Issue 43, December 1, 2020

CDC Science Clips: Volume 12, Issue 43, December 1, 2020

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

This week Science Clips is pleased to feature articles from the Annals of Internal Medicine supplement - Maternal Health in the United States: Findings from the Health Resources and Services Administration and Partners.

Maternal mortality and severe maternal morbidity are critical health issues in the United States, with unacceptably high rates and striking disparities, particularly by race, ethnicity, and geography.   The U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) has taken a leading role in addressing these issues through health promotion, risk prevention, and the training of health care professionals to identify and treat early warning signs. HRSA is the primary U.S. federal agency charged with improving the health care of individuals who are geographically isolated, economically, or medically vulnerable.

In June 2018, HRSA hosted a Maternal Mortality Summit, “Promising Global Practices to Improve Maternal Health Outcomes,” convening maternal health experts from Brazil, Canada, Finland, India, Rwanda, the United Kingdom, and the World Health Organization (WHO), to discuss evidence-based approaches for improving maternal health.  Following this Summit, HRSA developed a special supplement to the Annals of Internal Medicine focused on maternal health in the United States.  HRSA experts and partners contributed to the journal articles, which address specific HRSA maternal health initiatives, the impact of opioid use during pregnancy, and issues faced by rural populations.

This special collection of articles, “Maternal Health in the United States: Findings from the Health Resources and Services Administration and Partners," was published in the December 1 issue of the Annals of Internal Medicine.

Read more about the HRSA’s 2018 Maternal Health Global Summitexternal icon that spurred the development of this special issue and the accompanying HRSA Maternal Mortality Summit Technical Reportpdf iconexternal icon.

Special thanks to the guest editors for this issue: Catherine J. Vladutiu, PhD, MPH, HRSA Maternal and Child Health Bureau; Sylvia K. Fisher, PhD, HRSA Office of Planning, Analysis, and Evaluation; and Gopal K. Singh, PhD, MS, MSc, DPS, HRSA Office of Health Equity.

  1. Key Scientific Articles in Featured Topic Areas
    Subject matter experts decide what topic to feature, and articles are selected from the last 3 to 6 months of published literature. Key topic coincides monthly with other CDC products (e.g. Vital Signs).
    • Maternal Health in the United States

      1. Initiatives to reduce maternal mortality and severe maternal morbidity in the United States : A narrative reviewexternal icon
        Ahn R, Gonzalez GP, Anderson B, Vladutiu CJ, Fowler ER, Manning L.
        Ann Intern Med. 2020 Dec 1;173(11_Supplement):S3-s10.
        Maternal mortality and severe maternal morbidity are critical health issues in the United States, with unacceptably high rates and racial, ethnic, and geographic disparities. Various factors contribute to these adverse maternal health outcomes, ranging from patient-level to health system-level factors. Furthermore, a majority of pregnancy-related deaths are preventable. This review briefly describes the epidemiology of maternal mortality and severe maternal morbidity in the United States and discusses selected initiatives to reduce maternal mortality and severe maternal morbidity in the areas of data and surveillance; clinical workforce training and patient education; telehealth; comprehensive models and strategies; and clinical guidelines, protocols, and bundles. Related Health Resources and Services Administration initiatives are also described.

      2. Rural-urban differences in health care access among women of reproductive age: A 10-year pooled analysisexternal icon
        Lee H, Lin CC, Snyder JE.
        Ann Intern Med. 2020 Dec 1;173(11_Supplement):S55-s58.

      3. Rural-urban differences in delivery hospitalization costs by severe maternal morbidity statusexternal icon
        Lin CC, Hirai AH, Li R, Kuklina EV, Fisher SK.
        Ann Intern Med. 2020 Dec 1;173(11_Supplement):S59-s62.

      4. BACKGROUND: Rates of maternal mortality and severe maternal morbidity (SMM) are higher in the United States than in other high-resource countries and are increasing further. OBJECTIVE: To examine the association of maternal comorbid conditions, age, body mass index, and previous cesarean birth with occurrence of SMM. DESIGN: Population-based cohort study using linked delivery hospitalization discharge data and vital records. SETTING: California, 1997 to 2014. PATIENTS: All 9 179 472 mothers delivering in California during 1997 to 2014. MEASUREMENTS: SMM rate, total and without transfusion-only cases; 2019 maternal comorbidity index. RESULTS: Total SMM increased by 160% during this time, and SMM excluding transfusion-only cases increased by 53%. Medical comorbid conditions were associated with an increasing portion of SMM occurrences. Medical comorbid conditions increased over the study period by 111%, and obstetric comorbid conditions increased by 30% to 40%. Identified medical comorbid conditions had high relative risks ranging from 1.3 to 14.3 for total SMM and even higher relative risks for nontransfusion SMM (to 32.4). The obstetric comorbidity index that is most often used may be undervaluing the degree of association with SMM. LIMITATIONS: Hospital discharge diagnosis files and birth certificate records can have misclassifications and may not include all relevant clinical data or social determinants. The period for analysis ended in 2014 to avoid the transition to the International Classification of Diseases, 10th Revision, Clinical Modification, and therefore missed more recent years. CONCLUSION: Obstetric and, particularly, medical comorbid conditions are increasing among women who develop SMM. The maternal comorbidity index is a promising tool for patient risk assessment and case-mix adjustment, but refinement of factor weights may be indicated. PRIMARY FUNDING SOURCE: National Institutes of Health.

      5. BACKGROUND: Early prenatal care is vital for improving maternal health outcomes and health behaviors, but medically vulnerable and underserved populations are less likely to begin prenatal care in the first trimester. In 2017, the Health Center Program provided safety-net care to more than 27 million persons, including 573 026 prenatal patients, at approximately 12 000 sites across the United States and U.S. jurisdictions. As part of a mandatory reporting requirement, health centers tracked whether patients initiated prenatal care in their first trimester of pregnancy. OBJECTIVE: To identify health center characteristics associated with the initiation of prenatal care in the first trimester, as well as actionable steps policymakers, providers, and health centers can take to promote early initiation of prenatal care. DESIGN: Secondary analysis of cross-sectional data from the 2017 Uniform Data System. SETTING: The United States and 8 U.S. jurisdictions. PARTICIPANTS: Health center grantees with prenatal patients (n = 1281). MEASUREMENTS: Multinomial logistic regression (adjusted for state or jurisdiction clustering) was used to identify health center characteristics associated with achievement of the Healthy People 2020 baseline (77.1%) and target (84.8%) for women receiving prenatal care in the first trimester (Maternal, Infant, and Child Health Objective 10.1). RESULTS: Overall, 57.4% of health centers met the Healthy People 2020 baseline (mean, 78%; median, 81%), and 37.9% met the Healthy People 2020 target. Several characteristics were positively associated with meeting the baseline (larger proportion of prenatal patients aged 20 to 24 years) and target (more total patients, prenatal care by referral only, a larger proportion of prenatal patients aged 25 to 44 or ≥45 years, and a larger proportion of White or privately insured patients). Other characteristics were negatively associated with the baseline (location outside New England, location in a rural area, and a large proportion of prenatal patients aged <15 years) and target (more prenatal patients, location outside New England, provision of prenatal care to women living with HIV, and more uninsured patients or patients eligible for both Medicare and Medicaid). LIMITATION: The data set is at the health center grantee level and does not contain information on timing or quality of follow-up prenatal care. CONCLUSION: Most health centers met the Healthy People 2020 baseline, but opportunities for improvement remain and the Healthy People 2020 target is still a challenge for many health centers. Policymakers, providers, and health centers can learn from high-achieving centers to promote early initiation of prenatal care among medically vulnerable and underserved populations. PRIMARY FUNDING SOURCE: Health Resources and Services Administration.

      6. Regional variations in maternal mortality and health workforce availability in the United Statesexternal icon
        Snyder JE, Stahl AL, Streeter RA, Washko MM.
        Ann Intern Med. 2020 Dec 1;173(11_Supplement):S45-s54.
        BACKGROUND: Skilled, high-quality health providers and birth attendants are important for reducing maternal mortality. OBJECTIVE: To assess whether U.S. regional variations in maternal mortality rates relate to health workforce availability. DESIGN: Comparison of regional variations in maternal mortality rates and women's health provider rates per population and identification of a relationship between these measures. SETTING: U.S. health system. PARTICIPANTS: Women of child-bearing age and women's health providers, as captured in federal data sources from the Centers for Disease Control and Prevention, Census Bureau, and Health Resources and Services Administration. MEASUREMENTS: Regional-to-national rate ratios for maternal mortality and women's health provider availability, calculated per population for women of reproductive age. Provider availability was examined across occupations (obstetrician-gynecologists, internal medicine physicians, family medicine physicians, certified nurse-midwives), in service-based categories (birth-attending and primary care providers), and across the entire women's health workforce (all studied occupations). RESULTS: Maternal deaths per population increased nationally from 2009 to 2017 and, in 2017, were significantly higher in the South and lower in the Northeast (P < 0.001) than nationally. The occupational composition and per-population availability patterns of the women's health workforce varied regionally in 2017. The South had the lowest availability in the nation for nearly every health occupation and category studied, and the Northeast had the highest. This exploratory analysis suggests that subnational levels of provider availability across a region may be associated with higher maternal mortality rates. LIMITATIONS: No causal relationship was established. Nationally representative maternal mortality and health workforce data sources have well-known limitations. Low numbers of observations limit statistical analyses. CONCLUSION: Regional variations in maternal mortality rates may relate to the availability of birth-attending and primary care providers. PRIMARY FUNDING SOURCE: None.

      7. Trends in opioid and psychotropic prescription in pregnancy in the United States from 2001 to 2015 in a privately insured population : A cross-sectional studyexternal icon
        Venkatesh KK, Pate V, Boggess KA, Jones HE, Funk MJ, Smid MC.
        Ann Intern Med. 2020 Dec 1;173(11_Supplement):S19-s28.
        BACKGROUND: Opioid and psychotropic prescriptions are common during pregnancy. Little is known about coprescriptions of both medications in this setting. OBJECTIVE: To describe opioid prescription among women who are prescribed psychotropics compared with women who are not. DESIGN: Cross-sectional study. SETTING: U.S. commercial insurance beneficiaries from MarketScan (2001 to 2015). PARTICIPANTS: Pregnant women at 22 weeks' gestation or greater who were insured continuously for 3 months or more before pregnancy through delivery. MEASUREMENTS: Opioid prescription, dosage thresholds (morphine milligram equivalents [MME] of ≥50/day and ≥90/day), number of opioid agents (≥2), and duration (≥30 days) among those with and without prescription of psychotropics, from 2011 to 2015. RESULTS: Among 958 980 pregnant women, 10% received opioids only, 6% psychotropics only, and 2% opioids with coprescription of psychotropics. Opioid prescription was higher among women prescribed psychotropics versus those who were not (26.5% vs. 10.7%). From 2001 to 2015, psychotropic prescription overall increased from 4.4% to 7.6%, opioid prescription without coprescription of psychotropics decreased from 11.9% to 8.4%, and opioids with coprescription decreased from 28.1% to 22.0%. Morphine milligram equivalents of 50 or greater per day decreased for women with and without coprescription (29.6% to 17.3% and 22.8% to 18.5%, respectively); MME of 90 or greater per day also decreased in both groups (15.0% to 4.7% and 11.5% to 4.2%, respectively). Women prescribed opioids only were more likely to have an antepartum hospitalization compared with those with neither prescription, as were women with coprescription versus those prescribed psychotropics only. Compared with those prescribed opioids only, women with coprescriptions were more likely to exceed MME of 90 or greater per day and to be prescribed 2 or more opioid agents and for 30 days or longer. Number and duration of opioids increased with benzodiazepine and gabapentin coprescription. LIMITATION: Inability to determine appropriateness of prescribing or overdose events. CONCLUSION: Opioids are frequently coprescribed with psychotropic medication during pregnancy and are associated with antepartum hospitalization. A substantial proportion of pregnant women are prescribed opioids at doses that increase overdose risk and exceed daily recommendations. PRIMARY FUNDING SOURCE: None.

      8. Health needs of mothers of infants in a neonatal intensive care unit : A mixed-methods studyexternal icon
        Verbiest S, Ferrari R, Tucker C, McClain EK, Charles N, Stuebe AM.
        Ann Intern Med. 2020 Dec 1;173(11_Supplement):S37-s44.
        BACKGROUND: Mothers with babies in the neonatal intensive care unit (NICU) face a host of challenges following childbirth. Limited information is available on these mothers' postpartum health needs and access to services. OBJECTIVE: To identify health needs of NICU mothers, access to services, and potential service improvements. DESIGN: A mixed-methods study including a retrospective cohort study, in-depth interviews, and focus groups. SETTING: Large, Level IV, regional referral, university-affiliated hospital in the United States. PARTICIPANTS: Mothers of live-born infants born from 1 July 2014 to 30 June 2016 (n = 6849). Interviews included 50 NICU mothers and 59 stakeholders who provide services to these mothers or their infants. MEASUREMENTS: Severe maternal morbidity, chronic health conditions, health care encounters from discharge through 12 weeks postpartum, maternal health needs, care access, and system improvements. RESULTS: Compared with mothers of well babies, NICU mothers had more chronic diseases, experienced more perinatal complications, and utilized more acute care postpartum. Qualitative analyses revealed the desire to be at the baby's bedside as a driver of maternal health-seeking behaviors, with women not seeking or delaying medical care so as to stay by their infant. Stakeholders acknowledged the unique needs of NICU mothers and cited system challenges, lack of clarity about provider roles, and reimbursement policies as barriers to meeting needs. LIMITATIONS: The study was conducted within a single health care system, which may limit generalizability. Qualitative analyses did not explore the influence of fathers, other children in the home, or length of NICU stay. CONCLUSION: Universal screening and convenient access to maternal health services for NICU mothers should be explored to reduce adverse maternal health outcomes. PRIMARY FUNDING SOURCE: Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services.

  2. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Chronic Diseases and Conditions
      1. Quantitative measures of estrogen receptor expression in relation to breast cancer-specific mortality risk among white women and black womenexternal icon
        Ma H, Lu Y, Marchbanks PA, Folger SG, Strom BL, McDonald JA, Simon MS, Weiss LK, Malone KE, Burkman RT, Sullivan-Halley J, Deapen DM, Press MF, Bernstein L.
        Breast Cancer Res. 2013 ;15(5):R90.
        INTRODUCTION: The association of breast cancer patients’ mortality with estrogen receptor (ER) status (ER + versus ER-) has been well studied. However, little attention has been paid to the relationship between the quantitative measures of ER expression and mortality. METHODS: We evaluated the association between semi-quantitative, immunohistochemical staining of ER in formalin-fixed paraffin-embedded breast carcinomas and breast cancer-specific mortality risk in an observational cohort of invasive breast cancer in 681 white women and 523 black women ages 35-64 years at first diagnosis of invasive breast cancer, who were followed for a median of 10 years. The quantitative measures of ER examined here included the percentage of tumor cell nuclei positively stained for ER, ER Histo (H)-score, and a score based on an adaptation of an equation presented by Cuzick and colleagues, which combines weighted values of ER H-score, percentage of tumor cell nuclei positively stained for the progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) results. This is referred to as the ER/PR/HER2 score. RESULTS: After controlling for age at diagnosis, race, study site, tumor stage, and histologic grade in multivariable Cox proportional hazards regression models, both percentage of tumor cell nuclei positively stained for ER (Ptrend = 0.0003) and the ER H-score (Ptrend = 0.0004) were inversely associated with breast cancer-specific mortality risk. The ER/PR/HER2 score was positively associated with breast cancer-specific mortality risk in women with ER + tumor (Ptrend = 0.001). Analyses by race revealed that ER positivity was associated with reduced risk of breast cancer-specific mortality in white women and black women. The two quantitative measures for ER alone provided additional discrimination in breast cancer-specific mortality risk only among white women with ER + tumors (both Ptrend ≤ 0.01) while the ER/PR/HER2 score provided additional discrimination for both white women (Ptrend = 0.01) and black women (Ptrend = 0.03) with ER + tumors. CONCLUSIONS: Our data support quantitative immunohistochemical measures of ER, especially the ER/PR/HER2 score, as a more precise predictor for breast cancer-specific mortality risk than a simple determination of ER positivity.

      2. Does hormone therapy counter the beneficial effects of physical activity on breast cancer risk in postmenopausal women?external icon
        Dieli-Conwright CM, Sullivan-Halley J, Patel A, Press M, Malone K, Ursin G, Burkman R, Strom B, Simon M, Weiss L, Marchbanks P, Folger S, Spirtas R, Deapen D, Bernstein L.
        Cancer Causes Control. 2011 Mar;22(3):515-22.
        Studies consistently demonstrate that physical activity is inversely associated with postmenopausal breast cancer. Whether this association is stronger among non-hormone users or former users of menopausal hormone therapy (HT) is of interest given the marked decline in HT use since 2002. The Women's Contraceptive and Reproductive Experiences Study, a population-based case-control study of invasive breast cancer, recruited white women and black women ages 35-64 years and collected histories of lifetime recreational physical activity and HT use including estrogen-alone therapy (ET) and estrogen plus progestin therapy (EPT). Among postmenopausal women (1,908 cases, 2,013 control participants), breast cancer risk declined with increasing levels of lifetime physical activity among never HT users; among short-term HT users (fewer than 5 years); and among current ET users; P (trend) values ranged from 0.004 to 0.016. In contrast, physical activity had no significant association with risk among long-term and past HT users and among current EPT users. No statistical evidence of heterogeneity was demonstrated for duration or currency of HT use. Breast cancer risk decreases with increasing lifetime physical activity levels among postmenopausal women who have not used HT, have used HT for less than 5 years, or are current ET users, yet this study was unable to demonstrate statistically that HT use modifies the relationship between physical activity and breast cancer. With profound changes in HT use occurring since 2002, it will be important in future studies to learn whether or not any association between physical activity and breast cancer among former HT users is a function of time since last HT use.

      3. INTRODUCTION: Bleeding episodes in patients who have haemophilia A (HA), a hereditary bleeding disorder caused by a deficiency in factor VIII (FVIII), are treated or prophylactically prevented with infusions of exogenous FVIII. Neutralizing antibodies, referred to as inhibitors, against infusion products are a major complication experienced by up to 30% of patients who have severe HA. Bypassing agents (BPA), a class of therapeutics given to patients who have inhibitors, bypass the need for FVIII in the coagulation cascade, and long-term inhibitor eradication is accomplished using immune tolerance induction therapy (ITI). Data examining the antibody levels in patients receiving BPA and ITI are limited. AIM: Measure anti-FVIII antibody levels in specimens from patients receiving ITI or BPA in order to evaluate the anti-FVIII antibody response in those patients. METHODS: Specimens were tested using the CDC-modified Nijmegen-Bethesda assay (NBA) and the CDC fluorescence immunoassay (FLI) for anti-FVIII IgG(1) and IgG(4) . RESULTS: NBA-negative specimens from patients undergoing ITI or receiving BPAs have a higher frequency of anti-FVIII IgG(4) positivity compared with the previously published level for NBA-negative HA patients. Analysis of anti-FVIII antibody levels in serial samples from patients undergoing ITI reveals that antibodies can persist even after the patient's NBA result falls into the negative range. CONCLUSIONS: Measurement of anti-FVIII antibodies may be a useful means to better contextualize NBA results in specimens from patients receiving BPA or ITI. In addition, assessment of anti-FVIII antibody levels has the potential to improve inhibitor surveillance and clinical decision-making related to the progress of ITI.

