Issue 19, May 26, 2021

CDC Science Clips: Volume 13, Issue 19, May 26, 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!

  1. Top Articles of the Week
    Selected weekly by a senior CDC scientist from the standard sections listed below.
    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions
      • Prevalence of Visual Acuity Loss or Blindness in the US: A Bayesian Meta-analysisexternal icon
        Flaxman AD, Wittenborn JS, Robalik T, Gulia R, Gerzoff RB, Lundeen EA, Saaddine J, Rein DB.
        JAMA Ophthalmol. 2021 May 13.
        IMPORTANCE: Globally, more than 250 million people live with visual acuity loss or blindness, and people in the US fear losing vision more than memory, hearing, or speech. But it appears there are no recent empirical estimates of visual acuity loss or blindness for the US. OBJECTIVE: To produce estimates of visual acuity loss and blindness by age, sex, race/ethnicity, and US state. DATA SOURCES: Data from the American Community Survey (2017), National Health and Nutrition Examination Survey (1999-2008), and National Survey of Children's Health (2017), as well as population-based studies (2000-2013), were included. STUDY SELECTION: All relevant data from the US Centers for Disease Control and Prevention's Vision and Eye Health Surveillance System were included. DATA EXTRACTION AND SYNTHESIS: The prevalence of visual acuity loss or blindness was estimated, stratified when possible by factors including US state, age group, sex, race/ethnicity, and community-dwelling or group-quarters status. Data analysis occurred from March 2018 to March 2020. MAIN OUTCOMES OR MEASURES: The prevalence of visual acuity loss (defined as a best-corrected visual acuity greater than or equal to 0.3 logMAR) and blindness (defined as a logMAR of 1.0 or greater) in the better-seeing eye. RESULTS: For 2017, this meta-analysis generated an estimated US prevalence of 7.08 (95% uncertainty interval, 6.32-7.89) million people living with visual acuity loss, of whom 1.08 (95% uncertainty interval, 0.82-1.30) million people were living with blindness. Of this, 1.62 (95% uncertainty interval, 1.32-1.92) million persons with visual acuity loss are younger than 40 years, and 141 000 (95% uncertainty interval, 95 000-187 000) persons with blindness are younger than 40 years. CONCLUSIONS AND RELEVANCE: This analysis of all available data with modern methods produced estimates substantially higher than those previously published.

    • Communicable Diseases
      • Systematic Testing for Influenza and Coronavirus Disease 2019 Among Patients With Respiratory Illnessexternal icon
        Flannery B, Meece JK, Williams JV, Martin ET, Gaglani M, Jackson ML, Talbot HK.
        Clin Infect Dis. 2021 May 4;72(9):e426-e428.

      • The impact of disruptions caused by the COVID-19 pandemic on global polio eradicationexternal icon
        Kalkowska DA, Voorman A, Pallansch MA, Wassilak SG, Cochi SL, Badizadegan K, Thompson KM.
        Vaccine. 2021 Apr 27.
        In early 2020, the COVID-19 pandemic led to substantial disruptions in global activities. The disruptions also included intentional and unintentional reductions in health services, including immunization campaigns against the transmission of wild poliovirus (WPV) and persistent serotype 2 circulating vaccine-derived poliovirus (cVDPV2). Building on a recently updated global poliovirus transmission and Sabin-strain oral poliovirus vaccine (OPV) evolution model, we explored the implications of immunization disruption and restrictions of human interactions (i.e., population mixing) on the expected incidence of polio and on the resulting challenges faced by the Global Polio Eradication Initiative (GPEI). We demonstrate that with some resumption of activities in the fall of 2020 to respond to cVDPV2 outbreaks and full resumption on January 1, 2021 of all polio immunization activities to pre-COVID-19 levels, the GPEI could largely mitigate the impact of COVID-19 to the delays incurred. The relative importance of reduced mixing (leading to potentially decreased incidence) and reduced immunization (leading to potentially increased expected incidence) depends on the timing of the effects. Following resumption of immunization activities, the GPEI will likely face similar barriers to eradication of WPV and elimination of cVDPV2 as before COVID-19. The disruptions from the COVID-19 pandemic may further delay polio eradication due to indirect effects on vaccine and financial resources.

