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Issue 11, March 30, 2021

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CDC Science Clips: Volume 13, Issue 11, March 30, 2021

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.

The report consists of these components:

  1. Top Articles of the Week
    Selected weekly by a senior CDC scientist from the standard sections listed below.
    The names of CDC authors are indicated in bold text.
    • Communicable Diseases
      • Loss of Taste and Smell as Distinguishing Symptoms of Coronavirus Disease 2019external icon
        Dawson P, Rabold EM, Laws RL, Conners EE, Gharpure R, Yin S, Buono SA, Dasu T, Bhattacharyya S, Westergaard RP, Pray IW, Ye D, Nabity SA, Tate JE, Kirking HL.
        Clin Infect Dis. 2021 Feb 16;72(4):682-685.
        In a household study, loss of taste and/or smell was the fourth most reported symptom (26/42 [62%]) among coronavirus disease 2019 (COVID-19) case patients and had the highest positive predictive value (83% [95% confidence interval [CI], 55%-95%) among household contacts. Olfactory and taste dysfunctions should be considered for COVID-19 case identification and testing prioritization.

      • Countries with delayed COVID-19 introduction - characteristics, drivers, gaps, and opportunitiesexternal icon
        Li Z, Jones C, Ejigu GS, George N, Geller AL, Chang GC, Adamski A, Igboh LS, Merrill RD, Ricks P, Mirza SA, Lynch M.
        Global Health. 2021 Mar 17;17(1):28.
        BACKGROUND: Three months after the first reported cases, COVID-19 had spread to nearly 90% of World Health Organization (WHO) member states and only 24 countries had not reported cases as of 30 March 2020. This analysis aimed to 1) assess characteristics, capability to detect and monitor COVID-19, and disease control measures in these 24 countries, 2) understand potential factors for the reported delayed COVID-19 introduction, and 3) identify gaps and opportunities for outbreak preparedness, particularly in low and middle-income countries (LMICs). We collected and analyzed publicly available information on country characteristics, COVID-19 testing, influenza surveillance, border measures, and preparedness activities in these countries. We also assessed the association between the temporal spread of COVID-19 in all countries with reported cases with globalization indicator and geographic location. RESULTS: Temporal spreading of COVID-19 was strongly associated with countries' globalization indicator and geographic location. Most of the 24 countries with delayed COVID-19 introduction were LMICs; 88% were small island or landlocked developing countries. As of 30 March 2020, only 38% of these countries reported in-country COVID-19 testing capability, and 71% reported conducting influenza surveillance during the past year. All had implemented two or more border measures, (e.g., travel restrictions and border closures) and multiple preparedness activities (e.g., national preparedness plans and school closing). CONCLUSIONS: Limited testing capacity suggests that most of the 24 delayed countries may have lacked the capability to detect and identify cases early through sentinel and case-based surveillance. Low global connectedness, geographic isolation, and border measures were common among these countries and may have contributed to the delayed introduction of COVID-19 into these countries. This paper contributes to identifying opportunities for pandemic preparedness, such as increasing disease detection, surveillance, and international collaborations. As the global situation continues to evolve, it is essential for countries to improve and prioritize their capacities to rapidly prevent, detect, and respond, not only for COVID-19, but also for future outbreaks.

      • Estimating and Evaluating Tuberculosis Incidence Rates Among People Experiencing Homelessness, United States, 2007-2016external icon
        Self JL, McDaniel CJ, Bamrah Morris S, Silk BJ.
        Med Care. 2021 Apr 1;59(Suppl 2):S175-s181.
        OBJECTIVES: Persons experiencing homelessness (PEH) are disproportionately affected by tuberculosis (TB). We estimate area-specific rates of TB among PEH and characterize the extent to which available data support recent transmission as an explanation of high TB incidence. METHODS: We estimated TB incidence among PEH using National Tuberculosis Surveillance System data and population estimates for the US Department of Housing and Urban Development's Continuums of Care areas. For areas with TB incidence higher than the national average among PEH, we estimated recent transmission using genotyping and a plausible source-case method. For cases with ≥1 plausible source case, we assessed with TB program partners whether available whole-genome sequencing and local epidemiologic data were consistent with recent transmission. RESULTS: During 2011-2016, 3164 TB patients reported experiencing homelessness. National incidence was 36 cases/100,000 PEH. Incidence estimates varied among 21 areas with ≥10,000 PEH (9-150 cases/100,000 PEH); 9 areas had higher than average incidence. Of the 2349 cases with Mycobacterium tuberculosis genotyping results, 874 (37%) had ≥1 plausible source identified. In the 9 areas, 23%-82% of cases had ≥1 plausible source. Of cases with ≥1 plausible source, 63% were consistent and 7% were inconsistent with recent transmission; 29% were inconclusive. CONCLUSIONS: Disparities in TB incidence for PEH persist; estimates of TB incidence and recent transmission vary by area. With a better understanding of the TB risk among PEH in their jurisdictions and the role of recent transmission as a driver, programs can make more informed decisions about prioritizing TB prevention strategies.

    • Environmental Health
      • Blood Lead Levels in U.S. Children Ages 1-11 Years, 1976-2016external icon
        Egan KB, Cornwell CR, Courtney JG, Ettinger AS.
        Environ Health Perspect. 2021 Mar;129(3):37003.
        BACKGROUND: Lead can adversely affect child health across a wide range of exposure levels. We describe the distribution of blood lead levels (BLLs) in U.S. children ages 1-11 y by selected sociodemographic and housing characteristics over a 40-y period. METHODS: Data from the National Health and Nutrition Examination Survey (NHANES) II (1976-1980), NHANES III (Phase 1: 1988-1991 and Phase II: 1991-1994), and Continuous NHANES (1999-2016) were used to describe the distribution of BLLs (in micrograms per deciliter; 1 μg/dL = 0.0483 μmol/L) in U.S. children ages 1-11 y from 1976 to 2016. For all children with valid BLLs (n = 27,122), geometric mean (GM) BLLs [95% confidence intervals (CI)] and estimated prevalence  ≥ 5 μg/dL (95% CI) were calculated overall and by selected characteristics, stratified by age group (1-5 y and 6-11 y). RESULTS: The GM BLL in U.S. children ages 1-5 y declined from 15.2 μg/dL (95% CI: 14.3, 16.1) in 1976-1980 to 0.83 μg/dL (95% CI: 0.78, 0.88) in 2011-2016, representing a 94.5% decrease over time. For children ages 6-11 y, GM BLL declined from 12.7 μg/dL (95% CI: 11.9, 13.4) in 1976-1980 to 0.60 μg/dL (95% CI: 0.58, 0.63) in 2011-2016, representing a 95.3% decrease over time. Even so, for the most recent period (2011-2016), estimates indicate that approximately 385,775 children ages 1-11 y had BLLs greater than or equal to the CDC blood lead reference value of 5 μg/dL. Higher GM BLLs were associated with non-Hispanic Black race/ethnicity, lower family income-to-poverty-ratio, and older housing age. DISCUSSION: Overall, BLLs in U.S. children ages 1-11 y have decreased substantially over the past 40 y. Despite these notable declines in population exposures to lead over time, higher GM BLLs are consistently associated with risk factors such as race/ethnicity, poverty, and housing age that can be used to target blood lead screening efforts. https://doi.org/10.1289/EHP7932.

    • Health Disparities
      • Breastfeeding Disparities and Their Mediators in an Urban Birth Cohort of Black and White Mothersexternal icon
        Morrow AL, McClain J, Conrey SC, Niu L, Kinzer A, Cline AR, Piasecki AM, DeFranco E, Ward L, Ware J, Payne DC, Staat MA, Nommsen-Rivers LA.
        Breastfeed Med. 2021 Mar 17.
        Background: Black mothers in the United States have shorter breastfeeding (BF) durations and less exclusive breastfeeding (EBF) than others. The factors underlying these disparities require investigation. Methods: Using longitudinal data from a CDC-sponsored birth cohort in Cincinnati, Ohio, we analyzed the factors mediating racial disparity in BF outcomes. Study mothers were enrolled in prenatal clinics associated with two large birth hospitals. Analysis was restricted to racial groups with sufficient numbers in the cohort, non-Hispanic Black (n = 92) and White (n = 113) mothers, followed to at least 6 months postpartum. Results: Black mothers were 25 times more likely to reside in socioeconomically deprived neighborhoods and 20 times more likely to have an annual household income <$50,000/year than White mothers (p < 0.001). The gap in EBF for 6 weeks was 45 percentage points by racial group (13%-Black mothers versus 58%-White mothers, p < 0.001); in any BF at 6 months was 37 percentage points (28%-Black mothers versus 65%-White mothers, p < 0.001); and in mothers meeting their own intention to BF at least 6 months was 51 percentage points (29%-Black mothers versus 80%-White mothers, p < 0.001). Racial disparity in EBF at 6 weeks was mediated in logistic regression models by inequities in socioeconomic position, maternal hypertension, and BF intention. Racial disparities in BF at 6 months or meeting 6-month BF intention were mediated by inequities in socioeconomic position, maternal obesity, and EBF at 6 weeks. Not all BF disparities could be explained by models used in these analyses. Conclusions: Efforts to lessen BF disparities should address the underlying structural inequities that disproportionately affect Black mothers and children, should incorporate maternal health, and focus on breastfeeding exclusivity and duration. Few Black mothers achieved EBF at 6 weeks, which contributed to disparity in BF duration. Greater attention to Black mother-infant pairs is a public health priority.

    • Health Economics
      • Societal Costs of a Measles Outbreakexternal icon
        Pike J, Melnick A, Gastañaduy PA, Kay M, Harbison J, Leidner AJ, Rice S, Asato K, Schwartz L, DeBolt C.
        Pediatrics. 2021 Mar 12.
        BACKGROUND AND OBJECTIVES: Between December 31, 2018, and April 26, 2019, 72 confirmed cases of measles were identified in Clark County. Our objective was to estimate the economic burden of the measles outbreak from a societal perspective, including public health response costs as well as direct medical costs and productivity losses of affected individuals. METHODS: To estimate costs related to this outbreak from the societal perspective, 3 types of costs were collected or estimated: public health response (labor, material, and contractor costs used to contain the outbreak), direct medical (third party or patient out-of-pocket treatment costs of infected individuals), and productivity losses (costs of lost productivity due to illness, home isolation, quarantine, or informal caregiving). RESULTS: The overall societal cost of the 2019 Clark County measles outbreak was ∼$3.4 million ($47 479 per case or $814 per contact). The majority of the costs (∼$2.3 million) were incurred by the public health response to the outbreak, followed by productivity losses (∼$1.0 million) and direct medical costs (∼$76 000). CONCLUSIONS: Recent increases in incident measles cases in the United States and across the globe underscore the need to more fully understand the societal cost of measles cases and outbreaks and economic consequences of undervaccination. Our estimates can provide valuable inputs for policy makers and public health stakeholders as they consider budget determinations and the substantial value associated with increasing vaccine coverage and outbreak preparedness as well as the protection of society against vaccine-preventable diseases, such as measles, which are readily preventable with high vaccination coverage.

    • Healthcare Associated Infections
      • Assessment of the Appropriateness of Antimicrobial Use in US Hospitalsexternal icon
        Magill SS, O'Leary E, Ray SM, Kainer MA, Evans C, Bamberg WM, Johnston H, Janelle SJ, Oyewumi T, Lynfield R, Rainbow J, Warnke L, Nadle J, Thompson DL, Sharmin S, Pierce R, Zhang AY, Ocampo V, Maloney M, Greissman S, Wilson LE, Dumyati G, Edwards JR, Chea N, Neuhauser MM.
        JAMA Netw Open. 2021 Mar 1;4(3):e212007.
        IMPORTANCE: Hospital antimicrobial consumption data are widely available; however, large-scale assessments of the quality of antimicrobial use in US hospitals are limited. OBJECTIVE: To evaluate the appropriateness of antimicrobial use for hospitalized patients treated for community-acquired pneumonia (CAP) or urinary tract infection (UTI) present at admission or for patients who had received fluoroquinolone or intravenous vancomycin treatment. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study included data from a prevalence survey of hospitalized patients in 10 Emerging Infections Program sites. Random samples of inpatients on hospital survey dates from May 1 to September 30, 2015, were identified. Medical record data were collected for eligible patients with 1 or more of 4 treatment events (CAP, UTI, fluoroquinolone treatment, or vancomycin treatment), which were selected on the basis of common infection types reported and antimicrobials given to patients in the prevalence survey. Data were analyzed from August 1, 2017, to May 31, 2020. EXPOSURE: Antimicrobial treatment for CAP or UTI or with fluoroquinolones or vancomycin. MAIN OUTCOMES AND MEASURES: The percentage of antimicrobial use that was supported by medical record data (including infection signs and symptoms, microbiology test results, and antimicrobial treatment duration) or for which some aspect of use was unsupported. Unsupported antimicrobial use was defined as (1) use of antimicrobials to which the pathogen was not susceptible, use in the absence of documented infection signs or symptoms, or use without supporting microbiologic data; (2) use of antimicrobials that deviated from recommended guidelines; or (3) use that exceeded the recommended duration. RESULTS: Of 12 299 patients, 1566 patients (12.7%) in 192 hospitals were included; the median age was 67 years (interquartile range, 53-79 years), and 864 (55.2%) were female. A total of 219 patients (14.0%) were included in the CAP analysis, 452 (28.9%) in the UTI analysis, 550 (35.1%) in the fluoroquinolone analysis, and 403 (25.7%) in the vancomycin analysis; 58 patients (3.7%) were included in both fluoroquinolone and vancomycin analyses. Overall, treatment was unsupported for 876 of 1566 patients (55.9%; 95% CI, 53.5%-58.4%): 110 of 403 (27.3%) who received vancomycin, 256 of 550 (46.6%) who received fluoroquinolones, 347 of 452 (76.8%) with a diagnosis of UTI, and 174 of 219 (79.5%) with a diagnosis of CAP. Among patients with unsupported treatment, common reasons included excessive duration (103 of 174 patients with CAP [59.2%]) and lack of documented infection signs or symptoms (174 of 347 patients with UTI [50.1%]). CONCLUSIONS AND RELEVANCE: The findings suggest that standardized assessments of hospital antimicrobial prescribing quality can be used to estimate the appropriateness of antimicrobial use in large groups of hospitals. These assessments, performed over time, may inform evaluations of the effects of antimicrobial stewardship initiatives nationally.

    • Laboratory Sciences
      • Machine learning and applications in microbiologyexternal icon
        Goodswen SJ, Barratt JL, Kennedy PJ, Kaufer A, Calarco L, Ellis JT.
        FEMS Microbiol Rev. 2021 Mar 16.
        To understand the intricacies of microorganisms at the molecular level requires making sense of copious volumes of data such that it may now be humanly impossible to detect insightful data patterns without an artificial intelligence application called machine learning. Applying machine learning to address biological problems is expected to grow at an unprecedented rate, yet it is perceived by the uninitiated as a mysterious and daunting entity entrusted to the domain of mathematicians and computer scientists. The aim of this review is to identify key points required to start the journey of becoming an effective machine learning practitioner. These key points are further reinforced with an evaluation of how machine learning has been applied so far in a broad scope of real-life microbiology examples. This includes predicting drug targets or vaccine candidates, diagnosing microorganisms causing infectious diseases, classifying drug resistance against antimicrobial medicines, predicting disease outbreaks and exploring microbial interactions. Our hope is to inspire microbiologists and other related researchers to join the emerging machine learning revolution.