      4. Our objectives were to evaluate: 1) the associations of cognitive frailty with various health outcomes including disability, hospitalization, and death; 2) whether the associations differed by multimorbidity. We included data of 5113 Chinese older adults (aged 60+ years) who had baseline cognition and physical frailty assessments (2011 wave) and follow-up for 4 years. About 16.0% (n=820) had cognitive impairment; 6.7% (n=342) had physical frailty; and 1.6% (n=82) met criteria for cognitive frailty. Both cognitive impairment (odds ratios (ORs) range: 1.41 to 2.11) and physical frailty (ORs range: 1.51 to 2.43) were independently associated with basic activities of daily living (BADL), instrumental ADL (IADL), mobility disability, hospitalization, and death among participants without that corresponding outcome at baseline, even after accounting for covariates. Relative to participants who had normal cognition and were nonfrail, those with cognitive frailty had the highest risk for IADL disability (OR=3.40, 95% CI, 1.23-9.40) and death (OR=3.89, 95% CI, 2.25-6.47). We did not find significant interaction effects between cognitive frailty and multimorbidity (P(interactions)>0.05). Overall, cognitive frailty was associated with disability and death, independent of multimorbidity. This highlights the importance of assessing cognitive frailty in the community to promote primary and secondary preventions for healthy aging.

      5. Serum sodium and potassium distribution and characteristics in the US Population, National Health and Nutrition Examination Survey 2009-2016external icon
        Overwyk KJ, Pfeiffer CM, Storandt RJ, Zhao L, Zhang Z, Campbell NR, Wiltz JL, Merritt RK, Cogswell ME.
        J Appl Lab Med. 2020 Nov 23.
        BACKGROUND: Concern has been expressed by some that sodium reduction could lead to increased prevalence of hyponatremia and hyperkalemia for specific population subgroups. Current concentrations of serum sodium and potassium in the US population can help address this concern. METHODS: We used data from the National Health and Nutrition Examination Survey 2009-2016 to examine mean and selected percentiles of serum sodium and potassium by sex and age group among 25 520 US participants aged 12 years or older. Logistic regression models with predicted residuals were used to examine the age-adjusted prevalence of low serum sodium and high serum potassium among adults aged 20 or older by selected sociodemographic characteristics and by health conditions or medication use. RESULTS: The distributions of serum sodium and potassium concentrations were within normal reference intervals overall and across Dietary Reference Intake life-stage groups, with a few exceptions. Overall, 2% of US adults had low serum sodium (<135 mmol/L) and 0.6% had high serum potassium (>5 mmol/L). Prevalence of low serum sodium and high serum potassium was higher among adults aged 71 or older (4.7 and 2.0%, respectively) and among adults with chronic kidney disease (3.4 and 1.9%), diabetes (5.0 and 1.1%), or using certain medications (which varied by condition), adjusted for age; whereas, prevalence was <1% among adults without these conditions or medications. CONCLUSIONS: Most of the US population has normal serum sodium and potassium concentrations; these data describe population subgroups at higher risk of low serum sodium and high serum potassium and can inform clinical care.

      6. Health-related quality of life outcomes among breast cancer survivorsexternal icon
        Park J, Rodriguez JL, O'Brien KM, Nichols HB, Hodgson ME, Weinberg CR, Sandler DP.
        Cancer. 2020 Nov 25.
        BACKGROUND: Data from a nationwide sample of US breast cancer survivors were used to examine associations between patient characteristics (breast cancer clinical features, prognostic factors, and treatments) and health-related quality of life (HRQOL). Associations between postdiagnosis HRQOL and mortality were then evaluated. METHODS: The authors identified female breast cancer survivors (n = 2453) from the Sister Study or Two Sister Study who were at least 1 year from breast cancer diagnosis and who had responded to a survivorship survey in 2012. HRQOL was assessed with the Patient-Reported Outcomes Measurement Information System (PROMIS) Global 10 measures. Multivariable linear regression was used to assess predictors associated with HRQOL. Cox regression was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between HRQOL and all-cause mortality. RESULTS: HRQOL, assessed an average of 4.9 years after the cancer diagnosis (standard deviation of 1.9 years), was negatively associated with a higher cancer stage at diagnosis; a higher comorbidity score at the survey; experience of surgical complications; dissatisfaction with breast surgery; and experience of any recent recurrence, metastasis, or secondary malignancy. Since the completion of the survey, there were 85 deaths (3.5%) during a mean follow-up of 4 years (standard deviation of 0.5 years). In multivariate models, decreases in PROMIS physical T scores and mental T scores were associated with increased mortality (HR for physical T scores, 1.08; 95% CI, 1.05-1.11; HR for mental T scores, 1.03; 95% CI, 1.01-1.06). CONCLUSIONS: Prognostic and cancer treatment-related factors affect HRQOL in breast cancer survivors and may inform targeted survivorship care. PROMIS global health measures may offer additional insights into patients' well-being and mortality risk. LAY SUMMARY: Findings from a study suggest that prognostic and cancer treatment-related factors affect health-related quality of life (HRQOL) in breast cancer survivors and that poor HRQOL may increase the mortality risk. The evaluation of HRQOL is important because it may hold potential as a tool for optimizing survivorship care.

      7. Prevalence and trends in cigarette smoking among adults with epilepsy - United States, 2010-2017external icon
        Sapkota S, Kobau R, Croft JB, King BA, Thomas C, Zack MM.
        MMWR Morb Mortal Wkly Rep. 2020 Nov 27;69(47):1792-1796.
        Cigarette smoking remains the leading cause of preventable disease and death in the United States (1). Although the percentage of all U.S. adults who smoke cigarettes has declined substantially since the mid-1960s (1,2), marked disparities persist, and declines have not been consistent across population groups (1,2). Studies have shown that cigarette smoking is as common, and sometimes more so, among adults with a history of epilepsy compared with those without a history of epilepsy, but reasons for this are unclear (3-6). Compared with adults without epilepsy, adults with epilepsy report lower household income, more unemployment and disability, worse psychological health, and reduced health-related quality of life (3,4,6,7). Trends in cigarette smoking among U.S. adults with epilepsy have not been previously assessed. CDC analyzed National Health Interview Survey (NHIS) data among 121,497 U.S. adults from 2010, 2013, 2015, and 2017 to assess current cigarette smoking by epilepsy status. From 2010 through 2017, the age-standardized percentages of current smoking were 24.9% among adults with active epilepsy, 25.9% among adults with inactive epilepsy, and 16.6% among adults with no history of epilepsy. After accounting for differences in data collection intervals and patterns in smoking status among subgroups, CDC found that current cigarette smoking declined significantly from 2010 to 2017 among adults with no history of epilepsy (19.3% to 14.0% [p<0.001]) and inactive epilepsy (29.2% to 16.2% [p = 0.03]), but declines among adults with active epilepsy were not statistically significant (26.4% to 21.8% [p = 0.2]). Epilepsy health and social service providers should promote smoking cessation resources to adults with active epilepsy who smoke cigarettes to help them quit smoking and to reduce their risk of smoking-related disease and death.

    • Communicable Diseases
      1. Estimated SARS-CoV-2 seroprevalence in the US as of September 2020external icon
        Bajema KL, Wiegand RE, Cuffe K, Patel SV, Iachan R, Lim T, Lee A, Moyse D, Havers FP, Harding L, Fry AM, Hall AJ, Martin K, Biel M, Deng Y, Meyer WA, Mathur M, Kyle T, Gundlapalli AV, Thornburg NJ, Petersen LR, Edens C.
        JAMA Intern Med. 2020 Nov 24.
        IMPORTANCE: Case-based surveillance of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection likely underestimates the true prevalence of infections. Large-scale seroprevalence surveys can better estimate infection across many geographic regions. OBJECTIVE: To estimate the prevalence of persons with SARS-CoV-2 antibodies using residual sera from commercial laboratories across the US and assess changes over time. DESIGN, SETTING, AND PARTICIPANTS: This repeated, cross-sectional study conducted across all 50 states, the District of Columbia, and Puerto Rico used a convenience sample of residual serum specimens provided by persons of all ages that were originally submitted for routine screening or clinical management from 2 private clinical commercial laboratories. Samples were obtained during 4 collection periods: July 27 to August 13, August 10 to August 27, August 24 to September 10, and September 7 to September 24, 2020. EXPOSURES: Infection with SARS-CoV-2. MAIN OUTCOMES AND MEASURES: The proportion of persons previously infected with SARS-CoV-2 as measured by the presence of antibodies to SARS-CoV-2 by 1 of 3 chemiluminescent immunoassays. Iterative poststratification was used to adjust seroprevalence estimates to the demographic profile and urbanicity of each jurisdiction. Seroprevalence was estimated by jurisdiction, sex, age group (0-17, 18-49, 50-64, and ≥65 years), and metropolitan/nonmetropolitan status. RESULTS: Of 177 919 serum samples tested, 103 771 (58.3%) were from women, 26 716 (15.0%) from persons 17 years or younger, 47 513 (26.7%) from persons 65 years or older, and 26 290 (14.8%) from individuals living in nonmetropolitan areas. Jurisdiction-level seroprevalence over 4 collection periods ranged from less than 1% to 23%. In 42 of 49 jurisdictions with sufficient samples to estimate seroprevalence across all periods, fewer than 10% of people had detectable SARS-CoV-2 antibodies. Seroprevalence estimates varied between sexes, across age groups, and between metropolitan/nonmetropolitan areas. Changes from period 1 to 4 were less than 7 percentage points in all jurisdictions and varied across sites. CONCLUSIONS AND RELEVANCE: This cross-sectional study found that as of September 2020, most persons in the US did not have serologic evidence of previous SARS-CoV-2 infection, although prevalence varied widely by jurisdiction. Biweekly nationwide testing of commercial clinical laboratory sera can play an important role in helping track the spread of SARS-CoV-2 in the US.

      2. COVID-19 outbreak associated with a 10-day motorcycle rally in a neighboring state - Minnesota, August-September 2020external icon
        Firestone MJ, Wienkes H, Garfin J, Wang X, Vilen K, Smith KE, Holzbauer S, Plumb M, Pung K, Medus C, Yao JD, Binnicker MJ, Nelson AC, Yohe S, Como-Sabetti K, Ehresmann K, Lynfield R, Danila R.
        MMWR Morb Mortal Wkly Rep. 2020 Nov 27;69(47):1771-1776.
        During August 7-16, 2020, a motorcycle rally was held in western South Dakota that attracted approximately 460,000 persons from across the United States to numerous indoor and outdoor events over a 10-day period. During August-September 2020, the Minnesota Department of Health (MDH) investigated a coronavirus disease 2019 (COVID-19) outbreak associated with the rally in Minnesota residents. Fifty-one primary event-associated cases were identified, and 35 secondary or tertiary cases occurred among household, social, and workplace contacts, for a total of 86 cases; four patients were hospitalized, and one died. Approximately one third (34%) of 87 counties in Minnesota had at least one primary, secondary, or tertiary case associated with this rally. Genomic sequencing supported the associations with the motorcycle rally. These findings support current recommendations for mask use, physical distancing, reducing the number of attendees at gatherings, isolation for patients with COVID-19, and quarantine for close contacts to slow the spread of SARS-CoV-2 (1). Furthermore, although these findings did not capture the impact of the motorcycle rally on residents of other states, they demonstrate the rationale for consistent mitigation measures across states.

      3. Prevalence of nonsuppressed viral load and associated factors among HIV-positive adults receiving antiretroviral therapy in Eswatini, Lesotho, Malawi, Zambia and Zimbabwe (2015 to 2017): results from population-based nationally representative surveysexternal icon
        Haas AD, Radin E, Hakim AJ, Jahn A, Philip NM, Jonnalagadda S, Saito S, Low A, Patel H, Schwitters AM, Rogers JH, Frederix K, Kim E, Bello G, Williams DB, Parekh B, Sachathep K, Barradas DT, Kalua T, Birhanu S, Musuka G, Mugurungi O, Tippett Barr BA, Sleeman K, Mulenga LB, Thin K, Ao TT, Brown K, Voetsch AC, Justman JE.
        J Int AIDS Soc. 2020 Nov;23(11):e25631.
        INTRODUCTION: The global target for 2020 is that ≥90% of people living with HIV (PLHIV) receiving antiretroviral therapy (ART) will achieve viral load suppression (VLS). We examined VLS and its determinants among adults receiving ART for at least four months. METHODS: We analysed data from the population-based HIV impact assessment (PHIA) surveys in Eswatini, Lesotho, Malawi, Zambia and Zimbabwe (2015 to 2017). PHIA surveys are nationally representative, cross-sectional household surveys. Data collection included structured interviews, home-based HIV testing and laboratory testing. Blood samples from PLHIV were analysed for HIV RNA, CD4 counts and recent exposure to antiretroviral drugs (ARVs). We calculated representative estimates for the prevalence of VLS (viral load <1000 copies/mL), nonsuppressed viral load (NVL; viral load ≥1000 copies/mL), virologic failure (VF; ARVs present and viral load ≥1000 copies/mL), interrupted ART (ARVs absent and viral load ≥1000 copies/mL) and rates of switching to second-line ART (protease inhibitors present) among PLHIV aged 15 to 59 years who participated in the PHIA surveys in Eswatini, Lesotho, Malawi, Zambia and Zimbabwe, initiated ART at least four months before the survey and were receiving ART at the time of the survey (according to self-report or ARV testing). We calculated odds ratios and incidence rate ratios for factors associated with NVL, VF, interrupted ART, and switching to second-line ART. RESULTS: We included 9200 adults receiving ART of whom 88.8% had VLS and 11.2% had NVL including 8.2% who experienced VF and 3.0% who interrupted ART. Younger age, male sex, less education, suboptimal adherence, receiving nevirapine, HIV non-disclosure, never having married and residing in Zimbabwe, Lesotho or Zambia were associated with higher odds of NVL. Among people with NVL, marriage, female sex, shorter ART duration, higher CD4 count and alcohol use were associated with lower odds for VF and higher odds for interrupted ART. Many people with VF (44.8%) had CD4 counts <200 cells/µL, but few (0.31% per year) switched to second-line ART. CONCLUSIONS: Countries are approaching global VLS targets for adults. Treatment support, in particular for younger adults, and people with higher CD4 counts, and switching of people to protease inhibitor- or integrase inhibitor-based regimens may further reduce NVL prevalence.

      4. In the United States, new tuberculosis cases are increasingly concentrated within non-native-born populations. We estimated trends and differences in tuberculosis incidence rates for the non-U.S.-born population, at a resolution unobtainable from raw data. We obtained non-U.S.-born tuberculosis case reports for 2000-2016 from the National Tuberculosis Surveillance System, and population data from the American Community Survey and 2000 U.S. Census. We constructed generalized additive regression models to estimate incidence rates in terms of birth country, entry year, age at entry, and number of years since entry into the United States and described how these factors contribute to overall tuberculosis risk. Controlling for other factors, tuberculosis incidence rates were lower for more recent immigration cohorts, with an incidence risk ratio (IRR) of 10.2 (95 % confidence interval 7.0, 14.7) for the 1950 entry cohort compared to its 2016 counterpart. Greater years since entry and younger age at entry were associated with substantially lower incidence rates. IRRs for birth country varied between 8.86 (6.78, 11.52) for Somalia and 0.02 (0.01, 0.03) for Canada, compared to all non-U.S.-born residents in 2016. IRRs were positively correlated with WHO predicted incidence rate and negatively associated with wealth level for the birth country. Lower country wealth level was also associated with shallower declines in tuberculosis over time. Tuberculosis risks differ by several orders of magnitude within the non-U.S.-born population. A better understanding of these differences will allow more effective targeting of tuberculosis prevention efforts. The methods presented here may also be relevant for understanding tuberculosis trends in other high-income countries.

      5. Factors associated with hepatitis A mortality during person-to-person outbreaks: A matched case-control study-United 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.
        Hepatology. 2020 Nov 20.
        BACKGROUND & AIMS: During 2016-2020, the United States experienced person-to-person hepatitis A outbreaks that are unprecedented in the vaccine era, during which case-fatality ratios reported by some jurisdictions exceeded those historically associated with hepatitis A. APPROACH & RESULTS: To identify factors associated with hepatitis A-related mortality, we performed a matched case-control study (matched on age [±5 years] and county of residence in a 1:4 ratio) using data collected from health department and hospital medical records of outbreak-associated patients in Kentucky, Michigan, and West Virginia. Controls were hepatitis A outbreak-associated patients who did not die. There were 110 cases (mean age 53.6 years) and 414 matched controls (mean age 51.9 years); most cases (68.2%) and controls (63.8%) were male. Significantly (p<0.05) higher odds of mortality were associated with pre-existing non-viral liver disease (adjusted odds ratio [aOR] 5.2), history of hepatitis B (aOR 2.4), diabetes (aOR 2.2), and cardiovascular disease (aOR 2.2), as well as initial MELD score ≥30 (aOR 10.0), AST/ALT ratio >2 (aOR 10.3), and platelet count <150,000/uL (aOR 3.7) among hepatitis A outbreak-associated patients in the independent multivariable conditional logistic regression analyses (each model adjusted for sex). CONCLUSIONS: Pre-existing liver disease, diabetes, cardiovascular disease, and initial MELD score ≥30, AST/ALT ratio ≥1, or platelet count <150,000/uL among hepatitis A patients were independently associated with higher odds of mortality. Providers should be vigilant for such features and have a low threshold to escalate care and consider consultation for liver transplantation. Our findings support the Advisory Committee on Immunization Practices recommendation to vaccinate persons with chronic liver disease, though future recommendations to include adults with diabetes and cardiovascular disease should be considered.

      6. Though pre-exposure prophylaxis (PrEP) can prevent HIV acquisition, it provides no protection against bacterial sexually transmitted infections (STIs). PrEP use may increase STI acquisition due to sexual risk compensation, but that could be counterbalanced by increased STI screening at regular PrEP visits. We conducted a literature search of studies with quantitative data published prior to March 2020, assessing sexual risk compensation or STI screening among men who have sex with men (MSM) before and after PrEP initiation. We identified 16 relevant publications. Changes in condom use were inconsistent across studies. Partner acquisition following PrEP initiation decreased in most studies, likely due to behavioral counseling. In publications comparing a PrEP arm to a non-PrEP arm, serodiscordance increased in the PrEP arm and decreased in the non-PrEP arm. STI screening among MSM was low within a month of PrEP initiation. Monitoring trends in sexual risk compensation and STI screening will be critical to understand PrEP's effects on STI burden.