    • Disaster Control and Emergency Services
      • The Role of Noncommunicable Diseases in the Pursuit of Global Health Securityexternal icon
        Kostova D, Richter P, Van Vliet G, Mahar M, Moolenaar RL.
        Health Secur. 2021 May 7.
        Noncommunicable diseases and their risk factors are important for all aspects of outbreak preparedness and response, affecting a range of factors including host susceptibility, pathogen virulence, and health system capacity. This conceptual analysis has 2 objectives. First, we use the Haddon matrix paradigm to formulate a framework for assessing the relevance of noncommunicable diseases to health security efforts throughout all phases of the disaster life cycle: before, during, and after an event. Second, we build upon this framework to identify 6 technical action areas in global health security programs that are opportune integration points for global health security and noncommunicable disease objectives: surveillance, workforce development, laboratory systems, immunization, risk communication, and sustainable financing. We discuss approaches to integration with the goal of maximizing the reach of global health security where infectious disease threats and chronic disease burdens overlap.

    • Healthcare Associated Infections
      • Antibiotic use is necessary in the outpatient hemodialysis setting because patients receiving hemodialysis are at increased risk for infections and sepsis. However, inappropriate antibiotic use can lead to adverse drug events, including adverse drug reactions and infections with Clostridioides difficile and antibiotic-resistant bacteria. Optimizing antibiotic use can decrease adverse events and improve infection cure rates and patient outcomes. The American Society of Nephrology and the US Centers for Disease Control and Prevention created the Antibiotic Stewardship in Hemodialysis White Paper Writing Group, comprising experts in antibiotic stewardship, infectious diseases, nephrology, and public health, to highlight strategies that can improve antibiotic prescribing for patients receiving maintenance hemodialysis. Based on existing evidence and the unique patient and clinical setting characteristics, the following strategies for improving antibiotic use are reviewed: expanding infection and sepsis prevention activities, standardizing blood culture collection processes, treating methicillin-susceptible Staphylococcus aureus infections with β-lactams, optimizing communication between nurses and prescribing providers, and improving data sharing across transitions of care. Collaboration among the Centers for Disease Control and Prevention; American Society of Nephrology; other professional societies such as infectious diseases, hospital medicine, and vascular surgery societies; and dialysis provider organizations can improve antibiotic use and the quality of care for patients receiving maintenance hemodialysis.

    • Nutritional Sciences
      • Background: Infants and young children with high weight-for-length are at increased risk for obesity in later life. This study describes prevalence of high weight-for-length and examines changes during 2010-2018 among 11,366,755 infants and young children 3-23 months of age in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Methods: Children's weights and lengths were measured. High weight-for-length was defined as ≥2 standard deviations above sex and age-specific median on World Health Organization growth charts. Adjusted prevalence differences (APDs) between years were calculated as 100 times marginal effects from logistic regression models. APD was statistically significant if 95% confidence interval did not include 0. Results: Adjusted prevalence of high weight-for-length decreased from 2010 to 2014, and leveled off through 2018 overall, in boys and girls, those 6-11 and 18-23 months of age, and non-Hispanic whites, non-Hispanic blacks, Hispanics, and Asians/Pacific Islanders. For 12-17 months old and American Indian/Alaska Native infants and young children, adjusted prevalence decreased from 2010 to 2014, and then increased slightly through 2018. Among 56 WIC state or territorial agencies, 33 had significant decreases between 2010 and 2018, whereas 8 had significant increases. Between 2014 and 2018, prevalence decreased significantly in 12 agencies and increased significantly in 23. Conclusions: The results indicate overall declines in prevalence of high weight-for-length from 2010 to 2018, with a prevalence stabilization since 2014. Continued surveillance is needed. Obesity prevention strategies in WIC and multiple settings are important for ensuring healthy child growth.

