical illness and death. While an association between SARS-CoV-2 infection and intussusception has not been established, infants with symptoms consistent with intussusception may warrant testing for viral pathogens, including SARS-CoV-2, especially if presenting to healthcare with a history of SARS-CoV-2 exposure or with signs and symptoms of COVID-19. More investigation is needed to determine whether intussusception is part of the clinical spectrum of COVID-19 in infants or a coincidental finding among infants with SARS-CoV-2 infection.

      5. Measuring environmental exposure to enteric pathogens in low-income settings: Review and recommendations of an interdisciplinary working groupexternal icon
        Goddard FG, Ban R, Barr DB, Brown J, Cannon J, Colford JM, Eisenberg JN, Ercumen A, Petach H, Freeman MC, Levy K, Luby SP, Moe C, Pickering AJ, Sarnat JA, Stewart J, Thomas E, Taniuchi M, Clasen T.
        Environ Sci Technol. 2020 Oct 6;54(19):11673-11691.
        Infections with enteric pathogens impose a heavy disease burden, especially among young children in low-income countries. Recent findings from randomized controlled trials of water, sanitation, and hygiene interventions have raised questions about current methods for assessing environmental exposure to enteric pathogens. Approaches for estimating sources and doses of exposure suffer from a number of shortcomings, including reliance on imperfect indicators of fecal contamination instead of actual pathogens and estimating exposure indirectly from imprecise measurements of pathogens in the environment and human interaction therewith. These shortcomings limit the potential for effective surveillance of exposures, identification of important sources and modes of transmission, and evaluation of the effectiveness of interventions. In this review, we summarize current and emerging approaches used to characterize enteric pathogen hazards in different environmental media as well as human interaction with those media (external measures of exposure), and review methods that measure human infection with enteric pathogens as a proxy for past exposure (internal measures of exposure). We draw from lessons learned in other areas of environmental health to highlight how external and internal measures of exposure can be used to more comprehensively assess exposure. We conclude by recommending strategies for advancing enteric pathogen exposure assessments.

      6. Transmission of SARS-COV-2 infections in households - Tennessee and Wisconsin, April-September 2020external icon
        Grijalva CG, Rolfes MA, Zhu Y, McLean HQ, Hanson KE, Belongia EA, Halasa NB, Kim A, Reed C, Fry AM, Talbot HK.
        MMWR Morb Mortal Wkly Rep. 2020 Nov 6;69(44):1631-1634.
        Improved understanding of transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), within households could aid control measures. However, few studies have systematically characterized the transmission of SARS-CoV-2 in U.S. households (1). Previously reported transmission rates vary widely, and data on transmission rates from children are limited. To assess household transmission, a case-ascertained study was conducted in Nashville, Tennessee, and Marshfield, Wisconsin, commencing in April 2020. In this study, index patients were defined as the first household members with COVID-19-compatible symptoms who received a positive SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) test result, and who lived with at least one other household member. After enrollment, index patients and household members were trained remotely by study staff members to complete symptom diaries and obtain self-collected specimens, nasal swabs only or nasal swabs and saliva samples, daily for 14 days. For this analysis, specimens from the first 7 days were tested for SARS-CoV-2 using CDC RT-PCR protocols.(†) A total of 191 enrolled household contacts of 101 index patients reported having no symptoms on the day of the associated index patient's illness onset, and among these 191 contacts, 102 had SARS-CoV-2 detected in either nasal or saliva specimens during follow-up, for a secondary infection rate of 53% (95% confidence interval [CI] = 46%-60%). Among fourteen households in which the index patient was aged <18 years, the secondary infection rate from index patients aged <12 years was 53% (95% CI = 31%-74%) and from index patients aged 12-17 years was 38% (95% CI = 23%-56%). Approximately 75% of secondary infections were identified within 5 days of the index patient's illness onset, and substantial transmission occurred whether the index patient was an adult or a child. Because household transmission of SARS-CoV-2 is common and can occur rapidly after the index patient's illness onset, persons should self-isolate immediately at the onset of COVID-like symptoms, at the time of testing as a result of a high risk exposure, or at the time of a positive test result, whichever comes first. Concurrent to isolation, all members of the household should wear a mask when in shared spaces in the household.(§).

      7. A SARS-CoV-2 outbreak illustrating the challenges in limiting the spread of the virus - Hopi Tribe, May-June 2020external icon
        Hirschman J, Kaur H, Honanie K, Jenkins R, Humeyestewa DA, Burke RM, Billy TM, Mayer O, Herne M, Anderson M, Bhairavabhotla R, Yatabe G, Balajee SA.
        MMWR Morb Mortal Wkly Rep. 2020 Nov 6;69(44):1654-1659.
        On June 3, 2020, a woman aged 73 years (patient A) with symptoms consistent with coronavirus disease 2019 (COVID-19) (1) was evaluated at the emergency department of the Hopi Health Care Center (HHCC, an Indian Health Services facility) and received a positive test result for SARS-CoV-2, the virus that causes COVID-19. The patient's symptoms commenced on May 27, and a sibling (patient B) of the patient experienced symptom onset the following day. On May 23, both patients had driven together and spent time in a retail store in Flagstaff, Arizona. Because of their similar exposures, symptom onset dates, and overlapping close contacts, these patients are referred to as co-index patients. The co-index patients had a total of 58 primary (i.e., direct) and secondary contacts (i.e., contacts of a primary contact); among these, 27 (47%) received positive SARS-CoV-2 test results. Four (15%) of the 27 contacts who became ill were household members of co-index patient B, 14 (52%) had attended family gatherings, one was a child who might have transmitted SARS-CoV-2 to six contacts, and eight (30%) were community members. Findings from the outbreak investigation prompted the HHCC and Hopi Tribe leadership to strengthen community education through community health representatives, public health nurses, and radio campaigns. In communities with similar extended family interaction, emphasizing safe ways to stay in touch, along with wearing a mask, frequent hand washing, and physical distancing might help limit the spread of disease.

      8. Hepatitis A person-to-person outbreaks: Epidemiology, morbidity burden, and factors associated with hospitalization - multiple states, 2016-2019external icon
        Hofmeister MG, Xing J, Foster MA, Augustine RJ, Burkholder C, Collins J, McBee S, Thomasson ED, Thoroughman D, Weng MK, Spradling PR.
        J Infect Dis. 2020 Oct 24.
        BACKGROUND: Since 2016, the US has experienced person-to-person hepatitis A outbreaks unprecedented in the vaccine era. The proportion of cases hospitalized in these outbreaks exceeds historical national surveillance data. METHODS: We described the epidemiology, characterized the reported increased morbidity, and identified factors associated with hospitalization during the outbreaks by reviewing a 10% random sample of outbreak-associated hepatitis A cases in Kentucky, Michigan, and West Virginia-three heavily affected states. We calculated descriptive statistics and conducted age-adjusted log-binomial regression analyses to identify factors associated with hospitalization. RESULTS: Participants in the random sample (n=817) were primarily male (62.5%) with mean age of 39.0 years; 51.8% were hospitalized. Among those with available information, 73.2% reported drug use, 14.0% were experiencing homelessness, 29.7% were currently or recently incarcerated, and 61.6% were epidemiologically linked to a known outbreak-associated case. Residence in Michigan (adjusted risk ratio [aRR] 1.8), being a man who has sex with men (aRR 1.5), non-injection drug use (aRR 1.3), and homelessness (aRR 1.3) were significantly (p<0.05) associated with hepatitis A-related hospitalization. CONCLUSIONS: Our findings support current Advisory Committee on Immunization Practices recommendations to vaccinate all persons who use drugs, men who have sex with men, and persons experiencing homelessness against hepatitis A.

      9. Notes from the field: Development of an enhanced community-focused COVID-19 surveillance program - Hopi Tribe, June‒July 2020external icon
        Jenkins R, Burke RM, Hamilton J, Fazekas K, Humeyestewa D, Kaur H, Hirschman J, Honanie K, Herne M, Mayer O, Yatabe G, Balajee SA.
        MMWR Morb Mortal Wkly Rep. 2020 Nov 6;69(44):1660-1661.

      10. Network characteristics and visualization of COVID-19 outbreak in a large detention facility in the United States - Cook County, Illinois, 2020external icon
        Kırbıyık U, Binder AM, Ghinai I, Zawitz C, Levin R, Samala U, Smith MB, Gubser J, Jones B, Varela K, Rafinski J, Fitzgerald A, Orris P, Bahls A, Welbel S, Mennella C, Black SR, Armstrong PA.
        MMWR Morb Mortal Wkly Rep. 2020 Nov 6;69(44):1625-1630.
        Correctional and detention facilities have been disproportionately affected by coronavirus disease 2019 (COVID-19) because of shared space and movement of staff members and detained persons within facilities (1,2). During March 1-April 30, 2020, at Cook County Jail in Chicago, Illinois, >900 COVID-19 cases were diagnosed across all 10 housing divisions, representing 13 unique buildings.(†) Movement within the jail was examined through network analyses and visualization, a field that examines elements within a network and the connections between them. This methodology has been used to supplement contact tracing investigations for tuberculosis and to understand how social networks contribute to transmission of sexually transmitted infections (3-5). Movements and connections of 5,884 persons (3,843 [65%] detained persons and 2,041 [35%] staff members) at the jail during March 1-April 30 were analyzed. A total of 472 (12.3%) COVID-19 cases were identified among detained persons and 198 (9.7%) among staff members. Among 103,701 shared-shift connections among staff members, 1.4% occurred between persons with COVID-19, a percentage that is significantly higher than the expected 0.9% by random occurrence alone (p<0.001), suggesting that additional transmission occurred within this group. The observed connections among detained persons with COVID-19 were significantly lower than expected (1.0% versus 1.1%, p<0.001) when considering only the housing units in which initial transmission occurred, suggesting that the systematic isolation of persons with COVID-19 is effective at limiting transmission. A network-informed approach can identify likely points of high transmission, allowing for interventions to reduce transmission targeted at these groups or locations, such as by reducing convening of staff members, closing breakrooms, and cessation of contact sports.