      7. Hansen's disease and complications among Marshallese persons residing in northwest Arkansas, 2003-2017external icon
        Labuda SM, Williams SH, Mukasa LN, McGhee L.
        Am J Trop Med Hyg. 2020 Nov;103(5):1810-1812.
        Persons from the Republic of the Marshall Islands have among the highest rates of Hansen's disease (HD) in the world; the largest Marshallese community in the continental United States is in northwest Arkansas. In 2017, the HD Ambulatory Care Clinic in Springdale, Arkansas, informed the Arkansas Department of Health (ADH) that Marshallese persons with HD had severe disease with frequent complications. To characterize their illness, we reviewed ADH surveillance reports of HD among Marshallese persons in Arkansas treated during 2003-2017 (n = 42). Hansen's Disease prevalence among Marshallese in Arkansas (11.7/10,000) was greater than that in the general U.S. population. Complications included arthritis (38%), erythema nodosum leprosum (21%), and prolonged treatment lasting > 2 years (40%). The majority (82%) of patients treated for > 2 years had documented intermittent therapy. Culturally appropriate support for therapy and adherence is needed in Arkansas.

      8. BACKGROUND: HIV prevalence in Mozambique (12.6%) is one of the highest in the world, yet ~40% of people living with HIV (PLHIV) do not know their HIV status. Strategies to increase HIV testing uptake and diagnosis among PLHIV are urgently needed. Home-based HIV testing services (HBHTS) have been evaluated primarily as a 1-time campaign strategy. Little is known about the potential of repeating HBHTS to diagnose HIV infection among persons who have never been tested (NTs), nor about factors/reasons associated with never testing in a generalized epidemic setting. METHODS: During 2014-2017, counselors visited all households annually in the Chókwè Health and Demographic Surveillance System (CHDSS) and offered HBHTS. Cross-sectional surveys were administered to randomly selected 10% or 20% samples of CHDSS households with participants aged 15-59 years before HBHTS were conducted during the visit. Descriptive statistics and logistic regression were used to assess the proportion of NTs, factors/reasons associated with never having been tested, HBHTS acceptance, and HIV-positive diagnosis among NTs. RESULTS: The proportion of NTs decreased from 25% (95% confidence interval [CI]:23%-26%) during 2014 to 12% (95% CI:11% -13%), 7% (95% CI:6%-8%), and 7% (95% CI:6%-8%) during 2015, 2016, and 2017, respectively. Adolescent boys and girls and adult men were more likely than adult women to be NTs. In each of the four years, the majority of NTs (87%-90%) accepted HBHTS. HIV-positive yield among NTs subsequently accepting HBHTS was highest (13%, 95% CI:10%-15%) during 2014 and gradually reduced to 11% (95% CI:8%-15%), 9% (95% CI:6%-12%), and 2% (95% CI:0%-4%) during 2015, 2016, and 2017, respectively. CONCLUSIONS: Repeated HBHTS was helpful in increasing HIV testing coverage and identifying PLHIV in Chókwè. In high HIV-prevalence settings with low testing coverage, repeated HBHTS can be considered to increase HIV testing uptake and diagnosis among NTs.

      9. The Advisory Committee on Immunization Practices' ethical principles for allocating initial supplies of COVID-19 vaccine - United States, 2020external icon
        McClung N, Chamberland M, Kinlaw K, Bowen Matthew D, Wallace M, Bell BP, Lee GM, Talbot HK, Romero JR, Oliver SE, Dooling K.
        MMWR Morb Mortal Wkly Rep. 2020 Nov 27;69(47):1782-1786.
        To reduce the spread of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) and its associated impacts on health and society, COVID-19 vaccines are essential. The U.S. government is working to produce and deliver safe and effective COVID-19 vaccines for the entire U.S. population. The Advisory Committee on Immunization Practices (ACIP)* has broadly outlined its approach for developing recommendations for the use of each COVID-19 vaccine authorized or approved by the Food and Drug Administration (FDA) for Emergency Use Authorization or licensure (1). ACIP's recommendation process includes an explicit and transparent evidence-based method for assessing a vaccine's safety and efficacy as well as consideration of other factors, including implementation (2). Because the initial supply of vaccine will likely be limited, ACIP will also recommend which groups should receive the earliest allocations of vaccine. The ACIP COVID-19 Vaccines Work Group and consultants with expertise in ethics and health equity considered external expert committee reports and published literature and deliberated the ethical issues associated with COVID-19 vaccine allocation decisions. The purpose of this report is to describe the four ethical principles that will assist ACIP in formulating recommendations for the allocation of COVID-19 vaccine while supply is limited, in addition to scientific data and implementation feasibility: 1) maximize benefits and minimize harms; 2) promote justice; 3) mitigate health inequities; and 4) promote transparency. These principles can also aid state, tribal, local, and territorial public health authorities as they develop vaccine implementation strategies within their own communities based on ACIP recommendations.

      10. Early cases of SARS-CoV-2 infection in Uganda: epidemiology and lessons learned from risk-based testing approaches - March-April 2020external icon
        Migisha R, Kwesiga B, Mirembe BB, Amanya G, Kabwama SN, Kadobera D, Bulage L, Nsereko G, Wadunde I, Tindyebwa T, Lubwama B, Kagirita AA, Kayiwa JT, Lutwama JJ, Boore AL, Harris JR, Bosa HK, Ario AR.
        Global Health. 2020 Nov 25;16(1):114.
        BACKGROUND: On March 13, 2020, Uganda instituted COVID-19 symptom screening at its international airport, isolation and SARS-CoV-2 testing for symptomatic persons, and mandatory 14-day quarantine and testing of persons traveling through or from high-risk countries. On March 21, 2020, Uganda reported its first SARS-CoV-2 infection in a symptomatic traveler from Dubai. By April 12, 2020, 54 cases and 1257 contacts were identified. We describe the epidemiological, clinical, and transmission characteristics of these cases. METHODS: A confirmed case was laboratory-confirmed SARS-CoV-2 infection during March 21-April 12, 2020 in a resident of or traveler to Uganda. We reviewed case-person files and interviewed case-persons at isolation centers. We identified infected contacts from contact tracing records. RESULTS: Mean case-person age was 35 (±16) years; 34 (63%) were male. Forty-five (83%) had recently traveled internationally ('imported cases'), five (9.3%) were known contacts of travelers, and four (7.4%) were community cases. Of the 45 imported cases, only one (2.2%) was symptomatic at entry. Among all case-persons, 29 (54%) were symptomatic at testing and five (9.3%) were pre-symptomatic. Among the 34 (63%) case-persons who were ever symptomatic, all had mild disease: 16 (47%) had fever, 13 (38%) reported headache, and 10 (29%) reported cough. Fifteen (28%) case-persons had underlying conditions, including three persons with HIV. An average of 31 contacts (range, 4-130) were identified per case-person. Five (10%) case-persons, all symptomatic, infected one contact each. CONCLUSION: The first 54 case-persons with SARS-CoV-2 infection in Uganda primarily comprised incoming air travelers with asymptomatic or mild disease. Disease would likely not have been detected in these persons without the targeted testing interventions implemented in Uganda. Transmission was low among symptomatic persons and nonexistent from asymptomatic persons. Routine, systematic screening of travelers and at-risk persons, and thorough contact tracing will be needed for Uganda to maintain epidemic control.

      11. Point-of-care molecular testing and antiviral treatment of influenza in residents of homeless shelters in Seattle, WA: study protocol for a stepped-wedge cluster-randomized controlled trialexternal icon
        Newman KL, Rogers JH, McCulloch D, Wilcox N, Englund JA, Boeckh M, Uyeki TM, Jackson ML, Starita L, Hughes JP, Chu HY.
        Trials. 2020 Nov 23;21(1):956.
        INTRODUCTION: Influenza is an important public health problem, but data on the impact of influenza among homeless shelter residents are limited. The primary aim of this study is to evaluate whether on-site testing and antiviral treatment of influenza in residents of homeless shelters reduces influenza spread in these settings. METHODS AND ANALYSIS: This study is a stepped-wedge cluster-randomized trial of on-site testing and antiviral treatment for influenza in nine homeless shelter sites within the Seattle metropolitan area. Participants with acute respiratory illness (ARI), defined as two or more respiratory symptoms or new or worsening cough with onset in the prior 7 days, are eligible to enroll. Approximately 3200 individuals are estimated to participate from October to May across two influenza seasons. All sites will start enrollment in the control arm at the beginning of each season, with routine surveillance for ARI. Sites will be randomized at different timepoints to enter the intervention arm, with implementation of a test-and-treat strategy for individuals with two or fewer days of symptoms. Eligible individuals will be tested on-site with a point-of-care influenza test. If the influenza test is positive and symptom onset is within 48 h, participants will be administered antiviral treatment with baloxavir or oseltamivir depending upon age and comorbidities. Participants will complete a questionnaire on demographics and symptom duration and severity. The primary endpoint is the incidence of influenza in the intervention period compared to the control period, after adjusting for time trends. TRIAL REGISTRATION: NCT04141917 . Registered 28 October 2019. Trial sponsor: University of Washington.

      12. A cohort study to assess a communication intervention to improve linkage to HIV care in Nakivale Refugee Settlement, Ugandaexternal icon
        O'Laughlin KN, Xu A, Greenwald KE, Kasozi J, Parker RA, Bustamante N, Parmar P, Faustin ZM, Walensky RP, Bassett IV.
        Glob Public Health. 2020 Nov 21:1-8.
        Communication interventions to enhance linkage to HIV care have been successful in sub-Saharan Africa but have not been assessed among refugees. Refugees and Ugandan nationals participating in HIV testing in Nakivale Refugee Settlement were offered weekly phone call and short message service (SMS) reminders. We assessed linkage to care and predictors of linkage within 90 days of testing, comparing Intervention participants to those unwilling or ineligible to participate (Non-Intervention). Of 208 individuals diagnosed with HIV, 101 (49%) participated in the intervention. No difference existed between Intervention and Non-intervention groups in linkage to care (73 [72%] vs. 76 [71%], p = 0.88). Excluding those who linked prior to receipt of intervention, the intervention improved linkage (69 [68%] vs. 50 [47%], p = 0.002). Participants were more likely to link if they were older (aOR 2.39 [1.31, 4.37], p = 0.005) or Ugandan nationals (aOR 3.76 [1.12, 12.66], p = 0.033). Although the communication intervention did not significantly improve linkage to HIV care, the linkage was improved when excluding those with same-day linkage. Excluding participants without a phone was a significant limitation; these data are meant to inform more rigorous designs moving forward. Innovative methods to improve linkage to HIV care for this vulnerable population are urgently needed.

      13. Access to HIV viral load testing and antiretroviral therapy switch practices: A multicountry prospective cohort study in sub-Saharan Africaexternal icon
        Ondoa P, Kim AA, Boender TS, Zhang G, Kroeze S, Wiener J, Rinke de Wit T, Nkengasong J.
        AIDS Res Hum Retroviruses. 2020 Nov;36(11):918-926.
        Poor access to HIV viral load (VL) testing prevents the timely monitoring of HIV treatment adherence and efficacy. Factors enabling clinical benefits of VL testing when added to local standards of care, can inform the development of more cost-effective routine VL scale-up plans. We compared antiretroviral therapy (ART) switch practices in 13 clinics across 6 countries, with full (N = 8), phasing-in (N = 3) or no onsite access (N = 2) to VL. The analysis used data from the Pan-African Studies to Evaluate Resistance (PASER), observing virological and drug resistance outcomes among adults receiving first- or second-line ART between 2008 and 2015. Study plasma viral load (sVL) determined at baseline, every 12 months thereafter and at the time of switch served for retrospectively validating switch decisions, categorized into "necessary," "unnecessary," and "missed." Virological failure was defined as two consecutive sVL ≥1,000 HIV-RNA copies/mL. One thousand nine hundred ninety-five of the 2,420 (82.4%) study participants had continuous virological suppression during the median 30 months of follow-up. Among the 266 virological failures (11.0%), the proportion of necessary switches were similar in clinics with full (37%), phasing-in (25%), or no access (39%) to local VL testing. Documented utilization of local VL results for the switch decision was associated with higher percentage of necessary switch (87.6% vs. 67.9%). Shorter time to necessary switch was associated with higher rates of long-term virological suppression, regardless of access to local viral load. Availability of HIV VL testing capacity does not systematically result in adequate switch practices or better virological outcomes. Systems supporting sufficient test demand execution, and actual utilization of results for patient management need strengthening.

      14. Estimated incidence of COVID-19 illness and hospitalization - United States, February-September, 2020external icon
        Reese H, Iuliano AD, Patel NN, Garg S, Kim L, Silk BJ, Hall AJ, Fry A, Reed C.
        Clin Infect Dis. 2020 Nov 25.
        BACKGROUND: In the United States, laboratory confirmed coronavirus disease 2019 (COVID-19) is nationally notifiable. However, reported case counts are recognized to be less than the true number of cases because detection and reporting are incomplete and can vary by disease severity, geography, and over time. METHODS: To estimate the cumulative incidence SARS-CoV-2 infections, symptomatic illnesses, and hospitalizations, we adapted a simple probabilistic multiplier model. Laboratory-confirmed case counts that were reported nationally were adjusted for sources of under-detection based on testing practices in inpatient and outpatient settings and assay sensitivity. RESULTS: We estimated that through the end of September, 1 of every 2.5 (95% Uncertainty Interval (UI): 2.0-3.1) hospitalized infections and 1 of every 7.1 (95% UI: 5.8-9.0) non-hospitalized illnesses may have been nationally reported. Applying these multipliers to reported SARS-CoV-2 cases along with data on the prevalence of asymptomatic infection from published systematic reviews, we estimate that 2.4 million hospitalizations, 44.8 million symptomatic illnesses, and 52.9 million total infections may have occurred in the U.S. population from February 27-September 30, 2020. CONCLUSIONS: These preliminary estimates help demonstrate the societal and healthcare burdens of the COVID-19 pandemic and can help inform resource allocation and mitigation planning.

      15. Task shifting for initiation and monitoring of antiretroviral therapy for HIV-infected adults in Uganda: The SHARE Trialexternal icon
        Sekiziyivu AB, Bancroft E, Rodriguez EM, Sendagala S, Muniina PN, Sserunga MN, Kiragga NA, Musaazi J, Musinguzi J, Sande E, Bartholow B, Dalal S, Tusiime JB, Kambugu A.
        J Acquir Immune Defic Syndr. 2020 Nov 17.
        BACKGROUND: With countries moving towards the World Health Organization's "Treat All" recommendation, there is need to initiate more HIV-infected persons on antiretroviral therapy (ART). In resource-limited settings, task shifting is one approach that can address clinician shortages. SETTING: Uganda METHODS:: We conducted a randomized controlled trial to test if nurse-initiated and monitored antiretroviral therapy (NIMART) is non-inferior to clinician-initiated and monitored ART (CIMART) in HIV-infected adults in Uganda. Study participants were HIV-infected, ART-naïve, and clinically stable adults. The primary outcome was a composite endpoint of any of the following: all-cause mortality, virological failure, toxicity, and loss to follow up at 12 months post-ART initiation. RESULTS: Over half of the study cohort (1,760) was female (54.9%). The mean age was 35.1 years (standard deviation 9.51). Five hundred and thirty-three (31.6%) participants experienced the composite endpoint. At 12 months post-ART initiation, NIMART was non-inferior to CIMART. The intention-to-treat site-adjusted risk differences for the composite endpoint were -4.1 (97.5% CI = -9.8 to 0.2) with complete case analysis (CCA) and -3.4 (97.5% CI = -9.1 to 2.5) with multiple imputation analysis (MIA). Per-protocol site-adjusted risk differences were -3.6 (97.5% CI = -10.5 to 0.6) for CCA and -3.1 (-8.8 to 2.8) for MIA. This difference was within hypothesized margins (6%) for non-inferiority. CONCLUSIONS: Nurses were non-inferior to clinicians for initiation and monitoring of ART. Task shifting to trained nurses is a viable means to increase access to ART. Future studies should evaluate NIMART for other groups (e.g., children, adolescents, and unstable patients).

      16. Decline in SARS-CoV-2 antibodies after mild infection among frontline health care personnel in a multistate hospital network - 12 states, April-August 2020external icon
        Self WH, Tenforde MW, Stubblefield WB, Feldstein LR, Steingrub JS, Shapiro NI, Ginde AA, Prekker ME, Brown SM, Peltan ID, Gong MN, Aboodi MS, Khan A, Exline MC, Files DC, Gibbs KW, Lindsell CJ, Rice TW, Jones ID, Halasa N, Talbot HK, Grijalva CG, Casey JD, Hager DN, Qadir N, Henning DJ, Coughlin MM, Schiffer J, Semenova V, Li H, Thornburg NJ, Patel MM.
        MMWR Morb Mortal Wkly Rep. 2020 Nov 27;69(47):1762-1766.
        Most persons infected with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), develop virus-specific antibodies within several weeks, but antibody titers might decline over time. Understanding the timeline of antibody decline is important for interpreting SARS-CoV-2 serology results. Serum specimens were collected from a convenience sample of frontline health care personnel at 13 hospitals and tested for antibodies to SARS-CoV-2 during April 3-June 19, 2020, and again approximately 60 days later to assess this timeline. The percentage of participants who experienced seroreversion, defined as an antibody signal-to-threshold ratio >1.0 at baseline and <1.0 at the follow-up visit, was assessed. Overall, 194 (6.0%) of 3,248 participants had detectable antibodies to SARS-CoV-2 at baseline (1). Upon repeat testing approximately 60 days later (range = 50-91 days), 146 (93.6%) of 156 participants experienced a decline in antibody response indicated by a lower signal-to-threshold ratio at the follow-up visit, compared with the baseline visit, and 44 (28.2%) experienced seroreversion. Participants with higher initial antibody responses were more likely to have antibodies detected at the follow-up test than were those who had a lower initial antibody response. Whether decay in these antibodies increases risk for reinfection and disease remains unanswered. However, these results suggest that serology testing at a single time point is likely to underestimate the number of persons with previous SARS-CoV-2 infection, and a negative serologic test result might not reliably exclude prior infection.