    • Occupational Safety and Health
      • Health Care Access Among Essential Critical Infrastructure Workers, 31 States, 2017-2018external icon
        Boal WL, Li J, Silver SR.
        Public Health Rep. 2021 Mar 9:33354921996688.
        OBJECTIVES: Essential workers in the United States need access to health care services for preventive care and for diagnosis and treatment of illnesses (coronavirus disease 2019 [COVID-19] or other infectious or chronic diseases) to remain healthy and continue working during a pandemic. This study evaluated access to health care services among selected essential workers. METHODS: We used the most recent data from the Behavioral Risk Factor Surveillance System, 2017-2018, to estimate the prevalence of 4 measures of health care access (having health insurance, being able to afford to see a doctor when needed, having a personal health care provider, and having a routine checkup in the past year) by broad and detailed occupation group among 189 208 adults aged 18-64. RESULTS: Of all occupations studied, workers in farming, fishing, and forestry occupations were most likely to have no health insurance (46.4%). Personal care aides were most likely to have been unable to see a doctor when needed because of cost (29.3%). Construction laborers were most likely to lack a personal health care provider (51.1%) and to have not had a routine physical checkup in the past year (50.6%). Compared with workers in general, workers in 3 broad occupation groups-food preparation and serving; building and grounds cleaning and maintenance; and construction trades-had significantly lower levels of health care access for all 4 measures. CONCLUSION: Lack of health insurance and underinsurance were common among subsets of essential workers. Limited access to health care might decrease essential workers' access to medical testing and needed care and hinder their ability to address underlying conditions, thereby increasing their risk of severe outcomes from some infectious diseases, such as COVID-19. Improving access to health care for all workers, including essential workers, is critical to ensure workers' health and workforce stability.

    • Parasitic Diseases
      • Antimalarials, in particular artemisinin-based combination therapies (ACTs), are critical tools in reducing the global burden of malaria, which is concentrated in sub-Saharan Africa. Performing and reporting antimalarial efficacy studies in a transparent and standardized fashion permit comparison of efficacy outcomes across countries and time periods. This systematic review summarizes study compliance with WHO laboratory and reporting guidance pertaining to antimalarial therapeutic efficacy studies and evaluates how well studies from sub-Saharan Africa adhered to these guidelines. We included all published studies (January 2020 or before) performed in sub-Saharan Africa where ACT efficacy for treatment of uncomplicated Plasmodium falciparum infection was reported. The primary outcome was a composite indicator for study methodology consistent with WHO guidelines for statistical analysis of corrected efficacy, defined as an article presenting a Kaplan-Meier survival analysis of corrected efficacy or reporting a per-protocol analysis where new infections were excluded from the numerator and denominator. Of 581 articles screened, we identified 279 for the review. Molecular correction was used in 83% (232/279) to distinguish new infections from recrudescences in subjects experiencing recurrent parasitemia. Only 45% (99/221) of articles with therapeutic efficacy as a primary outcome and performing molecular correction reported corrected efficacy outcomes calculated in a way consistent with WHO recommendations. These results indicate a widespread lack of compliance with WHO-recommended methods of analysis, which may result in biases in how antimalarial effectiveness is being measured and reported from sub-Saharan Africa.

    • Reproductive Health
    • Substance Use and Abuse

  2. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Chronic Diseases and Conditions
      1. Manhattan Vision Screening and Follow-Up Study in Vulnerable Populations: 1-Month Feasibility Resultsexternal icon
        Hark LA, Tan CS, Kresch YS, De Moraes CG, Horowitz JD, Park L, Auran JD, Gorroochurn P, Stempel S, Maruri SC, Besagar S, Saaddine JB, Lambert BC, Pizzi LT, Sapru S, Price S, Williams OA, Cioffi GA, Liebmann JM.
        Curr Eye Res. 2021 Mar 16.
        PURPOSE/AIM: In the United States, high rates of vision impairment and eye disease disproportionately impact those who lack access to eye care, specifically vulnerable populations. The objective of our study was to test instruments, implement protocols, and collect preliminary data for a larger 5-year study, which aims to improve detection of eye diseases and follow-up eye care in vulnerable populations using community health workers (CHW) and patient navigators. In the study, trained CHWs conducted vision screening and patient navigators scheduled on-site eye exams and arranged appointments for those referred to ophthalmology to improve adherence to follow-up eye care. MATERIALS AND METHODS: Eligible individuals age 40-and-older were recruited from the Riverstone Senior Center in upper Manhattan, New York City. Participants underwent on-site vision screening (visual acuity with correction, intraocular pressure measurements, and fundus photography). Individuals who failed the vision screening were scheduled with an on-site optometrist for an eye exam; those with ocular pathologies were referred to an ophthalmologist. Participants were also administered the National Eye Institute Visual Function Questionnaire-8 (NEI-VFQ-8) and Stopping Elderly Accidents, Deaths, and Injuries (STEADI) test by community health workers. RESULTS: Participants (n=42) were predominantly older adults, with a mean age of 70.0 ± 9.8, female (61.9%), and Hispanic (78.6%). Most individuals (78.6%, n=33) failed vision screening. Of those who failed, 84.8% (n=28) attended the on-site eye exam with the optometrist. Ocular diagnoses: refractive error 13/28 (46.4%), glaucoma/glaucoma suspect 9/28 (32.1%), cataract 7/28 (25.0%), retina abnormalities 6/28 (21.4%); 13 people required eyeglasses. CONCLUSION: This study demonstrates the feasibility of using CHWs and patient navigators for reducing barriers to vision screening and optometrist-based eye exams in vulnerable populations, ultimately improving early detection of eye disease and linking individuals to additional eye care appointments. The full five-year study aims to further examine these outcomes.

      2. BACKGROUND: We sought to understand barriers and facilitators to implementing distress screening (DS) of cancer patients to inform and promote uptake in cancer treatment facilities. We describe the recruitment and data collection challenges and recommendations for assessing DS in oncology treatment facilities. METHODS: We recruited CoC-accredited facilities and collected data from each facility's electronic health record (EHR). Collected data included cancer diagnosis and demographics, details on DS, and other relevant patient health data. Data were collected by external study staff who were given access to the facility's EHR system, or by facility staff working locally within their own EHR system. Analyses are based on a pilot study of 9 facilities. RESULTS: Challenges stemmed from being a multi-facility-based study and local institutional review board (IRB) approval, facility review and approval processes, and issues associated with EHR systems and the lack of DS data standards. Facilities that provided study staff remote-access took longer for recruitment; facilities that performed their own extraction/abstraction took longer to complete data collection. CONCLUSION: Examining DS practices and follow-up among cancer survivors necessitated recruiting and working directly with multiple healthcare systems and facilities. There were a number of lessons learned related to recruitment, enrollment, and data collection. Using the facilitators described in this manuscript offers increased potential for working successfully with various cancer centers and insight into partnering with facilities collecting non-standardized DS clinical data.

    • Communicable Diseases
      1. Factors linked to severe outcomes in multisystem inflammatory syndrome in children (MIS-C) in the USA: a retrospective surveillance studyexternal icon
        Abrams JY, Oster ME, Godfred-Cato SE, Bryant B, Datta SD, Campbell AP, Leung JW, Tsang CA, Pierce TJ, Kennedy JL, Hammett TA, Belay ED.
        Lancet Child Adolesc Health. 2021 Mar 9.
        BACKGROUND: Multisystem inflammatory syndrome in children (MIS-C) is a newly identified and serious health condition associated with SARS-CoV-2 infection. Clinical manifestations vary widely among patients with MIS-C, and the aim of this study was to investigate factors associated with severe outcomes. METHODS: In this retrospective surveillance study, patients who met the US Centers for Disease Control and Prevention (CDC) case definition for MIS-C (younger than 21 years, fever, laboratory evidence of inflammation, admitted to hospital, multisystem [≥2] organ involvement [cardiac, renal, respiratory, haematological, gastrointestinal, dermatological, or neurological], no alternative plausible diagnosis, and either laboratory confirmation of SARS-CoV-2 infection by RT-PCR, serology, or antigen test, or known COVID-19 exposure within 4 weeks before symptom onset) were reported from state and local health departments to the CDC using standard case-report forms. Factors assessed for potential links to severe outcomes included pre-existing patient factors (sex, age, race or ethnicity, obesity, and MIS-C symptom onset date before June 1, 2020) and clinical findings (signs or symptoms and laboratory markers). Logistic regression models, adjusted for all pre-existing factors, were used to estimate odds ratios between potential explanatory factors and the following outcomes: intensive care unit (ICU) admission, shock, decreased cardiac function, myocarditis, and coronary artery abnormalities. FINDINGS: 1080 patients met the CDC case definition for MIS-C and had symptom onset between March 11 and Oct 10, 2020. ICU admission was more likely in patients aged 6-12 years (adjusted odds ratio 1·9 [95% CI 1·4-2·6) and patients aged 13-20 years (2·6 [1·8-3·8]), compared with patients aged 0-5 years, and more likely in non-Hispanic Black patients, compared with non-Hispanic White patients (1·6 [1·0-2·4]). ICU admission was more likely for patients with shortness of breath (1·9 [1·2-2·9]), abdominal pain (1·7 [1·2-2·7]), and patients with increased concentrations of C-reactive protein, troponin, ferritin, D-dimer, brain natriuretic peptide (BNP), N-terminal pro B-type BNP, or interleukin-6, or reduced platelet or lymphocyte counts. We found similar associations for decreased cardiac function, shock, and myocarditis. Coronary artery abnormalities were more common in male patients (1·5 [1·1-2·1]) than in female patients and patients with mucocutaneous lesions (2·2 [1·3-3·5]) or conjunctival injection (2·3 [1·4-3·7]). INTERPRETATION: Identification of important demographic and clinical characteristics could aid in early recognition and prompt management of severe outcomes for patients with MIS-C. FUNDING: None.

      2. Addressing Operational Challenges Faced by COVID-19 Public Health Rapid Response Teams in Non-United States Settingsexternal icon
        Anantharam P, Hoffman A, Noonan M, Bugli D, Pechta L, Bornemann J, Victory KR, Greiner AL.
        Disaster Med Public Health Prep. 2020 Dec 22:1-5.
        The coronavirus disease 2019 (COVID-19) global response underscores the need for a multidisciplinary approach that integrates and coordinates various public health systems-surveillance, laboratory, and health-care systems/networks, among others-as part of a larger emergency response system. Multidisciplinary public health rapid response teams (RRTs) are one mechanism used within a larger COVID-19 outbreak response strategy. As COVID-19 RRTs are deployed, countries are facing operational challenges in optimizing their RRT's impact, while ensuring the safety of their RRT responders. From March to May 2020, United States Centers for Disease Control and Prevention received requests from 12 countries for technical assistance related to COVID-19 RRTs and emergency operations support. Challenges included: (1) an insufficient number of RRT responders available for COVID-19 deployments; (2) limited capacity to monitor RRT responders' health, safety, and resiliency; (3) difficulty converting critical in-person RRT operational processes to remote information technology platforms; and (4) stigmatization of RRT responders hindering COVID-19 interventions. Although geographically and socioeconomically diverse, these 12 countries experienced similar RRT operational challenges, indicating potential applicability to other countries. As the response has highlighted the critical need for immediate and effective implementation measures, addressing these challenges is essential to ensuring an impactful and sustainable COVID-19 response strategy globally.

      3. Central monitoring in a randomized, open-label, controlled phase 3 clinical trial for a treatment-shortening regimen for pulmonary tuberculosisexternal icon
        Bryant KE, Yuan Y, Engle M, Kurbatova EV, Allen-Blige C, Batra K, Brown NE, Chiu KW, Davis H, Elskamp M, Fagley M, Fedrick P, Hedges KN, Narunsky K, Nassali J, Phan M, Phan H, Purfield AE, Ricaldi JN, Robergeau-Hunt K, Whitworth WC, Sizemore EE.
        Contemp Clin Trials. 2021 Mar 10:106355.
        INTRODUCTION: With the growing use of online study management systems and rapid availability of data, timely data review and quality assessments are necessary to ensure proper clinical trial implementation. In this report we describe central monitoring used to ensure protocol compliance and accurate data reporting, implemented during a large phase 3 clinical trial. MATERIAL AND METHODS: The Tuberculosis Trials Consortium (TBTC) Study 31/AIDS Clinical Trials Group (ACTG) study A5349 (S31) is an international, multi-site, randomized, open-label, controlled, non-inferiority phase 3 clinical trial comparing two 4-month regimens to a standard 6 month regimen for treatment of drug-susceptible tuberculosis (TB) among adolescents and adults with a sample size of 2500 participants. RESULTS: Central monitoring utilized primary study data in a five-tiered approach, including (1) real-time data checks & topic-specific intervention reports, (2) missing forms reports, (3) quality assurance metrics, (4) critical data reports and (5) protocol deviation identification, aimed to detect and resolve quality challenges. Over the course of the study, 240 data checks and reports were programed across the five tiers used. DISCUSSION: This use of primary study data to identify issues rapidly allowed the study sponsor to focus quality assurance and data cleaning activities on prioritized data, related to protocol compliance and accurate reporting of study results. Our approach enabled us to become more efficient and effective as we informed sites about deviations, resolved missing or inconsistent data, provided targeted guidance, and gained a deeper understanding of challenges experienced at clinical trial sites. TRIAL REGISTRATION: This trial was registered with ClinicalTrials.gov (Identifier: NCT02410772) on April 8, 2015.

      4. Treatment success for patients with tuberculosis receiving care in areas severely affected by Hurricane Matthew - Haiti, 2016external icon
        Charles M, Richard M, Reichler MR, Koama JB, Morose W, Fitter DL.
        PLoS One. 2021 ;16(3):e0247750.
        BACKGROUND: On October 4, 2016, Hurricane Matthew struck southwest Haiti as a category 4 storm. The goal of this study was to evaluate the impact of the hurricane on tuberculosis (TB) services and patient outcomes in the three severely affected departments-Sud, Grand'Anse, and Nippes-of southwest Haiti. METHODS: We developed a standard questionnaire to assess a convenience sample of health facilities in the affected areas, a patient tracking form, and a line list for tracking all patients with drug-susceptible TB registered in care six months before the hurricane. We analyzed data from the national TB electronic surveillance system to determine outcomes for all patients receiving anti-TB treatment in the affected areas. We used logistic regression analysis to determine factors associated with treatment success. RESULTS: Of the 66 health facilities in the three affected departments, we assessed 31, accounting for 536 (45.7%) of 1,174 TB patients registered in care when Hurricane Matthew made landfall in Haiti. Three (9.7%) health facilities sustained moderate to severe damage, whereas 18 (58.1%) were closed for <1 week, and five (16.1%) for ≥1 week. Four weeks after the hurricane, 398 (73.1%) of the 536 patients in the assessed facilities were located. Treatment success in the affected departments one year after the hurricane was 81.4%. Receiving care outside the municipality of residence (adjusted odds ratio [aOR]: 0.46, 95% confidence interval [CI]: 0.27-0.80) and HIV positivity (aOR: 0.31, 95% CI: 0.19-0.51) or unknown HIV status (aOR: 0.49, 95% CI: 0.33-0.74) were associated with significantly lower rates of treatment success. CONCLUSIONS: Despite major challenges, a high percentage of patients receiving anti-TB treatment before the hurricane were located and successfully treated in southwest Haiti. The lessons learned and results presented here may help inform policies and guidelines in similar settings for effective TB control after a natural disaster.

      5. Antibiotic prophylaxis in vaccinated eculizumab recipients who developed meningococcal diseaseexternal icon
        Crew PE, McNamara L, Waldron PE, McCulley L, Christopher Jones S, Bersoff-Matcha SJ.
        J Infect. 2020 Mar;80(3):350-371.