      11. Lack of serologic evidence of infection among health care personnel and other contacts of first 2 confirmed patients with COVID-19 in Illinois, 2020external icon
        McPherson TD, Ghinai I, Binder AM, Freeman BD, Hoskin Snelling C, Hunter JC, Anderson KM, Davenport P, Rudd DL, Zafer M, Christiansen D, Joshi K, Rubin R, Black SR, Fricchione MJ, Pacilli M, Walblay KA, Korpics J, Moeller D, Quartey-Kumapley P, Wang C, Charles EM, Kauerauf J, Patel MT, Disari VS, Fischer M, Jacobs MW, Lester SN, Midgley CM, Rasheed MA, Reese HE, Verani JR, Wallace M, Watson JT, Thornburg NJ, Layden JE, Kirking HL.
        Public Health Rep. 2020 Oct 27.
        OBJECTIVES: Widespread global transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus causing coronavirus disease 2019 (COVID-19), continues. Many questions remain about asymptomatic or atypical infections and transmission dynamics. We used comprehensive contact tracing of the first 2 confirmed patients in Illinois with COVID-19 and serologic SARS-CoV-2 antibody testing to determine whether contacts had evidence of undetected COVID-19. METHODS: Contacts were eligible for serologic follow-up if previously tested for COVID-19 during an initial investigation or had greater-risk exposures. Contacts completed a standardized questionnaire during the initial investigation. We classified exposure risk as high, medium, or low based on interactions with 2 index patients and use of personal protective equipment (PPE). Serologic testing used a SARS-CoV-2 spike enzyme-linked immunosorbent assay on serum specimens collected from participants approximately 6 weeks after initial exposure to either index patient. The 2 index patients provided serum specimens throughout their illness. We collected data on demographic, exposure, and epidemiologic characteristics. RESULTS: Of 347 contacts, 110 were eligible for serologic follow-up; 59 (17% of all contacts) enrolled. Of these, 53 (90%) were health care personnel and 6 (10%) were community contacts. Seventeen (29%) reported high-risk exposures, 15 (25%) medium-risk, and 27 (46%) low-risk. No participant had evidence of SARS-CoV-2 antibodies. The 2 index patients had antibodies detected at dilutions >1:6400 within 4 weeks after symptom onset. CONCLUSIONS: In serologic follow-up of the first 2 known patients in Illinois with COVID-19, we found no secondary transmission among tested contacts. Lack of seroconversion among these contacts adds to our understanding of conditions (ie, use of PPE) under which SARS-CoV-2 infections might not result in transmission and demonstrates that SARS-CoV-2 antibody testing is a useful tool to verify epidemiologic findings.

      12. Transmission dynamics and microevolution of Neisseria meningitidis during carriage and invasive disease in high school students, Georgia and Maryland, USA, 2006-2007external icon
        Mustapha MM, Marsh JW, Shutt KA, Schlackman J, Ezeonwuka C, Farley MM, Stephens DS, Wang X, Van Tyne D, Harrison LH.
        J Infect Dis. 2020 Oct 27.
        BACKGROUND: The mechanisms by which Neisseria meningitidis (Nm) cause persistent human carriage and transition from carriage to invasive disease have not been fully elucidated. METHODS: Georgia and Maryland high school students were sampled for pharyngeal carriage of Nm during the 2006-2007 school year. 321 isolates from 188 carriers and all 67 invasive isolates collected during the same time and from the same geographic region underwent whole genome sequencing. Core-genome MLST (cgMLST) was used to compare allelic profiles, and direct read mapping was employed to study strain evolution. RESULTS: Among 188 Nm culture-positive students, 98 (52.1%) were Nm culture-positive at two or three samplings. Most students who were positive at more than one sampling (98%) had persistence of a single strain. Over a third of students carried isolates that were highly genetically related to isolates from other students in the same school, and occasional transmission within the same county was also evident. The major pilin subunit gene, pilE, was the most variable gene, and no carrier had identical pilE sequences at different time points. CONCLUSION: We found strong evidence of local meningococcal transmission at both the school and county level. Allelic variation within genes encoding bacterial surface structures, particularly pilE, was common.

      13. Limited English proficiency among adults with HIV in the United States - Medical Monitoring Project, 2015-2018external icon
        Padilla M, Fagan J, Tie Y, Weiser J, Demeke HB, Luke Shouse R.
        AIDS Care. 2020 Oct 27:1-5.
        Research suggests that language barriers in health care settings may adversely affect clinical outcomes and patient satisfaction. We describe the characteristics of adults with limited English proficiency (LEP) and diagnosed HIV in the United States. The Medical Monitoring Project is a complex sample survey of adults with diagnosed HIV in the United States that uses two-stage, probability-proportional-to-size sampling. We analyzed weighted interview and medical record data collected from June 2015-May 2018. The prevalence of LEP among adults with HIV was 10%. Higher percentages of adults with LEP, compared with adults with English proficiency (EP), were female, Hispanic/Latino, less educated and poor, only had Ryan White HIV/AIDS Program (RWHAP) health care coverage, attended RWHAP-funded facilities, were satisfied with their HIV medical care, were prescribed antiretroviral therapy (ART), were virally suppressed and received testing for sexually transmitted diseases. We found no statistical difference in ART adherence among adults with LEP and EP. Despite the association between LEP and the risk for health disparities, more persons with LEP were virally suppressed compared with persons with EP. One possible explanation is attendance at RWHAP-funded facilities by adults with LEP; however, future studies are needed to explore other possible explanations.

      14. Birth and infant outcomes following laboratory-confirmed SARS-CoV-2 infection in pregnancy - SET-NET, 16 Jurisdictions, March 29-October 14, 2020external icon
        Woodworth KR, Olsen EO, Neelam V, Lewis EL, Galang RR, Oduyebo T, Aveni K, Yazdy MM, Harvey E, Longcore ND, Barton J, Fussman C, Siebman S, Lush M, Patrick PH, Halai UA, Valencia-Prado M, Orkis L, Sowunmi S, Schlosser L, Khuwaja S, Read JS, Hall AJ, Meaney-Delman D, Ellington SR, Gilboa SM, Tong VT.
        MMWR Morb Mortal Wkly Rep. 2020 Nov 6;69(44):1635-1640.
        Pregnant women with coronavirus disease 2019 (COVID-19) are at increased risk for severe illness and might be at risk for preterm birth (1-3). The full impact of infection with SARS-CoV-2, the virus that causes COVID-19, in pregnancy is unknown. Public health jurisdictions report information, including pregnancy status, on confirmed and probable COVID-19 cases to CDC through the National Notifiable Diseases Surveillance System.* Through the Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET), 16 jurisdictions collected supplementary information on pregnancy and infant outcomes among 5,252 women with laboratory-confirmed SARS-CoV-2 infection reported during March 29-October 14, 2020. Among 3,912 live births with known gestational age, 12.9% were preterm (<37 weeks), higher than the reported 10.2% among the general U.S. population in 2019 (4). Among 610 infants (21.3%) with reported SARS-CoV-2 test results, perinatal infection was infrequent (2.6%) and occurred primarily among infants whose mother had SARS-CoV-2 infection identified within 1 week of delivery. Because the majority of pregnant women with COVID-19 reported thus far experienced infection in the third trimester, ongoing surveillance is needed to assess effects of infections in early pregnancy, as well the longer-term outcomes of exposed infants. These findings can inform neonatal testing recommendations, clinical practice, and public health action and can be used by health care providers to counsel pregnant women on the risks of SARS-CoV-2 infection, including preterm births. Pregnant women and their household members should follow recommended infection prevention measures, including wearing a mask, social distancing, and frequent handwashing when going out or interacting with others or if there is a person within the household who has had exposure to COVID-19.(†).

      15. Update: Characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status - United States, January 22-October 3, 2020external icon
        Zambrano LD, Ellington S, Strid P, Galang RR, Oduyebo T, Tong VT, Woodworth KR, Nahabedian JF, Azziz-Baumgartner E, Gilboa SM, Meaney-Delman D.
        MMWR Morb Mortal Wkly Rep. 2020 Nov 6;69(44):1641-1647.
        Studies suggest that pregnant women might be at increased risk for severe illness associated with coronavirus disease 2019 (COVID-19) (1,2). This report provides updated information about symptomatic women of reproductive age (15-44 years) with laboratory-confirmed infection with SARS-CoV-2, the virus that causes COVID-19. During January 22-October 3, CDC received reports through national COVID-19 case surveillance or through the National Notifiable Diseases Surveillance System (NNDSS) of 1,300,938 women aged 15-44 years with laboratory results indicative of acute infection with SARS-CoV-2. Data on pregnancy status were available for 461,825 (35.5%) women with laboratory-confirmed infection, 409,462 (88.7%) of whom were symptomatic. Among symptomatic women, 23,434 (5.7%) were reported to be pregnant. After adjusting for age, race/ethnicity, and underlying medical conditions, pregnant women were significantly more likely than were nonpregnant women to be admitted to an intensive care unit (ICU) (10.5 versus 3.9 per 1,000 cases; adjusted risk ratio [aRR] = 3.0; 95% confidence interval [CI] = 2.6-3.4), receive invasive ventilation (2.9 versus 1.1 per 1,000 cases; aRR = 2.9; 95% CI = 2.2-3.8), receive extracorporeal membrane oxygenation (ECMO) (0.7 versus 0.3 per 1,000 cases; aRR = 2.4; 95% CI = 1.5-4.0), and die (1.5 versus 1.2 per 1,000 cases; aRR = 1.7; 95% CI = 1.2-2.4). Stratifying these analyses by age and race/ethnicity highlighted disparities in risk by subgroup. Although the absolute risks for severe outcomes for women were low, pregnant women were at increased risk for severe COVID-19-associated illness. To reduce the risk for severe illness and death from COVID-19, pregnant women should be counseled about the importance of seeking prompt medical care if they have symptoms and measures to prevent SARS-CoV-2 infection should be strongly emphasized for pregnant women and their families during all medical encounters, including prenatal care visits. Understanding COVID-19-associated risks among pregnant women is important for prevention counseling and clinical care and treatment.