      17. COVID-19 outbreak among a university's men's and women's soccer teams - Chicago, Illinois, July-August 2020
        Teran RA, Ghinai I, Gretsch S, Cable T, Black SR, Green SJ, Perez O, Chlipala GE, Maienschein-Cline M, Kunstman KJ, Bleasdale SC, Fricchione MJ.
        MMWR Morb Mortal Wkly Rep. 2020 ;69(43):1591-1594.
        Several reports have described the challenges associated with SARS-CoV-2 transmission among college students who live and socialize together and have ongoing exposure on and off campus (1-3). This investigation identified 17 COVID-19 cases among students on a university's men's and women's soccer teams who lived, trained, and socialized together. After commencement of training, numerous social events occurred. Little to no mask use or social distancing was reported at social events attended by symptomatic and asymptomatic students, which might have led to additional cases. Given the number of events during the investigation period, the precise event where transmission occurred cannot be determined and might have also occurred at an unreported event. Living in shared accommodations with persons who also participated in multiple social gatherings without complying with recommended prevention behaviors such as using masks might have compounded transmission risk within this group.

      18. Trends in county-level COVID-19 incidence in counties with and without a mask mandate - Kansas, June 1-August 23, 2020external icon
        Van Dyke ME, Rogers TM, Pevzner E, Satterwhite CL, Shah HB, Beckman WJ, Ahmed F, Hunt DC, Rule J.
        MMWR Morb Mortal Wkly Rep. 2020 Nov 27;69(47):1777-1781.
        Wearing masks is a CDC-recommended* approach to reduce the spread of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), by reducing the spread of respiratory droplets into the air when a person coughs, sneezes, or talks and by reducing the inhalation of these droplets by the wearer. On July 2, 2020, the governor of Kansas issued an executive order(†) (state mandate), effective July 3, requiring masks or other face coverings in public spaces. CDC and the Kansas Department of Health and Environment analyzed trends in county-level COVID-19 incidence before (June 1-July 2) and after (July 3-August 23) the governor's executive order among counties that ultimately had a mask mandate in place and those that did not. As of August 11, 24 of Kansas's 105 counties did not opt out of the state mandate(§) or adopted their own mask mandate shortly before or after the state mandate was issued; 81 counties opted out of the state mandate, as permitted by state law, and did not adopt their own mask mandate. After the governor's executive order, COVID-19 incidence (calculated as the 7-day rolling average number of new daily cases per 100,000 population) decreased (mean decrease of 0.08 cases per 100,000 per day; net decrease of 6%) among counties with a mask mandate (mandated counties) but continued to increase (mean increase of 0.11 cases per 100,000 per day; net increase of 100%) among counties without a mask mandate (nonmandated counties). The decrease in cases among mandated counties and the continued increase in cases in nonmandated counties adds to the evidence supporting the importance of wearing masks and implementing policies requiring their use to mitigate the spread of SARS-CoV-2 (1-6). Community-level mitigation strategies emphasizing wearing masks, maintaining physical distance, staying at home when ill, and enhancing hygiene practices can help reduce transmission of SARS-CoV-2.

    • Disaster Control and Emergency Services
      1. Preparing the CDC public health workforce for emergency responseexternal icon
        Davis XM, Rouse EN, Stampley C.
        J Homel Secur Emerg Manag. 2020 .
        A critical component of successful public health emergency responses is the availability of appropriate numbers of personnel with emergency response expertise. To achieve this, the United States Centers for Disease Control and Prevention (CDC) focused on strengthening training, personnel database systems, and responder outreach. To ensure availability of well-trained public health emergency responders, CDC and external partners coordinated training, planning, exercise, and evaluation activities; established the School of Preparedness and Emergency Response; and implemented Responder Training Tiers for response roles with defined functional competencies. For personnel information, CDC developed interoperable databases to streamline the search for specific staff expertise for a response. To improve responder outreach, CDC developed various mechanisms to efficiently identify and assign potential responders to responses. These measures work together to sustain a qualified workforce for public health emergencies, and may be helpful to other public health agencies for staffing and training of their response workforce.

      2. Measuring the efficacy of a pilot public health intervention for engaging communities of Puerto Rico to rapidly write hurricane protection plansexternal icon
        Keim ME, Runnels LA, Lovallo AP, Pagan Medina M, Roman Rosa E, Ramery Santos M, Mahany M, Cruz MA.
        Prehosp Disaster Med. 2020 Nov 26:1-10.
        OBJECTIVE: The efficacy is measured for a public health intervention related to community-based planning for population protection measures (PPMs; ie, shelter-in-place and evacuation). DESIGN: This is a mixed (qualitative and quantitative) prospective study of intervention efficacy, measured in terms of usability related to effectiveness, efficiency, satisfaction, and degree of community engagement. SETTING: Two municipalities in the Commonwealth of Puerto Rico are included. PARTICIPANTS: Community members consisting of individuals; traditional leaders; federal, territorial, and municipal emergency managers; municipal mayors; National Guard; territorial departments of education, health, housing, public works, and transportation; health care; police; Emergency Medical Services; faith-based organizations; nongovernmental organizations (NGOs); and the private sector. INTERVENTION: The intervention included four community convenings: one for risk communication; two for plan-writing; and one tabletop exercise (TTX). This study analyzed data collected from the project work plan; participant rosters; participant surveys; workshop outputs; and focus group interviews. MAIN OUTCOME MEASURES: Efficacy was measured in terms of ISO 9241-11, an international standard for usability that includes effectiveness, efficiency, user satisfaction, and "freedom from risk" among users. Degree of engagement was considered an indicator of "freedom from risk," measurable through workshop attendance. RESULTS: Two separate communities drafted and exercised ~60-page-long population protection plans, each within 14.5 hours. Plan-writing workshops completed 100% of plan objectives and activities. Efficiency rates were nearly the same in both communities. Interviews and surveys indicated high degrees of community satisfaction. Engagement was consistent among community members and variable among governmental officials. CONCLUSIONS: Frontline communities have successfully demonstrated the ability to understand the environmental health hazards in their own community; rapidly write consensus-based plans for PPMs; participate in an objective-based TTX; and perform these activities in a bi-lingual setting. This intervention appears to be efficacious for public use in the rapid development of community-based PPMs.

    • Disease Reservoirs and Vectors
      1. Enhanced Zika virus susceptibility of globally invasive Aedes aegypti populationsexternal icon
        Aubry F, Dabo S, Manet C, Filipović I, Rose NH, Miot EF, Martynow D, Baidaliuk A, Merkling SH, Dickson LB, Crist AB, Anyango VO, Romero-Vivas CM, Vega-Rúa A, Dusfour I, Jiolle D, Paupy C, Mayanja MN, Lutwama JJ, Kohl A, Duong V, Ponlawat A, Sylla M, Akorli J, Otoo S, Lutomiah J, Sang R, Mutebi JP, Cao-Lormeau VM, Jarman RG, Diagne CT, Faye O, Faye O, Sall AA, McBride CS, Montagutelli X, Rašić G, Lambrechts L.
        Science. 2020 Nov 20;370(6519):991-996.
        The drivers and patterns of zoonotic virus emergence in the human population are poorly understood. The mosquito Aedes aegypti is a major arbovirus vector native to Africa that invaded most of the world's tropical belt over the past four centuries, after the evolution of a "domestic" form that specialized in biting humans and breeding in water storage containers. Here, we show that human specialization and subsequent spread of A. aegypti out of Africa were accompanied by an increase in its intrinsic ability to acquire and transmit the emerging human pathogen Zika virus. Thus, the recent evolution and global expansion of A. aegypti promoted arbovirus emergence not solely through increased vector-host contact but also as a result of enhanced vector susceptibility.

      2. Urban Norway rats (Rattus norvegicus) carry pathogenic Bartonella spp. that are transmitted among rats and from rats to people through arthropod vectors, particularly fleas. There is marked temporospatial variation in Bartonella spp. carriage among Norway rats in Vancouver, Canada, and we investigated whether this variation is associated with flea presence or abundance. Bartonella triborocum was isolated from 96/370 (35%) rats and 211 (57%) rats had fleas with an average of one flea per rat. All fleas were identified as Nosopsyllus fasciatus. There was no significant relationship between B. tribocorum carriage and flea presence or abundance, suggesting that, in contrast to other rat-associated zoonoses transmitted by fleas (e.g., Yersinia pestis) flea indices may not be informative for understanding the ecology of Bartonella spp. in rats, particularly for N. fasciatus.

      3. Identification of a novel lineage of Crimean-Congo haemorrhagic fever virus in dromedary camels, United Arab Emiratesexternal icon
        Khalafalla AI, Li Y, Uehara A, Hussein NA, Zhang J, Tao Y, Bergeron E, Ibrahim IH, Al Hosani MA, Yusof MF, Alhammadi ZM, Alyammahi SM, Gasim EF, Ishag HZ, Hosani FA, Gerber SI, Almuhairi SS, Tong S.
        J Gen Virol. 2020 Nov 24.
        Crimean-Congo haemorrhagic fever virus (CCHFV) is a tick-borne virus causing Crimean-Congo haemorrhagic fever (CCHF), a disease reported to have a high fatality rate in numerous countries. The virus is geographically widespread due to its vector, and numerous wild and domestic animals can develop asymptomatic infection. Serological and limited molecular evidence of CCHFV has previously been reported in Camelus dromedarius (the dromedary, or one-humped camel) in the United Arab Emirates (UAE). In this study, 238 camel samples were screened for CCHFV RNA where 16 camel samples were positive for CCHFV by RT-PCR. Analysis of full-length CCHFV genome sequences revealed a novel lineage in camels from the UAE, and potential reassortment of the M segment of the genome.

      4. We evaluated the vector competence of three strains of Aedes aegypti formosus from Entebbe, Uganda, for Zika virus (ZIKV). The aim was to find out if these strains were competent or incompetent vectors for ZIKV, to explain the lack of ZIKV outbreaks in the city of Entebbe. We observed transmission rates ranging from 33% to 78%; however, these rates were not statistically significantly different, suggesting that there were no real differences among the strains. Nonetheless, this showed that populations of Ae. aegypti formosus in Entebbe are competent vectors for ZIKV. The reason why there is no detectable transmission of ZIKV to humans in Entebbe is currently unknown. The lack of detectable transmission despite Ae. aegypti formosus competence for ZIKV suggests that other parameters, such as preference for nonhuman blood, may be limiting its ability to serve as a vector.

      5. The "bio-crime model" of cross-border cooperation among veterinary public health, justice, law enforcements, and customs to tackle the illegal animal trade/bio-terrorism and to prevent the spread of zoonotic diseases among human populationexternal icon
        Zucca P, Rossmann MC, Osorio JE, Karem K, De Benedictis P, Haißl J, De Franceschi P, Calligaris E, Kohlweiß M, Meddi G, Gabrutsch W, Mairitsch H, Greco O, Furlani R, Maggio M, Tolomei M, Bremini A, Fischinger I, Zambotto P, Wagner P, Millard Y, Palei M, Zamaro G.
        Front Vet Sci. 2020 ;7:593683.
        Illegal animal trade (pet, wildlife, animal products, etc.) is an example of transnational organized crime (T.O.C.) that generates a large business with huge profit margins. This criminal activity causes several negative effects on human health (zoonoses), animal health and welfare, market protection, consumer fraud and may be used as tool of agro/bio-terrorism. Illegal animal trade can facilitate the spread of zoonoses that are defined as diseases and infections that are transmitted by vertebrate animals to man. Humans are affected by more than 1,700 known pathogens: 60% of existing human infectious diseases are zoonotic and at least 75% of emerging infectious diseases of humans have an animal origin and 72% of zoonoses originate from wildlife or exotic animals. The Bio-Crime Project was developed in 2017 by Friuli Venezia Giulia Region (Italy) and Land Carinthia (Austria) together with other public institutions to combat illegal animal trade and to reduce the risk of disease transmission from animals to humans. Project partners agreed that a multi-agency approach was required to tackle the illegal animal trade that was high value, easy to undertake and transnational crime. The Bio-crime model of cross-border cooperation introduces the novel approach of replicating the cooperative framework given by the triad of Veterinary Public Health, Justice and Law Enforcements/Customs across borders using the International Police and Custom Cooperation Centres (IPCCCs) as a connection link among public entities of the neighbor countries. This model has been recognized as a best practice at European level because it can be easily replicated and scaled up without any supplementary cost for Member States.

    • Environmental Health
      1. Developing an experimental climate and health monitor and outlookexternal icon
        Jones HM, Quintana AV, Trtanj J, Balbus J, Schramm P, Saha S, Castranio T, Di Liberto TE.
        Bull Am Meteorol Soc. 2020 ;101(10):E1690-E1696.

      2. Human aflatoxin exposure in Uganda: Estimates from a subset of the 2011 Uganda AIDS indicator survey (UAIS)external icon
        Zitomer NC, Awuor AO, Widdowson MA, Daniel JH, Sternberg MR, Rybak ME, Mbidde EK.
        Food Addit Contam Part A Chem Anal Control Expo Risk Assess. 2020 Nov 20:1-12.
        Aflatoxins are carcinogenic mycotoxins that contaminate a variety of crops worldwide. Acute exposure can cause liver failure, and chronic exposure can lead to stunting in children and liver cancer in adults. We estimated aflatoxin exposure across Uganda by measuring a serum biomarker of aflatoxin exposure in a subsample from the 2011 Uganda AIDS Indicator Survey, a nationally representative survey of HIV prevalence, and examined its association with geographic, demographic, and socioeconomic variables. We analysed a subsample of 985 serum specimens selected among HIV-negative participants from 10 survey-defined geographic regions for serum aflatoxin B1-lysine (AFB1-lys) by use of isotope dilution LC-MS/MS and calculated results normalised to serum albumin. We used statistical techniques for censored data to estimate geometric means (GMs), standard deviations, and percentiles. We detected serum AFB1-lys in 71.7% of specimens (LOD = 0.5 pg/mg albumin). Unadjusted GM AFB1-lys (pg/mg albumin) was 1.33 (95% CI: 1.21-1.47). Serum AFB1-lys was higher in males (GM: 1.57; 95% CI: 1.38-1.80) vs. females (GM: 1.12; 95% CI: 0.97-1.30) (P = .0019), and higher in persons residing in urban settings (GM: 2.83; 95% CI: 2.37-3.37) vs. rural (GM: 1.10; 95% CI: 0.99-1.23) (P < .0001). When we used a multivariable censored regression model to assess confounding and interactions among variables we found that survey region, gender, age, occupation, distance to marketplace, and number of meals per day were statistically significant predictors of aflatoxin exposure. While not nationally representative, our findings provide an improved understanding of the widespread burden of aflatoxin exposure throughout Uganda and identify key geographic, demographic, and socioeconomic factors that may modulate aflatoxin exposure risk.

    • Epidemiology and Surveillance

    • Food Safety
      1. Gen-FS coordinated proficiency test data for genomic foodborne pathogen surveillance, 2017 and 2018 exercisesexternal icon
        Timme RE, Lafon PC, Balkey M, Adams JK, Wagner D, Carleton H, Strain E, Hoffmann M, Sabol A, Rand H, Lindsey R, Sheehan D, Baugher JD, Trees E.
        Sci Data. 2020 Nov 19;7(1):402.
        The US PulseNet and GenomeTrakr laboratory networks work together within the Genomics for Food Safety (Gen-FS) consortium to collect and analyze genomic data for foodborne pathogen surveillance (species include Salmonella enterica, Listeria monocytogenes, Escherichia coli (STECs), and Campylobactor). In 2017 these two laboratory networks started harmonizing their respective proficiency test exercises, agreeing on distributing a single strain-set and following the same standard operating procedure (SOP) for genomic data collection, running a jointly coordinated annual proficiency test exercise. In this data release we are publishing the reference genomes and raw data submissions for the 2017 and 2018 proficiency test exercises.

    • Health Disparities
      1. Rural disparities in surgical care from gynecologic oncologists among Midwestern ovarian cancer patientsexternal icon
        Weeks K, Lynch CF, West M, Carnahan R, O'Rorke M, Oleson J, McDonald M, Stewart SL, Charlton M.
        Gynecol Oncol. 2020 Nov 17.
        OBJECTIVE: Up to one-third of women with ovarian cancer in the United States do not receive surgical care from a gynecologic oncologist specialist despite guideline recommendations. We aim to investigate the impact of rurality on receiving surgical care from a specialist, referral to a specialist, and specialist surgery after referral, and the consequences of specialist care. METHODS: We utilized a retrospective cohort created through an extension of standard cancer surveillance in three Midwestern states. Multivariable adjusted logistic regression was utilized to assess gynecologic oncologist treatment of women 18-89 years old, who were diagnosed with primary, histologically confirmed, malignant ovarian cancer in 2010-2012 in Kansas, Missouri and Iowa by rurality. RESULTS: Rural women were significantly less likely to receive surgical care from a gynecologic oncologist specialist (adjusted odds ratio (OR) 0.37, 95% confidence interval (CI) 0.24-0.58) and referral to a specialist (OR 0.37, 95% CI 0.23-0.59) compared to urban women. There was no significant difference in specialist surgery after a referral (OR 0.56, 95% CI 0.26-1.20). Rural women treated surgically by a gynecologic oncologist versus non-specialist were more likely to receive cytoreduction and more complete tumor removal to ≤1 cm. CONCLUSION: There is a large rural-urban difference in receipt of ovarian cancer surgery from a gynecologic oncologist specialist (versus a non-specialist). Disparities in referral rates contribute to the rural-urban difference. Further research will help define the causes of referral disparities, as well as promising strategies to address them.

    • Health Economics
      1. A framework for cancer health economics researchexternal icon
        Halpern MT, Shih YT, Yabroff KR, Ekwueme DU, Bradley CJ, Davidoff AJ, Sabik LM, Lipscomb J.
        Cancer. 2020 Nov 25.
        Cancer has substantial economic impacts for patients, their families and/or caregivers, employers, and the health care system. However, there is only limited understanding of how economic issues can affect access to cancer care services and the receipt of high-quality cancer care. Health economics research in cancer is particularly timely due to the large and increasing number of patients with cancer and cancer survivors, but there are many factors that may create barriers to performing cancer health economics research. This commentary has identified important topics and questions in cancer health economics research and will assist in the development of this critical field.

      2. Anti-poverty policy and health: Attributes and diffusion of state earned income tax credits across U.S. states from 1980 to 2020external icon
        Komro KA, Dunlap P, Sroczynski N, Livingston MD, Kelly MA, Pepin D, Markowitz S, Rentmeester S, Wagenaar AC.
        PLoS One. 2020 ;15(11):e0242514.
        PURPOSE: The U.S. federal Earned Income Tax Credit (EITC) is often considered the most effective antipoverty program for families in the U.S., leading to a variety of improved outcomes such as educational attainment, work incentives, economic activity, income, and health benefits for mothers, infants and children. State EITC supplements to the federal credit can significantly enhance the magnitude of this intervention. In this paper we advance EITC and health research by: 1) describing the diffusion of state EITC policies over 40 years, 2) presenting patterns in important EITC policy dimensions across space and time, and 3) disseminating a robust data set to advance future research by policy analysts and scientists. METHODS: We used current public health law research methods to systematically collect, conduct textual legal analysis, and numerically code all EITC legislative changes from 1980 through 2020 in the 50 states and Washington, D.C. RESULTS: First, the pattern of diffusion across states and time shows initial introductions during the 1990s in the Midwest, then spreading to the Northeast, with more recent expansions in the West and South. Second, differences by state and time of important policy dimensions are evident, including size of credit and refundability. Third, state EITC benefits vary considerably by household structure. CONCLUSION: Continued research on health outcomes is warranted to capture the full range of potential beneficial effects of EITCs on family and child wellbeing. Lawyers and policy analysts can collaborate with epidemiologists and economists on other high-quality empirical studies to assess the many dimensions of policy and law that potentially affect the social determinants of health.