      6. Community-based progress indicators for prevention of mother-to-child transmission and mortality rates in HIV-exposed children in rural Mozambiqueexternal icon
        Fuente-Soro L, Fernández-Luis S, López-Varela E, Augusto O, Nhampossa T, Nhacolo A, Bernardo E, Burgueño B, Ngeno B, Couto A, Guambe H, Tibana K, Urso M, Naniche D.
        BMC Public Health. 2021 Mar 17;21(1):520.
        BACKGROUND: Eliminating mother-to-child HIV-transmission (EMTCT) implies a case rate target of new pediatric HIV-infections< 50/100,000 live-births and a transmission rate < 5%. We assessed these indicators at community-level in Mozambique, where MTCT is the second highest globally.. METHODS: A cross-sectional household survey was conducted within the Manhiça Health Demographic Surveillance System in Mozambique (October 2017-April 2018). Live births in the previous 4 years were randomly selected, and mother/child HIV-status was ascertained through documentation or age-appropriate testing. Estimates on prevalence and transmission were adjusted by multiple imputation chained equation (MICE) for participants with missing HIV-status. Retrospective cumulative mortality rate and risk factors were estimate by Fine-Gray model. RESULTS: Among 5000 selected mother-child pairs, 3486 consented participate. Community HIV-prevalence estimate in mothers after MICE adjustment was 37.6% (95%CI:35.8-39.4%). Estimates doubled in adolescents aged < 19 years (from 8.0 to 19.1%) and increased 1.5-times in mothers aged < 25 years. Overall adjusted vertical HIV-transmission at the time of the study were 4.4% (95% CI:3.1-5.7%) in HIV-exposed children (HEC). Pediatric case rate-infection was estimated at 1654/100,000 live-births. Testing coverage in HEC was close to 96.0%; however, only 69.1% of them were tested early(< 2 months of age). Cumulative child mortality rate was 41.6/1000 live-births. HIV-positive status and later birth order were significantly associated with death. Neonatal complications, HIV and pneumonia were main pediatric causes of death. CONCLUSIONS: In Mozambique, SPECTRUM modeling estimated 15% MTCT, higher than our district-level community-based estimates of MTCT among HIV-exposed children. Community-based subnational assessments of progress towards EMTCT are needed to complement clinic-based and modeling estimates.

      7. Hepatitis C virus (HCV) infection remains an important cause of morbidity and mortality throughout the world, leading to serious health problems among those who are chronically infected. Since 1992, the Centers for Disease Control and Prevention has been collecting data on the incidence of HCV infection in the United States. In 2018, more than 50 000 individuals were estimated to have acute HCV infection.The most recently reported data on the prevalence of infection indicate that approximately 2.4 million people are living with hepatitis C in the United States. Transmission of HCV occurs predominantly through sharing contaminated equipment for injecting drugs.Two major events have had a significant impact on the incidence and prevalence of hepatitis C in the past few decades: the US opioid crisis and the discovery of curative treatments for HCV infection. To better understand the impact of these events, we examine reported trends in the incidence and prevalence of infection. (Am J Public Health. Published online ahead of print March 18, 2021: e1-e7. https://doi.org/10.2105/AJPH.2020.306149).

      8. Assessment of US Public School District Policies for Pandemic Preparedness and Implications for COVID-19 Response Activitiesexternal icon
        Kersten CA, Chamberlain AT, Jones SE, Uzicanin A, Ahmed F.
        Disaster Med Public Health Prep. 2021 .
        Objectives: To describe school district preparedness for school closures and other relevant strategies before the coronavirus disease 2019 (COVID-19) pandemic. Methods: A stratified random sample of 957 public school districts from the 50 US states and the District of Columbia were surveyed between October 2015 and August 2016. The response rates for the questionnaires were as follows: Healthy and Safe School Environment, Crisis Preparedness Module (60%; N = 572), Nutrition Services (63%; N = 599), and Health Services (64%; N = 613). Data were analyzed using descriptive and regression techniques. Results: Most school districts had procedures that would facilitate the implementation of school closures (88.7%). Fewer districts had plans for ensuring continuity of education (43.0%) or feeding students during closure (33.8%). The prevalence of continuity of education plans was lower in the Midwest than the Northeast (adjusted prevalence ratio [aPR] = 0.68; 95% confidence interval [CI]: 0.51-0.90). Presence of plans for feeding students was higher in high-poverty than low-poverty districts (aPR = 1.41; 95% CI: 1.01-1.99) and in large districts than small districts (aPR = 2.06; 95% CI: 1.37-3.09). Conclusions: Understanding factors associated with having comprehensive emergency plans could help decision makers to target assistance during the current COVID-19 pandemic and for future planning purposes. © 2020 Society for Disaster Medicine and Public Health, Inc.

      9. Tuberculosis Outbreak Associated With Delayed Diagnosis and Long Infectious Periods in Rural Arkansas, 2010-2018external icon
        Labuda SM, McDaniel C, Talwar A, Braumuller A, Parker S, McGaha S, Blissett C, Wortham J, Mukasa L, Stewart RJ.
        Public Health Rep. 2021 Mar 17:33354921999167.
        OBJECTIVES: During 2010-2018, the Arkansas Department of Health reported 21 genotype-matched cases of tuberculosis (TB) among residents of a rural county in Arkansas with a low incidence of TB and in nearby counties. The Arkansas Department of Health and the Centers for Disease Control and Prevention investigated to determine the extent of TB transmission and provide recommendations for TB control. METHODS: We reviewed medical and public health records, interviewed patients, and reviewed patients' social media posts to describe patient characteristics, identify epidemiologic links, and establish likely chains of transmission. RESULTS: We identified 21 cases; 11 reported during 2010-2013 and 10 during 2016-2018. All case patients were US-born non-Hispanic Black people. Eighteen case patients had the outbreak genotype, and 3 clinically diagnosed (non-culture-confirmed) case patients had epidemiologic links to patients with the outbreak genotype. Social media reviews revealed epidemiologic links among 10 case patients not previously disclosed during interviews. Eight case patients (38%) had ≥1 health care visit during their infectious period, and 7 patients had estimated infectious periods of >12 months. CONCLUSIONS: Delayed diagnoses and prolonged infectiousness led to TB transmission in this rural community. TB education and awareness is critical to reducing transmission, morbidity, and mortality, especially in areas where health care providers have limited TB experience. Use of social media can help elucidate people at risk, especially when traditional TB investigation techniques are insufficient.

      10. Early post-partum viremia predicts long-term non-suppression of viral load in HIV-positive women on ART in Malawi: Implications for the elimination of infant transmissionexternal icon
        Landes M, van Lettow M, van Oosterhout JJ, Schouten E, Auld A, Kalua T, Jahn A, Tippett Barr BA.
        PLoS One. 2021 ;16(3):e0248559.
        BACKGROUND: Long-term viral load (VL) suppression among HIV-positive, reproductive-aged women on ART is key to eliminating mother-to-child transmission (MTCT) but few data exist from sub-Saharan Africa. We report trends in post-partum VL in Malawian women on ART and factors associated with detectable VL up to 24 months post-partum. METHODS: 1-6 months post-partum mothers, screened HIV-positive at outpatient clinics in Malawi, were enrolled (2014-2016) with their infants. At enrollment, 12- and 24-months post-partum socio-demographic and PMTCT indicators were collected. Venous samples were collected for determination of maternal VL (limit of detection 40 copies/ml). Results were returned to clinics for routine management. RESULTS: 596/1281 (46.5%) women were retained in the study to 24 months. Those retained were older (p<0.01), had higher parity (p = 0.03) and more likely to have undetectable VL at enrollment than those lost to follow-up (80.0% vs 70.2%, p<0.01). Of 590 women on ART (median 30.1 months; inter-quartile range 26.8-61.3), 442 (74.9%) with complete VL data at 3 visits were included in further analysis. Prevalence of detectable VL at 12 and 24 months was higher among women with detectable VL at enrollment than among those with undetectable VL (74 detectable VL results/66 women vs. 19/359; p<0.001). In multivariable analysis (adjusted for age, parity, education, partner disclosure, timing of ART start and self-reported adherence), detectable VL at 24 months was 9 times more likely among women with 1 prior detectable VL (aOR 9.0; 95%CI 3.5-23.0, p<0.001) and 226 times more likely for women with 2 prior detectable VLs (aOR 226.4; 95%CI 73.0-701.8, p<0.001). CONCLUSIONS: Detectable virus early post-partum strongly increases risk of ongoing post-partum viremia. Due to high loss to follow-up, the true incidence of detectable VL over time is probably underestimated. These findings have implications for MTCT, as well as for the mothers, and call for intensified VL monitoring and targeted adherence support for women during pregnancy and post-partum.

      11. Hepatitis B surface antigen seroprevalence among children in the Philippines, 2018external icon
        Minta AA, Silva MW, Shrestha A, de Quiroz-Castro M, Tohme RA, Quimson ME, Jiz MA, Woodring J.
        Vaccine. 2021 Mar 9.
        The World Health Organization Western Pacific Region (WPR) set a hepatitis B virus (HBV) control target to achieve HBV surface antigen (HBsAg) prevalence of <1% among children aged 5 years by 2017. The estimated HBsAg prevalence in the Philippines among adults was 16.7% during the pre-vaccine era. We estimated the HBsAg seroprevalence among children aged 5-7 years to measure the impact of vaccination. We conducted a household serosurvey, using a three-stage cluster survey methodology (provinces, clusters, and households). We estimated HBsAg prevalence using a rapid, point-of-care HBsAg test and calculated vaccination coverage by reviewing vaccination records or by caregiver recall. A questionnaire was administered to assess demographic variables for the child and family. We assessed the association between chronic HBV infection, vaccination coverage, and demographic variables, accounting for the complex survey design. Of the 2178 children tested, HBsAg was detected in 15 children [0.8%, 95% confidence interval (CI): 0.4, 1.7]. Only two of the HBsAg-positive children had been fully vaccinated against HBV. Based on documented vaccination or caregiver recall for the survey population, hepatitis B vaccine birth dose (HepB-BD) coverage was 53%, and the third dose hepatitis B vaccination (HepB3) coverage was 73 percent. Among the 1362 children with documented HepB-BD, timely HepB-BD coverage (given within 24 h of birth) was 43%; children born outside a health facility were less likely to receive a timely HepB-BD than those born in a health facility (adjusted odds ratio 0.10, 95% CI: 0.04, 0.23). HBsAg prevalence among children in the Philippines has decreased compared to the prevalence among adults in the pre-vaccination era. Strategies to further reduce HBsAg prevalence include ensuring that all children, whether born in health facilities or at home, receive a timely HepB-BD, and increasing HepB-BD and HepB3 coverage to reach the WPR goals of ≥95% coverage.

      12. Prevalence of SARS-CoV-2 in six districts in Zambia in July, 2020: a cross-sectional cluster sample surveyexternal icon
        Mulenga LB, Hines JZ, Fwoloshi S, Chirwa L, Siwingwa M, Yingst S, Wolkon A, Barradas DT, Favaloro J, Zulu JE, Banda D, Nikoi KI, Kampamba D, Banda N, Chilopa B, Hanunka B, Stevens TL, Shibemba A, Mwale C, Sivile S, Zyambo KD, Makupe A, Kapina M, Mweemba A, Sinyange N, Kapata N, Zulu PM, Chanda D, Mupeta F, Chilufya C, Mukonka V, Agolory S, Malama K.
        Lancet Glob Health. 2021 Mar 9.
        BACKGROUND: Between March and December, 2020, more than 20 000 laboratory-confirmed cases of SARS-CoV-2 infection were reported in Zambia. However, the number of SARS-CoV-2 infections is likely to be higher than the confirmed case counts because many infected people have mild or no symptoms, and limitations exist with regard to testing capacity and surveillance systems in Zambia. We aimed to estimate SARS-CoV-2 prevalence in six districts of Zambia in July, 2020, using a population-based household survey. METHODS: Between July 4 and July 27, 2020, we did a cross-sectional cluster-sample survey of households in six districts of Zambia. Within each district, 16 standardised enumeration areas were randomly selected as primary sampling units using probability proportional to size. 20 households from each standardised enumeration area were selected using simple random sampling. All members of selected households were eligible to participate. Consenting participants completed a questionnaire and were tested for SARS-CoV-2 infection using real-time PCR (rtPCR) and anti-SARS-CoV-2 antibodies using ELISA. Prevalence estimates, adjusted for the survey design, were calculated for each diagnostic test separately, and combined. We applied the prevalence estimates to census population projections for each district to derive the estimated number of SARS-CoV-2 infections. FINDINGS: Overall, 4258 people from 1866 households participated in the study. The median age of participants was 18·2 years (IQR 7·7-31·4) and 50·6% of participants were female. SARS-CoV-2 prevalence for the combined measure was 10·6% (95% CI 7·3-13·9). The rtPCR-positive prevalence was 7·6% (4·7-10·6) and ELISA-positive prevalence was 2·1% (1·1-3·1). An estimated 454 708 SARS-CoV-2 infections (95% CI 312 705-596 713) occurred in the six districts between March and July, 2020, compared with 4917 laboratory-confirmed cases reported in official statistics from the Zambia National Public Health Institute. INTERPRETATION: The estimated number of SARS-CoV-2 infections was much higher than the number of reported cases in six districts in Zambia. The high rtPCR-positive SARS-CoV-2 prevalence was consistent with observed community transmission during the study period. The low ELISA-positive SARS-CoV-2 prevalence might be associated with mitigation measures instituted after initial cases were reported in March, 2020. Zambia should monitor patterns of SARS-CoV-2 prevalence and promote measures that can reduce transmission. FUNDING: US Centers for Disease Control and Prevention.

      13. Altered Antibody Responses in Persons Infected with HIV-1 While Using Preexposure Prophylaxisexternal icon
        Parker I, Khalil G, Martin A, Martin M, Vanichseni S, Leelawiwat W, McNicholl J, Hickey A, García-Lerma JG, Choopanya K, Curtis KA.
        AIDS Res Hum Retroviruses. 2021 Mar;37(3):189-195.
        Preexposure prophylaxis (PrEP) is an effective HIV prevention tool, although effectiveness is dependent upon adherence. It is important to characterize the impact of PrEP on HIV antibody responses in people who experience breakthrough infections to understand the potential impact on timely diagnosis and treatment. Longitudinal HIV-1-specific antibody responses were evaluated in 42 people who inject drugs (PWID) from the Bangkok Tenofovir Study (BTS) (placebo = 28; PrEP = 14) who acquired HIV while receiving PrEP. HIV-1 antibody levels and avidity to three envelope proteins (gp41, gp160, and gp120) were measured in the plasma using a customized Bio-Plex (Bio-Rad Laboratories, Hercules, CA) assay. A time-to-event analysis was performed for each biomarker to compare the distribution of times at which study subjects exceeded the recent/long-term assay threshold, comparing PrEP and placebo treatment groups. We fit mixed-effects models to identify longitudinal differences in antibody levels and avidity between groups. Overall, longitudinal antibody levels and avidity were notably lower in the PrEP breakthrough group compared to the placebo group. Time-to-event analyses demonstrated a difference in time to antibody reactivity between treatment groups for all Bio-Plex biomarkers. Longitudinal gp120 antibody levels within the PrEP breakthrough group were decreased compared to the placebo group. When accounting for PrEP adherence, both gp120 and gp160 antibody levels were lower in the PrEP breakthrough group compared to the placebo group. We demonstrate hindered envelope antibody maturation in PWID who became infected while receiving PrEP in the BTS, which has significant implications for HIV diagnosis. Delayed maturation of the antibody response to HIV may increase the time to detection for antibody-based tests. Clinical Trial Registration Number, NCT00119106.

      14. Shelter Characteristics, Infection Prevention Practices, and Universal Testing for SARS-CoV-2 at Homeless Shelters in 7 US Urban Areasexternal icon
        Self JL, Montgomery MP, Toews KA, Samuels EA, Imbert E, McMichael TM, Marx GE, Lohff C, Andrews T, Ghinai I, Mosites E.
        Am J Public Health. 2021 Mar 18:e1-e6.
        Objectives. To examine shelter characteristics and infection prevention practices in relation to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection point prevalence during universal testing at homeless shelters in the United States.Methods. SARS-CoV-2 testing was offered to clients and staff at homeless shelters, irrespective of symptoms. Site assessments were conducted from March 30 to June 1, 2020, to collect information on shelter characteristics and infection prevention practices. We assessed the association between SARS-CoV-2 infection prevalence and shelter characteristics, including 20 infection prevention practices by using crude risk ratios (RRs) and exact unconditional 95% confidence intervals (CIs).Results. Site assessments and SARS-CoV-2 testing results were reported for 63 homeless shelters in 7 US urban areas. Median infection prevalence was 2.9% (range = 0%-71.4%). Shelters implementing head-to-toe sleeping and excluding symptomatic staff from working were less likely to have high infection prevalence (RR = 0.5; 95% CI = 0.3, 0.8; and RR = 0.5; 95% CI = 0.4, 0.6; respectively); shelters with medical services available were less likely to have very high infection prevalence (RR = 0.5; 95% CI = 0.2, 1.0).Conclusions. Sleeping arrangements and staffing policies are modifiable factors that might be associated with SARS-CoV-2 infection prevalence in homeless shelters. Shelters should follow recommended practices to reduce the risk of SARS-CoV-2 transmission. (Am J Public Health. Published online ahead of print March 18, 2021: e1-e6. https://doi.org/10.2105/AJPH.2021.306198).