    • Disaster Control and Emergency Services
      1. CDC's Flu on Call simulation: Testing a national helpline for use during an influenza pandemicexternal icon
        Koonin LM, Sliger K, Kerr J, Bullen-Austin L, Graeden E, Farris K, Ionta C, Krause D, Patel A.
        Health Secur. 2020 Sep/Oct;18(5):392-402.
        During an influenza pandemic, healthcare facilities are likely to be filled to capacity, leading to delays in seeing a provider and obtaining treatment. Flu on Call is a collaborative effort between the US Centers for Disease Control and Prevention and partners to develop a toll-free telephone helpline to reduce the burden on healthcare facilities and improve access to antivirals for people who are ill during an influenza pandemic. This study tested the feasibility of Flu on Call during a 1-day simulation using a severe pandemic scenario. Trained volunteer actors placed calls to the helpline using prepared scripts that were precoded for an expected outcome ("disposition") of the call. Scripts represented callers who were ill, those calling for someone else who was ill, and callers who were only seeking information. Information specialists and medical professionals managed the calls. Results demonstrated that Flu on Call may effectively assist callers during a pandemic, increase access to antiviral prescriptions, and direct patients to the appropriate level of care. Overall, 84% of calls exactly matched the expected call disposition; few calls (2%) were undermanaged (eg, the caller was ill but not transferred to a medical professional or received advice from the medical professional that was less intensive than what was warranted). Callers indicated a high level of satisfaction (83% reported their needs were met). Because of the high volume of calls that may be received during a severe pandemic, the Flu on Call platform should evolve to include additional triage channels (eg, through internet, chat, and/or text access).

    • Disease Reservoirs and Vectors
      1. Love the ones you're with: Characteristics and behaviour of Maryland pets and their owners in relation to tick encountersexternal icon
        de Wet S, Rutz H, Hinckley AF, Hook SA, Campbell S, Feldman KA.
        Zoonoses Public Health. 2020 Oct 28.
        We conducted a cross-sectional study to evaluate associations between pet characteristics and behaviours and risk of tick encounters among pets and pet owners. We defined a tick encounter as ticks found crawling on or attached to a pet or pet owner. Information about pet characteristics, interactions between owners and pets, and tick encounters were captured through an online survey. Associations were evaluated using univariate and multivariable analyses. In univariate analysis, walking dogs only on pavement reduced risk of tick encounter among owners (prevalence ratio (PR) = 0.51, 95% confidence interval (CI): 0.30, 0.84). Having a dog or cat that hunted small animals increased risk of tick encounter among owners (PR = 1.66, 95% CI: 1.30, 2.13; PR = 1.57, 95% CI: 1.05, 2.34, respectively). No direct interactions between owners and pets (e.g., pets sleeping on owners' beds) were associated with increased risk of tick encounters among owners. In multivariable analysis among dog owners, having a pet with a tick encounter within the last six months was associated with increased risk of owner tick encounter (adjusted odds ratio (aOR) = 4.17, 95% CI: 2.94, 5.92); in addition, having a dog that hunts small animals was associated with increased risk of owner tick encounter (aOR = 1.97, 95% CI: 1.25, 3.11). These results suggest that the location of pet-owner interactions may be more important than the type of interactions. Pet owners should avoid tick habitat with pets; when that is not possible, proper use of tick preventive products for pets, wearing repellents by owners and conducting tick checks for both pets and owners is critical for prevention of tick encounters and tick-borne disease.

      2. Occurrence of Taenia species in pigs in slaughterhouses in Phu Tho province, northern Vietnamexternal icon
        Nguyen TT, Dermauw V, Noh J, Chien NH, Dao TT, Nguyen TG, Van Hul A, Dorny P.
        J Helminthol. 2020 Oct 14;94:e201.
        Pigs act as the intermediate hosts of the zoonotic tapeworms Taenia solium and Taenia asiatica, as well as of the non-zoonotic Taenia hydatigena. In Vietnam, human taeniasis and cysticercosis have been reported throughout the country; however, data on porcine cysticercosis are scarce. Our study aimed to estimate the prevalence of Taenia spp. in slaughtered pigs in two districts in Phu Tho, a mountainous province in northern Vietnam from where neurocysticercosis patients commonly originate. The carcasses of 399 pigs from 51 small-scale abattoirs were checked for cysticerci, while tongue, liver, masseter muscles, diaphragm and heart were sliced and examined. Retrieved cysticerci underwent polymerase chain reaction-restriction fragment length polymorphism and sequencing for species confirmation. Blood was also collected to detect antibodies by lentil lectin-purified glycoprotein enzyme-linked immunoelectrotransfer blot (LLGP-EITB) and recombinant T24H antigen (rT24H)-EITB and circulating antigens by B158/B60 Ag-ELISA. In two pigs, T. asiatica cysticerci were found, confirming the presence of the parasite in pigs in Vietnam at a low prevalence (0.5%; 95% exact confidence interval (CI): 0-1.19%). Cysticerci of T. solium were found in none of the pigs, although one serum sample was positive for antibodies in both LLGP-EITB and rT24H-EITB. Furthermore, a high prevalence of T. hydatigena cysticercosis was observed (18.0%; 95% Wilson score CI: 14.6-22.1%). In more than half of the T. hydatigena-positive pigs, circulating antigens were detected by Ag-ELISA, confirming that this test cannot be used to diagnose T. solium cysticercosis in this region. Finally, Spirometra erinaceieuropaei was found in one pig liver. It is the first record of this zoonotic cestode species in pigs in Vietnam. Overall, the findings confirmed the complex epidemiology of Taenia spp. in pigs in Vietnam.

      3. The global climate has been changing over the last century due to greenhouse gas emissions and will continue to change over this century, accelerating without effective global efforts to reduce emissions. Ticks and tick-borne diseases (TTBDs) are inherently climate-sensitive due to the sensitivity of tick lifecycles to climate. Key direct climate and weather sensitivities include survival of individual ticks, and the duration of development and host-seeking activity of ticks. These sensitivities mean that in some regions a warming climate may increase tick survival, shorten life-cycles and lengthen the duration of tick activity seasons. Indirect effects of climate change on host communities may, with changes in tick abundance, facilitate enhanced transmission of tick-borne pathogens. High temperatures, and extreme weather events (heat, cold, and flooding) are anticipated with climate change, and these may reduce tick survival and pathogen transmission in some locations. Studies of the possible effects of climate change on TTBDs to date generally project poleward range expansion of geographical ranges (with possible contraction of ranges away from the increasingly hot tropics), upslope elevational range spread in mountainous regions, and increased abundance of ticks in many current endemic regions. However, relatively few studies, using long-term (multi-decade) observations, provide evidence of recent range changes of tick populations that could be attributed to recent climate change. Further integrated 'One Health' observational and modeling studies are needed to detect changes in TTBD occurrence, attribute them to climate change, and to develop predictive models of public- and animal-health needs to plan for TTBD emergence.

    • Environmental Health
      1. Effectiveness of gas and chimney biomass stoves for reducing household air pollution pregnancy exposure in Guatemala: Sociodemographic effect modifiersexternal icon
        Grajeda LM, Thompson LM, Arriaga W, Canuz E, Omer SB, Sage M, Azziz-Baumgartner E, Bryan JP, McCracken JP.
        Int J Environ Res Public Health. 2020 Oct 22;17(21).
        Household air pollution (HAP) due to solid fuel use during pregnancy is associated with adverse birth outcomes. The real-life effectiveness of clean cooking interventions has been disappointing overall yet variable, but the sociodemographic determinants are not well described. We measured personal 24-h PM(2.5) (particulate matter <2.5 µm in aerodynamic diameter) thrice in pregnant women (n = 218) gravimetrically with Teflon filter, impactor, and personal pump setups. To estimate the effectiveness of owning chimney and liquefied petroleum gas (LPG) stoves (i.e., proportion of PM(2.5) exposure that would be prevented) and to predict subject-specific typical exposures, we used linear mixed-effects models with log (PM(2.5)) as dependent variable and random intercept for subject. Median (IQR) personal PM(2.5) in µg/m(3) was 148 (90-249) for open fire, 78 (51-125) for chimney stove, and 55 (34-79) for LPG stoves. Adjusted effectiveness of LPG stoves was greater in women with ≥6 years of education (49% (95% CI: 34, 60)) versus <6 years (26% (95% CI: 5, 42)). In contrast, chimney stove adjusted effectiveness was greater in women with <6 years of education (50% (95% CI: 38, 60)), rural residence (46% (95% CI: 34, 55)) and lowest SES (socio-economic status) quartile (59% (95% CI: 45, 70)) than ≥6 years education (16% (95% CI: 22, 43)), urban (23% (95% CI: -164, 42)) and highest SES quartile (-44% (95% CI: -183, 27)), respectively. A minority of LPG stove owners (12%) and no chimney owner had typical exposure below World Health Organization Air Quality guidelines (35 μg/m(3)). Although having a cleaner stove alone typically does not lower exposure enough to protect health, understanding sociodemographic determinants of effectiveness may lead to better targeting, implementation, and adoption of interventions.

      2. Climate change and health: Local solutions to local challengesexternal icon
        Schramm PJ, Ahmed M, Siegel H, Donatuto J, Campbell L, Raab K, Svendsen E.
        Curr Environ Health Rep. 2020 Oct 28:1-8.
        PURPOSE OF REVIEW: Climate change has direct impacts on human health, but those impacts vary widely by location. Local health impacts depend on a large number of factors including specific regional climate impacts, demographics and human vulnerabilities, and existing local adaptation capacity. There is a need to incorporate local data and concerns into climate adaptation plans and evaluate different approaches. RECENT FINDINGS: The Centers for Disease Control and Prevention (CDC) has provided funding, technical assistance, and an adaptation framework to assist localities with climate planning and activities. The differing processes with which states, cities, and tribes develop and implement adaptation plans have been observed. We outline examples of the implementation of CDC's framework and activities for local adaptation, with a focus on case studies at differing jurisdictional levels (a state, a city, and a sovereign tribe). The use of local considerations and data are important to inform climate adaptation. The adaptable implementation of CDC's framework is helping communities protect health.

    • Genetics and Genomics
      1. The intersection of genomics and big data with public health: Opportunities for precision public healthexternal icon
        Khoury MJ, Armstrong GL, Bunnell RE, Cyril J, Iademarco MF.
        PLoS Med. 2020 Oct;17(10):e1003373.
        Muin Khoury and co-authors discuss anticipated contributions of genomics and other forms of large-scale data in public health.