      3. INTRODUCTION: Improving the utilization of preventive care among adolescents is important for achieving individual-level and population-level health goals. The Healthcare Effectiveness Data and Information Set reports data submitted by managed care health plans, capturing a large number of individuals in the U.S. METHODS: Using Healthcare Effectiveness Data and Information Set from 2018, mean performance levels were calculated for 5 preventive care measures among adolescents. Differences in performance between states that use Healthcare Effectiveness Data and Information Set or Health Plan Accreditation and those that use neither were estimated. Analysis was conducted in January-July 2020. RESULTS: The sample included data from 39 states, with 32 that use Healthcare Effectiveness Data and Information Set or Health Plan Accreditation and 7 that do not. Adolescent vaccination coverage was 28% for the complete human papillomavirus series, 81% for meningococcal, and 88% for tetanus, diphtheria, and acellular pertussis. Access to a primary care practitioner (a 2-year measure) was 91%, and well-care visits (a 1-year measure) were 50%. When compared with states that do not use Healthcare Effectiveness Data and Information Set or Health Plan Accreditation, the mean performance of states that used either Healthcare Effectiveness Data and Information Set or Health Plan Accreditation was statistically significantly higher for 4 of the 5 assessed measures. CONCLUSIONS: Healthcare Effectiveness Data and Information Set measures can help public health officials to monitor progress toward health goals, such as Healthy People 2020, and identify poorly performing health plans and types of preventive services in greatest need of improvement. States using Healthcare Effectiveness Data and Information Set or Health Plan Accreditation were associated with better performance in some adolescent measures, which suggests that health plan accountability may have a role in achieving health outcomes and could be an important area for future research.

      4. Cost-effectiveness of dual maternal HIV and syphilis testing strategies in high and low HIV prevalence countries: a modelling studyexternal icon
        Rodriguez PJ, Roberts DA, Meisner J, Sharma M, Owiredu MN, Gomez B, Mello MB, Bobrik A, Vodianyk A, Storey A, Githuka G, Chidarikire T, Barnabas R, Barr-Dichiara M, Jamil MS, Baggaley R, Johnson C, Taylor MM, Drake AL.
        Lancet Glob Health. 2020 Nov 20.
        BACKGROUND: Dual HIV and syphilis testing might help to prevent mother-to-child transmission (MTCT) of HIV and syphilis through increased case detection and treatment. We aimed to model and assess the cost-effectiveness of dual testing during antenatal care in four countries with varying HIV and syphilis prevalence. METHODS: In this modelling study, we developed Markov models of HIV and syphilis in pregnant women to estimate costs and infant health outcomes of maternal testing at the first antenatal care visit with individual HIV and syphilis tests (base case) and at the first antenatal care visit with a dual rapid diagnostic test (scenario one). We additionally evaluated retesting during late antenatal care and at delivery with either individual tests (scenario two) or a dual rapid diagnosis test (scenario three). We modelled four countries: South Africa, Kenya, Colombia, and Ukraine. Strategies with an incremental cost-effectiveness ratio (ICER) less than the country-specific cost-effectiveness threshold (US$500 in Kenya, $750 in South Africa, $3000 in Colombia, and $1000 in Ukraine) per disability-adjusted life-year averted were considered cost-effective. FINDINGS: Routinely offering testing at the first antenatal care visit with a dual rapid diagnosis test was cost-saving compared with the base case in all four countries (ICER: -$26 in Kenya,-$559 in South Africa, -$844 in Colombia, and -$454 in Ukraine). Retesting during late antenatal care with a dual rapid diagnostic test (scenario three) was cost-effective compared with scenario one in all four countries (ICER: $270 in Kenya, $260 in South Africa, $2207 in Colombia, and $205 in Ukraine). INTERPRETATION: Incorporating dual rapid diagnostic tests in antenatal care can be cost-saving across countries with varying HIV prevalence. Countries should consider incorporating dual HIV and syphilis rapid diagnostic tests as the first test in antenatal care to support efforts to eliminate MTCT of HIV and syphilis. FUNDING: WHO, US Agency for International Development, and the Bill & Melinda Gates Foundation.

    • Healthcare Associated Infections
      1. Colonization of carbapenem-resistant Klebsiella pneumoniae in a sink-drain model biofilm systemexternal icon
        Burgos-Garay M, Ganim C, de Man TJ, Davy T, Mathers AJ, Kotay S, Daniels J, Perry KA, Breaker E, Donlan RM.
        Infect Control Hosp Epidemiol. 2020 Nov 25:1-9.
        BACKGROUND: Sink drains in healthcare facilities may provide an environment for antimicrobial-resistant microorganisms, including carbapenemase-producing Klebsiella pneumoniae (CPKP). METHODS: We investigated the colonization of a biofilm consortia by CPKP in a model system simulating a sink-drain P-trap. Centers for Disease Control (CDC) biofilm reactors (CBRs) were inoculated with microbial consortia originally recovered from 2 P-traps collected from separate patient rooms (designated rooms A and B) in a hospital. Biofilms were grown on stainless steel (SS) or polyvinyl chloride (PVC) coupons in autoclaved municipal drinking water (ATW) for 7 or 28 days. RESULTS: Microbial communities in model systems (designated CBR-A or CBR-B) were less diverse than communities in respective P-traps A and B, and they were primarily composed of β and γ Proteobacteria, as determined using 16S rRNA community analysis. Following biofilm development CBRs were inoculated with either K. pneumoniae ST45 (ie, strain CAV1016) or K. pneumoniae ST258 KPC+ (ie, strain 258), and samples were collected over 21 days. Under most conditions tested (CBR-A: SS, 7-day biofilm; CBR-A: PVC, 28-day biofilm; CBR-B: SS, 7-day and 28-day biofilm; CBR-B: PVC, 28-day biofilm) significantly higher numbers of CAV1016 were observed compared to 258. CAV1016 showed no significant difference in quantity or persistence based on biofilm age (7 days vs 28 days) or substratum type (SS vs PVC). However, counts of 258 were significantly higher on 28-day biofilms and on SS. CONCLUSIONS: These results suggest that CPKP persistence in P-trap biofilms may be strain specific or may be related to the type of P-trap material or age of the biofilm.

      2. Pediatric research priorities in healthcare-associated infections and antimicrobial stewardshipexternal icon
        Coffin SE, Abanyie F, Bryant K, Cantey J, Fiore A, Fritz S, Guzman-Cottrill J, Hersh AL, Huskins WC, Kociolek LK, Kronman M, Lautenbach E, Lee G, Linam M, Logan LK, Milstone A, Newland J, Nyquist AC, Palazzi DL, Patel S, Puopolo K, Reddy SC, Saiman L, Sandora T, Shane AL, Smith M, Tamma PD, Zaoutis T, Zerr D, Gerber JS.
        Infect Control Hosp Epidemiol. 2020 Nov 26:1-4.
        OBJECTIVE: To develop a pediatric research agenda focused on pediatric healthcare-associated infections and antimicrobial stewardship topics that will yield the highest impact on child health. PARTICIPANTS: The study included 26 geographically diverse adult and pediatric infectious diseases clinicians with expertise in healthcare-associated infection prevention and/or antimicrobial stewardship (topic identification and ranking of priorities), as well as members of the Division of Healthcare Quality and Promotion at the Centers for Disease Control and Prevention (topic identification). METHODS: Using a modified Delphi approach, expert recommendations were generated through an iterative process for identifying pediatric research priorities in healthcare associated infection prevention and antimicrobial stewardship. The multistep, 7-month process included a literature review, interactive teleconferences, web-based surveys, and 2 in-person meetings. RESULTS: A final list of 12 high-priority research topics were generated in the 2 domains. High-priority healthcare-associated infection topics included judicious testing for Clostridioides difficile infection, chlorhexidine (CHG) bathing, measuring and preventing hospital-onset bloodstream infection rates, surgical site infection prevention, surveillance and prevention of multidrug resistant gram-negative rod infections. Antimicrobial stewardship topics included β-lactam allergy de-labeling, judicious use of perioperative antibiotics, intravenous to oral conversion of antimicrobial therapy, developing a patient-level "harm index" for antibiotic exposure, and benchmarking and or peer comparison of antibiotic use for common inpatient conditions. CONCLUSIONS: We identified 6 healthcare-associated infection topics and 6 antimicrobial stewardship topics as potentially high-impact targets for pediatric research.

      3. Infection control response to an outbreak of OXA-23 carbapenemase-producing carbapenem-resistant Acinetobacter baumannii in a skilled nursing facility in Utahexternal icon
        Smith AR, Vowles M, Horth RZ, Smith L, Rider L, Wagner JM, Sangster A, Young EL, Schuckel H, Stewart J, Gruninger RJ, Rossi A, Oakeson KF, Nakashima AK.
        Am J Infect Control. 2020 Nov 17.
        BACKGROUND: Antibiotic-resistant Acinetobacter spp. are a growing public health threat, yet are not nationally notifiable, and most states do not mandate reporting. Additionally, there are no standardized methods to detect Acinetobacter spp. colonization. METHODS: An outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) was identified at a Utah skilled nursing facility with a ventilator unit (vSNF). An investigation was conducted to identify transmission modes in order to control spread of CRAB. Culture-based methods were used to identify patient colonization and environmental contamination in the facility. RESULTS: Of the 47 patients screened, OXA-23-producing CRAB were detected in 10 patients (21%), with 7 patients (15%) having been transferred from out-of-state facilities. Of patients who screened positive, 60% did not exhibit any signs or symptoms of active infection by chart review. A total of 38 environmental samples were collected and CRAB was recovered from 37% of those samples. Whole genome sequencing analyses of patient and environmental isolates suggested repeated CRAB introduction into the facility and highlighted the role of shared equipment in transmission. CONCLUSION: The investigation demonstrated this vSNF was an important reservoir for CRAB in the community and highlights the need for improved surveillance, strengthened infection control and inter-facility communication within and across states.

    • Immunity and Immunization
      1. Persistence of IgM antibodies after vaccination with live attenuated Japanese encephalitis vaccineexternal icon
        Hills S, Van Keulen A, Feser J, Panella A, Letson B, Staples E, Marfin T, Brault A.
        Am J Trop Med Hyg. 2020 Nov 23.
        Japanese encephalitis (JE) is a vaccine-preventable, mosquito-borne disease. Substantial progress with JE control in Asia has been made during the past decade, with most endemic countries now having JE vaccination programs, commonly using live attenuated SA14-14-2 JE vaccine (CD-JEV). If a child develops encephalitis during the weeks to months following CD-JEV vaccination and anti-JE virus IgM (JE IgM) antibody is detected in serum, the question arises if this is JE virus infection indicating vaccine failure, or persistent JE IgM antibody postvaccination. To better understand JE IgM seropositivity following vaccination, sera from 268 children from a previous CD-JEV study were tested by two different JE IgM assays to determine JE IgM antibody frequency on days 28, 180, and 365 postvaccination. With the CDC JE IgM antibody capture ELISA (MAC-ELISA), 110 children (41%) had JE IgM positive or equivocal results on their day 28 sample, and eight (3%) and two (1%) had positive or equivocal results on day 180 and day 365 samples, respectively. With the Inbios JE Detect™ MAC-ELISA, 118 (44%) children had positive or equivocal results on day 28 sample, and three (1%) and one (0.4%) had positive or equivocal results on day 180 and day 365 samples, respectively. Our results indicate that more than 40% children vaccinated with CD-JEV can have JE IgM antibodies in their serum at 1 month postvaccination but JE IgM antibody is rare by 6 months. These data will help healthcare workers assess the likelihood that JE IgM antibodies in the serum of a child with encephalitis after vaccination are vaccine related.

      2. Duration of seropositivity following yellow fever vaccination in U.S. military service membersexternal icon
        Lindsey NP, Perry L, Fischer M, Woolpert T, Biggerstaff BJ, Brice G, Fitzpatrick K, Kosoy OI, Laven JJ, Myers CA, Hollis EM, Staples JE.
        Vaccine. 2020 Nov 22.
        BACKGROUND: The United States military regularly deploys thousands of service members throughout areas of South America and Africa that are endemic for yellow fever (YF) virus. To determine if booster doses might be needed for service members who are repetitively or continually deployed to YF endemic areas, we evaluated seropositivity among US military personnel receiving a single dose of YF vaccine based on time post-vaccination. METHODS: Serum antibodies were measured using a plaque reduction neutralization test with 50% cutoff in 682 military personnel at 5-39 years post-vaccination. We determined noninferiority of immune response by comparing the proportion seropositive among those vaccinated 10-14 years previously with those vaccinated 5-9 years previously. Noninferiority was supported if the lower-bound of the 2-tailed 95% CI for p(10-14years) - p(5-9years) was ≥-0.10. Additionally, the geometric mean antibody titer (GMT) at various timepoints following vaccination were compared to the GMT at 5-9 years. RESULTS: The proportion of military service members with detectable neutralizing antibodies 10-14 years after a single dose of YF vaccine (95.8%, 95% CI 91.2-98.1%) was non-inferior to the proportion 5-9 years after vaccination (97.8%, 95% CI 93.7-99.3%). Additionally, GMT among vaccine recipients at 10-14 years post vaccination (99, 95% CI 82-121) was non-inferior to GMT in YF vaccine recipients at 5-9 years post vaccination (115, 95% CI 96-139). The proportion of vaccinees with neutralizing antibodies remained high, and non-inferior, among those vaccinated 15-19 years prior (98.5%, 95%CI 95.5-99.7%). Although the proportion seropositive decreased among vaccinees ≥ 20 years post vaccination, >90% remained seropositive. CONCLUSIONS: Neutralizing antibodies were present in > 95% of vaccine recipients for at least 19 years after vaccination, suggesting that booster doses every 10 years are not essential for most U.S. military personnel.

      3. An immunization program for US-bound refugees: Development, challenges, and opportunities 2012-presentexternal icon
        Mitchell T, Dalal W, Klosovsky A, Yen C, Phares C, Burkhardt M, Amin F, Froes I, Hamadeh A, Lynn SA, Quintanilla J, Doney AC, Cetron M, Weinberg M.
        Vaccine. 2020 Nov 17.
        BACKGROUND: US-bound refugees undergo required health assessments overseas to identify and treat communicable diseases of public health significance-such as pulmonary tuberculosis-before migration. Immunizations are not required, leaving refugees at risk for vaccine-preventable diseases. In response, the US Centers for Disease Control and Prevention and the US Department of State developed and co-funded a global immunization program for US-bound refugees, implemented in 2012 in collaboration with the International Organization for Migration. METHODS: We describe the Vaccination Program for US-bound Refugees, including vaccination schedule development, program implementation and procedures, and responses to challenges. We estimate 2019 immunization coverage rates using the number of age-eligible refugees who received ≥1 dose of measles-containing vaccine during overseas health assessment, and calculated hepatitis B infection prevalence using hepatitis B surface antigen testing results. We report descriptive data on adverse events following immunization. RESULTS: By September 2019, the program was active in >80 countries on five continents. Nearly 320,000 examined refugees had ≥1 documented vaccine doses since program inception. During federal fiscal year 2019, 95% of arriving refugees had ≥1 documented measles-containing vaccine. The program's immunization schedule included eleven vaccines preventing fourteen diseases. In 2015-2019, only two vaccine preventable disease-associated refugee group travel cancellations occurred, compared to 2-8 cancellations annually prior to program initiation. To maintain uniform standards, dedicated staff and program-specific protocols for vaccination and monitoring were introduced. CONCLUSIONS: An overseas immunization program was successfully implemented for US-bound refugees. Due to reductions in refugee movement cancellation, lower cost of immunization overseas, and likely reductions in vaccine preventable disease-associated morbidity, we anticipate significant cost savings. Although maintaining uniform standards across diverse settings is challenging, solutions such as introduction of dedicated staff, protocol development, and ongoing technical support have ensured program cohesion, continuity, and advancement. Lessons learned can benefit similar programs implemented in the migration setting.

      4. Randomized controlled clinical trial of bivalent oral poliovirus vaccine and inactivated poliovirus vaccine in Nigerian childrenexternal icon
        Tagbo BN, Verma H, Mahmud ZM, Ernest K, Nnani RO, Chukwubike C, Craig KT, Hamisu A, Weldon WC, Oberste SM, Jeyaseelan V, Braka F, Mkanda P, Esangbedo D, Olowu A, Nwaze E, Sutter RW.
        J Infect Dis. 2020 Nov 24.
        BACKGROUND: We conducted a trial in Nigeria to assess the immunogenicity of the new bOPV + IPV immunization schedule and gains in type 2 immunity with addition of second dose of IPV. The trial was conducted in August 2016-March 2017 period, well past the tOPV-bOPV switch in April 2016. METHODS: This was an open-label, two-arm, non-inferiority, multi-center, randomized controlled trial. We enrolled 572 infants of age ≤14 days and randomized them into two arms. Arm A received bOPV at birth, 6 and 10 weeks, bOPV+IPV at week 14 and IPV at week 18. Arm B received IPV each at 6, 10, 14 weeks and bOPV at 18 weeks of age. RESULTS: Seroconversion rates for poliovirus types 1 and 3, respectively, were 98.9% (95%CI:96.7-99.8) and 98.1% (95%CI:88.2-94.8) in Arm A, and 89.6% (95%CI:85.4-93.0) and 98.5% (95%CI:96.3-99.6) in Arm B. Type 2 seroconversion with one dose IPV in Arm A was 72.0% (95%CI:66.2-77.3), which increased significantly with addition of second dose to 95.9% (95%CI:92.8-97.9). CONCLUSION: This first trial on the new EPI schedule in a sub-Saharan African country demonstrated excellent immunogenicity against poliovirus types 1 and 3, and substantial/enhanced immunogenicity against poliovirus type 2 after 1 to 2 doses of IPV respectively.