      15. Infectious Period of Severe Acute Respiratory Syndrome Coronavirus 2 in 17 Nursing Home Residents-Arkansas, June-August 2020external icon
        Surie D, Huang JY, Brown AC, Gable P, Biedron C, Gilbert SE, Garner K, Bollinger S, Gulley T, Haney T, Lyons AK, Beshearse E, Gregory CJ, Sabour S, Clemmons NS, James AE, Tamin A, Reese N, Perry-Dow KA, Brown R, Harcourt JL, Campbell D, Houston H, Chakravorty R, Paulick A, Whitaker B, Murdoch J, Spicer L, Stumpf MM, Mills L, Coughlin MM, Higdem P, Rasheed MA, Lonsway D, Bhatnagar A, Kothari A, Anderson K, Thornburg NJ, Breaker E, Adamczyk M, McAllister GA, Halpin AL, Seely KA, Patil N, McDonald LC, Kutty PK.
        Open Forum Infect Dis. 2021 Mar;8(3):ofab048.
        BACKGROUND: To estimate the infectious period of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in older adults with underlying conditions, we assessed duration of coronavirus disease 2019 (COVID-19) symptoms, reverse-transcription polymerase chain reaction (RT-PCR) positivity, and culture positivity among nursing home residents. METHODS: We enrolled residents within 15 days of their first positive SARS-CoV-2 test (diagnosis) at an Arkansas facility from July 7 to 15, 2020 and instead them for 42 days. Every 3 days for 21 days and then weekly, we assessed COVID-19 symptoms, collected specimens (oropharyngeal, anterior nares, and saliva), and reviewed medical charts. Blood for serology was collected on days 0, 6, 12, 21, and 42. Infectivity was defined by positive culture. Duration of culture positivity was compared with duration of COVID-19 symptoms and RT-PCR positivity. Data were summarized using measures of central tendency, frequencies, and proportions. RESULTS: We enrolled 17 of 39 (44%) eligible residents. Median participant age was 82 years (range, 58-97 years). All had ≥3 underlying conditions. Median duration of RT-PCR positivity was 22 days (interquartile range [IQR], 8-31 days) from diagnosis; median duration of symptoms was 42 days (IQR, 28-49 days). Of 9 (53%) participants with any culture-positive specimens, 1 (11%) severely immunocompromised participant remained culture-positive 19 days from diagnosis; 8 of 9 (89%) were culture-positive ≤8 days from diagnosis. Seroconversion occurred in 12 of 12 (100%) surviving participants with ≥1 blood specimen; all participants were culture-negative before seroconversion. CONCLUSIONS: Duration of infectivity was considerably shorter than duration of symptoms and RT-PCR positivity. Severe immunocompromise may prolong SARS-CoV-2 infectivity. Seroconversion indicated noninfectivity in this cohort.

      16. Mass SARS-CoV-2 Testing in a Dormitory-Style Correctional Facility in Arkansasexternal icon
        Tompkins LK, Gunn JK, Cherney B, Ham JE, Horth R, Rossetti R, Bower WA, Benson K, Hagan LM, Crist MB, Mettee Zarecki SL, Dixon MG, Dillaha JA, Patil N, Dusseau C, Ross T, Matthews HS, Garner K, Starks AM, Weiner Z, Bowen MD, Bankamp B, Newton AE, Logan N, Schuh AJ, Trimble S, Pfeiffer H, James AE, Tian N, Jacobs JR, Ruiz F, McDonald K, Thompson M, Cooley L, Honein MA, Rose DA.
        Am J Public Health. 2021 Mar 18:e1-e10.
        Objectives. To assess SARS-CoV-2 transmission within a correctional facility and recommend mitigation strategies.Methods. From April 29 to May 15, 2020, we established the point prevalence of COVID-19 among incarcerated persons and staff within a correctional facility in Arkansas. Participants provided respiratory specimens for SARS-CoV-2 testing and completed questionnaires on symptoms and factors associated with transmission.Results. Of 1647 incarcerated persons and 128 staff tested, 30.5% of incarcerated persons (range by housing unit = 0.0%-58.2%) and 2.3% of staff tested positive for SARS-CoV-2. Among those who tested positive and responded to symptom questions (431 incarcerated persons, 3 staff), 81.2% and 33.3% were asymptomatic, respectively. Most incarcerated persons (58.0%) reported wearing cloth face coverings 8 hours or less per day, and 63.3% reported close contact with someone other than their bunkmate.Conclusions. If testing remained limited to symptomatic individuals, fewer cases would have been detected or detection would have been delayed, allowing transmission to continue. Rapid implementation of mass testing and strict enforcement of infection prevention and control measures may be needed to mitigate spread of SARS-CoV-2 in this setting. (Am J Public Health. Published online ahead of print March 18, 2021: e1-e10. https://doi.org/10.2105/AJPH.2020.306117).

      17. Racial and Ethnic Disparities in COVID-19 Incidence by Age, Sex, and Period Among Persons Aged <25 Years - 16 U.S. Jurisdictions, January 1-December 31, 2020external icon
        Van Dyke ME, Mendoza MC, Li W, Parker EM, Belay B, Davis EM, Quint JJ, Penman-Aguilar A, Clarke KE.
        MMWR Morb Mortal Wkly Rep. 2021 Mar 19;70(11):382-388.
        The COVID-19 pandemic has disproportionately affected racial and ethnic minority groups in the United States. Whereas racial and ethnic disparities in severe COVID-19-associated outcomes, including mortality, have been documented (1-3), less is known about population-based disparities in infection with SARS-CoV-2, the virus that causes COVID-19. In addition, although persons aged <30 years account for approximately one third of reported infections,(§) there is limited information on racial and ethnic disparities in infection among young persons over time and by sex and age. Based on 689,672 U.S. COVID-19 cases reported to CDC's case-based surveillance system by jurisdictional health departments, racial and ethnic disparities in COVID-19 incidence among persons aged <25 years in 16 U.S. jurisdictions(¶) were described by age group and sex and across three periods during January 1-December 31, 2020. During January-April, COVID-19 incidence was substantially higher among most racial and ethnic minority groups compared with that among non-Hispanic White (White) persons (rate ratio [RR] range = 1.09-4.62). During May-August, the RR increased from 2.49 to 4.57 among non-Hispanic Native Hawaiian and Pacific Islander (NH/PI) persons but decreased among other racial and ethnic minority groups (RR range = 0.52-2.82). Decreases in disparities were observed during September-December (RR range = 0.37-1.69); these decreases were largely because of a greater increase in incidence among White persons, rather than a decline in incidence among racial and ethnic minority groups. NH/PI, non-Hispanic American Indian or Alaska Native (AI/AN), and Hispanic or Latino (Hispanic) persons experienced the largest persistent disparities over the entire period. Ensuring equitable and timely access to preventive measures, including testing, safe work and education settings, and vaccination when eligible is important to address racial/ethnic disparities.

      18. Association of Children's Mode of School Instruction with Child and Parent Experiences and Well-Being During the COVID-19 Pandemic - COVID Experiences Survey, United States, October 8-November 13, 2020external icon
        Verlenden JV, Pampati S, Rasberry CN, Liddon N, Hertz M, Kilmer G, Viox MH, Lee S, Cramer NK, Barrios LC, Ethier KA.
        MMWR Morb Mortal Wkly Rep. 2021 Mar 19;70(11):369-376.
        In March 2020, efforts to slow transmission of SARS-CoV-2, the virus that causes COVID-19, resulted in widespread closures of school buildings, shifts to virtual educational models, modifications to school-based services, and disruptions in the educational experiences of school-aged children. Changes in modes of instruction have presented psychosocial stressors to children and parents that can increase risks to mental health and well-being and might exacerbate educational and health disparities (1,2). CDC examined differences in child and parent experiences and indicators of well-being according to children's mode of school instruction (i.e., in-person only [in-person], virtual-only [virtual], or combined virtual and in-person [combined]) using data from the COVID Experiences nationwide survey. During October 8-November 13, 2020, parents or legal guardians (parents) of children aged 5-12 years were surveyed using the NORC at the University of Chicago AmeriSpeak panel,* a probability-based panel designed to be representative of the U.S. household population. Among 1,290 respondents with a child enrolled in public or private school, 45.7% reported that their child received virtual instruction, 30.9% in-person instruction, and 23.4% combined instruction. For 11 of 17 stress and well-being indicators concerning child mental health and physical activity and parental emotional distress, findings were worse for parents of children receiving virtual or combined instruction than were those for parents of children receiving in-person instruction. Children not receiving in-person instruction and their parents might experience increased risk for negative mental, emotional, or physical health outcomes and might need additional support to mitigate pandemic effects. Community-wide actions to reduce COVID-19 incidence and support mitigation strategies in schools are critically important to support students' return to in-person learning.

      19. During fall 2020, many U.S. kindergarten through grade 12 (K-12) schools closed campuses and instituted remote learning to limit in-school transmission of SARS-CoV-2, the virus that causes COVID-19 (1,2). A New Jersey grade 9-12 boarding school with 520 full-time resident students, 255 commuter students, and 405 faculty and staff members implemented a comprehensive mitigation strategy that included universal masking, testing, upgraded air-handling equipment to improve ventilation, physical distancing of ≥6 ft, contact tracing, and quarantine and isolation protocols to prevent and control transmission of SARS-CoV-2 among students, faculty, and staff members. Mandatory twice-weekly screening using real-time reverse transcription-polymerase chain reaction (RT-PCR) testing of all students and staff members during August 20-November 27, 2020, resulted in the testing of 21,449 specimens. A total of 19 (5%) of 405 faculty and staff members and eight (1%) of 775 students received positive test results; only two identified cases were plausibly caused by secondary transmission on campus. Comprehensive mitigation approaches including frequent testing and universal masking can help prevent outbreaks in in-person high school settings even when community transmission is ongoing.

    • Disaster Control and Emergency Services
      1. Social Vulnerability and Access of Local Medical Care During Hurricane Harvey: A Spatial Analysisexternal icon
        Rickless DS, Wilt GE, Sharpe JD, Molinari N, Stephens W, LeBlanc TT.
        Disaster Med Public Health Prep. 2021 Mar 15:1-9.
        OBJECTIVES: When Hurricane Harvey struck the coastline of Texas in 2017, it caused 88 fatalities and over US $125 billion in damage, along with increased emergency department visits in Houston and in cities receiving hurricane evacuees, such as the Dallas-Fort Worth metroplex (DFW).This study explored demographic indicators of vulnerability for patients from the Hurricane Harvey impact area who sought medical care in Houston and in DFW. The objectives were to characterize the vulnerability of affected populations presenting locally, as well as those presenting away from home, and to determine whether more vulnerable communities were more likely to seek medical care locally or elsewhere. METHODS: We used syndromic surveillance data alongside the Centers for Disease Control and Prevention Social Vulnerability Index to calculate the percentage of patients seeking care locally by zip code tabulation area. We used this variable to fit a spatial lag regression model, controlling for population density and flood extent. RESULTS: Communities with more patients presenting for medical care locally were significantly clustered and tended to have greater socioeconomic vulnerability, lower household composition vulnerability, and more extensive flooding. CONCLUSIONS: These findings suggest that populations remaining in place during a natural disaster event may have needs related to income, education, and employment, while evacuees may have more needs related to age, disability, and single-parent household status.

    • Disease Reservoirs and Vectors
      1. Experimental Infection of Amblyomma americanum (Acari: Ixodidae) With Bourbon Virus (Orthomyxoviridae: Thogotovirus)external icon
        Godsey MS, Rose D, Burkhalter KL, Breuner N, Bosco-Lauth AM, Kosoy OI, Savage HM.
        J Med Entomol. 2021 Mar 12;58(2):873-879.
        Following the recent discovery of Bourbon virus (BRBV) as a human pathogen, and the isolation of the virus from Amblyomma americanum (L.) collected near the location of a fatal human case, we undertook a series of experiments to assess the laboratory vector competence of this tick species for BRBV. Larval ticks were infected using an immersion technique, and transstadial transmission of virus to the nymphal and then to the adult stages was demonstrated. Transstadially infected nymphs transmitted virus to adult ticks at very high rates during cofeeding, indicating the presence of infectious virus in the saliva of engorging ticks. Vertical transmission by transstadially infected females to their progeny occurred, but at a low rate. Rabbits fed on by infected ticks of all active life stages developed high titers of antibody to the virus, demonstrating host exposure to BRBV antigens/live virus during tick blood feeding. These results demonstrate that A. americanum is a competent vector of BRBV and indicate that cofeeding could be critical for enzootic maintenance.

      2. The vector competence of mosquitoes for pathogens has been shown to be influenced by the status of insecticide resistance in the mosquito population. However, to date, only two studies has explored the impact of insecticide resistance on arbovirus transmission. The global and widespread use of pyrethroids has led to the development of insecticide resistance in many mosquito species, including Aedes aegypti (Linnaeus) (Diptera: Culicidae), the primary vector of Zika virus. Strains of Ae. aegypti that were genetically similar, but responded differently to pyrethroid exposure, were developed using backcrossing techniques. These populations were orally infected with Zika virus and susceptibility to infection, disseminated infection, and transmission potential were evaluated. Analyses revealed differences in susceptibility to infection and disseminated infection between the pyrethroid susceptible and resistant strains of Ae. aegypti during the infection period. Here, we identify an additional challenge to that of widespread pyrethroid resistance. Specifically, resistance is associated with altered phenotypic traits that influence susceptibility to arbovirus infection and progression of infection in the mosquito, factors which ultimately influence risk of arbovirus transmission. These findings support the need to 1) consider insecticide resistance status during times of arbovirus transmission and 2) to implement insecticide resistance management/ mitigation strategies in vector control programs.

    • Drug Safety
      1. Prescription medication use among Canadian children and youth, 2012 to 2017external icon
        Servais J, Ramage-Morin PL, Gal J, Hales CM.
        Health Rep. 2021 Mar 17;32(3):3-16.
        BACKGROUND: Prescription medications are used throughout the life course, including among children and youth. Prescribing practices may be influenced by emerging medical conditions, the availability of new medications, changing clinical practices, and evolving knowledge of the safety and effectiveness of medications. The Canadian Health Measures Survey (CHMS) provides national-level information to help monitor the use of prescribed medications in the population. DATA AND METHODS: Based on data from the CHMS (2012 to 2017), this article describes prescription medication use in the past month among those aged 3 to 19 years. Information on up to 45 prescription medications was recorded and classified according to Health Canada's Anatomical Therapeutic Chemical classification. Frequencies and bivariate analyses examined medication use by sociodemographic and health-related factors. The most common medication classes were identified for each age group. RESULTS: An estimated 23% of Canadian children and youth (1.5 million) had used at least one prescription medication in the past month and 9% had used two or more prescription medications.Prescription medication use was more common among those who reported lower levels of general and mental health, as well as among those with asthma (51%), a mood disorder (71%), attention deficit disorder (60%) or a learning disability (43%). Medications for the respiratory and nervous systems were among those most commonly prescribed. Of youth aged 14 years or older, 4% had misused prescription medications for non-medicinal purposes, for the experience, for the feeling they cause or to get high. DISCUSSION: Prescription medication use among children and youth is common in Canada. It is associated with lower levels of self-reported health and the presence of chronic conditions. The estimates provide a benchmark to help monitor prescription drug use in Canada.