    • Health Behavior and Risk
      1. Transgender youth are more likely than cisgender youth to report health risks related to violence victimization, substance use, mental health, and sexual health. Parental support may help foster resilience and better health outcomes among this population. However, limited research has characterized parental support among transgender youth. To address this gap, we conducted a thematic analysis of 33 in-depth interviews with transgender youth. We coded interviews using the dimensions of the social support framework (i.e., emotional, instrumental, appraisal, and informational) as well as inductive codes to identify emergent themes. Almost all participants described some form of general parental support (e.g., expressions of love, housing, advice, and affirmation). Parental support specific to gender identity was also noted (e.g., emotional support for coming out as transgender and chosen name and pronoun use) but was more limited. Parents may benefit from resources and programming to promote acceptance and gender-affirming behaviors.

    • Health Economics
      1. Costs of providing HIV care and optimal allocation of HIV resources in Guyanaexternal icon
        Suraratdecha C, Stuart RM, Edwards M, Moore R, Liu N, Wilson DP, Albalak R.
        PLoS One. 2020 ;15(10):e0238499.
        INTRODUCTION: Great strides in responding to the HIV epidemic have led to improved access to and uptake of HIV services in Guyana, a lower-middle-income country with a generalized HIV epidemic. Despite efforts to scale up HIV treatment and adopt the test and start strategy, little is known about costs of HIV services across the care cascade. METHODS: We collected cost data from the national laboratory and nine selected treatment facilities in five of the country's ten Regions, and estimated the costs associated with HIV testing and services (HTS) and antiretroviral therapy (ART) from a provider perspective from January 1, 2016 to December 31, 2016. We then used the unit costs to construct four resource allocation scenarios. In the first two scenarios, we calculated how close Guyana would currently be to its 2020 targets if the allocation of funding across programs and regions over 2017-2020 had (a) remained unchanged from latest-reported levels, or (b) been optimally distributed to minimize incidence and deaths. In the next two, we estimated the resources that would have been required to meet the 2020 targets if those resources had been distributed (a) according to latest-reported patterns, or (b) optimally to minimize incidence and deaths. RESULTS: The mean cost per test was US$15 and the mean cost per person tested positive was US$796. The mean annual cost per of maintaining established adult and pediatric patients on ART were US$428 and US$410, respectively. The mean annual cost of maintaining virally suppressed patients was US$648. Cost variation across sites may suggest opportunities for improvements in efficiency, or may reflect variation in facility type and patient volume. There may also be scope for improvements in allocative efficiency; we estimated a 28% reduction in the total resources required to meet Guyana's 2020 targets if funds had been optimally distributed to minimize infections and deaths. CONCLUSIONS: We provide the first estimates of costs along the HIV cascade in the Caribbean and assessed efficiencies using novel context-specific data on the costs associated with diagnostic, treatment, and viral suppression. The findings call for better targeting of services, and efficient service delivery models and resource allocation, while scaling up HIV services to maximize investment impact.

      2. Healthcare costs of pediatric autism spectrum disorder in the United States, 2003-2015external icon
        Zuvekas SH, Grosse SD, Lavelle TA, Maenner MJ, Dietz P, Ji X.
        J Autism Dev Disord. 2020 Oct 28.
        Published healthcare cost estimates for children with autism spectrum disorder (ASD) vary widely. One possible contributor is different methods of case ascertainment. In this study, ASD case status was determined using two sources of parent reports among 45,944 children ages 3-17 years in the Medical Expenditure Panel Survey (MEPS) linked to the National Health Interview Survey (NHIS) Sample Child Core questionnaire. In a two-part regression model, the incremental annual per-child cost of ASD relative to no ASD diagnosis was $3930 (2018 US dollars) using ASD case status from the NHIS Child Core and $5621 using current-year ASD case status from MEPS. Both estimates are lower than some published estimates but still represent substantial costs to the US healthcare system.

    • Healthcare Associated Infections
      1. Members of the family Enterobacteriaceae, such as Klebsiella pneumoniae, are considered both serious and urgent public health threats. Biofilms formed by these health care-associated pathogens can lead to negative and costly health outcomes. The global spread of antibiotic resistance, coupled with increased tolerance to antimicrobial treatments in biofilm-associated bacteria, highlights the need for novel strategies to overcome treatment hurdles. Bacteriophages (phages), or viruses that infect bacteria, have reemerged as one such potential strategy. Virulent phages are capable of infecting and killing their bacterial hosts, in some cases producing depolymerases that are able to hydrolyze biofilms. Phage therapy does have its limitations, however, including potential narrow host ranges, development of bacterial resistance to infection, and the potential spread of phage-encoded virulence genes. That being said, advances in phage isolation, screening, and genome sequencing tools provide an upside in overcoming some of these limitations and open up the possibilities of using phages as effective biofilm control agents.

    • Informatics
      1. Preventive care or follow-up care have the potential to improve health outcomes, reduce disease in the population, and decrease health care costs in the long-term (1). Approximately one half of persons in the United States receive general recommended preventive services (2,3). Missed physician appointments can hinder the receipt of needed health care (4). With electronic health record (EHR) systems able to improve interaction and communication between patients and providers (5), electronic reminders are used to decrease missed care. These reminders can improve various types of preventive and follow-up care, such as immunizations (6) and cancer screening (7); however, computerized capability must exist to make use of these reminders. To examine this capability among U.S. office-based physicians, data from the National Electronic Health Records Survey (NEHRS) for 2017, the most recent data available, were analyzed. An estimated 64.7% of office-based physicians had computerized capability to identify patients who were due for preventive or follow-up care, with 72.9% of primary care physicians and 71.4% of physicians with an EHR system having this capability compared with surgeons (54.8%), nonprimary care physicians (58.5%), and physicians without an EHR system (23.4%). Having an EHR system is associated with the ability to send electronic reminders to increase receipt of preventive or follow-up care, which has been shown to improve patient health outcomes (8).

    • Injury and Violence
      1. PURPOSE: In 2018, the Centers for Disease Control and Prevention (CDC) released an evidence-based guideline on pediatric mild traumatic brain injury (mTBI) to educate health care providers on best practices of mTBI diagnosis, prognosis, and management/treatment. As residents living in rural areas have higher rates of mTBI, and may have limited access to care, it is particularly important to disseminate the CDC guideline to rural health care providers. The purpose of this paper is to describe rural health care providers' experience with pediatric mTBI patients and their perceptions on incorporating the guideline recommendations into their practice. METHOD: Interviews with 9 pediatric rural health care providers from all US regions were conducted. Interview transcripts were coded and analyzed for themes for each of the main topic areas covered in the interview guide. FINDINGS: Common causes of mTBI reported by health care providers included sports and all-terrain vehicles. While health care providers found the guideline recommendations to be helpful and feasible, they reported barriers to implementation, such as lack of access to specialists. To help with uptake of the CDC guideline, they suggested the development of concise implementation tools that can be referenced quickly, integrated into electronic health record-based systems, and that are customized by visit type and health care setting (eg, initial vs follow-up visits and emergency department vs primary care visits). CONCLUSION: Length, accessibility, and usability are important considerations when designing clinical tools for busy rural health care providers caring for pediatric patients with mTBI. Customized information, in both print and digital formats, may help with uptake of best practices.

      2. Potential injuries and costs averted by increased use of evidence-based behavioral road safety policies in North Carolinaexternal icon
        Singichetti B, Naumann RB, Sauber-Schatz E, Proescholdbell S, Marshall SW.
        Traffic Inj Prev. 2020 Oct 23:1-7.
        OBJECTIVE: The purpose of this study was to estimate the potential injuries and costs that could be averted by implementing evidence-based road safety policies and interventions not currently utilized in one U.S. state, North Carolina (NC). NC consistently has annual motor vehicle-related death rates above the national average. METHODS: We used the Centers for Disease Control and Prevention's Motor Vehicle Prioritizing Interventions and Cost Calculator for States (MV PICCS) tool as a foundation for examining the potential injuries and costs that could be averted from underutilized evidence-based policies, assuming a $1.5 million implementation budget and that income generated from policy-related fines and fees would help offset costs. We further examined costs by payer source. RESULTS: Model results indicated that seven interventions should be prioritized for implementation in NC: increased alcohol ignition interlock use, increased seat belt fines, in-person license renewal for ages 70 and older, license plate impoundment, seat belt enforcement campaigns, saturation patrols, and speed cameras. Increasing the seat belt fine had the potential to avert the greatest number of fatal (n = 70) and non-fatal (n = 6,597) injuries annually, along with being the most cost-effective of the recommended interventions. Collectively, the seven recommended evidence-based policies/interventions have the potential to avert 302 fatal injuries, 16,607 non-fatal injuries, and $839 million annually in NC with the greatest costs averted for insurers. CONCLUSIONS: This study demonstrates the utility of the MV PICCS tool as a foundation for exploring state-specific impacts that could be realized through increased evidence-based road safety policy and intervention implementation. For NC, we found that increasing the seat belt fine would avert the most injuries, and had the greatest financial benefits for the state, and the lowest implementation costs. Incorporating fines and fees into policy implementation can create important financial feedbacks that allow for implementation of additional evidence-based and cost-effective policies/interventions. Given the recent uptick in U.S. motor vehicle-related deaths, analyses informed by the MV PICCS tool can help researchers and policy makers initiate discussions about successful state-specific strategies for reducing the burden of crashes.

    • Laboratory Sciences
      1. There are over forty species within the genus Entamoeba, eight of which infect humans. Of these, four species (Entamoeba histolytica, E. dispar, E. moshkovskii, and E. bangladeshi) are morphologically indistinguishable from each other, yet differentiation is important for appropriate treatment decisions. Here, we developed a hydrolysis probe-based tetraplex real-time PCR assay that can simultaneously detect and differentiate these four species in clinical samples. In this assay, multi-copy SSU rDNA sequences were used as targets. We determined that the tetraplex real-time PCR can detect amebic DNA corresponding to as few as 0.1 trophozoite-equivalent of any of these species. We also determined that this assay can detect E. histolytica DNA in the presence of 10-fold more DNA from another Entamoeba species in the mixed infection scenarios. With a panel of more than 100 well-characterized clinical samples diagnosed and confirmed using a previously published duplex real-time PCR (capable of detecting E. histolytica and E. dispar), our tetraplex real-time PCR assay demonstrated comparable sensitivity and specificity with that of the duplex real-time PCR assay. The advantage of our assay over the duplex assay is that it can specifically detect two additional Entamoeba species and can be used in conventional PCR format. This newly-developed assay will allow further characterization of the epidemiology and pathogenicity of the four morphologically-identical Entamoeba species especially in low resource settings.