      5. Social and behavioral determinants of attitudes towards and practices of hepatitis B vaccine birth dose in Vietnamexternal icon
        Thanh Thi Le X, Ishizumi A, Thi Thu Nguyen H, Thi Duong H, Thi Thanh Dang H, Manh Do C, Thi Pham Q, Thi Le H, Iijima M, Tohme RA, Patel P, Abad N.
        Vaccine. 2020 Nov 18.
        BACKGROUND: Hepatitis B virus (HBV) infection is a significant public health issue in Vietnam. Our goal was to understand the determinants of attitudes towards and practices of hepatitis B vaccine birth dose (HepB-BD) in certain regions of Vietnam. METHOD: A rapid qualitative assessment was conducted in three geographically diverse provinces that reported low coverage (<50%) of HepB-BD. Using purposive sampling of participants, 29 focus group discussions and 20 in-depth interviews were held with caregivers (n = 96), healthcare providers (n = 75), and healthcare administrators (n = 16). Summary notes from these were translated, and inductive coding was used to derive themes. The SAGE Vaccine Hesitancy Determinants Matrix was used as a theoretical framework to organize barriers and facilitators associated with the themes into three levels of influence. RESULTS: At the individual and group level, caregivers who had higher levels of knowledge about HepB-BD sought the vaccine proactively, while others with lower knowledge faced barriers to the vaccine. Some caregivers reported a negative attitude toward health services because of a language barrier or had generalized concerns about HepB-BD due to media reporting of the past adverse events. Distress arising from potential adverse events was equally common among healthcare providers. At the contextual level, the physical environment made it difficult for caregivers to access healthcare facilities and for providers to conduct outreach. Home births posed a challenge for timely administration of HepB-BD, while health facility births facilitated it. Vaccination-specific barriers included misinterpretation of pre-vaccination screening criteria and asking for the consent of caregivers. Inadequate resources for service delivery negatively influenced HepB-BD attitudes and practices. CONCLUSION: Given the diversity of barriers associated with attitudes towards and practices of HepB-BD in the three provinces, tailored interventions will be necessary for both demand- and supply-side factors. Rural areas, often with more home births and geographic barriers, may require focused attention.

    • Informatics
      1. Developing algorithms for identifying major structural birth defects using automated electronic health dataexternal icon
        Kharbanda EO, Vazquez-Benitez G, DeSilva MB, Spaulding AB, Daley MF, Naleway AL, Irving SA, Klein NP, Tseng HF, Jackson LA, Hambidge SJ, Olaiya O, Panozzo CA, Myers TR, Romitti PA.
        Pharmacoepidemiol Drug Saf. 2020 Nov 20.
        PURPOSE: Given the 2015 transition to International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic coding, updates to our previously published algorithms for major structural birth defects (BDs) were necessary. Aims of this study were to update, validate, and refine algorithms for identifying selected BDs, and then to use these algorithms to describe BD prevalence in the Vaccine Safety Datalink (VSD) population. METHODS: We converted our ICD-9-CM list of selected BDs to ICD-10-CM using available crosswalks with manual review of codes. We identified, chart reviewed, and adjudicated a sample of infants in the VSD with ≥2 ICD-10-CM diagnoses for one of seven common BDs. Positive predictive values (PPVs) were calculated; for BDs with sub-optimal PPV, algorithms were refined. Final automated algorithms were applied to a cohort of live births delivered 10/1/2015-9/30/2017 at eight VSD sites to estimate BD prevalence. RESULTS: Of 573 infants with ≥2 diagnoses for a targeted BD, on adjudication, we classified 399 (69.6%) as probable cases, 31 (5.4%) as possible cases and 143 (25.0%) as not having the targeted BD. PPVs for the final BD algorithms ranged from 0.76 (hypospadias) to 1.0 (gastroschisis). Among 212,857 births over two years following transition to ICD-10-CM coding, prevalence for the full list of selected defects in the VSD was 1.8%. CONCLUSIONS: Algorithms can identify infants with selected BDs using automated healthcare data with reasonable accuracy. Our updated algorithms can be used in observational studies of maternal vaccine safety and may be adapted for use in other surveillance systems.

    • Injury and Violence
      1. Sexual violence in the media: An exploration of traditional print media reporting in the United States, 2014-2017external icon
        Egen O, Mercer Kollar LM, Dills J, Basile KC, Besrat B, Palumbo L, Carlyle KE.
        MMWR Morb Mortal Wkly Rep. 2020 Nov 27;69(47):1757-1761.
        Sexual violence is prevalent and, for many victims, begins early in life (1). In the United States, one in five women and one in 38 men report completed or attempted rape victimization during their lifetime, with 43.2% of female and 51.3% of male victims reporting that their first rape victimization occurred before age 18 years (1). Media have been shown to act as a socializing agent for a range of health and social behaviors (2). Media portrayals might influence, reinforce, or modify how the public responds to incidents of sexual violence and their support for prevention efforts and media might construct a lens through which the public can understand who is affected by sexual violence, what forms it takes, why it happens, and who is responsible for addressing it (3). Media portrayals of sexual violence were assessed using a systematic random sample of newspaper articles from 48 of the top 50 distributed traditional print media outlets that were examined for sexual violence content and potential differences by geographic region and year of publication. Differences by year and region in type of sexual violence covered, media language used, and outcomes reported were identified, highlighting an opportunity for public health officials, practitioners, and journalists to frame sexual violence as a preventable public health issue and to incorporate best practices from CDC and the National Sexual Violence Resource Center's Sexual Violence Media Guide (4).

      2. Comparing prevalence estimates of concussion/head injury in U.S. children and adolescents in national surveysexternal icon
        Haarbauer-Krupa J, Lebrun-Harris LA, Black LI, Veliz P, Daugherty J, Desrocher R, Schulenberg J, Pilkey D, Breiding M.
        Ann Epidemiol. 2020 Nov 20.
        BACKGROUND AND OBJECTIVES: Reports on pediatric lifetime concussions/head injuries (LCHI) from national surveys have offered estimates on prevalence that range from 2.5% to 18% in the general population. The purpose of this study is to examine national surveys to compare methodologies and limitations pertaining to LCHI data collection. METHODS: Three nationally representative surveys that measure LCHI in children, including the National Survey of Children's Health (NSCH), the National Health Interview Survey (NHIS), and the Monitoring the Future (MTF) Survey were examined. Children were grouped by ages 3-17 years and adolescents ages 13-17 years, stratified by selected demographic characteristics. Participants in the surveys included parents (NSCH, NHIS) and adolescents (MTF Survey). The primary outcome measure is an estimate of LCHI in children. RESULTS: Estimates of prevalence of LCHI ranged from 3.6% to 7.0% for children ages 3-17 years and from 6.5% to 18.3% for adolescents 13-17 years. Survey modality, question wording, and respondent may contribute to differing estimates. Prevalence showed consistent variation by age, sex, and race/ethnicity across surveys. Associations were inconsistent between LCHI and insurance status, parental education, and household primary language. CONCLUSIONS: Although there are methodological differences in capturing pediatric LCHI across surveys, the prevalence estimates and correlational associations generated can offer awareness about the burden of these injuries and insights to research and clinical care.

      3. Sexual minority adolescents (SMA) report more suicide risk behaviors than heterosexual adolescents. Polyvictimization (co-occurrence of multiple types of victimization) may be an important, underresearched correlate of this disparity. With the 2017 national Youth Risk Behavior Survey (N = 13,179), national estimates of polyvictimization and suicide risk were assessed among high school students by sexual minority status (SM vs. heterosexual), and multivariate relationships between sexual minority status, polyvictimization, and suicide risk were tested. Additionally, risk profiles of those who experienced polyvictimization (2 + types of victimization; n = 1,932) were compared across sexual minority status. Results confirm that SMA are more likely to experience polyvictimization than heterosexual adolescents (31.8% v. 12.9%, respectively); however, also indicate that polyvictimization does not fully explain elevated suicide risk among SMA.

      4. Adolescent dating violence prevention programmes: a global systematic review of evaluation studiesexternal icon
        McNaughton Reyes HL, Graham LM, Chen MS, Baron D, Gibbs A, Groves AK, Kajula L, Bowler S, Maman S.
        Lancet Child Adolesc Health. 2020 Nov 19.
        Adolescent dating violence negatively affects millions of young people worldwide. Through a global systematic review, we synthesised evidence from rigorous studies of prevention programmes for adolescent dating violence. Our aims were to: (1) describe the breadth of research in this area and evidence of programme effects, and (2) identify gaps in the evidence base. We included experimental and controlled quasi-experimental programme evaluations, published before Jan 1, 2020, that assessed effects on victimisation or perpetration, or both, in adolescent dating violence and in which at least half of the study population was 10-19 years old. Study design, programme elements, and outcomes were compared between evaluations implemented in high-income countries (HICs) and low-income and middle-income countries (LMICs). 52 evaluations met inclusion criteria, of which 20 (38%) were implemented in LMICs. Evaluations in HICs were more likely to assess effects on adolescent dating violence victimisation and perpetration, rather than just victimisation, than those in LMICs, and they were also more likely to include boys and girls, as opposed to just a single sex. Overall, 26 (50%) of the 52 evaluations reported a significant preventive effect on at least one outcome for adolescent dating violence, of which nine were implemented in LMICs. Across LMICs and HICs, findings suggest research is needed to shed light on how adolescent dating violence prevention programmes work and to identify whether programme effects generalise across different settings, outcomes, and subgroups. TRANSLATIONS: For the Chinese, French and Spanish translations of the abstract see Supplementary Materials section.

    • Laboratory Sciences
      1. "Making the right decisions: Adapting to emerging needs": The 7th Annual Meeting of the Southeastern Association of Shared Resources, Atlanta, GA, USA, June 12-14, 2019external icon
        Dahlman KB, Bagarozzi D, Bagchi P, Blum D, Boukli NM, Colton-Lee F, Constable S, Seagroves TN, Somasundaram T.
        J Biomol Tech. 2020 Nov 12.

      2. Interleukin-36γ Is elevated in cervicovaginal epithelial cells in women with bacterial vaginosis and in vitro after infection with microbes associated with bacterial vaginosisexternal icon
        Gardner JK, Łaniewski P, Knight A, Haddad LB, Swaims-Kohlmeier A, Herbst-Kralovetz MM.
        J Infect Dis. 2020 Mar 2;221(6):983-988.
        In recent studies, the interleukin (IL)-36 cytokines were shown to be elevated in women with non-Lactobacillus-dominated vaginal microbiomes. In this study, we evaluated IL36G expression in clinical samples from women with and without bacterial vaginosis (BV) and a human 3-dimensional cervical epithelial cell model. IL36G expression was significantly elevated in cervicovaginal epithelial cells isolated from BV-positive women and corresponded with increased neutrophil counts relative to BV-negative women. In addition, specific BV-associated bacterial species as well as a polymicrobial cocktail significantly induced IL36G expression in vitro. These findings suggest that IL-36γ may exhibit an important function in the host response to BV and other sexually transmitted infections.

      3. Appendix Q: Recommendations for developing molecular assays for microbial pathogen detection using modern in silico approachesexternal icon
        SantaLucia J, Sozhamannan S, Gans JD, Koehler JW, Soong R, Lin NJ, Xie G, Olson V, Roth K, Beck L.
        J AOAC Int. 2020 Jul 1;103(4):882-899.

      4. Hantavirus infection is inhibited by griffithsin in cell cultureexternal icon
        Shrivastava-Ranjan P, Lo MK, Chatterjee P, Flint M, Nichol ST, Montgomery JM, O'Keefe BR, Spiropoulou CF.
        Front Cell Infect Microbiol. 2020 ;10:561502.
        Andes virus (ANDV) and Sin Nombre virus (SNV), highly pathogenic hantaviruses, cause hantavirus pulmonary syndrome in the Americas. Currently no therapeutics are approved for use against these infections. Griffithsin (GRFT) is a high-mannose oligosaccharide-binding lectin currently being evaluated in phase I clinical trials as a topical microbicide for the prevention of human immunodeficiency virus (HIV-1) infection ( Identifiers: NCT04032717, NCT02875119) and has shown broad-spectrum in vivo activity against other viruses, including severe acute respiratory syndrome coronavirus, hepatitis C virus, Japanese encephalitis virus, and Nipah virus. In this study, we evaluated the in vitro antiviral activity of GRFT and its synthetic trimeric tandemer 3mGRFT against ANDV and SNV. Our results demonstrate that GRFT is a potent inhibitor of ANDV infection. GRFT inhibited entry of pseudo-particles typed with ANDV envelope glycoprotein into host cells, suggesting that it inhibits viral envelope protein function during entry. 3mGRFT is more potent than GRFT against ANDV and SNV infection. Our results warrant the testing of GRFT and 3mGRFT against ANDV infection in animal models.

      5. The effect of transport temperature and time on the recovery of antimicrobial-resistant Enterobacterales in stoolexternal icon
        Turbett SE, Becker M, Desrosiers L, Oliver E, Rao SR, Walker AT, Walters M, Ryan ET, LaRocque RC.
        Diagn Microbiol Infect Dis. 2020 Sep 19;99(2):115210.
        Surveillance for antibiotic-resistant (AR) bacteria is challenging. We evaluated AR Enterobacterales survival in stool over various transport conditions. Stool in Cary-Blair medium was spiked with AR Enterobacterales, held at 3 °C, 20 °C, or 37 °C, and cultured on days 3, 8, and 15. Stool from US international travelers sent through the US mail was also screened. We compared recovery rates using Fisher's exact tests and linear regression models. AR Enterobacterales recovery reduced with time (86% versus 75% versus 61% at days 3, 8, and 15; Beta for linear trend=-0.02, r(2)=0.99, P=0.02) and colder temperatures [56% (3 °C) versus 89% (20 °C) versus 86% (37 °C); P=0.003]. Traveler sample recovery also reduced with transport time (Beta for linear trend=-0.03, r(2)=0.70, P=0.01) but not with season [20% (cold) versus 22% (warm), P=0.7]. AR Enterobacterales are found over variable transport conditions, providing rationale for expanding surveillance sample processing timelines.

      6. Microbial volatile organic compounds (MVOCs) are primary and secondary metabolites of fungal and bacterial growth. Changes in environmental conditions (e.g., humidity, light, oxygen, and carbon dioxide) influence microbial growth in indoor environments. Prolonged human exposure to MVOCs has been directly associated with sick building syndrome (SBS), respiratory irritation, and asthma-like symptoms. However, no method exists for assessing MVOC exposure by quantifying them in human serum. We developed a novel, high-throughput automated method for quantifying seven MVOCs (3-methylfuran, 2-hexanone, 2-heptanone, 3-octanone, 1-octen-3-ol, 2-ethyl-1-hexanol, and geosmin) in human serum. The method quantifies the target analytes using solid-phase microextraction gas chromatography-tandem mass spectrometry at low parts-per-billion levels. Limits of detection ranged from 0.076 to 2.77 μg/L. This method provides excellent linearity over the concentration range for the analytes, with coefficients of determination >0.992. Recovery in human serum was between 84.5% and 113%, and analyte precision ranged from 0.38% to 8.78%. The intra-day and inter-day reproducibility showed coefficients of variation ≤11% and ≤8%, respectively. Accurate and precise quantification of MVOCs is necessary for detecting and quantifying harmful human exposures in environments with active microbial growth. The method is well suited for high-throughput analysis to aid investigations of unhealthy exposures to microbial emissions.

    • Maternal and Child Health
      1. Factors associated with self-regulation in a nationally representative sample of children ages 3-5 years: United States, 2016external icon
        Claussen AH, Robinson LR, Kaminski JW, Charania S, Holbrook JR, So M, Ghandour R, Smith C, Satterfield-Nash A, Peacock G, Boyle C.
        Matern Child Health J. 2020 Nov 21.
        OBJECTIVE: The aim of the present study was to describe self-regulation (the ability to influence or control one's thoughts or behavior in response to situational demands and social norms) in children ages 3-5 years using a nationally representative sample and examine risk and protective factors to identify opportunities to support children and families. METHODS: Using a cross-sectional design, we examined data from a parent-reported pilot measure of self-regulation from the 2016 National Survey of Children's Health (NSCH). We compared U.S. children aged 3-5 years who were described by parents as "on track" with self-regulation development with children who were not. In addition, we described how health care and developmental services, community, family, and child health and development factors are associated with children's self-regulation. RESULTS: The majority of children (4 of 5) were described by their parents to be developmentally on track with self-regulation. Compared to children described as not on track, children described as on track more often lived in financially and socially advantaged environments and less often experienced family adversity. They also had other positive health and development indicators, whether or not they were receiving developmental services. However, only half of children not on track received developmental surveillance, and only 1 in 4 children described as not on track received educational, mental health, or developmental services. CONCLUSION: The findings are a step towards using self-regulation as an indicator of healthy child development and as a potential strategy to identify groups of children who may need additional support.

      2. The MATernaL and Infant NetworK to Understand Outcomes Associated with Treatment of Opioid Use Disorder During Pregnancy (MAT-LINK): Surveillance opportunityexternal icon
        Tran EL, Kim SY, England LJ, Green C, Dang EP, Broussard CS, Fehrenbach N, Hudson A, Yowe-Conley T, Gilboa SM, Meaney-Delman D.
        J Womens Health (Larchmt). 2020 Nov 23.
        Pregnant women with opioid use disorder (OUD) are at risk of overdose, infectious diseases, and inadequate prenatal care. Additional risks include adverse pregnancy and infant outcomes, such as preterm birth and neonatal abstinence syndrome. Management and treatment of OUD during pregnancy are associated with improved maternal and infant outcomes. Professional organizations, including the American College of Obstetricians and Gynecologists, recommend offering opioid agonist pharmacotherapy (i.e., methadone or buprenorphine) combined with behavioral therapy as standard treatment for pregnant women with OUD. Other medications and herbal supplements have also been used by pregnant women for OUD. Determining which OUD treatments optimize maternal and infant outcomes is challenging given the host of potential factors that affect these outcomes. The Centers for Disease Control and Prevention initiated the MATernaL and Infant NetworK to Understand Outcomes Associated with Treatment of Opioid Use Disorder during Pregnancy (MAT-LINK) to monitor more than 2000 mothers and their infants, using data collected from geographically diverse clinical sites. Information learned from MAT-LINK will inform the future management and treatment of pregnant women with OUD.

      3. The co-occurrence of autism spectrum disorder in children with ADHDexternal icon
        Zablotsky B, Bramlett MD, Blumberg SJ.
        J Atten Disord. 2020 Jan;24(1):94-103.
        Objective: Children with ADHD frequently present with autism spectrum disorder (ASD) symptomatology, yet there is a notable gap in the treatment needs of this subpopulation, including whether the presence of ASD may be associated with more severe ADHD symptoms. Method: Data from the 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome (n = 2,464) were used to compare children diagnosed with ADHD and ASD with children with ADHD, but not ASD. Children were classified as needing treatment if it was received or their parents reported it was needed, but not received. Results: Approximately one in eight children currently diagnosed with ADHD was also diagnosed with ASD. Children diagnosed with both disorders had greater treatment needs, more co-occurring conditions, and were more likely to have a combined hyperactive/impulsive and inattentive ADHD subtype. Conclusion: These findings highlight the complexity of children diagnosed with both ADHD and ASD.