    • Environmental Health
      1. Machine Learning Models of Arsenic in Private Wells Throughout the Conterminous United States As a Tool for Exposure Assessment in Human Health Studiesexternal icon
        Lombard MA, Bryan MS, Jones DK, Bulka C, Bradley PM, Backer LC, Focazio MJ, Silverman DT, Toccalino P, Argos M, Gribble MO, Ayotte JD.
        Environ Sci Technol. 2021 Mar 17.
        Arsenic from geologic sources is widespread in groundwater within the United States (U.S.). In several areas, groundwater arsenic concentrations exceed the U.S. Environmental Protection Agency maximum contaminant level of 10 μg per liter (μg/L). However, this standard applies only to public-supply drinking water and not to private-supply, which is not federally regulated and is rarely monitored. As a result, arsenic exposure from private wells is a potentially substantial, but largely hidden, public health concern. Machine learning models using boosted regression trees (BRT) and random forest classification (RFC) techniques were developed to estimate probabilities and concentration ranges of arsenic in private wells throughout the conterminous U.S. Three BRT models were fit separately to estimate the probability of private well arsenic concentrations exceeding 1, 5, or 10 μg/L whereas the RFC model estimates the most probable category (≤5, >5 to ≤10, or >10 μg/L). Overall, the models perform best at identifying areas with low concentrations of arsenic in private wells. The BRT 10 μg/L model estimates for testing data have an overall accuracy of 91.2%, sensitivity of 33.9%, and specificity of 98.2%. Influential variables identified across all models included average annual precipitation and soil geochemistry. Models were developed in collaboration with public health experts to support U.S.-based studies focused on health effects from arsenic exposure.

      2. Exposure to 1,3-Butadiene in the U.S. Population: National Health and Nutrition Examination Survey 2011-2016external icon
        Nieto A, Zhang L, Bhandari D, Zhu W, Blount BC, De Jesús VR.
        Biomarkers. 2021 Mar 17:1-40.
        1,3-Butadiene is a volatile organic compound with a gasoline-like odor that is primarily used as a monomer in the production of synthetic rubber. The International Agency for Research on Cancer has classified 1,3-butadiene as a human carcinogen. We assessed 1,3-butadiene exposure in the U.S. population by measuring its urinary metabolites N-acetyl-S-(3,4-dihydroxybutyl)-L-cysteine (34HBMA), N-acetyl-S-(1-hydroxymethyl-2-propenyl)-L-cysteine (1HMPEMA), N-acetyl-S-(2-hydroxy-3-butenyl)-L-cysteine (2HBEMA), and N-acetyl-S-(4-hydroxy-2-buten-1-yl)-L-cysteine (t4HBEMA). Urine samples from the 2011-2016 National Health and Nutrition Examination Survey were analyzed for 1,3-butadiene metabolites using ultrahigh-performance liquid chromatography/tandem mass spectrometry. 34HBMA and t4HBEMA were detected in >96% of the samples; 1HMPEMA and 2HBEMA were detected in 0.66% and 9.84% of the samples, respectively. We used sample-weighted linear regression models to examine the influence of smoking status (using a combination of self-reporting and serum-cotinine data), demographic variables, and diet on biomarker levels. The median t4HBEMA among exclusive smokers (31.5 µg/g creatinine) was higher than in non-users (4.11 µg/g creatinine). Similarly, the median 34HBMA among exclusive smokers (391 µg/g creatinine) was higher than in non-users (296 µg/g creatinine). Furthermore, smoking 1-10, 11-20, and >20 cigarettes per day (CPD) was associated with 475%, 849%, and 1,143% higher t4HBEMA (p < 0.0001), respectively. Additionally, smoking 1-10, 11-20, and >20 CPD was associated with 33%, 44%, and 102% higher 34HBMA (p < 0.0001). These results provide significant baseline data for 1,3-butadiene exposure in the U.S. population, and demonstrate that tobacco smoke is a major exposure source.

    • Epidemiology and Surveillance
      1. Female sex workers population size estimation in Rwanda using a three-source capture-recapture methodexternal icon
        Musengimana G, Tuyishime E, Remera E, Dong M, Sebuhoro D, Mulindabigwi A, Kayirangwa E, Malamba SS, Gutreuter S, Prybylski D, Doshi RH, Catherine K, Mutarabayire V, Nsanzimana S, Mugwaneza P.
        Epidemiol Infect. 2021 Mar 18:1-25.

    • Healthcare Associated Infections
      1. Urinary tract infection treatment practices in nursing homes reporting to the National Healthcare Safety Network, 2017external icon
        Kabbani S, Palms D, Bell JM, Hicks LA, Stone ND.
        Infect Control Hosp Epidemiol. 2021 Mar 12:1-3.
        We describe differences between urinary tract infection treatment and events reported by nursing homes enrolled in the National Healthcare Safety Network. In 2017, almost 4 times as many antibiotic starts as infection events were reported, suggesting that opportunities exist for antibiotic stewardship and improvement of urinary tract infection reporting.

      2. Impact of COVID-19 Pandemic on Central Line-Associated Bloodstream Infections During the Early Months of 2020, National Healthcare Safety Networkexternal icon
        Patel PR, Weiner-Lastinger LM, Dudeck MA, Fike LV, Kuhar DT, Edwards JR, Pollock D, Benin A.
        Infect Control Hosp Epidemiol. 2021 Mar 15:1-8.
        Data reported to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) were analyzed to understand the potential impact of the COVID-19 pandemic on central line-associated bloodstream infections (CLABSIs) in acute care hospitals. Descriptive analysis of the Standardized Infection Ratio (SIR) was conducted by locations, location type, geographic area, and bed size.

    • Immunity and Immunization
      1. Effectiveness of the Pfizer-BioNTech COVID-19 Vaccine Among Residents of Two Skilled Nursing Facilities Experiencing COVID-19 Outbreaks - Connecticut, December 2020-February 2021external icon
        Britton A, Jacobs Slifka KM, Edens C, Nanduri SA, Bart SM, Shang N, Harizaj A, Armstrong J, Xu K, Ehrlich HY, Soda E, Derado G, Verani JR, Schrag SJ, Jernigan JA, Leung VH, Parikh S.
        MMWR Morb Mortal Wkly Rep. 2021 Mar 19;70(11):396-401.
        Residents of long-term care facilities (LTCFs), particularly those in skilled nursing facilities (SNFs), have experienced disproportionately high levels of COVID-19-associated morbidity and mortality and were prioritized for early COVID-19 vaccination (1,2). However, this group was not included in COVID-19 vaccine clinical trials, and limited postauthorization vaccine effectiveness (VE) data are available for this critical population (3). It is not known how well COVID-19 vaccines protect SNF residents, who typically are more medically frail, are older, and have more underlying medical conditions than the general population (1). In addition, immunogenicity of the Pfizer-BioNTech vaccine was found to be lower in adults aged 65-85 years than in younger adults (4). Through the CDC Pharmacy Partnership for Long-Term Care Program, SNF residents and staff members in Connecticut began receiving the Pfizer-BioNTech COVID-19 vaccine on December 18, 2020 (5). Administration of the vaccine was conducted during several on-site pharmacy clinics. In late January 2021, the Connecticut Department of Public Health (CT DPH) identified two SNFs experiencing COVID-19 outbreaks among residents and staff members that occurred after each facility's first vaccination clinic. CT DPH, in partnership with CDC, performed electronic chart review in these facilities to obtain information on resident vaccination status and infection with SARS-CoV-2, the virus that causes COVID-19. Partial vaccination, defined as the period from >14 days after the first dose through 7 days after the second dose, had an estimated effectiveness of 63% (95% confidence interval [CI] = 33%-79%) against SARS-CoV-2 infection (regardless of symptoms) among residents within these SNFs. This is similar to estimated effectiveness for a single dose of the Pfizer-BioNTech COVID-19 vaccine in adults across a range of age groups in noncongregate settings (6) and suggests that to optimize vaccine impact among this population, high coverage with the complete 2-dose series should be recommended for SNF residents and staff members.

      2. American College of Rheumatology Guidance for COVID-19 Vaccination in Patients with Rheumatic and Musculoskeletal Diseases - Version 1external icon
        Curtis JR, Johnson SR, Anthony DD, Arasaratnam RJ, Baden LR, Bass AR, Calabrese C, Gravallese EM, Harpaz R, Kroger A, Sadun RE, Turner AS, Anderson Williams E, Mikuls TR.
        Arthritis Rheumatol. 2021 Mar 17.
        OBJECTIVE: To provide guidance to rheumatology providers on the use of COVID-19 vaccines for patients with rheumatic and musculoskeletal diseases (RMDs). METHODS: A task force was assembled that included 9 rheumatologists/immunologists, 2 infectious disease specialists, and 2 public health physicians. After agreeing on scoping questions, an evidence report was created that summarized the published literature and publicly available data regarding COVID-19 vaccine efficacy and safety, as well as literature for other vaccines in RMD patients. Task force members rated their agreement with draft consensus statements on a 1 to 9 point numerical rating scale using a modified Delphi process and the RAND/UCLA appropriateness method, with refinement and iteration over two sessions. Consensus was determined based on the distribution of ratings. RESULTS: Despite a paucity of direct evidence, seventy-four draft guidance statements were developed by the task force and agreed upon with consensus to provide guidance for use of the COVID-19 vaccines in RMD patients and to offer recommendations regarding the use and timing of immunomodulatory therapies around the time of vaccination. CONCLUSION: These guidance statements, made in the context of limited clinical data, are intended to provide direction to rheumatology healthcare providers on how to best use COVID-19 vaccines and to facilitate implementation of vaccination strategies for RMD patients.

      3. Background: Competing priorities make using a transparent and evidence-based approach important when deciding to recommend new vaccines. We conducted a literature review to document the processes and frameworks for national decision-making on new vaccine introductions and explored which key features have evolved since 2010. Methods: We searched literature published on policymaking related to vaccine introduction from March 2010 to August 2020 in six databases. We screened articles for eligibility with the following exclusion criteria: non-human or hypothetical vaccines, the sole focus on economic evaluation or decision to adopt rather than policy decision-making. We employed nine broad categories of criteria from the 2012 review for categorization and abstracted data on the country, income level, vaccine, and other relevant criteria. Results: Of the 3808 unique references screened, 116 met eligibility criteria and were classified as: a) framework of vaccine adoption decision-making (27), b) studies that analyse empirical data on or examples of vaccine adoption decision-making (45), c) theoretical and empirical articles that provide insights into the vaccine policymaking process (44 + 17 already included in the previous categories). Commonly reported criteria for decision-making were the burden of disease; vaccine efficacy/effectiveness, safety; impact on health and non-health outcomes; economic evaluation and cost-effectiveness of alternative interventions. Programmatic and acceptability aspects were not as often considered. Most (50; 82%) of the 61 articles describing the process of vaccine introduction policymaking highlighted the role of country, regional, or global evidence-informed recommendations and a robust national governance as enabling factors for vaccine adoption. Conclusions: The literature on vaccine adoption decision-making has expanded since 2010. We found that policymakers and expert advisory committee members (e.g., National Immunization Technical Advisory Group [NITAG]) increasingly value the interventions based on economic evaluations. The results of this review could guide discussions on evidence-informed immunization decision-making among country, sub-regional, and regional stakeholders.

      4. Ancillary benefits of seasonal influenza vaccination in middle-income countriesexternal icon
        Ebama MS, Chu SY, Azziz-Baumgartner E, Lafond KE, McCarron M, Hadler SC, Porter RM, McKinlay M, Bresee J.
        Vaccine. 2021 Mar 10.
        While seasonal influenza vaccines (SIV) remain the best method to prevent influenza-associated illnesses, implementing SIV programs may benefit countries beyond disease reduction, strengthening health systems and national immunization programs, or conversely, introduce new challenges. Few studies have examined perceived impacts of SIV introduction beyond disease reduction on health systems; understanding such impacts will be particularly salient in the context of COVID-19 vaccine introduction. We collected qualitative data from key informants-Partnership for Influenza Vaccine Introduction (PIVI) contacts in six middle-income PIVI vaccine recipient countries-to understand perceptions of ancillary benefits and challenges from SIV implementation. Respondents reported benefits associated with SIV introduction, including improved attitudes to SIV among risk groups (characterized by increased demand) and perceptions that SIV introduction improved relationships with other ministries and collaboration with mass media. Challenges included sustaining investment in SIV programs, as vaccine supply did not always meet coverage goals, and managing SIV campaigns.

      5. Differences between Frequentist and Bayesian inference in routine surveillance for influenza vaccine effectiveness: a test-negative case-control studyexternal icon
        Jackson ML, Ferdinands J, Nowalk MP, Zimmerman RK, Kieke B, Gaglani M, Murthy K, Petrie JG, Martin ET, Chung JR, Flannery B, Jackson LA.
        BMC Public Health. 2021 Mar 16;21(1):516.
        BACKGROUND: Routine influenza vaccine effectiveness (VE) surveillance networks use frequentist methods to estimate VE. With data from more than a decade of VE surveillance from diverse global populations now available, using Bayesian methods to explicitly account for this knowledge may be beneficial. This study explores differences between Bayesian vs. frequentist inference in multiple seasons with varying VE. METHODS: We used data from the United States Influenza Vaccine Effectiveness (US Flu VE) Network. Ambulatory care patients with acute respiratory illness were enrolled during seasons of varying observed VE based on traditional frequentist methods. We estimated VE against A(H1N1)pdm in 2015/16, dominated by A(H1N1)pdm; against A(H3N2) in 2017/18, dominated by A(H3N2); and compared VE for live attenuated influenza vaccine (LAIV) vs. inactivated influenza vaccine (IIV) among children aged 2-17 years in 2013/14, also dominated by A(H1N1)pdm. VE was estimated using both frequentist and Bayesian methods using the test-negative design. For the Bayesian estimates, prior VE distributions were based on data from all published test-negative studies of the same influenza type/subtype available prior to the season of interest. RESULTS: Across the three seasons, 16,342 subjects were included in the analyses. For 2015/16, frequentist and Bayesian VE estimates were essentially identical (41% each). For 2017/18, frequentist and Bayesian estimates of VE against A(H3N2) viruses were also nearly identical (26% vs. 23%, respectively), even though the presence of apparent antigenic match could potentially have pulled Bayesian estimates upward. Precision of estimates was similar between methods in both seasons. Frequentist and Bayesian estimates diverged for children in 2013/14. Under the frequentist approach, LAIV effectiveness was 62 percentage points lower than IIV, while LAIV was only 27 percentage points lower than IIV under the Bayesian approach. CONCLUSION: Bayesian estimates of influenza VE can differ from frequentist estimates to a clinically meaningful degree when VE diverges substantially from previous seasons.

      6. COVID-19 Vaccine Second-Dose Completion and Interval Between First and Second Doses Among Vaccinated Persons - United States, December 14, 2020-February 14, 2021external icon
        Kriss JL, Reynolds LE, Wang A, Stokley S, Cole MM, Harris LQ, Shaw LK, Black CL, Singleton JA, Fitter DL, Rose DA, Ritchey MD, Toblin RL.
        MMWR Morb Mortal Wkly Rep. 2021 Mar 19;70(11):389-395.
        In December 2020, two COVID-19 vaccines (Pfizer-BioNTech and Moderna) received Emergency Use Authorization from the Food and Drug Administration.*(,)(†) Both vaccines require 2 doses for a completed series. The recommended interval between doses is 21 days for Pfizer-BioNTech and 28 days for Moderna; however, up to 42 days between doses is permissible when a delay is unavoidable.(§) Two analyses of COVID-19 vaccine administration data were conducted among persons who initiated the vaccination series during December 14, 2020-February 14, 2021, and whose doses were reported to CDC through February 20, 2021. The first analysis was conducted to determine whether persons who received a first dose and had sufficient time to receive the second dose (i.e., as of February 14, 2021, >25 days from receipt of Pfizer-BioNTech vaccine or >32 days from receipt of Moderna vaccine had elapsed) had received the second dose. A second analysis was conducted among persons who received a second COVID-19 dose by February 14, 2021, to determine whether the dose was received during the recommended dosing interval, which in this study was defined as 17-25 days (Pfizer-BioNTech) and 24-32 days (Moderna) after the first dose. Analyses were stratified by jurisdiction and by demographic characteristics. In the first analysis, among 12,496,258 persons who received the first vaccine dose and for whom sufficient time had elapsed to receive the second dose, 88.0% had completed the series, 8.6% had not received the second dose but remained within the allowable interval (≤42 days since the first dose), and 3.4% had missed the second dose (outside the allowable interval, >42 days since the first dose). The percentage of persons who missed the second dose varied by jurisdiction (range = 0.0%-9.1%) and among demographic groups was highest among non-Hispanic American Indian/Alaska Native (AI/AN) persons (5.1%) and persons aged 16-44 years (4.0%). In the second analysis, among 14,205,768 persons who received a second dose, 95.6% received the dose within the recommended interval, although percentages varied by jurisdiction (range = 79.0%-99.9%). Public health officials should identify and address possible barriers to completing the COVID-19 vaccination series to ensure equitable coverage across communities and maximum health benefits for recipients. Strategies to ensure series completion could include scheduling second-dose appointments at the first-dose administration and sending reminders for second-dose visits.