    • Occupational Safety and Health
      • Cohort profile: Four early uranium processing facilities in the US and Canadaexternal icon
        Golden AP, Milder CM, Ellis ED, Anderson JL, Boice JD, Bertke SJ, Zablotska LB.
        Int J Radiat Biol. 2021 May 10:1-33.
        PURPOSE: Risks of occupational radiation exposures of workers involved in uranium refining and processing ("uranium processing workers") may be different from risks of other workers from the nuclear fuel cycle. Pooling of individual-level data from published studies and analysis using similar dosimetry and statistical methods might provide valuable insights into risks from occupational uranium and external ionizing radiation exposures. METHODS: We pooled the data for workers from four uranium processing facilities (Fernald Feed Materials Production Center, Ohio; Mallinckrodt Chemical Works Uranium Division, Missouri; Middlesex Sampling Plant, New Jersey; and the Port Hope Radium and Uranium Refining and Processing Plant, Canada). Employment began as early as the 1930s in Canada and follow-up for vital status was as late as 2017. These facilities used similar methods to process Belgian Congo pitchblende ore which contained high concentrations of uranium, radium, and their decay products. In addition, workers were exposed to elevated levels of gamma radiation, fission product contaminants in recycled uranium and ambient radon decay products. Non-radiation exposures of industrial hygiene concern were silica dust inhalation, heavy metal toxicity from uranium, solvents, acid mists and chemicals associated with uranium processing. Exposure and outcome data were harmonized using similar definitions and dose reconstruction methods. Standardized mortality ratios (SMR) were estimated by comparing mortality in the pooled cohort with age-, sex- and calendar time-specific general population mortality rates for the U.S. and Canada. RESULTS: Over 12,400 workers will be evaluated for cancer and non-cancer mortality in relation to exposures to uranium byproducts and gamma radiation (including ∼1,300 females). In total, death from 560 lung cancers, 503 nonmalignant respiratory diseases, 67 renal diseases, 1,596 ischemic heart diseases, and 101 dementia and Alzheimer's diseases (AD) were detected among male workers during follow-up. Mean cumulative doses were 45 millisievert for whole-body external exposures and 172 milligray for lung dose from radon decay products. Of the 16 pooled SMRs, seven were above 1.00, none were significantly low, and only one was significantly high, i.e., dementia and AD among males (SMR =1.29; 95% confidence interval: 1.04,1.54). CONCLUSIONS: This is the largest study to date to examine health risks in uranium processing workers (excluding uranium enrichment workers). The pooling of uranium processing worker data will address issues of importance today, specifically the concerns for cleanup workers and environmental contamination from the operation of past and present nuclear reactor and radiation facilities, reactor accidents, and possible terrorist events.

    • Physical Activity
      • Types of Physical Activity Recommended by Primary Care Providers for Patients at Risk for Cardiovascular Diseaseexternal icon
        Omura JD, Watson KB, Loustalot F, Fulton JE, Carlson SA.
        Prev Chronic Dis. 2021 May 6;18:E43.
        Primary care providers (PCPs) are uniquely positioned to promote physical activity for cardiovascular health. We sought to determine the types of physical activity that PCPs most often recommend to patients at risk for cardiovascular disease (CVD) and how these recommendations vary by PCPs' physical activity counseling practices. We examined the types of physical activity (walking, supervised exercise sessions, or other) PCPs most often suggested for CVD prevention among respondents to the 2018 DocStyles survey (N = 1,088). Most PCPs (80.0%) suggested walking to their patients at risk for CVD; however, PCPs who infrequently discussed physical activity with their patients at risk for CVD suggested walking less often than those who more frequently discussed physical activity. Walking is an easy and low-cost form of physical activity, and opportunities exist for certain PCPs to promote walking as part of their physical activity counseling practices for CVD prevention.

    • Public Health Leadership and Management
      • Introduction: As part of scaling up the response to the opioid overdose epidemic, there is an opportunity to examine how state public health departments addressed workforce and other infrastructure needs to implement a large-scale opioid overdose prevention program. Understanding how this was done—and any lessons learned from the process—can inform future workforce development and capital improvement efforts. Methods: Administrative data from the Centers for Disease Control and Prevention (CDC) Prescription Drug Overdose Prevention for States (PfS) program were analyzed to understand how states adapted to this emerging public health priority. Results: Six months into the first year of funding, 6 of the 16 state health departments had filled all anticipated staffing positions. States faced challenges obtaining timely expenditure authority and hiring staff. However, states were able to overcome these challenges by strategically reassigning staff, hiring from within, and utilizing existing contract mechanisms. Conclusion: Our analysis revealed how planning, using existing infrastructure, and maintaining a prepared workforce are critical to ensure that public health agencies have the ability to surge to meet emerging challenges and effectively utilize resources to achieve program goals. practical applications: Greater attention should be directed toward strategically addressing known barriers and timelines in work plans and budgets during the application and selection process to ensure implementation readiness. © 2021