    • Nutritional Sciences
      1. Timing of introduction of complementary foods - United States, 2016-2018external icon
        Chiang KV, Hamner HC, Li R, Perrine CG.
        MMWR Morb Mortal Wkly Rep. 2020 Nov 27;69(47):1787-1791.
        The American Academy of Pediatrics (AAP) recommends introducing complementary foods (i.e., any solid or liquid other than breast milk or infant formula) to infants at approximately age 6 months (1). Although a consensus on ideal timing is lacking, most experts agree that introduction of complementary foods before age 4 months is too early because of infant gastrointestinal and motor immaturity (1,2). In addition, early introduction prevents exclusively breastfed infants from reaching the recommended 6 months of exclusive breastfeeding (1) and might be associated with increased risk for overweight and obesity (3). Nationally representative data on complementary feeding are limited; state-level estimates have been previously unavailable. CDC analyzed 2016-2018 data from the National Survey of Children's Health (NSCH) (N = 23,927) to describe timing of complementary feeding introduction and prevalence of early introduction of complementary foods before age 4 months (early introduction) among children aged 1-5 years. Prevalence of early introduction was 31.9% nationally and varied geographically and across sociodemographic and infant feeding characteristics. These estimates suggest that many infants are introduced to complementary foods before they are developmentally ready. Efforts by health care providers and others who might influence infant feeding practices could help decrease the number of infants who are introduced to complementary foods too early.

      2. Implementation of hospital practices supportive of breastfeeding in the context of COVID-19 - United States, July 15-August 20, 2020external icon
        Perrine CG, Chiang KV, Anstey EH, Grossniklaus DA, Boundy EO, Sauber-Schatz EK, Nelson JM.
        MMWR Morb Mortal Wkly Rep. 2020 Nov 27;69(47):1767-1770.
        Breastfeeding has health benefits for both infants and mothers and is recommended by numerous health and medical organizations*(,†) (1). The birth hospitalization is a critical period for establishing breastfeeding; however, some hospital practices, particularly related to mother-newborn contact, have given rise to concern about the potential for mother-to-newborn transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (2). CDC conducted a COVID-19 survey (July 15-August 20, 2020) among 1,344 hospitals that completed the 2018 Maternity Practices in Infant Nutrition and Care (mPINC) survey to assess current practices and breastfeeding support while in the hospital. Among mothers with suspected or confirmed COVID-19, 14.0% of hospitals discouraged and 6.5% prohibited skin-to-skin care; 37.8% discouraged and 5.3% prohibited rooming-in; 20.1% discouraged direct breastfeeding but allowed it if the mother chose; and 12.7% did not support direct breastfeeding, but encouraged feeding of expressed breast milk. In response to the pandemic, 17.9% of hospitals reported reduced in-person lactation support, and 72.9% reported discharging mothers and their newborns <48 hours after birth. Some of the infection prevention and control (IPC) practices that hospitals were implementing conflicted with evidence-based care to support breastfeeding. Mothers who are separated from their newborn or not feeding directly at the breast might need additional postdischarge breastfeeding support. In addition, the American Academy of Pediatrics (AAP) recommends that newborns discharged before 48 hours receive prompt follow-up with a pediatric health care provider.

    • Occupational Safety and Health
      1. Exploring evaluation variables for low-cost particulate matter monitors to assess occupational exposureexternal icon
        Ruiter S, Kuijpers E, Saunders J, Snawder J, Warren N, Gorce JP, Blom M, Krone T, Bard D, Pronk A, Cauda E.
        Int J Environ Res Public Health. 2020 Nov 19;17(22).
        (1) Background: Small, lightweight, low-cost optical particulate matter (PM) monitors are becoming popular in the field of occupational exposure monitoring, because these devices allow for real-time static measurements to be collected at multiple locations throughout a work site as well as being used as wearables providing personal exposure estimates. Prior to deployment, devices should be evaluated to optimize and quantify measurement accuracy. However, this can turn out to be difficult, as no standardized methods are yet available and different deployments may require different evaluation procedures. To gain insight in the relevance of different variables that may affect the monitor readings, six PM monitors were selected based on current availability and evaluated in the laboratory; (2) Methods: Existing strategies that were judged appropriate for the evaluation of PM monitors were reviewed and seven evaluation variables were selected, namely the type of dust, within- and between-device variations, nature of the power supply, temperature, relative humidity, and exposure pattern (peak and constant). Each variable was tested and analyzed individually and, if found to affect the readings significantly, included in a final correction model specific to each monitor. Finally, the accuracy for each monitor after correction was calculated; (3) Results: The reference materials and exposure patterns were found to be main factors needing correction for most monitors. One PM monitor was found to be sufficiently accurate at concentrations up to 2000 µg/m(3) PM(2.5), with other monitors appropriate at lower concentrations. The average accuracy increased by up to three-fold compared to when the correction model did not include evaluation variables; (4) Conclusions: Laboratory evaluation and readings correction can greatly increase the accuracy of PM monitors and set boundaries for appropriate use. However, this requires identifying the relevant evaluation variables, which are heavily reliant on how the monitors are used in the workplace. This, together with the lack of current consensus on standardized procedures, shows the need for harmonized PM monitor evaluation methods for occupational exposure monitoring.

      2. Resistance-related injuries among law enforcement officers: Addressing the empirical gapexternal icon
        Tiesman HM, Konda S, Grieco J, Gwilliam M, Rojek J, Montgomery B.
        Am J Prev Med. 2020 Dec;59(6):e231-e238.
        INTRODUCTION: Officers can be unintentionally injured during officer-suspect interactions, and these injuries are often not coded as assaults. This article defines and enumerates injuries that officers sustain while chasing, detaining, arresting, or pursuing suspects. These are termed resistance-related injuries. METHODS: Data on law enforcement officer injuries treated in U.S. emergency departments were obtained from the National Electronic Injury Surveillance System-Occupational Supplement from 2012 to 2017. Resistance-related injuries were defined using the Bureau of Labor Statistics Occupational Injury and Illness Classification System, version 2.01. Injury rates were calculated using denominators from the Current Population Survey. Negative binomial regression was used to analyze temporal trends. Data were analyzed in 2019. RESULTS: Between 2012 and 2017, an estimated 303,500 officers were treated in U.S. emergency departments for nonfatal injuries for an overall injury rate of 568 per 10,000 full-time equivalents. Emergency department-treated injuries significantly decreased by 3.8% annually during this time period (p<0.0001). The leading causes of injury were assaults and violent acts (48%), transportation incidents (11%), and falls (11%). Of the total injuries, more than half were resistance-related (53%). A total of 88% of violence-related injuries, nearly 50% of falls, and 31% of overexertion injuries were considered resistance related. CONCLUSIONS: More than half of officers' nonfatal injuries occurred when they were interacting, detaining, or pursuing a suspect. This highlights the need to code nonfatal injuries in a consistent and meaningful way that informs police policy and practice.

    • Occupational Safety and Health - Mining
      1. Mining vehicle manufacturers are developing lithium-ion (Li-ion) battery electric vehicles as an alternative to diesel-powered vehicles. In gassy underground mines, explosion-proof (XP) enclosures are commonly used to enclose electrical ignition sources to prevent propagation of an internal methane (CH4) air explosion to a surrounding explosive atmosphere. Li-ion batteries can create pressurized explosions within sealed enclosures due to thermal runaway (TR). Researchers at the National Institute for Occupational Safety and Health (NIOSH) measured TR pressures of lithium iron phosphate (LFP) cells as a function of free space within sealed enclosures and observed an inverse power relationship. A well-confined cell produced 294 bar (4260 psia) of pressure during a TR, far exceeding minimum pressure containment specifications for conventional XP enclosures. Results indicate that adding enough free space surrounding LFP cells can reduce TR pressures to levels below that expected for CH4-air ignitions. Measured TR temperatures were below the minimum autoignition temperature of CH4-air.

      2. Mortality among uranium miners in North America and Europe: the Pooled Uranium Miners Analysis (PUMA)external icon
        Richardson DB, Rage E, Demers PA, Do MT, DeBono N, Fenske N, Deffner V, Kreuzer M, Samet J, Wiggins C, Schubauer-Berigan MK, Kelly-Reif K, Tomasek L, Zablotska LB, Laurier D.
        Int J Epidemiol. 2020 Nov 24.
        BACKGROUND: The Pooled Uranium Miners Analysis (PUMA) study draws together information from cohorts of uranium miners from Canada, the Czech Republic, France, Germany and the USA. METHODS: Vital status and cause of death were ascertained and compared with expectations based upon national mortality rates by computing standardized mortality ratios (SMRs) overall and by categories of time since first hire, calendar period of first employment and duration of employment as a miner. RESULTS: There were 51 787 deaths observed among 118 329 male miners [SMR = 1.05; 95% confidence interval (CI): 1.04, 1.06]. The SMR was elevated for all cancers (n = 16 633, SMR = 1.23; 95% CI: 1.21, 1.25), due primarily to excess mortality from cancers of the lung (n = 7756, SMR = 1.90; 95% CI: 1.86, 1.94), liver and gallbladder (n = 549, SMR = 1.15; 95% CI: 1.06, 1.25), larynx (n = 229, SMR = 1.10; 95% CI: 0.97, 1.26), stomach (n = 1058, SMR = 1.08; 95% CI: 1.02, 1.15) and pleura (n = 39, SMR = 1.06; 95% CI: 0.75, 1.44). Lung-cancer SMRs increased with duration of employment, decreased with calendar period and persisted with time since first hire. Among non-malignant causes, the SMR was elevated for external causes (n = 3362, SMR = 1.41; 95% CI: 1.36, 1.46) and respiratory diseases (n = 4508, SMR = 1.32; 95% CI: 1.28, 1.36), most notably silicosis (n = 814, SMR = 13.56; 95% CI: 12.64, 14.52), but not chronic obstructive pulmonary disease (n = 1729, SMR = 0.98; 95% CI: 0.93, 1.02). CONCLUSIONS: Whereas there are important obstacles to the ability to detect adverse effects of occupational exposures via SMR analyses, PUMA provides evidence of excess mortality among uranium miners due to a range of categories of cause of death. The persistent elevation of SMRs with time since first hire as a uranium miner underscores the importance of long-term follow-up of these workers.

    • Parasitic Diseases
      1. BACKGROUND: Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended for preventing malaria in pregnancy in areas of moderate-to-high transmission in sub-Saharan Africa. However, due to increasing parasite resistance to SP, research on alternative strategies is a priority. The study assessed the implementation feasibility of intermittent screening and treatment (ISTp) in the second and third trimester at antenatal care (ANC) with malaria rapid diagnostic tests (RDTs) and treatment of positive cases with dihydroartemisinin-piperaquine (DP) compared to IPTp-SP in western Kenya. METHODS: A 10-month implementation study was conducted in 12 government health facilities in four sub-counties. Six health facilities were assigned to either ISTp-DP or IPTp-SP. Evaluation comprised of facility audits, ANC observations, and exit interviews. Intermediate and cumulative effectiveness analyses were performed on all processes involved in delivery of ISTp-DP including RDT proficiency and IPTp-SP ± directly observed therapy (DOT, standard of care). Logistic regression was used to identify predictors of receiving each intervention. RESULTS: A total of 388 and 389 women were recruited in the ISTp-DP and IPTp-SP arms, respectively. For ISTp-DP, 90% (289/320) of eligible women received an RDT. Of 11% (32/289) who tested positive, 71% received the correct dose of DP and 31% the first dose by DOT, and only 6% were counselled on subsequent doses. Women making a sick visit and being tested in a facility with a resident microscopist were more likely to receive ISTp-DP (AOR 1.78, 95% CI 1.31, 2.41; and AOR 3.75, 95% CI 1.31, 2.40, respectively). For IPTp-SP, only 57% received a dose of SP by DOT. Payment for a laboratory test was independently associated with receipt of SP by DOT (AOR 6.43, 95% CI 2.07, 19.98). CONCLUSIONS: The findings indicate that the systems effectiveness of ANC clinics to deliver ISTp-DP under routine conditions was poor in comparison to IPTp-SP. Several challenges to integration of ISTp with ANC were identified that may need to be considered by countries that have introduced screening at first ANC visit and, potentially, for future adoption of ISTp with more sensitive RDTs. Understanding the effectiveness of ISTp-DP will require additional research on pregnant women's adherence to ACT.

    • Reproductive Health
      1. Abortion surveillance - United States, 2018external icon
        Kortsmit K, Jatlaoui TC, Mandel MG, Reeves JA, Oduyebo T, Petersen E, Whiteman MK.
        MMWR Surveill Summ. 2020 Nov 27;69(7):1-29.
        PROBLEM/CONDITION: CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States. PERIOD COVERED: 2018. DESCRIPTION OF SYSTEM: Each year, CDC requests abortion data from the central health agencies for 50 states, the District of Columbia, and New York City. For 2018, 49 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 48 reporting areas provided data each year during 2009-2018. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2017 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS). RESULTS: A total of 619,591 abortions for 2018 were reported to CDC from 49 reporting areas. Among 48 reporting areas with data each year during 2009-2018, in 2018, a total of 614,820 abortions were reported, the abortion rate was 11.3 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 189 abortions per 1,000 live births. From 2017 to 2018, the total number of abortions and abortion rate increased 1% (from 609,095 total abortions and from 11.2 abortions per 1,000 women aged 15-44 years, respectively), and the abortion ratio increased 2% (from 185 abortions per 1,000 live births). From 2009 to 2018, the total number of reported abortions, abortion rate, and abortion ratio decreased 22% (from 786,621), 24% (from 14.9 abortions per 1,000 women aged 15-44 years), and 16% (from 224 abortions per 1,000 live births), respectively. In 2018, women in their 20s accounted for more than half of abortions (57.7%). In 2018 and during 2009-2018, women aged 20-24 and 25-29 years accounted for the highest percentages of abortions; in 2018, they accounted for 28.3% and 29.4% of abortions, respectively, and had the highest abortion rates (19.1 and 18.5 per 1,000 women aged 20-24 and 25-29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.6%, respectively) and had the lowest abortion rates (0.4 and 2.6 per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios in 2018 and throughout 2009-2018 were highest among adolescents (aged ≤19 years) and lowest among women aged 25-39 years. Abortion rates decreased from 2009 to 2018 for all women, regardless of age. The decrease in abortion rate was highest among adolescents compared with women in any other age group. From 2009 to 2013, the abortion rates decreased for all age groups and from 2014 to 2018, the abortion rates decreased for all age groups, except for women aged 30-34 years and those aged ≥40 years. In addition, from 2017 to 2018, abortion rates did not change or decreased among women aged ≤24 and ≥40 years; however, the abortion rate increased among women aged 25-39 years. Abortion ratios also decreased from 2009 to 2018 among all women, except adolescents aged <15 years. The decrease in abortion ratio was highest among women aged ≥40 years compared with women in any other age group. The abortion ratio decreased for all age groups from 2009 to 2013; however, from 2014 to 2018, abortion ratios only decreased for women aged ≥35 years. From 2017 to 2018, abortion ratios increased for all age groups, except women aged ≥40 years. In 2018, approximately three fourths (77.7%) of abortions were performed at ≤9 weeks' gestation, and nearly all (92.2%) were performed at ≤13 weeks' gestation. In 2018, and during 2009-2018, the percentage of abortions performed at >13 weeks' gestation remained consistently low (≤9.0%). In 2018, the highest proportion of abortions were performed by surgical abortion at ≤13 weeks' gestation (52.1%), followed by early medical abortion at ≤9 weeks' gestation (38.6%), surgical abortion at >13 weeks' gestation (7.8%), and medical abortion at >9 weeks' gestation (1.4%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks' gestation), 50.0% of abortions were early medical abortions. In 2017, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, two women were identified to have died as a result of complications from legal induced abortion. INTERPRETATION: Among the 48 areas that reported data continuously during 2009-2018, decreases were observed during 2009-2017 in the total number, rate, and ratio of reported abortions, and these decreases resulted in historic lows for this period for all three measures. These decreases were followed by 1%-2% increases across all measures from 2017 to 2018. PUBLIC HEALTH ACTION: The data in this report can help program planners and policymakers identify groups of women with the highest rates of abortion. Unintended pregnancy is a major contributor to induced abortion. Increasing access to and use of effective contraception can reduce unintended pregnancies and further reduce the number of abortions performed in the United States.

      2. Sporadic contraceptive use and nonuse: age-specific prevalence and associated factorsexternal icon
        Pazol K, Whiteman MK, Folger SG, Kourtis AP, Marchbanks PA, Jamieson DJ.
        Am J Obstet Gynecol. 2015 Mar;212(3):324.e1-8.
        OBJECTIVE: The purpose of this study was to characterize age-group specific patterns in the stability of contraceptive use and to evaluate whether factors that are associated with nonuse and sporadic use, compared with stable use, differ by age among women who are at risk for unintended pregnancy. STUDY DESIGN: We used data from the 2006-2010 National Survey of Family Growth to characterize the prevalence of stable and sporadic contraceptive use and nonuse by age over a 1-year period. We used polytomous logistic regression models to assess the odds of contraceptive nonuse and sporadic use vs stable use. Age-stratified models were used to show age-group differences in associated characteristics. RESULTS: Over a 1-year period, stable contraceptive use decreased across age groups from 80% for teens 15-19 years old to 74% for women 20-24 years old, and 70-71% for women 25-34 and 35-44 years old. Contraceptive nonuse increased across age groups from 5% for teens 15-19 years old to 9-20% for older women. By contrast, sporadic use was least common for women 35-44 years old (10% compared with 16-17% for younger women). Among teens 15-19 years old, a history of method discontinuation because of dissatisfaction was associated with nonuse. Among older women, intentions to have children in the future and reported difficulty achieving pregnancy were associated with nonuse and sporadic use. CONCLUSION: Because the stability of contraceptive use and associated factors differ by age, providers may need to consider these differences when talking to women about contraception. To address nonuse, helping teens identify a method that they are comfortable using may be especially important; for older women, discussing the potential for continuing fertility may be more important. To address sporadic use, discussing the benefits of user-independent methods may be helpful, with a particular emphasis on long-acting reversible contraceptives for younger women and teens who are less likely to have completed their desired childbearing and who have tended to rely on methods that are more difficult to use consistently.