      7. Myopericarditis Associated With Smallpox Vaccination Among US Army Personnel - Fort Hood, Texas, 2018external icon
        Mandra AM, Superior MJ, Guagliardo SA, Hesse E, Pacha LA, Stidham RA, Colbeck DC, Hrncir DE, Hall N, Petersen BW, Rao AK.
        Disaster Med Public Health Prep. 2021 Mar 15:1-7.
        OBJECTIVE: In March 2018, the US Department of Defense (DOD) added the smallpox vaccination, using ACAM2000, to its routine immunizations, increasing the number of persons receiving the vaccine. The following month, Fort Hood reported a cluster of 5 myopericarditis cases. The Centers for Disease Control and Prevention and the DOD launched an investigation. METHODS: The investigation consisted of a review of medical records, establishment of case definitions, causality assessment, patient interviews, and active surveillance. A 2-sided exact rate ratio test was used to compare myopericarditis incidence rates. RESULTS: This investigation identified 4 cases of probable myopericarditis and 1 case of suspected myopericarditis. No alternative etiology was identified as a cause. No additional cases were identified. There was no statistically significant difference in incidence rates between the observed cluster (5.23 per 1000 vaccinated individuals, 95% CI: 1.7-12.2) and the ACAM2000 clinical trial outcomes for symptomatic persons, which was 2.29 per 1000 vaccinated individuals (95% CI: 0.3-8.3). CONCLUSIONS: Vaccination with ACAM2000 is the presumptive cause of this cluster. Caution should be exercised before considering vaccination campaigns for smallpox given the clinical morbidity and costs incurred by a case of myopericarditis. Risk of myopericarditis should be carefully weighed with risk of exposure to smallpox.

    • Injury and Violence
      1. Child disciplinary practices, abuse, and neglect: Findings from a formative study in Chitungwiza, Zimbabweexternal icon
        Patel SN, Shanmugam I, Obong'o C, Mupambireyi Z, Kasese C, Bangani Z, Miller KS.
        Child Abuse Negl. 2021 Mar 10;115:105016.
        BACKGROUND: Zimbabwe has a high prevalence of children who have experienced abuse according to national data. OBJECTIVE: To understand how parents/caregivers and children describe child discipline, abuse, and neglect and what factors influence each, in order to inform the adaptation of a positive parenting/caregiving intervention in Chitungwiza, Zimbabwe. PARTICIPANTS: A total of eight focus groups were conducted, four with parents/caregivers (N = 40) and four with their children ages 10-14 (N = 40), separately, between June-July 2016. SETTING: Chitungwiza, Zimbabwe. METHODS: We used an inductive and deductive analytic approach to analyze focus group transcripts, using MAXQDA 12. RESULTS: There were similar themes across focus groups of children and parents/caregivers. Findings suggest that parents/caregivers and children may be somewhat aware of the differences between discipline and abuse, but they are not completely clear about what the definitions of discipline and abuse are, and where the boundaries between discipline and abuse lie. The use of both non-physical and physical forms of discipline were described in the community, however physical discipline was a reoccurring theme in the focus groups of both parents/caregivers and their children. There were several factors that influenced discipline and/or abuse of children in the community, including the child's gender and theseverity of the child's misbehavior/actions. Parents/caregivers shared that orphan/non-biological children were particularly vulnerable to forms of abuse and neglect committed by parents/caregivers in the community, for example, withholding food and overworking a child. CONCLUSIONS: Understanding the differences between discipline, abuse and neglect, as well as factors that influence occurrences of abuse/neglect and/or severity of abuse/neglect, need to be considered when assessing the vulnerability of children, in order to develop and refine parenting/caregiving interventions for the Zimbabwean context.

    • Laboratory Sciences
      1. Development of a Measles and Rubella Multiplex Bead Serological Assay for Assessing Population Immunityexternal icon
        Coughlin MM, Matson Z, Sowers SB, Priest JW, Smits GP, van der Klis FR, Mitchell A, Hickman CJ, Scobie HM, Goodson JL, Alexander JP, Rota PA, Bankamp B.
        J Clin Microbiol. 2021 Mar 17.
        Serosurveys are important tools for estimating population immunity and providing immunization activity guidance. The measles and rubella multiplex bead assay (MBA) offers multiple advantages over standard serological assays and was validated by comparison with the enzyme-linked immunosorbent assay (ELISA) and the measles plaque reduction neutralization (PRN) assay. Results from a laboratory-produced purified measles whole virus antigen MBA (MeV WVA(L)) correlated better with ELISA and PRN than results from the baculovirus-expressed measles nucleoprotein (N) MBA. Therefore, a commercially produced whole virus antigen (MeV WVA(C)) was evaluated. Serum IgG antibody concentrations correlated significantly with a strong linear relationship between the MeV WVA(C) and MeV WVA(L) MBAs (R=0.962, R(2)=0.926). IgG concentrations from the MeV WVA(C) MBA showed strong correlation with PRN titers (R=0.846) with a linear relationship comparable to values obtained with the MeV WVA(L) MBA and PRN assay (R(2)=0.716 and R(2)=0.768, respectively). Receiver-operating characteristic (ROC) curve analysis of the MeV WVA(C) using PRN titer as the comparator resulted in a seroprotection cutoff of 153 mIU/ml, similar to the established correlate of protection of 120 mIU/ml, with a sensitivity of 98% and a specificity of 84%. IgG concentrations correlated strongly between the rubella WVA MBA and ELISA (R=0.959 and R(2)=0.919). ROC analysis of the rubella MBA using ELISA as the comparator yielded a cutoff of 9.36 IU/ml, similar to the accepted cutoff of 10 IU/ml for seroprotection, with a sensitivity of 99% and a specificity of 100%. These results support use of the MBA for multi-antigen serosurveys assessing measles and rubella population immunity.

      2. Molecular diagnostic assays for the detection of common bacterial meningitis pathogens: A narrative reviewexternal icon
        Diallo K, Feteh VF, Ibe L, Antonio M, Caugant DA, du Plessis M, Deghmane AE, Feavers IM, Fernandez K, Fox LM, Rodrigues CM, Ronveaux O, Taha MK, Wang X, Brueggemann AB, Maiden MC, Harrison OB.
        EBioMedicine. 2021 Mar 12;65:103274.
        Bacterial meningitis is a major global cause of morbidity and mortality. Rapid identification of the aetiological agent of meningitis is essential for clinical and public health management and disease prevention given the wide range of pathogens that cause the clinical syndrome and the availability of vaccines that protect against some, but not all, of these. Since microbiological culture is complex, slow, and often impacted by prior antimicrobial treatment of the patient, molecular diagnostic assays have been developed for bacterial detection. Distinguishing between meningitis caused by Neisseria meningitidis (meningococcus), Streptococcus pneumoniae (pneumococcus), Haemophilus influenzae, and Streptococcus agalactiae and identifying their polysaccharide capsules is especially important. Here, we review methods used in the identification of these bacteria, providing an up-to-date account of available assays, allowing clinicians and diagnostic laboratories to make informed decisions about which assays to use.

      3. Quantification of nitromethane in mainstream smoke using gas chromatography and tandem mass spectrometryexternal icon
        Junco JG, Chapman GM, Bravo Cardenas R, Watson CH, Valentín-Blasini L.
        Toxicol Rep. 2021 ;8:405-410.
        Nitromethane is a volatile organic compound categorized as a Group 2B carcinogen by the International Agency for Research on Cancer. It has been detected in mainstream cigarette smoke, but few reliable methods have been reported for accurate quantification. We developed, a sensitive, selective, fully validated method for the targeted determination of nitromethane in mainstream tobacco smoke in ten U.S. domestic brands and two quality control materials (3R4F and CM6). The vapor phase portion of machine-generated cigarette mainstream smoke, under modified ISO 3308:2000 regime (ISO) and modified intense regime (HCI), from single cigarettes was collected using airtight polyvinylfluoride sampling bags. The bags' contents were extracted using methanol containing an isotopically labeled internal standard followed by gas chromatography-tandem mass spectrometry. This approach is sufficiently sensitive to measure nitromethane levels in the nanogram range, with a method limit of detection of 72.3 ng/cig. Within-product variability estimated from the replicate analysis of 10 products ranged from 4.6%-16.3% (n = 6) over the two different smoking regimes, and method reproducibility estimated from two products used as quality control materials (3R4F and CM6) yielded intermediate precision values ranging from 16.6 to 20.8% (n = 20). Under HCI, nitromethane yields in machine-generated cigarette smoke from ten different domestic cigarette products ranged from 3.2 to 12 μg/cig; under ISO yields ranged from 1.6 to 4.9 μg/cig under standardized smoking machine conditions. Nitromethane yields are related to both the smoke regime (blocking of vent holes, puff duration and puff volume) and the heterogeneity of tobacco mixtures. This method provides a selective and fully validated technique to accurately quantify nitromethane in mainstream cigarette smoke, with minimal waste generation. It is an improvement over previous methods with regards to specificity, throughput, and simplicity of the sample collection process.

      4. Molecular Techniques for Genus and Species Determination of Fungi From Fresh and Paraffin-Embedded Formalin-Fixed Tissue in the Revised EORTC/MSGERC Definitions of Invasive Fungal Infectionexternal icon
        Lockhart SR, Bialek R, Kibbler CC, Cuenca-Estrella M, Jensen HE, Kontoyiannis DP.
        Clin Infect Dis. 2021 Mar 12;72(Supplement_2):S109-s113.
        The EORTC/MSGERC have revised the definitions for proven, probable, and possible fungal diseases. The tissue diagnosis subcommittee was tasked with determining how and when species can be determined from tissue in the absence of culture. The subcommittee reached a consensus decision that polymerase chain reaction (PCR) from tissue, but not immunohistochemistry or in situ hybridization, can be used for genus or species determination under the new EORTC/MSGERC guidelines, but only when fungal elements are identified by histology. Fungal elements seen in tissue samples by histopathology and identified by PCR followed by sequencing should fulfill the definition of a proven fungal infection, identified to genus/species, even in the absence of culture. This summary discusses the issues that were deliberated by the subcommittee to reach the consensus decision and outlines the criteria a laboratory should follow in order to produce data that meet the EORTC/MSGERC definitions.

      5. COVID-19 Response Efforts of Washington State Public Health Laboratory: Lessons Learnedexternal icon
        McLaughlin HP, Hiatt BC, Russell D, Carlson CM, Jacobs JR, Perez-Osorio AC, Holshue ML, Choi SW, Gautom RK.
        Am J Public Health. 2021 Mar 18:e1-e9.
        Laboratory diagnostics play an essential role in pandemic preparedness. In January 2020, the first US case of COVID-19 was confirmed in Washington State. At the same time, the Washington State Public Health Laboratory (WA PHL) was in the process of building upon and initiating innovative preparedness activities to strengthen laboratory testing capabilities, operations, and logistics. The response efforts of WA PHL, in conjunction with the Centers for Disease Control and Prevention, to the COVID-19 outbreak in Washington are described herein-from the initial detection of severe acute respiratory syndrome coronavirus 2 through the subsequent 2 months.Factors that contributed to an effective laboratory response are described, including preparing early to establish testing capacity, instituting dynamic workforce solutions, advancing information management systems, refining laboratory operations, and leveraging laboratory partnerships. We also report on the challenges faced, successful steps taken, and lessons learned by WA PHL to respond to COVID-19.The actions taken by WA PHL to mount an effective public health response may be useful for US laboratories as they continue to respond to the COVID-19 pandemic and may help inform current and future laboratory pandemic preparedness activities. (Am J Public Health. Published online ahead of print March 18, 2021: e1-e9. https://doi.org/10.2105/AJPH.2021.306212).

      6. Regional Consortia : A Framework for Public Health Laboratory Collaboration and Service Sharingexternal icon
        Ned-Sykes RM, Pentella M, Kurimski L, Zanto S, Matt Charles E, Bean C, Gibson D, Breckenridge K, Su B, Ridderhof J.
        Public Health Rep. 2021 Mar 15:333549211002774.
        Public health laboratories (PHLs) provide specialized testing services for programs focused on the prevention and control of communicable diseases, early detection of congenital disorders, testing for antimicrobial resistance, and identification of environmental contaminants, among other responsibilities. Although national public health programs and partners provide some funding support, training, and technical resources to PHLs, no dedicated funding is provided from federal programs to fully support comprehensive PHL services across the United States or the underlying infrastructure needed for PHLs to provide and ensure their core functions and capabilities. Public health laboratories have begun to rely on a "community of practice" approach to addressing various service needs by creating and formalizing regional consortia, which are organized groups of geographically clustered PHLs that share expertise, capacities, and capabilities to enhance PHL services. The number of states participating in these networks increased from 13 to 48 from 2015 to 2020, including participation by multiple local PHLs and a territorial PHL. These consortia have enabled strengthening of partnerships and collaboration among PHLs to address regional priorities and challenges. We explore the background and evolution of regional consortia, outline some of their practices and activities, review lessons learned from these successful collaborations, and discuss the positive effect they have on the national public health system.

      7. Particle transfer and adherence to human skin compared with cotton glove and pre-moistened polyvinyl alcohol exposure sampling substratesexternal icon
        Stefaniak AB, Wade EE, Lawrence RB, Arnold ED, Virji MA.
        J Environ Sci Health A Tox Hazard Subst Environ Eng. 2021 Mar 15:1-12.
        Measurement of skin exposure to particles using interception (e.g., cotton gloves) and removal (e.g., wiping) sampling techniques could be inaccurate because these substrates do not have the same topography and adhesion characteristics as skin. The objective of this study was to compare particle transfer and adherence to cotton gloves, cotton gloves with artificial sebum, and a pre-moistened polyvinyl alcohol (PVA) material with bare human skin (fingertip, palm). Experiments were performed with aluminum oxide powder under standardized conditions for three types of surfaces touched, applied loads, contact times, and powder mass levels. In the final mixed model, the fixed effects of substrate, surface type, applied load, and powder mass and their significant two-way interaction terms explained 71% (transfer) and 74% (adherence) of the observed total variance in measurements. For particle mass transfer, compared with bare skin, bias was -77% (cotton glove with sebum) to +197% (PVA material) and for adherence bias ranged from -40% (cotton glove) to +428% (PVA material), which indicated under- and over-sampling by these substrates, respectively. Dermal exposure assessment would benefit from sampling substrates that better reflect human skin characteristics and more accurately estimate exposures. Mischaracterization of dermal exposure has important implications for exposure and risk assessment.