    • Zoonotic and Vectorborne Diseases
      • Identifying urban hotspots of dengue, chikungunya, and Zika transmission in Mexico to support risk stratification efforts: a spatial analysisexternal icon
        Dzul-Manzanilla F, Correa-Morales F, Che-Mendoza A, Palacio-Vargas J, Sánchez-Tejeda G, González-Roldan JF, López-Gatell H, Flores-Suárez AE, Gómez-Dantes H, Coelho GE, da Silva Bezerra HS, Pavia-Ruz N, Lenhart A, Manrique-Saide P, Vazquez-Prokopec GM.
        Lancet Planet Health. 2021 May;5(5):e277-e285.
        BACKGROUND: Effective Aedes aegypti control is limited, in part, by the difficulty in achieving sufficient intervention coverage. To maximise the effect of vector control, areas with persistently high numbers of Aedes-borne disease cases could be identified and prioritised for preventive interventions. We aimed to identify persistent Aedes-borne disease hotspots in cities across southern Mexico. METHODS: In this spatial analysis, geocoded cases of dengue, chikungunya, and Zika from nine endemic Mexican cities were aggregated at the census-tract level. We included cities that were located in southern Mexico (the arbovirus endemic region of Mexico), with a high burden of dengue cases (ie, more than 5000 cases reported during a 10-year period), and listed as high priority for the Mexican dengue control and prevention programme. The Getis-Ord Gi*(d) statistic was applied to yearly slices of the dataset to identify spatial hotspots of each disease in each city. We used Kendall's W coefficient to quantify the agreement in the distribution of each virus. FINDINGS: 128 507 dengue, 4752 chikungunya and 25 755 Zika clinical cases were reported between Jan 1, 2008, and Dec 31, 2016. All cities showed evidence of transmission heterogeneity, with a mean of 17·6% (SD 4·7) of their total area identified as persistent disease hotspots. Hotspots accounted for 25·6% (SD 9·7; range 12·8-43·0) of the population and 32·1% (10·5; 19·6-50·5) of all Aedes-borne disease cases reported. We found an overlap between hotspots of 61·7% for dengue and Zika and 53·3% for dengue and chikungunya. Dengue hotspots in 2008-16 were significantly associated with dengue hotspots detected during 2017-20 in five of the nine cities. Heads of vector control confirmed hotspot areas as problem zones for arbovirus transmission. INTERPRETATION: This study provides evidence of the overlap of Aedes-borne diseases within geographical hotspots and a methodological framework for the stratification of arbovirus transmission risk within urban areas, which can guide the implementation of surveillance and vector control. FUNDING: USAID, the US Centers for Disease Control and Prevention, the Canadian Institutes of Health Research, International Development Research Centre, Fondo Mixto CONACyT (Mexico)-Gobierno del Estado de Yucatan, and the US National Institutes of Health. TRANSLATION: For the Spanish translation of the abstract see Supplementary Materials section.

  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. Emergency department visits among people with cancer: Frequency, symptoms, and characteristicsexternal icon
        Gallaway MS, Idaikkadar N, Tai E, Momin B, Rohan EA, Townsend J, Puckett M, Stewart SL.
        J Am Coll Emerg Physicians Open. 2021 Jun;2(3):e12438.
        OBJECTIVE: People with cancer are increasingly more likely to visit an emergency department for acute care than the general population. They often have long wait times and more exposure to infection and receive treatment from staff less experienced with cancer-related problems. Our objective was to examine emergency department (ED) visits among people with cancer to understand how often and why they seek care. METHODS: We conducted a retrospective study of ED visits using the National Syndromic Surveillance Program BioSense Platform. Cancer reported during an ED visit was identified using International Classification of Diseases, Tenth Revision codes for any cancer type, including bladder, breast, cervical, colorectal, kidney, liver, lung, ovary, pancreas, prostate, or uterine cancers. Symptoms prompting the visit were identified for people with cancer who visited EDs in the United States from June 2017 to May 2018 in ≈4500 facilities, including 3000 EDs in 46 states and the District of Columbia (66% of all ED visits during a 1-year period). RESULTS: Of 97 million ED visits examined, 710,297 (0.8%) were among people with cancer. Percentages were higher among women (50.1%) than men (49.5%) and among adults aged ≥65 years (53.6%) than among those ≤64 years (45.7%). The most common presenting symptoms were pain (19.1%); gastrointestinal (13.8%), respiratory (11.5%), and neurologic (5.3%) complaints; fever (4.9%); injury (4.1%); and bleeding (2.4%). Symptom prevalence differed significantly by cancer type. CONCLUSIONS: The Centers for Medicare & Medicaid Services encourages efforts to reduce acute care visits among people with cancer. We characterized almost 70% of ED visits among this population.