      2. Molecular detection and typing of pathogenic Leptospira in febrile patients and phylogenetic comparison with Leptospira detected among animals in Tanzaniaexternal icon
        Allan KJ, Maze MJ, Galloway RL, Rubach MP, Biggs HM, Halliday JE, Cleaveland S, Saganda W, Lwezaula BF, Kazwala RR, Mmbaga BT, Maro VP, Crump JA.
        Am J Trop Med Hyg. 2020 Oct;103(4):1427-1434.
        Molecular data are required to improve our understanding of the epidemiology of leptospirosis in Africa and to identify sources of human infection. We applied molecular methods to identify the infecting Leptospira species and genotypes among patients hospitalized with fever in Tanzania and compared these with Leptospira genotypes detected among animals in Tanzania to infer potential sources of human infection. We performed lipL32 real-time PCR to detect the presence of pathogenic Leptospira in acute-phase plasma, serum, and urine samples obtained from study participants with serologically confirmed leptospirosis and participants who had died with febrile illness. Leptospira blood culture was also performed. In positive specimens, we performed species-specific PCR and compared participant Leptospira secY sequences with Leptospira reference sequences and sequences previously obtained from animals in Tanzania. We detected Leptospira DNA in four (3.6%) of 111 participant blood samples. We detected Leptospira borgpetersenii (one participant, 25.0%), Leptospira interrogans (one participant, 25.0%), and Leptospira kirschneri (one participant, 25.0%) (one [25%] undetermined). Phylogenetic comparison of secY sequence from the L. borgpetersenii and L. kirschneri genotypes detected from participants was closely related to but distinct from genotypes detected among local livestock species. Our results indicate that a diverse range of Leptospira species is causing human infection. Although our analysis suggests a close relationship between Leptospira genotypes found in people and livestock, continued efforts are needed to obtain more Leptospira genetic material from human leptospirosis cases to help prioritize Leptospira species and genotypes for control.

      3. Development of a pregnancy-specific reference material for thyroid biomarkers, vitamin D, and nutritional trace elements in serumexternal icon
        Boggs AS, Kilpatrick LE, Burdette CQ, Tevis DS, Fultz ZA, Nelson MA, Jarrett JM, Kemp JV, Singh RJ, Grebe SK, Wise SA, Kassim BL, Long SE.
        Clin Chem Lab Med. 2020 Oct 26.
        Objectives Matrix differences among serum samples from non-pregnant and pregnant patients could bias measurements. Standard Reference Material 1949, Frozen Human Prenatal Serum, was developed to provide a quality assurance material for the measurement of hormones and nutritional elements throughout pregnancy. Methods Serum from non-pregnant women and women in each trimester were bottled into four levels based on pregnancy status and trimester. Liquid chromatography tandem mass spectrometry (LC-MS/MS) methods were developed and applied to the measurement of thyroid hormones, vitamin D metabolites, and vitamin D-binding protein (VDBP). Copper, selenium, and zinc measurements were conducted by inductively coupled plasma dynamic reaction cell MS. Thyroid stimulating hormone (TSH), thyroglobulin (Tg), and thyroglobulin antibody concentrations were analyzed using immunoassays and LC-MS/MS (Tg only). Results Certified values for thyroxine and triiodothyronine, reference values for vitamin D metabolites, VDBP, selenium, copper, and zinc, and information values for reverse triiodothyronine, TSH, Tg, and Tg antibodies were assigned. Significant differences in serum concentrations were evident for all analytes across the four levels (p≤0.003). TSH measurements were significantly different (p<0.0001) among research-only immunoassays. Tg concentrations were elevated in research-only immunoassays vs. Federal Drug Administration-approved automated immunoassay and LC-MS/MS. Presence of Tg antibodies increased differences between automated immunoassay and LC-MS/MS. Conclusions The analyte concentrations' changes consistent with the literature and the demonstration of matrix interferences in immunoassay Tg measurements indicate the functionality of this material by providing a relevant matrix-matched reference material for the different stages of pregnancy.

      4. Comparison of Zika virus inactivation methods for reagent production and disinfection methodsexternal icon
        Chida AS, Goldstein JM, Lee J, Tang X, Bedi K, Herzegh O, Moon JL, Petway D, Bagarozzi DA, Hughes LJ.
        J Virol Methods. 2020 Oct 21:114004.
        Zika virus (ZIKV) infection remains a public health concern necessitating demand for long-term virus production for diagnostic assays and R&D activities. Inactivated virus constitutes an important component of the Trioplex rRT-PCR assay and serological IgM assay (MAC-ELISA). The aim of our study is to establish standard methods of ZIKV inactivation while maintaining antigenicity and RNA integrity. We tested viral supernatants by four different inactivation methods: 1. Heat inactivation at 56 °C and 60 °C; 2. Gamma-Irradiation; 3. Chemical inactivation by Beta-propiolactone (BPL) and 4. Fast-acting commercial disinfecting agents. Effectivity was measured by cytopathic effect (CPE) and plaque assay. RNA stability and antigenicity were measured by RT-PCR and MAC-ELISA, respectively. Results: Heat inactivation: Low titer samples, incubated at 56 °C for 2 hrs, showed neither CPE or plaques compared to high titer supernatants that required 2.5 hrs. Inactivation occurred at 60 °C for 60 min with all virus titers. Gamma irradiation: Samples irradiated at ≥3 Mrad for low virus concentrations and ≥5Mrad for high virus titer completely inactivated virus. Chemical Inactivation: Neither CPE nor plaques were observed with ≥0.045% BPL inactivation of ZIKV. Disinfectant: Treatment of viral supernatants with Micro-Chem Plus(TM), inactivated virus in 2 min, whereas, Ethanol (70%) and STERIS Coverage® Spray TB inactivated the virus in 5 min.

      5. Detection and characterization of swine-origin influenza A(H1N1) pandemic 2009 viruses in humans following zoonotic transmissionexternal icon
        Cook PW, Stark T, Jones J, Kondor R, Zanders N, Benfer J, Scott S, Jang Y, Janas-Martindale A, Lindstrom S, Blanton L, Schiltz J, Tell R, Griesser R, Shult P, Reisdorf E, Danz T, Fry A, Barnes J, Vincent A, Wentworth DE, Davis CT.
        J Virol. 2020 Oct 28.
        Human-to-swine transmission of seasonal influenza viruses has led to sustained human-like influenza viruses circulating in the United States swine population. While some reverse zoonotic-origin viruses adapt and become enzootic in swine, nascent reverse zoonoses may result in virus detections that are difficult to classify as 'swine-origin' or 'human-origin' due to the genetic similarity of circulating viruses. This is the case for human-origin influenza A(H1N1) pandemic 2009 (pdm09) viruses detected in pigs following numerous reverse zoonosis events since the 2009 pandemic. We report the identification of two human infections with A(H1N1)pdm09 viruses originating from swine hosts and classify them as 'swine-origin' variant influenza viruses based on phylogenetic analysis and sequence comparison methods. Phylogenetic analyses of viral genomes from two cases revealed these viruses were reassortants containing A(H1N1)pdm09 HA and NA genes with genetic combinations derived from the triple reassortant internal gene cassette. Follow-up investigations determined that one individual had direct exposure to swine in the week preceding illness onset, while another did not report swine exposure. The swine-origin A(H1N1) variant cases were resolved by full genome sequence comparison of the variant viruses to swine influenza genomes. However, if reassortment does not result in the acquisition of swine-associated genes and swine virus genomic sequences are not available from the exposure source future cases may not be discernible. We have developed a pipeline that performs maximum likelihood analyses, a k-mer-based set difference algorithm, and random forest algorithms to identify swine-associated sequences in the hemagglutinin gene to differentiate between human-origin and swine-origin A(H1N1)pdm09 viruses.IMPORTANCE Influenza virus infects a wide range of hosts resulting in illnesses that vary from asymptomatic cases to severe pneumonia and death. Viral transfer can occur between human and non-human hosts resulting in human and non-human origin viruses circulating in novel hosts. In this work, we have identified the first case of a swine-origin influenza A(H1N1)pdm09 virus resulting in a human infection. This shows that as these viruses not only circulate in swine hosts, but are continuing to evolve and distinguish themselves from previously circulating human-origin influenza viruses. The development of techniques for distinguishing human-origin and swine-origin viruses are necessary for the continued surveillance of influenza viruses. We show that unique genetic signatures can differentiate circulating swine-associated strains from circulating human-associated strains of influenza A(H1N1)pdm09, and these signatures can be used to enhance surveillance of swine-origin influenza.

      6. Duplex real-time PCR assay for clinical differentiation of Onchocerca lupi and Onchocerca volvulusexternal icon
        de Almeida M, Nascimento FS, Mathison BA, Bishop H, Bradbury RS, Cama VA, da Silva AJ.
        Am J Trop Med Hyg. 2020 Oct;103(4):1556-1562.
        In the United States and Europe, human onchocerciasis is a rare disease caused by zoonotic or anthropophilic parasites in the genus Onchocerca. The zoonotic species identified in focal areas of Europe and United States is Onchocerca lupi, and Onchocerca volvulus, the anthroponotic species, may be found among people who had lived in endemic areas of Africa, the Arabian Peninsula, or Latin America. Onchocerciasis due to O. lupi is an emergent parasitic disease, with limited diagnostic methods, in addition to the lack of information on its biology, transmission, and epidemiology. Cutaneous nodules are the disease's most prevalent manifestation but lack diagnostic specificity. To address the diagnosis of onchocerciasis at reference laboratories, we developed a duplex TaqMan real-time PCR (qPCR) method, targeting the cytochrome oxidase subunit I locus which has species-specific probes to identify and differentiate O. lupi from O. volvulus. We determined the performance of the duplex with a panel of 45 samples: 11 positives for O. lupi, six for O. volvulus, five samples with negative results for Onchocerca spp., and 23 non-Onchocerca nematodes. The duplex qPCR correctly detected 10 of 11 O. lupi- and six of six O. volvulus-positive specimens. The new duplex assay allowed the simultaneous detection and discrimination of O. lupi and O. volvulus in clinical specimens, expediting and facilitating the clinical diagnosis of O. lupi in non-endemic settings where the disease is an infrequent finding.