    • Maternal and Child Health
      1. Survival of infants born with esophageal atresia among 24 international birth defects surveillance programsexternal icon
        Bell JC, Baynam G, Bergman JE, Bermejo-Sánchez E, Botto LD, Canfield MA, Dastgiri S, Gatt M, Groisman B, Hurtado-Villa P, Kallen K, Khoshnood B, Konrad V, Landau D, Lopez-Camelo JS, Martinez L, Morgan M, Mutchinick OM, Nance AE, Nembhard W, Pierini A, Rissmann A, Shan X, Sipek A, Szabova E, Tagliabue G, Yevtushok LS, Zarante I, Nassar N.
        Birth Defects Res. 2021 Mar 18.
        BACKGROUND: Esophageal atresia (EA) affects around 2.3-2.6 per 10,000 births world-wide. Infants born with this condition require surgical correction soon after birth. Most survival studies of infants with EA are locally or regionally based. We aimed to describe survival across multiple world regions. METHODS: We included infants diagnosed with EA between 1980 and 2015 from 24 birth defects surveillance programs that are members of the International Clearinghouse for Birth Defects Surveillance and Research. We calculated survival as the proportion of liveborn infants alive at 1 month, 1- and 5-years, among all infants with EA, those with isolated EA, those with EA and additional anomalies or EA and a chromosomal anomaly or genetic syndrome. We also investigated trends in survival over the decades, 1980s-2010s. RESULTS: We included 6,466 liveborn infants with EA. Survival was 89.4% (95% CI 88.1-90.5) at 1-month, 84.5% (95% CI 83.0-85.9) at 1-year and 82.7% (95% CI 81.2-84.2) at 5-years. One-month survival for infants with isolated EA (97.1%) was higher than for infants with additional anomalies (89.7%) or infants with chromosomal or genetic syndrome diagnoses (57.3%) with little change at 1- and 5-years. Survival at 1 month improved from the 1980s to the 2010s, by 6.5% for infants with isolated EA and by 21.5% for infants with EA and additional anomalies. CONCLUSIONS: Almost all infants with isolated EA survived to 5 years. Mortality was higher for infants with EA and an additional anomaly, including chromosomal or genetic syndromes. Survival improved from the 1980s, particularly for those with additional anomalies.

    • Occupational Safety and Health
      1. Introduction: This paper describes occupations in the U.S. that involve close contact with others and whether the work is outdoors or indoors (risk factors for coronavirus disease 2019 [COVID- 19]), including the distribution of Black and Hispanic workers over these occupations. Methods: U.S. data released from 2014 to 2019 on employment, proximity to others at work, outdoor or indoor work, and Black and Hispanic worker percentages for occupations were used. Occupations were assigned to 6 categories defined as low, medium, or high physical closeness (proximity) at work and outdoor or indoor work. Three of the 6 categories represent higher risk for exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): medium proximity indoor, high proximity outdoor, and high proximity indoor exposure. Results: A high proportion of U.S. workers may be at higher risk for exposure to SARS-CoV-2 because their occupations involve either high proximity to others indoors and outdoors (25.2%, 36.5 million workers) or medium proximity indoors (48%, 69.6 million workers). There is differential distribution of proximity and outdoor/indoor work by occupation, which disproportionately affects Black and Hispanic workers in some occupations. Conclusions: Implementation of COVID-19 preventive measures in work settings should be based on occupation-specific risk factors, including the extent of proximity to others and whether the work is conducted outdoors or indoors. It is important that communication messages are tailored to the languages and preferred media of the workforce.

      2. An analysis of shiftwork and self-reported depressive symptoms in a police cohort from Buffalo, New Yorkexternal icon
        Holst MM, Wirth MD, Allison P, Burch JB, Andrew ME, Fekedulegn D, Hussey J, Charles LE, Violanti JM.
        Chronobiol Int. 2021 Mar 11:1-9.
        Shiftwork has been associated with elevated depressive symptoms; police officers frequently work shifts and may experience depressive symptoms. This study assessed the association between depressive symptoms and shiftwork in a police cohort from Buffalo, New York, USA using a repeated cross-sectional design with data collected in 2004-2009 (n = 428) and 2010-2014 (n = 261). Electronic payroll records were used to quantitatively classify officers on the day, evening, or night shift based on the shift they spent most of their working hours. Two self-reported depressive symptomology measures were used as outcomes - the Center for Epidemiological Studies - Depression (CES-D) scale and the Beck Depression Inventory (BDI). Repeated measures linear and logistic regression analyses were used to estimate least squares means or odds, respectively, of depressive symptom questionnaire scores by shiftwork category. Those working the evening/night shift had higher odds for depressive symptoms according to the BDI (based on a cut-point score of 14) than those working the day shift (OR = 4.60, 95% CI = 1.15-18.39). Similar results were observed for the evening shift group. No differences in mean CES-D or BDI scores were observed between groups for short-term shiftwork, long-term shiftwork, or shift changes. After stratifying by stress, as measured by the Perceived Stress Scale (PSS), total Impact of Events (IES), and the Spielberger Police Stress Survey (SPSS), mean values for depressive symptoms were higher in the high-stress categories regardless of shiftwork status. Further research should include biomarkers for depression, a longitudinal study design with a larger cohort, and joint effects of shiftwork and stress on depressive symptoms.

      3. The International Standard Organization (ISO) standard 13091-1 describes methods and procedures for performing the vibrotactile perception threshold (VPT) testing to diagnose changes in tactile sensory function associated with occupational exposures. However, the VPT test also has been used in the diagnosis of peripheral neuropathies associated with a number of disorders. This review examines the VPT test, variations in procedures that have been used, as well as disorders and diseases in which this test has been reliable for the detection of sensory changes. Mechanisms potentially underlying the changes in VPTs are also discussed along with procedural and subject/patient factors that may affect the interpretation of test results. Based upon the review of the literature, there are also suggestions for where additional research might improve the administration of this test, depending upon the subject/patient population and interpretation of data.

    • Occupational Safety and Health - Mining
      1. There were 37 longwall faces operating in mines in the United States in 2019. The average panel width for these longwalls was approximately 368.5 m (1209 ft). This translates to a range of approximately 170–240 shields per longwall, depending upon the width of shield. The movement of longwall shields is a significant contributor to respirable dust overexposures to longwall operators. Foam is expected to have the potential to reduce this shield dust generation. The foam is applied to the area on the roof between the coal face and the shield tip after the shearer passes. In this study, the longwall shield dust simulator was used to test three foam agents for their ability to control dust from longwall shield movements. Results showed that at low-velocity ventilation (≈ 3.0 m/s (600 fpm)) all foam agents were able to produce dust reduction levels of at least 45%. At high-velocity ventilation (≈ 5.1 m/s (1000 fpm)), the reductions were lower and more variable, ranging from being undeterminable for one foam agent to having 46%–63% reductions for the other two foam agents, with one instance of an increase in dust concentration. Overall, the use of foam agents can provide longwall shield dust control. Important factors are roof coverage and the ability of foam to remain on the roof for extended time periods.

    • Parasitic Diseases
      1. Malaria Surveillance - United States, 2017external icon
        Mace KE, Lucchi NW, Tan KR.
        MMWR Surveill Summ. 2021 Mar 19;70(2):1-35.
        PROBLEM/CONDITION: Malaria in humans is caused by intraerythrocytic protozoa of the genus Plasmodium. These parasites are transmitted by the bite of an infective female Anopheles species mosquito. The majority of malaria infections in the United States occur among persons who have traveled to regions with ongoing malaria transmission. However, malaria is occasionally acquired by persons who have not traveled out of the country through exposure to infected blood products, congenital transmission, nosocomial exposure, or local mosquitoborne transmission. Malaria surveillance in the United States is conducted to provide information on its occurrence (e.g., temporal, geographic, and demographic), guide prevention and treatment recommendations for travelers and patients, and facilitate rapid transmission control measures if locally acquired cases are identified. PERIOD COVERED: This report summarizes confirmed malaria cases in persons with onset of illness in 2017 and trends in previous years. DESCRIPTION OF SYSTEM: Malaria cases diagnosed by blood film microscopy, polymerase chain reaction, or rapid diagnostic tests are reported to local and state health departments through electronic laboratory reports or by health care providers or laboratory staff members. Case investigations are conducted by local and state health departments, and reports are transmitted to CDC through the National Malaria Surveillance System (NMSS), the National Notifiable Diseases Surveillance System (NNDSS), or direct CDC consultations. CDC reference laboratories provide diagnostic assistance and conduct antimalarial drug resistance marker testing on blood samples submitted by health care providers or local or state health departments. This report summarizes data from the integration of all cases from NMSS and NNDSS, CDC reference laboratory reports, and CDC clinical consultations. RESULTS: CDC received reports of 2,161 confirmed malaria cases with onset of symptoms in 2017, including two congenital cases, three cryptic cases, and two cases acquired through blood transfusion. The number of malaria cases diagnosed in the United States has been increasing since the mid-1970s; in 2017, the number of cases reported was the highest in 45 years, surpassing the previous peak of 2,078 confirmed cases reported in 2016. Of the cases in 2017, a total of 1,819 (86.1%) were imported cases that originated from Africa; 1,216 (66.9%) of these came from West Africa. The overall proportion of imported cases originating from West Africa was greater in 2017 (57.6%) than in 2016 (51.6%). Among all cases, P. falciparum accounted for the majority of infections (1,523 [70.5%]), followed by P. vivax (216 [10.0%]), P. ovale (119 [5.5%]), and P. malariae (55 [2.6%]). Infections by two or more species accounted for 22 cases (1.0%). The infecting species was not reported or was undetermined in 226 cases (10.5%). CDC provided diagnostic assistance for 9.5% of confirmed cases and tested 8.0% of specimens with P. falciparum infections for antimalarial resistance markers. Most patients (94.8%) had symptom onset <90 days after returning to the United States from a country with malaria transmission. Of the U.S. civilian patients who reported reason for travel, 73.1% were visiting friends and relatives. The proportion of U.S. residents with malaria who reported taking any chemoprophylaxis in 2017 (28.4%) was similar to that in 2016 (26.4%), and adherence was poor among those who took chemoprophylaxis. Among the 996 U.S. residents with malaria for whom information on chemoprophylaxis use and travel region were known, 93.3% did not adhere to or did not take a CDC-recommended chemoprophylaxis regimen. Among 805 women with malaria, 27 reported being pregnant. Of these, 10 pregnant women were U.S. residents, and none reported taking chemoprophylaxis to prevent malaria. A total of 26 (1.2%) malaria cases occurred among U.S. military personnel in 2017, fewer than in 2016 (41 [2.0%]). Among all reported cases in 2017, a total of 312 (14.4%) were classified as severe malaria illnesses, and seven persons died. In 2017, CDC analyzed 117 P. falciparum-positive and six P. falciparum mixed-species samples for antimalarial resistance markers (although certain loci were untestable in some samples); identification of genetic polymorphisms associated with resistance to pyrimethamine were found in 108 (97.3%), to sulfadoxine in 77 (69.4%), to chloroquine in 38 (33.3%), to mefloquine in three (2.7%), and to atovaquone in three (2.7%); no specimens tested contained a marker for artemisinin resistance. The data completeness of key variables (species, country of acquisition, and resident status) was lower in 2017 (74.4%) than in 2016 (79.4%). INTERPRETATION: The number of reported malaria cases in 2017 continued a decades-long increasing trend, and for the second year in a row the highest number of cases since 1971 have been reported. Despite progress in malaria control in recent years, the disease remains endemic in many areas globally. The importation of malaria reflects the overall increase in global travel to and from these areas. Fifty-six percent of all cases were among persons who had traveled from West Africa, and among U.S. civilians, visiting friends and relatives was the most common reason for travel (73.1%). Frequent international travel combined with the inadequate use of prevention measures by travelers resulted in the highest number of imported malaria cases detected in the United States in 4 decades. PUBLIC HEALTH ACTIONS: The best way to prevent malaria is to take chemoprophylaxis medication during travel to a country where malaria is endemic. Adherence to recommended malaria prevention strategies among U.S. travelers would reduce the numbers of imported cases; reasons for nonadherence include prematurely stopping after leaving the area where malaria was endemic, forgetting to take the medication, and experiencing a side effect. Travelers might not understand the risk that malaria poses to them; thus, health care providers should incorporate risk education to motivate travelers to be adherent to chemoprophylaxis. Malaria infections can be fatal if not diagnosed and treated promptly with antimalarial medications appropriate for the patient's age, medical history, the likely country of malaria acquisition, and previous use of antimalarial chemoprophylaxis. Antimalarial use for chemoprophylaxis and treatment should be informed by the most recent guidelines, which are frequently updated. In 2018, two formulations of tafenoquine (i.e., Arakoda and Krintafel) were approved by the Food and Drug Administration (FDA) for use in the United States. Arakoda was approved for use by adults for chemoprophylaxis; the regimen requires a predeparture loading dose, taking the medication weekly during travel, and a short course posttravel. The Arakoda chemoprophylaxis regimen is shorter than alternative regimens, which could possibly improve adherence. This medication also might prevent relapses. Krintafel was approved for radical cure of P. vivax infections in those aged >16 years and should be co-administered with chloroquine (https://www.cdc.gov/malaria/new_info/2020/tafenoquine_2020.html). In April 2019, intravenous artesunate became the first-line medication for treatment of severe malaria in the United States. Artesunate was recently FDA approved but is not yet commercially available. The drug can be obtained from CDC under an investigational new drug protocol. Detailed recommendations for preventing malaria are available to the general public at the CDC website (https://www.cdc.gov/malaria/travelers/drugs.html). Health care providers should consult the CDC Guidelines for Treatment of Malaria in the United States and contact the CDC's Malaria Hotline for case management advice when needed. Malaria treatment recommendations are available online (https://www.cdc.gov/malaria/diagnosis_treatment) and from the Malaria Hotline (770-488-7788 or toll-free 855-856-4713). Persons submitting malaria case reports (care providers, laboratories, and state and local public health officials) should provide complete information because incomplete reporting compromises case investigations and efforts to prevent infections and examine trends in malaria cases. Molecular surveillance of antimalarial drug resistance markers (https://www.cdc.gov/malaria/features/ars.html) enables CDC to track, guide treatment, and manage drug resistance in malaria parasites both domestically and internationally. More samples are needed to improve the completeness of antimalarial drug resistance analysis; therefore, CDC requests that blood specimens be submitted for any case of malaria diagnosed in the United States.

      2. Community-based Guinea worm surveillance in Chad: Evaluating a system at the intersection of human and animal diseaseexternal icon
        Rubenstein BL, Roy SL, Unterwegner K, Yerian S, Weiss A, Zirimwabagabo H, Chop E, Romero M, Ouakou PT, Moundai T, Guagliardo SA.
        PLoS Negl Trop Dis. 2021 Mar 18;15(3):e0009285.
        BACKGROUND: Guinea worm is a debilitating parasitic infection targeted for eradication. Annual human cases have dropped from approximately 3,500,000 in 1986 to 54 in 2019. Recent identification of canine cases in Chad threatens progress, and therefore detection, prevention, and containment of canine cases is a priority. We investigated associations between disease knowledge, community engagement, and canine cases in Chad to identify opportunities to improve active surveillance. METHODS: We surveyed 627 respondents (villagers, local leaders, community volunteers, and supervisors) across 45 villages under active surveillance. Descriptive statistics were analyzed by respondent category. Logistic regression models were fitted to assess the effects of volunteer visit frequency on villager knowledge. RESULTS: Knowledge increased with respondents' associations with the Guinea worm program. Household visit frequency by community volunteers was uneven: 53.0% of villagers reported visits at least twice weekly and 21.4% of villagers reported never being visited. Villagers visited by a volunteer at least twice weekly had better knowledge of Guinea worm symptoms (OR: 1.71; 95% CI: 1.04-2.79) and could name more prevention strategies (OR: 2.04; 95% CI: 1.32-3.15) than villagers visited less frequently. The primary motivation to report was to facilitate care-seeking for people with Guinea worm. Knowledge of animal "containment" to prevent contamination of water, knowledge of rewards for reporting animal cases, and ability to name any reasons to report Guinea worm were each positively correlated with village canine case counts. CONCLUSIONS: Community volunteers play crucial roles in educating their neighbors about Guinea worm and facilitating surveillance. Additional training and more attentive management of volunteers and supervisors could increase visit frequency and further amplify their impact. Emphasizing links between animal and human cases, the importance of animal containment, and animal rewards might improve surveillance and canine case detection. The surveillance system should be evaluated routinely to expand generalizability of data and monitor changes over time.