      3. Assisted reproductive technology surveillance -- United States, 2010external icon
        Sunderam S, Kissin DM, Crawford S, Anderson JE, Folger SG, Jamieson DJ, Barfield WD.
        MMWR Surveill Summ. 2013 Dec 6;62(9):1-24.
        PROBLEM/CONDITION: Since the first U.S. infant conceived with Assisted Reproductive Technology (ART) was born in 1981, both the use of advanced technologies to overcome infertility and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which both eggs and sperm are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Women who undergo ART procedures are more likely to deliver multiple-birth infants than those who conceive naturally because more than one embryo might be transferred during a procedure. Multiple births pose substantial risks to both mothers and infants, including pregnancy complications, preterm delivery, and low birthweight infants. This report provides state-specific information on U.S. ART procedures performed in 2010 and compares infant outcomes that occurred in 2010 (resulting from procedures performed in 2009 and 2010) with outcomes for all infants born in the United States in 2010. REPORTING PERIOD COVERED: 2010. DESCRIPTION OF SYSTEM: In 1996, CDC began collecting data on all ART procedures performed in fertility clinics in the United States and U.S. territories, as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493). Data are collected through the National ART Surveillance System (NASS), a web-based data collecting system developed by CDC. RESULTS: In 2010, a total of 147,260 ART procedures performed in 443 U.S. fertility clinics were reported to CDC. These procedures resulted in 47,090 live-birth deliveries and 61,564 infants. The largest numbers of ART procedures were performed among residents of six states: California (18,524), New York (excluding New York City) (14,212), Illinois (10,110), Massachusetts (9,854), New Jersey (8,783), and Texas (8,754). These six states also had the highest number of live-birth deliveries as a result of ART procedures and together accounted for 48.0% of all ART procedures performed, 45.0% of all infants born from ART, and 45.0% of all multiple live-birth deliveries but only 34.0% of all infants born in the United States and U.S. territories. Nationally, the average number of ART procedures performed per 1 million women of reproductive age (15-44 years), which is a proxy indicator of ART use, was 2,331. In 13 states (California, Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Virginia), this proxy measure was higher than the national rate, and in four states (Connecticut, Massachusetts, New Jersey, and New York) and the District of Columbia, it exceeded twice the national rate. Nationally, among cycles in which at least one embryo was transferred, the average number of embryos transferred increased with increasing age (2.0 among women aged <35 years, 2.4 among women aged 35-40 years, and 3.0 among women aged >40 years). Elective single-embryo transfer (eSET) rates decreased with increasing age (10.0% among women aged <35 years, 3.8% among women aged 35-40 years, and 0.6% among women aged >40 years). ESET rates also varied substantially between states (range: 0 to 45.0% among women aged <35 years). The number of ART births as a percentage of total infants born in the state or territory is considered as another measure of ART use. Overall, ART contributed to 1.5% of U.S. births (range: 0.1% in Guam to 4.8% in Massachusetts) with the highest rates (>3.5% of all infants born) observed in four states (Connecticut, Massachusetts, New Jersey, and New York), and the District of Columbia. The proportion of ART births was ≤2.5% in the remaining states and territories. Infants conceived with ART comprised 20.0% of all multiple-birth infants (range: 0 in Guam to 40.5% in Massachusetts), 19.0% of all twin infants (range: 0 in Guam to 40.0% in Massachusetts), and 33.0% of triplet or higher order infants (range: 0 in several states to 60.0% in Arizona). Among infants conceived with ART, 46.0% were born in multiple deliveries (range: 0 in Guam to 55.4% in Utah), compared with only 3.0% of infants among all births in the general population (range: 1.3% in Guam to 4.7% in Connecticut). A substantial proportion (43.4%) of ART-conceived infants were twin infants, and a smaller proportion (3.0%) were triplets and higher order infants. Nationally, infants conceived with ART comprised 5.6% of all low birthweight (<2,500 grams) infants (range: 0 in Guam to 16.0% in Massachusetts) and 5.6% of all very low birthweight (<1,500 grams) infants (range: 0 in Guam to 15.8% in Massachusetts). Overall, among ART-conceived infants, 31.6% were low birthweight (range: 22.6% in New Hampshire to 48.2% in Puerto Rico), compared with 8.0% among all infants (range: 5.7% in Alaska to 12.6% in Puerto Rico); 5.6% of ART infants were very low birthweight (range: 1.9% in Maine to 14.3% in Montana), compared with 1.4% among all infants (range: 0.9% in Alaska to 2.3% in the District of Columbia). Finally, ART-conceived infants comprised 4.4% of all infants born preterm (<37 weeks; range: 0 in Guam to 13.3% in Massachusetts) and 4.9% of all infants born very preterm (<32 weeks; range: 0 in Guam to 16.2% in Massachusetts). Overall, among infants conceived with ART, 36.6% were born preterm (range: 23.6% in New Hampshire to 56.8% in Wyoming), compared with 12.0% among all infants born in the general population (range: 8.4% in Vermont to 17.9% in Guam); 6.6% of ART infants were born very preterm (range: 0 in Maine to 14.5% in Puerto Rico), compared with 2.0% among all infants born in the general population (range: 1.3% in Alaska to 3.0% in the District of Columbia). INTERPRETATION: The percentage of infants conceived with ART varied considerably by state and territory (range: 0.1% to 4.8%). In most states, multiples from ART comprised a substantial proportion of all twin, triplet, and higher-order infants born in the state, and the rates of low birthweight and preterm infants were disproportionately higher among ART infants than in the birth population overall. Even among women aged <35 years, for whom single embryo transfers should be considered (particularly in patients with a favorable prognosis) according to American Society of Reproductive Medicine (ASRM) guidelines, on average, two embryos were transferred per cycle in ART procedures, influencing the overall multiple infant rates in the United States. ART use per population unit was distributed disproportionately in the United States, with only 13 states showing ART use above the national rate, which might suggest barriers to ART services in the remaining states. Of the four states (Illinois, Massachusetts, New Jersey, and Rhode Island) with comprehensive statewide-mandated health insurance coverage for ART procedures (e.g., coverage for at least four cycles of IVF), three states (Illinois, Massachusetts, and New Jersey) also had rates of ART use >1.5 times the national level. This type of mandated insurance has been associated with greater use of ART and might account for the differences observed in other states. PUBLIC HEALTH ACTIONS: Reducing the number of embryos transferred per ART procedure among all age groups and promotion of eSET procedures, when clinically appropriate, is needed to reduce multiple births, including twin births, and related adverse consequences of ART. Improved patient education and counseling on the risks of twins might be useful in reducing twin births because twins account for the majority of multiples. Although ART contributes to increasing rates of multiple births, it does not explain all of the increases, and therefore the possible role of non-ART fertility treatments warrants further study.

      4. Assisted reproductive technology surveillance--United States, 2009external icon
        Sunderam S, Kissin DM, Flowers L, Anderson JE, Folger SG, Jamieson DJ, Barfield WD.
        MMWR Surveill Summ. 2012 Nov 2;61(7):1-23.
        PROBLEM/CONDITION: Since the birth of the first U.S. infant conceived with Assisted Reproductive Technology (ART) in 1981, use of advanced technologies to overcome the problem of infertility has increased steadily, as has the number of fertility clinics providing ART services in the United States. ART includes fertility treatments in which both eggs and sperm are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Women who undergo ART procedures are more likely to deliver multiple-birth infants than those who conceive naturally. Multiple births pose substantial risks to both mothers and infants, including pregnancy complications, preterm delivery, and low birthweight infants. This report presents the most recent data on ART use and birth outcomes for U.S. states and territories. REPORTING PERIOD COVERED: 2009. DESCRIPTION OF SYSTEM: In 1996, CDC began collecting data on all ART procedures performed in the United States, as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493 [October 24, 1992]). ART data for 1995-2003 were obtained from the Society of Assisted Reproductive Technology (SART) through its proprietary Clinical Outcomes Reporting System data base (SART CORS). Since 2004, CDC has contracted with Westat, Inc., a statistical survey research organization, to obtain data from fertility clinics in the United States through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. RESULTS: In 2009, a total of 146,244 ART procedures were reported to CDC. These procedures resulted in 45,870 live-birth deliveries and 60,190 infants. The largest numbers of ART procedures were performed among residents of California (18,405), New York (14,539), Illinois (10,192), Massachusetts (9,845), New Jersey (9,146), and Texas (8,244). Together, these six states reported the highest number of live-birth deliveries as a result of ART and accounted for 48% of all ART procedures initiated, 46% of all infants born from ART, and 45% of all ART multiple-birth deliveries but only 34% of all births in the United States. Nationally, the average number of ART procedures performed per 1 million women of reproductive age (15-44 years), which is a proxy indicator of ART utilization, was 2,361. In four states (Massachusetts, New York, New Jersey, and Connecticut) and the District of Columbia, this proxy measure of ART use exceeded twice the national average. Nationally, the average number of embryos transferred was 2.1 among women aged <35 years, 2.5 among women aged 35-40 years, and 3.0 among women aged >40 years (and varied most in this age group from 1.7 in Maine to 3.5 in Missouri). Age-specific elective single-embryo transfer (eSET) rates were approximately 7% among women aged <35 years, 3% among women aged 35-40 years, and 0.5% among women aged >40 years. The highest rates of eSET were observed among women aged <35 years (41% in Delaware, 20% in Iowa, and 17% Massachusetts). Overall, ART contributed to 1.4% of U.S. births (ranging from 0.2% in Puerto Rico to 4.3 % in Massachusetts). The proportion of ART to total infants born in the state or territory, which is another measure of ART utilization, was highest in Massachusetts (>4%) with high rates also observed in New Jersey, New York, Connecticut, and the District of Columbia (>3% of all infants born). Infants conceived with ART accounted for 20% of all multiple-birth infants (ranging from 4% in Maine to 41% in New York), 19% of all twin births (ranging from 4% in Maine to 42% in New York) and 34% of triplet or higher order births (ranging from 0 in several states to 61.5% in New Jersey). Among infants conceived with ART, 47% were born as multiple-birth infants (ranging from 35% in Delaware to 60.8% in Wyoming), compared with only 3% of infants among the general birth population (ranging from 1% in New York to 5% in Connecticut). Nationally, infants conceived with ART contributed to approximately 6% of all low birthweight (<2,500 grams) infants, ranging from 1.3% in Mississippi to 15% in Massachusetts and to 6% of all very low birthweight (<1,500 grams) infants, ranging from 1% in Alaska to 15% in New Jersey. Overall, among ART-conceived infants, 32% were low birthweight (ranging from 20% in Alaska to 48% in Puerto Rico), compared with 8% among the general birth population (ranging from 5.8% in South Dakota to 12.2% in Mississippi), and 6% of ART infants were very low birthweight (ranging from 1.5% in Alaska to 13% in South Dakota), compared with 1% among the general birth population (ranging from 1% in Alaska to 2% in Mississippi and District of Columbia). Finally, ART-conceived infants accounted for 3.9% of all preterm (<37 weeks; range: 0.5% in Puerto Rico to 11.1% in Massachusetts) and 4.5% of all very preterm births (<32 weeks; range: 0.5% in Puerto Rico to 12% in New York). Overall, among infants conceived with ART, 33.4% were born preterm (ranging from 21.3% in Vermont to 47.1% in Wyoming), compared with 12.2% of the general birth population (ranging from 9.3% in Vermont to 18.0% in Mississippi), and 6.1% of ART infants were very preterm births (ranging from 1.5% in Alaska to 14.7% in South Dakota), compared with 2% among the general birth population (ranging from 1.4% in Alaska, Oregon, Utah, and Washington to 3% in Mississippi). INTERPRETATION: The proportion of births from ART varied considerably by state and territory (ranging from 0.2% to 4.3%) with substantial impact on perinatal outcomes in some states. In most states, multiple births from ART accounted for substantial proportions of twins and triplets and higher order infants, and the rates of low birthweight and preterm births were disproportionately higher among ART infants than in the general birth population. More than one embryo was transferred per procedure in most states and territories for all age groups, influencing the overall multiple birth rates in the United States. ART use was represented disproportionately in the United States, with only 13 states having above-average ART use. High rates of ART utilization were observed in Massachusetts and New Jersey, which have comprehensive statewide-mandated health insurance coverage for ART procedures. Insurance mandates might influence ART utilization and ART-related birth outcomes. PUBLIC HEALTH ACTIONS: Promotion of single-embryo transfer, where feasible, is needed to reduce multiple births and related adverse consequences of ART. Nevertheless, because ART accounts for a relatively small fraction of total births in most states and territories, the overall prevalence of low birthweight and preterm births cannot be explained solely by the use of ART, and therefore non-ART causes of these adverse outcomes must be examined. Monitoring the use of non-ART infertility treatments (e.g., ovulation stimulation medications without ART) in the general population might be useful because these treatments also might be associated with high rates of multiple births and adverse outcomes such as preterm delivery and infants born with low birthweight.

    • Statistics as Topic
      1. Exposure measurement error (ME) biases exposure-outcome associations. Calibration dietary intake data used in the regression calibration (RC) response to adjust for ME are usually right-skewed, heteroscedastic and with excess zeroes. We proposed three-part RC models to handle these distributional complexities simultaneously, while correcting for ME in fish intake. We applied data from the National Health and Nutrition Examination Survey (NHANES), where long-term intake was measured with food frequency questionnaire (FFQ) in the main study and short-term intake with 24-hour recall (24HR) in the calibration study. In the three-part RC models, never consumers were modelled using two approaches: a zero distribution (Three-part RC-het-det), and logistic distribution (Three-part RC-het-prob); heteroscedasticity using an exponential distribution and right-skewness using generalized gamma distribution. The proposed models were compared with two-part RC model that ignores never consumers, and with methods that estimate intakes using FFQ and 24HR. The models were evaluated in a simulation study. With NHANES data, mean increase in the mercury level (in (Formula presented.)) was 1.20 using FFQ-method, 0.4 using 24HR-method, 1.87 using two-part RC and 2.02 using three-part RC-het-prob method. The three-part RC estimated the association with the least bias in the simulation study.

    • Substance Use and Abuse
      1. Trends in manufacturer-reported nicotine yields in cigarettes sold in the United States, 2013-2016external icon
        Kuiper N, Coats EM, Crawford TN, Gammon DG, Loomis B, Watson CH, Melstrom PC, Lavinghouze R, Rogers T, King BA.
        Prev Chronic Dis. 2020 Nov 25;17:E148.
        INTRODUCTION: A gradual reduction of cigarette nicotine content to nonaddictive levels has been proposed as an endgame strategy to accelerate declines in combustible tobacco smoking. We assessed manufacturer-reported nicotine yield in cigarettes sold in the United States from 2013 to 2016. METHODS: We merged machine-measured nicotine yield in cigarette smoke and pack characteristics obtained from reports filed by tobacco manufacturers with the Federal Trade Commission for 2013-2016 with monthly Nielsen data on US cigarette sales. Manufacturer-reported, sales-weighted, average annual nicotine yield was assessed, as were nicotine yield sales trends by quartile: markedly low (0.10-0.60 mg/stick), low (0.61-0.80 mg/stick), moderate (0.81-0.90 mg/stick), and high (0.91-3.00 mg/stick). Trends in overall, menthol, and nonmenthol pack sales, by nicotine yield quartiles over the study period and by year, were determined by using Joinpoint regression. RESULTS: During 2013-2016, average annual sales-weighted nicotine yield for all cigarettes increased from 0.903 mg/stick (95% CI, 0.882-0.925) in 2013 to 0.938 mg/stick (95% CI, 0.915-0.962) in 2016 (P < .05). For menthol cigarettes, yield increased from 0.943 mg/stick in 2013 (95% CI, 0.909-0.977) to 1.037 mg/stick in 2016 (95% CI, 0.993-1.081), increasing 0.2% each month (P < .05). Most pack sales occurred among high (41.5%) and low (30.7%) nicotine yield quartiles. Cigarette sales for the markedly low quartile decreased by an average of 0.4% each month during 2013-2016 (P < .05). CONCLUSION: During 2013-2016, manufacturer-reported, sales-weighted nicotine yield in cigarettes increased, most notably for menthol cigarettes. Continued monitoring of nicotine yield and content in cigarettes can inform tobacco control strategies.

    • Zoonotic and Vectorborne Diseases
      1. Vaccination of contacts of Ebola virus disease survivors to prevent further transmissionexternal icon
        Doshi RH, Fleming M, Mukoka AK, Carter RJ, Hyde TB, Choi M, Nzaji MK, Bateyi SH, Christie A, Nichol ST, Damon IK, Beach M, Musenga EM, Fitter DL.
        Lancet Glob Health. 2020 Dec;8(12):e1455-e1456.

      2. Epidemiological investigation of a Rift Valley fever outbreak in humans and livestock in Kenya, 2018external icon
        Hassan A, Muturi M, Mwatondo A, Omolo J, Bett B, Gikundi S, Konongoi L, Ofula V, Makayotto L, Kasiti J, Oele E, Onyango C, Gura Z, Njenga K, Munyua P.
        Am J Trop Med Hyg. 2020 Oct;103(4):1649-1655.
        On the last week of May of 2018, a community-based syndromic surveillance system detected mass abortions and deaths of young livestock in northeastern Kenya. Two weeks later, Rift Valley fever (RVF) was confirmed in humans presenting with febrile illness and hemorrhagic syndrome in the same region. A joint animal and human response team carried out an investigation to characterize the outbreak and identify drivers of disease transmission. Here, we describe the outbreak investigation and findings. A total of 106 human cases were identified in the months of May and June 2018: 92% (98) and 8% (8) of these cases occurring in the northern and western regions of Kenya, respectively. Seventy-six (72%) were probable cases, and 30 (28%) were laboratory confirmed by ELISA and/or PCR. Among the confirmed cases, the median age was 27.5 years (interquartile range = 20), and 60% (18) were males. Overall, the case fatality rate was 7% (n = 8). The majority of the confirmed cases, 19 (63%), reported contact with livestock during slaughter and consumption of meat from sick animals. All confirmed cases had fever, 40% (12) presented with hemorrhagic syndrome, and 23% (7) presented with jaundice. Forty-three livestock herds with at least one suspect and/or confirmed animal case were identified. Death of young animals was reported in 93% (40) and abortions in 84% (36) of livestock herds. The outbreak is indicative of the emergence potential of RVF in traditionally high- and low-risk areas and the risk posed by zoonosis to livestock keepers.

      3. Consistent and effective use of personal prevention methods for tickborne diseases, including Lyme disease (LD), is dependent on risk awareness. To improve our understanding of the general U.S. population's experiences with tick exposure and use of personal prevention methods, we used data from ConsumerStyles, a web-based, nationally representative questionnaire on health-related topics. Questions addressed tick bites and LD diagnosis in the last year, use of personal prevention methods to prevent tick bites, and willingness to receive a theoretical LD vaccine. Of 10,551 participants surveyed over three years, 12.3 % reported a tick bite for themselves or a household member in the last year, including 15.4 % of participants in high LD incidence (LDI) states, 16.3 % in states neighboring high LDI states, and 9.4 % in low LDI states. Participants in high LDI states and neighboring states were most likely to use personal prevention methods, though 46.6 % of participants in high LDI states and 53.9 % in neighboring states reported not using any method. Participants in low LDI states, adults ≥ 75 years of age, those with higher incomes, and those living in urban housing tended to be less likely to practice personal prevention methods. Likeliness to receive a theoretical LD vaccine was high in high LDI (64.5 %), neighboring (52.5 %), and low LDI (49.7 %) states. Targeted educational efforts are needed to ensure those in high LDI and neighboring states, particularly older adults, are aware of their risk of LD and recommended personal prevention methods.

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

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