      7. Development of dried tube specimens for Xpert MTB/RIF proficiency testingexternal icon
        DeGruy K, Klein K, Rey Z, Hall P, Kim A, Alexander H.
        Afr J Lab Med. 2020 ;9(1):1166.
        BACKGROUND: Proficiency testing (PT) is part of a comprehensive quality assurance programme, which is critical to ensuring patients receive accurate and reliable diagnostic testing. Implementation of the Cepheid Xpert® MTB/RIF assay to aid in the diagnosis of tuberculosis has expanded rapidly in recent years; however, PT material for Xpert MTB/RIF is not readily available in many resource-limited settings. OBJECTIVE: To develop an accurate and precise PT material based on the dried tube specimen (DTS) method, using supplies and reagents available in most tuberculosis culture laboratories. METHODS: Dried tube specimens were produced at the United States Centers for Disease Control and Prevention from 2013 to 2015 by inactivating liquid cultures of well-characterised mycobacterial strains. Ten percent of DTS produced were tested with Xpert MTB/RIF and evaluated for accuracy and precision. RESULTS: Validation testing across eight rounds of PT demonstrated that DTS are highly accurate, achieving an average of 96.8% concordance with the Xpert MTB/RIF results from the original mycobacterial strains. Dried tube specimen testing was also precise, with cycle threshold standard deviations below two cycles when inherent test cartridge variability was low. CONCLUSION: Dried tube specimens can be produced using equipment already present in tuberculosis culture laboratories, making Xpert MTB/RIF PT scale-up more feasible in resource-limited settings. Use of DTS may fill the gap in tuberculosis laboratory access to external quality assessment, which is an essential component of a comprehensive continuous quality improvement programme.

      8. HMG-CoA reductase inhibitors as drug leads against Naegleria fowleriexternal icon
        Hahn HJ, Abagyan R, Podust LM, Roy S, Ali IK, Debnath A.
        ACS Chem Neurosci. 2020 Oct 7;11(19):3089-3096.
        Primary amebic meningoencephalitis (PAM), caused by the free-living ameba Naegleria fowleri, has a fatality rate of over 97%. Treatment of PAM relies on amphotericin B in combination with other drugs, but few patients have survived with the existing drug treatment regimens. Therefore, development of effective drugs is a critical unmet need to avert deaths from PAM. Since ergosterol is one of the major sterols in the membrane of N. fowleri, disruption of isoprenoid and sterol biosynthesis by small-molecule inhibitors may be an effective intervention strategy against N. fowleri. The genome of N. fowleri contains a gene encoding HMG-CoA reductase (HMGR); the catalytic domains of human and N. fowleri HMGR share <60% sequence identity with only two amino acid substitutions in the active site of the enzyme. Considering the similarity of human and N. fowleri HMGR, we tested well-tolerated and widely used HMGR inhibitors, known as cholesterol-lowering statins, against N. fowleri. We identified blood-brain-barrier-permeable pitavastatin as a potent amebicidal agent against the U.S., Australian, and European strains of N. fowleri. Pitavastatin was equipotent to amphotericin B against the European strain of N. fowleri; it killed about 80% of trophozoites within 16 h of drug exposure. Pretreatment of trophozoites with mevalonate, the product of HMGR, rescued N. fowleri from inhibitory effects of statins, demonstrating that HMGR of N. fowleri is the target of statins. Because of the good safety profile and availability for both adult and pediatric uses, consideration should be given to repurposing the fast-acting pitavastatin for the treatment of PAM.

      9. SARS-CoV-2 RBD neutralizing antibody induction is enhanced by particulate vaccinationexternal icon
        Huang WC, Zhou S, He X, Chiem K, Mabrouk MT, Nissly RH, Bird IM, Strauss M, Sambhara S, Ortega J, Wohlfert EA, Martinez-Sobrido L, Kuchipudi SV, Davidson BA, Lovell JF.
        Adv Mater. 2020 Oct 28:e2005637.
        The receptor-binding domain (RBD) of the SARS-CoV-2 spike protein is a candidate vaccine antigen that binds angiotensin-converting enzyme 2 (ACE2), leading to virus entry. Here, it is shown that rapid conversion of recombinant RBD into particulate form via admixing with liposomes containing cobalt-porphyrin-phospholipid (CoPoP) potently enhances the functional antibody response. Antigen binding via His-tag insertion into the CoPoP bilayer results in a serum-stable and conformationally intact display of the RBD on the liposome surface. Compared to other vaccine formulations, immunization using CoPoP liposomes admixed with recombinant RBD induces multiple orders of magnitude higher levels of antibody titers in mice that neutralize pseudovirus cell entry, block RBD interaction with ACE2, and inhibit live virus replication. Enhanced immunogenicity can be accounted for by greater RBD uptake into antigen-presenting cells in particulate form and improved immune cell infiltration in draining lymph nodes. QS-21 inclusion in the liposomes results in an enhanced antigen-specific polyfunctional T cell response. In mice, high dose immunization results in minimal local reactogenicity, is well-tolerated, and does not elevate serum cobalt levels. Taken together, these results confirm that particulate presentation strategies for the RBD immunogen should be considered for inducing strongly neutralizing antibody responses against SARS-CoV-2.

      10. A respiratory syncytial virus attachment (G) gene variant associated with more severe disease in infants decreases fusion (F) protein expression which may facilitate immune evasionexternal icon
        Human S, Hotard AL, Rostad CA, Lee S, McCormick L, Larkin EK, Peret TC, Jorba J, Lanzone J, Gebretsadik T, Williams JV, Bloodworth M, Stier M, Carroll K, Peebles RS, Anderson LJ, Hartert TV, Moore ML.
        J Virol. 2020 Oct 28.
        This study identified a genotype of RSV associated with increased acute respiratory disease severity in a cohort of term, previously healthy infants. The genotype (2stop+A4G) consists of two components. The A4G component is a prevalent point mutation in the 4(th) position of the gene end transcription termination signal of the G gene of currently circulating RSV strains. The 2stop component is two tandem stop codons at the G gene terminus, preceding the gene end transcription termination signal. To investigate the biological role of these RSV G gene mutations, recombinant RSV strains harboring either a wild type A2 strain G gene (one stop codon preceding a wild type gene end signal), an A4G gene end signal preceded by one stop codon, or the 2stop+A4G virulence-associated combination were generated and characterized. Infection with the rA4G RSV mutant resulted in transcriptional read-through and lower G and fusion (F) protein levels relative to wild type. Addition of a second stop codon preceding the A4G point mutation (2stop+A4G) restored G protein expression but retained lower F protein levels. These data suggest that RSV G and F glycoprotein expression is regulated by transcriptional and translational read-through. Notably, while rA4G and r2stop+A4G RSV were attenuated in cells and in naïve BALB/c mice compared to wild type RSV, the r2stop+A4G RSV was better able to infect BALB/c mice in the presence of pre-existing immunity in comparison to rA4G RSV. Together these factors may contribute to the maintenance and virulence of the 2stop+A4G genotype in currently circulating RSV-A strains.IMPORTANCE Strain-specific differences in respiratory syncytial virus (RSV) isolates are associated with differential pathogenesis in mice. However, the role of RSV genotypes in human infection is incompletely understood. This work demonstrates that one such genotype, 2stop+A4G, present in the RSV attachment (G) gene terminus is associated with greater infant disease severity. The genotype consists of two tandem stop codons preceding an A-to-G point mutation in the 4(th) position of the G gene end transcription termination signal. Virologically, the 2stop+A4G RSV genotype results in reduced levels of the RSV fusion (F) glycoprotein. A recombinant 2stop+A4G RSV was better able to establish infection in the presence of existing RSV immunity compared to a virus harboring the common A4G mutation. These data suggest that regulation of G and F expression has implications for virulence and potentially immune evasion.

      11. Rearing Aedes aegypti mosquitoes in a laboratory settingexternal icon
        Masters SW, Knapek KJ, Kendall LV.
        Lab Animal Sci Prof. 2020 Nov;55(6):42-45.

      12. Multi-ancestry fine mapping of interferon lambda and the outcome of acute hepatitis C virus infectionexternal icon
        Vergara C, Duggal P, Thio CL, Valencia A, Brien TR, Latanich R, Timp W, Johnson EO, Kral AH, Mangia A, Goedert JJ, Piazzola V, Mehta SH, Kirk GD, Peters MG, Donfield SM, Edlin BR, Busch MP, Alexander G, Murphy EL, Kim AY, Lauer GM, Chung RT, Cramp ME, Cox AL, Khakoo SI, Rosen HR, Alric L, Wheelan SJ, Wojcik GL, Thomas DL, Taub MA.
        Genes Immun. 2020 Oct 28.
        Clearance of acute infection with hepatitis C virus (HCV) is associated with the chr19q13.13 region containing the rs368234815 (TT/ΔG) polymorphism. We fine-mapped this region to detect possible causal variants that may contribute to HCV clearance. First, we performed sequencing of IFNL1-IFNL4 region in 64 individuals sampled according to rs368234815 genotype: TT/clearance (N = 16) and ΔG/persistent (N = 15) (genotype-outcome concordant) or TT/persistent (N = 19) and ΔG/clearance (N = 14) (discordant). 25 SNPs had a difference in counts of alternative allele >5 between clearance and persistence individuals. Then, we evaluated those markers in an association analysis of HCV clearance conditioning on rs368234815 in two groups of European (692 clearance/1 025 persistence) and African ancestry (320 clearance/1 515 persistence) individuals. 10/25 variants were associated (P < 0.05) in the conditioned analysis leaded by rs4803221 (P value = 4.9 × 10(-04)) and rs8099917 (P value = 5.5 × 10(-04)). In the European ancestry group, individuals with the haplotype rs368234815ΔG/rs4803221C were 1.7× more likely to clear than those with the rs368234815ΔG/rs4803221G haplotype (P value = 3.6 × 10(-05)). For another nearby SNP, the haplotype of rs368234815ΔG/rs8099917T was associated with HCV clearance compared to rs368234815ΔG/rs8099917G (OR: 1.6, P value = 1.8 × 10(-04)). We identified four possible causal variants: rs368234815, rs12982533, rs10612351 and rs4803221. Our results suggest a main signal of association represented by rs368234815, with contributions from rs4803221, and/or nearby SNPs including rs8099917.