      2. Long-term mortality among kidney transplant recipients with and without diabetes: a nationwide cohort study in the USAexternal icon
        Harding JL, Pavkov M, Wang Z, Benoit S, Burrows NR, Imperatore G, Albright AL, Patzer R.
        BMJ Open Diabetes Res Care. 2021 May;9(1).
        INTRODUCTION: Little is known about the role diabetes (type 1 (T1D) and type 2 (T2D)) plays in modifying prognosis among kidney transplant recipients. Here, we compare mortality among transplant recipients with T1D, T2D and non-diabetes-related end-stage kidney disease (ESKD). RESEARCH DESIGN AND METHODS: We included 254 188 first-time single kidney transplant recipients aged ≥18 years from the US Renal Data System (2000-2018). Diabetes status, as primary cause of ESKD, was defined using International Classification of Disease 9th and 10th Clinical Modification codes. Multivariable-adjusted Cox regression models (right-censored) computed risk of death associated with T1D and T2D relative to non-diabetes. Trends in standardized mortality ratios (SMRs) (2000-2017), relative to the general US population, were assessed using Joinpoint regression. RESULTS: A total of 72 175 (28.4%) deaths occurred over a median survival time of 14.6 years. 5-year survival probabilities were 88%, 85% and 77% for non-diabetes, T1D and T2D, respectively. In adjusted models, mortality was highest for T1D (HR=1.95, (95% CI: 1.88 to 2.03)) and then T2D (1.65 (1.62 to 1.69)), as compared with non-diabetes. SMRs declined for non-diabetes, T1D, and T2D. However, in 2017, SMRs were 2.38 (2.31 to 2.45), 6.55 (6.07 to 7.06), and 3.82 (3.68 to 3.98), for non-diabetes, T1D and T2D, respectively. CONCLUSIONS: In the USA, diabetes type is an important modifier in mortality risk among kidney transplant recipients with highest rates among people with T1D-related ESKD. Development of effective interventions that reduce excess mortality in transplant recipients with diabetes is needed, especially for T1D.

      3. Prevalence of Inflammatory Bowel Disease Among Medicare Fee-For-Service Beneficiaries - United States, 2001-2018external icon
        Xu F, Carlson SA, Liu Y, Greenlund KJ.
        MMWR Morb Mortal Wkly Rep. 2021 May 14;70(19):698-701.
        Inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, is characterized by chronic inflammation of the gastrointestinal tract. The number of affected persons worldwide has increased from 3.7 million in 1990 to 6.8 million in 2017 (1). The disease is more prevalent among non-Hispanic White persons than it is among persons in other racial/ethnic groups (2). As the prevalence increases with age group (2), it is important to understand the disease epidemiology among the older population. CDC analyzed 2018 Medicare data among beneficiaries aged ≥67 years to examine differences by demographic characteristics for both diseases and to assess trends of prevalence from 2001 through 2018 both overall and by race and ethnicity. In 2018, 0.40% and 0.64% of 25.1 million Medicare fee-for-service beneficiaries aged ≥67 years had received a diagnosis of either Crohn's disease or ulcerative colitis. Prevalence varied by age, sex, race and ethnicity, urban-rural residency, and state. During 2001-2018, the age-adjusted prevalence of both diseases increased (Crohn's disease annual percentage change [APC] = 3.4%, ulcerative colitis APC = 2.8%). The increase was higher among non-Hispanic Black persons (Crohn's disease APC = 5.0%, ulcerative colitis APC = 3.5%) than it was among non-Hispanic White, Hispanic, and Asian/Pacific Islander (A/PI) persons. Prevalence was consistently highest among non-Hispanic White persons for both diseases and lowest among A/PI persons for Crohn's disease. The study findings of increasing prevalence in all racial/ethnic groups among older adults, especially the higher rate of increase among certain racial/ethnic minority groups, underscore the importance for promoting health equity, guiding efforts to tailor disease management strategies for different populations, and continuing to monitor the temporal trends of the disease.