    • Public Health Leadership and Management
      1. Public Health Emergency Response Leadership Training: A Qualitative Assessment of Existing Educational Opportunities and Perceived Facilitators, Barriers, and Priorities in Professional Developmentexternal icon
        Li Y, Hsu EB, Davis XM, Stennies GM, Pham NN, Fisher MC, Pearson JL, Barnett DJ, Trigoso SM, Podgornik MN, Hunter DW, Vagi SJ.
        J Public Health Manag Pract. 2021 Mar 12.
        OBJECTIVE: We aimed to understand the current training environment for developing public health emergency response leaders and highlight facilitators and barriers in accessing targeted training. DESIGN: We designed 4 focus groups to gather organizational perspectives on public health emergency response leadership development. Discussions were recorded, transcribed, coded, and analyzed to synthesize key themes. SETTING: Focus groups were convened at the 2019 Preparedness Summit (March 27-28) in St Louis, Missouri. PARTICIPANTS: Twenty-three public health professionals from 9 Public Health Emergency Preparedness (PHEP) Cooperative Agreement award recipient jurisdictions and 12 local health departments participated. MAIN OUTCOME MEASURES: We examined the current availability, relevance, specificity, and utility of educational content and delivery modalities. Facilitators and barriers were identified as opportunities to improve training access. RESULTS: Generic emergency management training is considered important and widely available but with limited application in public health practice. Existing leadership training opportunities in public health emergency response are limited and not widely known. While organizational support and accessible training facilitate participation, resource constraints (ie, funding, time, and staff) exist as key barriers. In addition, frequent staff turnover and attrition that result in loss of institutional knowledge likely hinder effective public health emergency responses. CONCLUSION: Effective public health emergency response depends on capable leaders not only well versed in specialized technical disciplines and practices but also familiar with-or preferably fluent in-emergency management principles and functions. This study demonstrated that well-aimed training strategies and organizational planning are essential in developing public health emergency response leaders. Specifically, leadership development may accrue considerable benefit from a standardized training curriculum. In addition, scalable training programs developed through public, private, and academic partnerships may lessen resource demands on individual organizations to facilitate training access. Finally, training practicums (eg, mentoring, shadowing) may provide opportunities to facilitate active learning and preserve institutional knowledge through leadership transitions.

    • Reproductive Health
      1. Culture clash of female Somali adolescents and sexual and reproductive health services in Oslo, Norwayexternal icon
        Afroz T, Gele A, Thorsen VC.
        Eur J Contracept Reprod Health Care. 2021 Mar 16:1-7.
        OBJECTIVE: Culture influences an individual's perception of health needs. The influence of culture also applies to Somali individuals' perception of their sexual and reproductive health (SRH) and uptake of related services. An understanding of female Somali adolescents' SRH needs is vital to achieve inclusive health coverage. No research has, however, been conducted to explore the SRH needs of this population group in Oslo; hence, the aim of this qualitative study was to minimise the knowledge gap. METHODS: Fourteen young women aged 16-20 years were recruited using the snowball technique with purposive sampling. In-depth interviews using a semi-structured interview guide were used to collect data, and thematic analysis was applied. RESULTS: Participants perceived SRH as a very private matter and open discussion of SRH was extremely limited owing to certain Somali cultural beliefs and values. As the participants intend to practise chastity before marriage, they believed that existing SRH services were largely irrelevant and inappropriate. Where they felt the need to access SRH services, participants wished to do so in a way they considered culturally appropriate. CONCLUSION: Somali culture markedly influences individuals' perceptions of SRH services. It is recommended to modify existing SRH services by increasing confidentiality and anonymity in order to take into account the cultural requirements of female Somali adolescents.

      2. Access to Contraceptive Services in Puerto Rico: An Analysis of Policy and Practice Change Strategies, 2015-2018external icon
        Romero L, Corrada-Rivera RM, Huertas-Pagan X, Aquino-Serrano FV, Morales-Boscio AM, Sanchez-Cesareo M, Acosta-Perez E, Mendoza Z, Lathrop E.
        J Public Health Manag Pract. 2021 Mar 12.
        CONTEXT: During the 2016-2017 Zika virus outbreak in Puerto Rico, preventing unintended pregnancy was a primary strategy to reduce Zika-related adverse birth outcomes. The Zika Contraception Access Network (Z-CAN) was a short-term emergency response intervention that used contraception to prevent unintended pregnancy among women who chose to delay or avoid pregnancy. OBJECTIVE: This analysis reports on the identified policy and practice change strategies to increase access to or provision of contraceptive services in Puerto Rico between 2015 and 2018. METHODS: A policy review was conducted to document federal- and territorial-level programs with contraceptive coverage and payment policies in Puerto Rico and to identify policy and practice change. Semistructured interviews with key stakeholders in Puerto Rico were also conducted to understand perceptions of policy and practice change efforts following the Zika virus outbreak, including emergency response, local, and policy efforts to improve contraception access in Puerto Rico. RESULTS: Publicly available information on federal and territorial programs with policies that facilitate access, delivery, and utilization of contraceptive coverage and family planning services in Puerto Rico to support contraceptive access was documented; however, interview results indicated that the implementation of the policies was often limited by barriers and that policy and practice changes as the result of the Zika virus outbreak were short-term. CONCLUSION: Consideration of long-term policy and practice changes related to contraceptive access is warranted. Similar analyses can be used to identify policies, practices, and perceptions in other settings in which the goal is to increase access to contraception or reduce unintended pregnancy.

    • Substance Use and Abuse
      1. Concurrent Naloxone Dispensing Among Individuals with High-Risk Opioid Prescriptions, USA, 2015–2019external icon
        Guy GP, Strahan AE, Haegerich T, Losby JL, Ragan K, Evans ME, Jones CM.
        J Gen Intern Med. 2021 .

      2. Chemical Composition of JUUL Pods Collected From Students in California High Schoolsexternal icon
        Shamout M, Wang P, Wong F, Chen W, Kumagai K, Pérez JJ, Watson CH, Valentín-Blasini L, Tanz L, Herzig C, Oakley LP, Peak CM, Heinzerling A, Williams RJ, Hess C, Wang C, Planche S, Al-Shawaf M, Melstrom P, Marynak K, Tynan MA, Agaku IT, King BA.
        J Adolesc Health. 2021 Mar 9.
        PURPOSE: To examine the chemical composition of JUUL pods collected from a convenience sample of 16 high schools in California to identify possible consumer modification or counterfeit use. METHODS: Using Gas Chromatography-Mass Spectrometry, we quantitatively analyzed the nicotine, propylene glycol (PG), and vegetable glycerin (VG) in JUUL pods (n = 26) collected from California high schools and compared results to commercial 3% (n = 15) and 5% (n = 24) JUUL pods purchased online. RESULTS: Most of the collected JUUL pods (24/26 pods) had a nicotine concentration (43.3 mg/ml, 95% PI: 21.5-65.1) outside the prediction intervals (PI) of the 3% (33.5 mg/ml, 95% PI: 31.8-35.2) and 5% (55.0 mg/ml, 95% PI: 51.5-58.3) commercial JUUL pods. Most (73%) collected JUUL pods had VG concentrations (583.5 mg/ml, PI: 428.9-738.1) lower than the 3% (722.2 mg/ml, PI: 643.0-801.4) and 5% (710.5 mg/ml, PI: 653.1-767.8) commercial JUUL pods. CONCLUSIONS: Used JUUL products collected from high school students or found on school grounds were not chemically consistent with the manufacturer's stated formulations.

      3. Screening for Excessive Alcohol Consumption in Emergency Departments: A Nationwide Assessment of Emergency Department Physiciansexternal icon
        Uong S, Tomedi LE, Gloppen KM, Stahre M, Hindman P, Goodson VN, Crandall C, Sklar D, Brewer RD.
        J Public Health Manag Pract. 2021 Mar 12.
        OBJECTIVE: To assess current screening practices for excessive alcohol consumption, as well as perceived barriers, perceptions, and attitudes toward performing this screening among emergency department (ED) physicians. DESIGN: A brief online assessment of screening practices for excessive drinking was disseminated electronically to a representative panel of ED physicians from November 2016 to January 2017. Descriptive statistics were calculated on the frequency of alcohol screening, factors affecting screening, and attitudes toward screening. SETTING: An online assessment was sent to a national panel of ED physicians. PARTICIPANTS: A panel of ED physicians who volunteered to be part of the American College of Emergency Physicians Emergency Medicine Practice Research Network survey panel. MAIN OUTCOME MEASURE: The primary outcome measures were the percentage of respondents who reported screening for excessive alcohol consumption and the percentage of respondents using a validated excessive alcohol consumption screening tool. RESULTS: Of the 347 ED physicians evaluated (38.6% response rate), approximately 16% reported "always/usually," 70% "sometimes," and 14% "never" screening adult patients (≥18 years) for excessive alcohol use. Less than 20% of the respondents who screened for excessive drinking used a recommended screening tool. Only 10.5% of all respondents (15.4% "always," 9.5% "sometimes" screened) received an electronic health record (EHR) reminder to screen for excessive alcohol use. Key barriers to screening included limited time (66.2%) and treatment options for patients with drinking problems (43.1%). CONCLUSIONS: Only 1 in 6 ED physicians consistently screened their patients for excessive drinking. Increased use of EHR reminders and other systems interventions (eg, electronic screening and brief intervention) could help improve the delivery of screening and follow-up services for excessive drinkers in EDs.

    • Zoonotic and Vectorborne Diseases
      1. Microcephaly Outcomes among Zika Virus-Infected Pregnant Women in Hondurasexternal icon
        Alger J, Buekens P, Cafferata ML, Alvarez Z, Berrueta M, Bock H, Bustillo C, Calderón A, Callejas A, Castillo M, Ciganda A, Fúnes J, García J, García K, Gibbons L, Gilboa SM, Harville EW, Hernández G, López R, López W, Lorenzana I, Tulio Luque M, Maldonado C, Moore CA, Ochoa C, Parham L, Pastrana K, Rico F, Rodríguez H, Stella C, Valencia D, Varela D, Wesson DM, Zúniga C, Tong VT.
        Am J Trop Med Hyg. 2021 Mar 15.
        The impact of Zika virus (ZIKV) infection on pregnancies shows regional variation emphasizing the importance of studies in different geographical areas. We conducted a prospective study in Tegucigalpa, Honduras, recruiting 668 pregnant women between July 20, 2016, and December 31, 2016. We performed Trioplex real-time reverse transcriptase-PCR (rRT-PCR) in 357 serum samples taken at the first prenatal visit. The presence of ZIKV was confirmed in seven pregnancies (7/357, 2.0%). Nine babies (1.6%) had microcephaly (head circumference more than two SDs below the mean), including two (0.3%) with severe microcephaly (head circumference [HC] more than three SDs below the mean). The mothers of both babies with severe microcephaly had evidence of ZIKV infection. A positive ZIKV Trioplex rRT-PCR was associated with a 33.3% (95% CI: 4.3-77.7%) risk of HC more than three SDs below the mean.

      2. West Nile virus (WNV) outbreaks raise the concern of WNV infection in donated blood and blood products destined for transfusion. We describe methods we developed to estimate time-dependent risk of WNV infection in donated blood, including improvements not previously detailed. The methods are then extended for use in estimation of the risk of WNV infection in donated cadaveric tissues by introducing stratification and stratum-specific weighting to address novel aspects of this application. Data from the WNV outbreak in Colorado in 2003 are used to estimate risk for donated cardiac tissue.

      3. An evaluation of Bacillus thuringiensis israelensis (AM65-52) treatment for the control of Aedes aegypti using vehicle-mounted WALS® application in a densely populated urban area of Puerto Ricoexternal icon
        Harris AF, Sanchez Prats J, Nazario Maldonado N, Piovanetti Fiol C, García Pérez M, Ramírez-Vera P, Miranda-Bermúdez J, Ortiz M, DeChant P.
        Pest Manag Sci. 2021 Apr;77(4):1981-1989.
        BACKGROUND: With a shortage of effective options for control of Aedes aegypti in Puerto Rico due to widespread resistance to conventional mosquito adulticides, an alternative approach was investigated to reduce vector populations. In two areas (totaling 144 ha) of the municipality of Bayamón, Puerto Rico, Bacillus thuringiensis israelensis (Bti) AM65-52 WDG was applied at a rate of 500 g/ha using vehicle-mounted aqueous wide-area larvicide spray applications weekly for 4 weeks and then every other week for a further 16 weeks. Bioassay jars were placed in the field to monitor for deposition of Bti droplets in open spaces, and under vegetation and building coverage. Autocidal gravid ovitraps were placed throughout the field site to monitor the population of adult female Ae. aegypti in both treatment and control sites. RESULTS: Larvicide spray was successfully deposited into jars in an array of open and covered locations, as confirmed by larval bioassays. After the fourth weekly spraying, differences in autocidal gravid ovitrap densities were observed between treatment and control sites resulting in 62% (P = 0.0001) and 28% (P < 0.0001) reductions in adult female Ae. aegypti numbers. CONCLUSION: Repeated wide-area larvicide spray application of Bti AM65-52 WDG to residential areas in Puerto Rico effectively suppressed dengue vector populations. The success of this trial has led to expansion of the WALS® program to a larger area of Bayamón and other municipalities in Puerto Rico. © 2020 Society of Chemical Industry.

      4. Willingness to Pay for Select Tick-Borne Disease Prevention Measures in Endemic Areasexternal icon
        Niesobecki S, Rutz H, Niccolai L, Hook S, Feldman K, Hinckley A.
        J Public Health Manag Pract. 2021 Mar 12.
        Tick-borne diseases (TBDs) are increasing despite prevention recommendations. We explored whether cost is a barrier to prevention use in Connecticut and Maryland, using a cross-sectional survey. Respondents were queried regarding their willingness to pay for chemical, natural, and rodent-targeted yard pesticide treatments and permethrin-treated clothing. We evaluated associations between demographics, TBD knowledge and attitudes, and willingness to pay for prevention methods. Most respondents would pay for yard treatments (85%); 95% preferring natural pesticide, and 82% would pay for permethrin-treated clothing. Most did not want to pay more than $99 for any of the yard treatments. Having a household income of $100 000 was associated with willingness to pay $100 or more for chemical, natural, or rodent-targeted treatments and $25 or more for permethrin self-treated and pretreated clothing. Yard treatments, especially natural pesticides, were acceptable for TBD prevention; however, current pricing may be cost-prohibitive. Permethrin-treated clothing may be an affordable and acceptable prevention method.

      5. Clinical and epidemiologic findings from enhanced monkeypox surveillance in Tshuapa Province, Democratic Republic of the Congo during 2011-2015external icon
        Whitehouse ER, Bonwitt J, Hughes CM, Lushima RS, Likafi T, Nguete B, Kabamba J, Monroe B, Doty JB, Nakazawa Y, Damon I, Malekani J, Davidson W, Wilkins K, Li Y, Radford KW, Schmid DS, Pukuta E, Muyamuna E, Karhemere S, Tamfum JM, Okitolonda EW, McCollum AM, Reynolds MG.
        J Infect Dis. 2021 Mar 17.
        BACKGROUND: Monkeypox is a poorly described emerging zoonosis endemic to Central and Western Africa. METHODS: Using surveillance data from Tshuapa Province, Democratic Republic of the Congo during 2011-2015, we evaluated differences in incidence, exposures, and clinical presentation of PCR-confirmed cases by sex and age. RESULTS: We report 1,057 confirmed cases. Average annual incidence was 14·1 per 100,000 (95% CI: 13·3-15·0). Incidence was higher in males (incidence rate ratio [IRR] males: females: 1·21, 95% CI 1·07-1·37), except among 20-29-year-old (IRR: 0·70, 95% CI: 0·51-0·95). Females aged 20-29 years also reported a high frequency of exposures (26·2%) to people with monkeypox-like symptoms. Highest incidence was among 10-19-year-old males, the cohort reporting the highest proportion of animal exposures (37·5%). Incidence was lower among those presumed to have received smallpox vaccination versus those presumed unvaccinated. No differences were observed by age group in lesion count or lesion severity score. CONCLUSIONS: Monkeypox incidence was twice that reported during 1980-1985, an increase possibly linked to declining immunity provided by smallpox vaccination. The high proportion of cases attributed to human exposures suggests changing exposure patterns. Cases were distributed across age and sex, suggesting frequent exposures that follow socio-cultural norms.


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