      13. Molecular evaluation of fluoroquinolone resistance in serial Mycobacterium tuberculosis isolates from individuals diagnosed with multidrug-resistant tuberculosisexternal icon
        Willby M, Chopra P, Lemmer D, Klein K, Dalton TL, Engelthaler DM, Cegielski P, Posey JE.
        Antimicrob Agents Chemother. 2020 Oct 26.
        Fluoroquinolones (FQ) are crucial components of multidrug-resistant tuberculosis (MDR TB) treatment. Varying levels of resistance are associated with specific mutations within the Quinolone Resistance Determining Region (QRDR) of gyrA We sequenced the QRDR from serial isolates of MDR TB patients in the Preserving Effective TB Treatment Study (PETTS) with baseline (FQ(R)) or acquired FQ resistance (FQ(ACQR)) using the IonTorrent™ Personal Genome Machine to a depth of 10,000x and reported single nucleotide polymorphisms in ≥1% of reads. FQ(R) isolates harbored 15 distinct alleles with 1.3 (max=6) on average per isolate. Eighteen alleles were identified in FQ(ACQR) isolates with an average of 1.6 (max=9) per isolate. Isolates from 78% of FQ(ACQR) individuals had mutant alleles identified within 6 months of treatment initiation. Asp94Gly followed by Ala90Val were the predominant alleles in initial FQ-resistant isolates. Seventy-seven percent (36/47) of FQ(ACQR) group patients had isolates with FQ resistance alleles prior to changes to the FQ component of their treatment. Unlike individuals treated initially with other FQs, none of the 21 individuals treated initially with levofloxacin developed genotypic or phenotypic FQ resistance, although, country of residence is likely a contributing factor since 69% of these individuals were from a single country. Initial detection of phenotypic and genotypic resistance occurred simultaneously for most; however, phenotypic resistance occurred earlier in isolates harboring mixtures of very low-abundance (<1% of reads) alleles while genotypic resistance often occurred earlier for low-level resistance-associated alleles. Understanding factors influencing acquisition and evolution of FQ resistance could reveal strategies for improved treatment success.

    • Maternal and Child Health
      1. State-based perinatal quality collaboratives (PQCs) address preventable causes of maternal and infant morbidity and mortality by implementing statewide quality improvement (QI) initiatives. They work with hospital clinical teams, obstetric provider and nursing leaders, patients and families, public health officials, and other stakeholders to provide opportunities for collaborative learning, rapid-response data, and QI science support to achieve clinical culture change. PQCs show that the application of collaborative improvement science methods to advance evidence-informed clinical practices using QI strategies contributes to improved perinatal outcomes. With appropriate staffing, infrastructure, and partnerships, PQCs can achieve sustainable improvements in perinatal care.

      2. Neonatal opioid withdrawal syndromeexternal icon
        Patrick SW, Barfield WD, Poindexter BB.
        Pediatrics. 2020 Nov;146(5).
        The opioid crisis has grown to affect pregnant women and infants across the United States, as evidenced by rising rates of opioid use disorder among pregnant women and neonatal opioid withdrawal syndrome among infants. Across the country, pregnant women lack access to evidence-based therapies, including medications for opioid use disorder, and infants with opioid exposure frequently receive variable care. In addition, public systems, such as child welfare and early intervention, are increasingly stretched by increasing numbers of children affected by the crisis. Systematic, enduring, coordinated, and holistic approaches are needed to improve care for the mother-infant dyad. In this statement, we provide an overview of the effect of the opioid crisis on the mother-infant dyad and provide recommendations for management of the infant with opioid exposure, including clinical presentation, assessment, treatment, and discharge.

      3. Evaluation of an active population-based surveillance system for major birth defects in South Carolinaexternal icon
        Samson ME, Leedom V, Mai CT, Humphries B, Yeung LF.
        Birth Defects Res. 2020 Oct 23.
        INTRODUCTION: Birth defects are common, costly, and contribute substantially to infant mortality. The South Carolina Birth Defects Program (SCBDP) employs active population-based surveillance to monitor major birth defects statewide. We evaluated SCBDP's system attributes using published CDC guidelines. METHODS: To determine timeliness, completeness, and accuracy of birth defects information, we examined SCBDP's reports, program and education materials, advisory group meeting minutes, and strategic plan. We also met with program staff and stakeholders (n = 10) to discuss program goals and data utilization. We calculated the percentage of birth defects cases found 6 months after a birth cohort year for 2016-2018. RESULTS: SCBDP identifies 900-1,200 birth defects cases for a birth population of approximately 55,000 live births annually through active case reviews. SCBDP uses trained medical staff to abstract detailed information from maternal and infant medical records; SCBDP also has established auto-linkage with state vital statistics to capture demographic and birth data. SCBDP is timely and captures 97.1% (range 96.7-97.6%) of birth defects cases within 6 months after the birth cohort year closes. Active case identification using medical records as the primary data source improves quality assurance and completeness, while prepopulating demographic information improves timeliness. CONCLUSIONS: Given that birth defects significantly contribute to infant morbidity and mortality, monitoring these conditions is important to understand their impact on communities and to drive public health actions. SCBDP active surveillance and rigorous data quality practices provide the program with timely, complete, and accurate birth defects data.

    • Nutritional Sciences
      1. In this study, we examined the associations between the consumption of foods derived from crops subsidized under the 2008 United States (US) Farm Bill and cardiometabolic risk factors and whether the magnitude of these associations has changed since the 2002 US Farm Bill. Four federal databases were used to estimate daily consumption of the top seven subsidized commodities (corn, soybeans, wheat, rice, sorghum, dairy, and livestock) and to calculate a subsidy score (0-1 scale) for Americans' daily dietary intake during 2009-2014, with a higher score indicative of a higher proportion of the diet derived from subsidized commodities. The cardiometabolic risk factors included obesity, abdominal adiposity, hypertension, dyslipidemia, and dysglycemia. Linear and logistic regression models were adjusted for age, sex, race/ethnicity, the poverty-income ratio, the smoking status, educational attainment, physical activity, and daily calorie intake. During 2009-2014, adults with the highest subsidy score had higher probabilities of obesity, abdominal adiposity, and dysglycemia compared to the lowest subsidy score. After the 2002 Farm Bill (measured using data from 2001-2006), the subsidy score decreased from 56% to 50% and associations between consuming a highly-subsidized diet and dysglycemia did not change (p = 0.54), whereas associations with obesity (p = 0.004) and abdominal adiposity (p = 0.002) significantly attenuated by more than half. The proportion of calories derived from subsidized food commodities continues to be associated with adverse cardiometabolic risk factors, though the relationship with obesity and abdominal adiposity has weakened in recent years.

    • Occupational Safety and Health
      1. A review of decontamination methods for filtering facepiece respiratorsexternal icon
        Bergman M, Fisher EM, Heimbuch BK.
        J Int Soc Respir Prot. 2020 Oct;37(2):71-86.
        During the current COVID-19 infectious disease pandemic, the demand for NIOSH-approved filtering facepiece respirators (FFR) has exceeded supplies and decontamination and reuse of FFRs has been implemented by various user groups. FFR decontamination and reuse is only intended to be implemented as a crisis capacity strategy. This paper provides a review of decontamination procedures in the published literature and calls attention to their benefits and limitations. In most cases, the data are limited to a few FFR models and a limited number of decontamination cycles. Institutions planning to implement a decontamination method must understand its limitations in terms of the degree of inactivation of the intended mircroorganisms and the treatment's effects on the fit and filtration of the device. A supplement to this publication is available public-abstracts/1215-vol-37-no-2-2020-supplementary-material

      2. Workers' compensation injury claims of aviation industry worker injuries in Alaska, 2014-2015external icon
        Moller KM, O'Connor MB, Lee JR, Lucas DL, Watson JR.
        Int J Circumpolar Health. 2020 Dec;79(1):1838163.
        Aviation operations in Alaska often occur in remote locations and during inclement weather. Limited infrastructure and staff in some locations often requires aviation workers to perform tasks outside of their specific job descriptions. Researchers identified workers' compensation claims as a valuable data source to characterise nonfatal injuries among Alaskan aviation workers. Keyword searches of injury claim narrative fields and industry codes were used to identify potentially aviation-related workers' compensation claims during 2014-2015. These claims were manually reviewed to verify whether aviation related and manually coded according to the US Bureau of Labour Statistics' Occupational Injury and Illness Classification System. There were 875 aviation-related injury claims accepted during 2014-2015. Ramp/baggage/cargo agents incurred the most injuries (35%), followed by mechanics/maintenance workers (15%). Among all workers, Overexertion and Bodily Reaction (40%) was most often cited as the injury event, followed by Contact with Objects and Equipment (28%), and Falls, Slips, Trips (22%). Sprains, strains, tears were the most frequent nature of injury (55%). Cargo/freight/luggage was the most frequent source of injury (24%). The 3 most frequently identified injury event types were responsible for over 90% of all injuries, which indicates that preventive interventions should be directed towards tasks rather than occupational groups.

      3. Purpose: The purpose of this paper is to update the assessment of national data on law enforcement worker suicide based on the National Occupational Mortality Surveillance database (NOMS, Centers for Disease Control and Prevention). Design/methodology/approach: Death certificate data for 4,441,814 decedents, age 18–90 who died in one of the 26 reporting states were the source of NOMS data. Utilizing proportionate mortality ratios (PMRs), the ratio of suicides in law enforcement occupations in those who are 18–90 years old with a designated usual occupation was calculated. Findings: Findings indicate a significantly higher proportion of deaths from suicide for law enforcement officers (PMR = 154, 95% CI = 147–162), compared to all the US decedents in the study population who were employed during their lifetime. Law enforcement personnel are 54% more likely to die of suicide than all decedents with a usual occupation. PMRs were highest for African-Americans, Hispanic males and for females. PMRs were similar for detectives, corrections officers and all law enforcement jobs, when not stratified by race, ethnicity and sex. Research limitations/implications: Bias may arise because a PMR can be affected by disproportionate increased or decreased mortality from causes of death other than suicide. Practical implications: A better understanding of the scope of law enforcement suicide can inform policy focused on the planning and initiation of prevention programs. Originality/value: The use of a national database to study law enforcement worker suicide adds to other information available on law enforcement worker suicide in specific geographic areas. The discussion on prevention in this paper presents ideas for policy.

    • Occupational Safety and Health - Mining
      1. BACKGROUND: Within the mining industrial sector, workers in the mining and oil and gas extraction (OGE) industries have demonstrated disparities in chronic health status compared with the general working population. However, we know much less about miner and OGE worker health once retired. This study separately compares chronic illnesses in retired miners and OGE workers with all other retirees. METHODS: National Health Interview Survey (NHIS) public data were analyzed for the years 2007-2017 to estimate weighted unadjusted and adjusted prevalence of selected health conditions (cancer, cardiovascular disease, high cholesterol, diabetes, hypertension, respiratory conditions, health status, and hearing loss) in retirees. Three retired worker groups (miners, OGE, and other retirees) were defined using the respondents' longest-held industry and occupation. RESULTS: Higher prevalence of a number of adverse health conditions was noted in miners and OGE workers when compared with all other retirees. A significantly higher adjusted prevalence of hypertension, hearing loss, functionally limiting lung problems, and fair or poor health was seen in miners over other retirees. Retired OGE workers demonstrated a significantly higher adjusted prevalence of both hearing loss and poor health status. CONCLUSIONS: Miners and OGE workers have higher morbidity during their working years, and this study demonstrates that poorer health appears to continue into retirement. These results suggest the need to expand occupational health and safety programs in the mining sector to improve the health of workers into retirement. Future studies that include more robust information on workplace exposures are needed to evaluate the long-term health of retired workers.

    • Parasitic Diseases
      1. Genetic analysis reveals unique characteristics of Plasmodium falciparum parasite populations in Haitiexternal icon
        Daniels RF, Chenet S, Rogier E, Lucchi N, Herman C, Pierre B, Lemoine JF, Boncy J, Wirth DF, Chang MA, Udhayakumar V, Volkman SK.
        Malar J. 2020 Oct 23;19(1):379.
        BACKGROUND: With increasing interest in eliminating malaria from the Caribbean region, Haiti is one of the two countries on the island of Hispaniola with continued malaria transmission. While the Haitian population remains at risk for malaria, there are a limited number of cases annually, making conventional epidemiological measures such as case incidence and prevalence of potentially limited value for fine-scale resolution of transmission patterns and trends. In this context, genetic signatures may be useful for the identification and characterization of the Plasmodium falciparum parasite population in order to identify foci of transmission, detect outbreaks, and track parasite movement to potentially inform malaria control and elimination strategies. METHODS: This study evaluated the genetic signals based on analysis of 21 single-nucleotide polymorphisms (SNPs) from 462 monogenomic (single-genome) P. falciparum DNA samples extracted from dried blood spots collected from malaria-positive patients reporting to health facilities in three southwestern Haitian departments (Nippes, Grand'Anse, and Sud) in 2016. RESULTS: Assessment of the parasite genetic relatedness revealed evidence of clonal expansion within Nippes and the exchange of parasite lineages between Nippes, Sud, and Grand'Anse. Furthermore, 437 of the 462 samples shared high levels of genetic similarity-at least 20 of 21 SNPS-with at least one other sample in the dataset. CONCLUSIONS: These results revealed patterns of relatedness suggestive of the repeated recombination of a limited number of founding parasite types without significant outcrossing. These genetic signals offer clues to the underlying relatedness of parasite populations and may be useful for the identification of the foci of transmission and tracking of parasite movement in Haiti for malaria elimination.

    • Physical Activity
      1. Cross-sectional association between physical activity level and subjective cognitive decline among US adults aged >/= 45 years, 2015external icon
        Omura JD, Brown DR, McGuire LC, Taylor CA, Fulton JE, Carlson SA.
        Prev Med. 2020 Oct 6;141:106279.
        Subjective cognitive decline (SCD) is the self-reported experience of worsening or more frequent confusion or memory loss within the previous 12 months and can be one of the earliest symptoms of Alzheimer's disease. Regular physical activity can contribute to the primary, secondary, and tertiary prevention of cognitive decline. At the national level, prevalence estimates of SCD by physical activity level in the United States are currently unknown. The purpose of this study is to examine the prevalence of SCD and resulting functional limitations by physical activity level among US adults aged ≥45 years. Data from 33 states and the District of Columbia participating in the 2015 Behavioral Risk Factor Surveillance System (N = 128,925) were analyzed. We estimated the prevalence of SCD (a positive response to a question about worsening or more frequent confusion or memory loss within the previous 12 months) and resulting functional limitations overall and by self-reported physical activity level based on current guidelines (i.e., active, insufficiently active, and inactive). Odds ratios were estimated using logistic regression models adjusting for respondent characteristics. Overall, 11.3% of US adults aged ≥45 years reported SCD. Prevalence of SCD increased as physical activity level decreased (active: 8.8%; insufficiently active: 11.4%; inactive: 15.7%). Among those with SCD, the prevalence of functional limitations also increased as physical activity level decreased (active: 40.5%; insufficiently active: 50.0%; inactive: 57.4%). These differences largely remained after adjusting for respondent characteristics. Findings highlight the potential public health impact nationally of efforts to promote physical activity for cognitive health.

    • Program Evaluation
      1. The flexibility federal block grants provide recipients poses challenges for evaluation. These challenges include aggregating data on wide-ranging activities grant recipients implement and the outcomes they achieve. In 2014, we began designing an evaluation to address the challenges of assessing outcomes and to improve outcome accountability for the Preventive Health and Health Services Block Grant. Through the use of evaluability assessment methodology, review of existing data and the literature, and key informant interviews, we developed a measurement framework to assess outcomes resulting from recipients’ ability to use grant funds to meet their locally prioritized needs. We argue our evaluation approach demonstrates that block grants, and other similarly flexible programs, can be evaluated through appropriately designed measures. Our efforts challenge the idea that flexibility presents an insurmountable barrier to evaluation and outcome accountability for federal block grants.

    • Substance Use and Abuse
      1. COVID-19 pandemic: an opportunity for tobacco use cessationexternal icon
        Ahluwalia IB, Myers M, Cohen JE.
        Lancet Public Health. 2020 Nov;5(11):e577.

    • Zoonotic and Vectorborne Diseases
      1. Determination of the emergency phase for response against endemic disease outbreak: A case of Lassa fever outbreak in Nigeriaexternal icon
        Ipadeola O, Furuse Y, de Gooyer T, Dan-Nwafor C, Namara G, Ilori E, Ihekweazu C.
        J Glob Health. 2020 Dec;10(2):020353.

      2. A One Health approach to combatting Sporothrix brasiliensis: Narrative review of an emerging zoonotic fungal pathogen in South Americaexternal icon
        Rossow JA, Queiroz-Telles F, Caceres DH, Beer KD, Jackson BR, Pereira JG, Ferreira Gremião ID, Pereira SA.
        J Fungi (Basel). 2020 Oct 26;6(4).
        Cat-transmitted sporotrichosis caused by Sporothrix brasiliensis has become a major public health concern and presents a distinct divergence from the traditional epidemiology of sporotrichosis. This emerging fungal pathogen spreads readily among cat populations, and human infections occur exclusively via zoonotic transmission. While sporotrichosis is an implantation mycosis that typically manifests as cutaneous lesions in humans and cats, severe extracutaneous manifestations are more common with S. brasiliensis than other Sporothrix species infections. Rapid diagnosis and appropriate treatment regimens are critical for successful clinical resolution of sporotrichosis in both cats and humans. Species-level identification of Sporothrix is possible with molecular diagnostics and necessary for tracking the geographic expansion of S. brasiliensis and better understanding its epidemiology. Combatting cat-transmitted sporotrichosis requires a One Health approach to successfully implement public health control measures.

      3. Serological evidence of human infection with avian influenza A(H7N9) virus: a systematic review and meta-analysisexternal icon
        Wang W, Chen X, Wang Y, Lai S, Yang J, Cowling BJ, Horby PW, Uyeki TM, Yu H.
        J Infect Dis. 2020 Oct 29.
        BACKGROUND: The extent of human infections with avian influenza A(H7N9) virus, including mild and asymptomatic infections, is uncertain. METHODS: We performed a systematic review and meta-analysis of serosurveys for avian influenza A(H7N9) virus infections in humans published during 2013-2020. Three seropositive definitions were assessed to estimate pooled seroprevalence, seroconversion rate and seroincidence by types of exposures. We applied a scoring system to assess the quality of included studies. RESULTS: Of 31 included studies, pooled seroprevalence of A(H7N9)-virus antibodies from all participants was 0.02%, with poultry workers, close contacts, and general populations having seroprevalence of 0.1%, 0.2% and 0.02% based on the WHO-recommended definition, respectively. Although most infections were asymptomatic, evidence of infection was highest in poultry workers (5% seroconversion, 19.1% seroincidence per 100 person-years). Use of different virus clades did not significantly affect seroprevalence estimates. Most serological studies were of low to moderate quality and did not follow standardized seroepidemiological protocols or WHO-recommended laboratory methods. CONCLUSIONS: Human infections with avian influenza A(H7N9) virus have been uncommon, especially for general populations. Workers with occupational exposures to poultry and close contacts of A(H7N9) human cases had low risks of infection.

Back to Top

CDC Science Clips Production Staff

  • Takudzwa Sayi, Editor
  • Gail Bang, MLIS, Librarian
  • Kathy Tucker, Librarian
  • William (Bill) Thomas, MLIS, Librarian
  • Jarvis Sims, MIT, MLIS, Librarian


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

Page last reviewed: October 27, 2020, 12:00 AM