    • Communicable Diseases
      1. Diagnostic Performance of an Antigen Test with RT-PCR for the Detection of SARS-CoV-2 in a Hospital Setting - Los Angeles County, California, June-August 2020external icon
        Brihn A, Chang J, O. Yong K, Balter S, Terashita D, Rubin Z, Yeganeh N.
        MMWR Morb Mortal Wkly Rep. 2021 May 14;70(19):702-706.
        Prompt and accurate detection of SARS-CoV-2, the virus that causes COVID-19, has been important during public health responses for containing the spread of COVID-19, including in hospital settings (1-3). In vitro diagnostic nucleic acid amplification tests (NAAT), such as real-time reverse transcription-polymerase chain reaction (RT-PCR) can be expensive, have relatively long turnaround times, and require experienced laboratory personnel.* Antigen detection tests can be rapidly and more easily performed and are less expensive. The performance(†) of antigen detection tests, compared with that of NAATs, is an area of interest for the rapid diagnosis of SARS-CoV-2 infection. The Quidel Sofia 2 SARS Antigen Fluorescent Immunoassay (FIA) (Quidel Corporation) received Food and Drug Administration Emergency Use Authorization for use in symptomatic patients within 5 days of symptom onset (4). The reported test positive percentage agreement(§) between this test and an RT-PCR test result is 96.7% (95% confidence interval [CI] = 83.3%-99.4%), and the negative percentage agreement is 100.0% (95% CI = 97.9%-100.0%) in symptomatic patients.(¶) However, performance in asymptomatic persons in a university setting has shown lower sensitivity (5); assessment of performance in a clinical setting is ongoing. Data collected during June 30-August 31, 2020, were analyzed to compare antigen test performance with that of RT-PCR in a hospital setting. Among 1,732 paired samples from asymptomatic patients, the antigen test sensitivity was 60.5%, and specificity was 99.5% when compared with RT-PCR. Among 307 symptomatic persons, sensitivity and specificity were 72.1% and 98.7%, respectively. Health care providers must remain aware of the lower sensitivity of this test among asymptomatic and symptomatic persons and consider confirmatory NAAT testing in high-prevalence settings because a false-negative result might lead to failures in infection control and prevention practices and cause delays in diagnosis, isolation, and treatment.

      2. Factors Associated With HIV Testing Among High-School Girls in the U.S., 2015‒2017external icon
        Cyrus AC, Dunville R, Kourtis AP, Hoover KW, Tucker P.
        Am J Prev Med. 2021 May 5.
        INTRODUCTION: Few studies have examined the factors associated with HIV testing, specifically among U.S. high-school girls. METHODS: Investigators analyzed 2015 and 2017 Youth Risk Behavior Survey data to calculate the prevalence ratios and the corresponding 95% CIs for the association of HIV-related risk behaviors and other factors with HIV testing. Analyses were completed in March 2020. RESULTS: Approximately 1 in 10 high-school girls reported ever having had an HIV test. Ever having had an HIV test was most common among girls who had ≥4 lifetime sexual partners and those who had ever injected illegal drugs. CONCLUSIONS: High-school girls who engage in behaviors or experience other factors that put them at higher risk for HIV are more likely to have ever gotten tested. However, the prevalence of having ever had an HIV test remains relatively low, indicating that continued efforts may be warranted to reduce risk behaviors and increase testing among high-school girls.

      3. Comprehensive approach to HIV/AIDS testing and linkage to treatment among men who have sex with men in Curitiba, Brazilexternal icon
        da Cruz MM, Cota VL, Lentini N, Bingham T, Parent G, Kanso S, Rosso LR, Almeida B, Cardoso Torres RM, Nakamura CY, Santelli AC.
        PLoS One. 2021 ;16(5):e0249877.
        INTRODUCTION: The Curitiba (Brazil)-based Project, A Hora é Agora (AHA), evaluated a comprehensive HIV control strategy among men who have sex with men (MSM) aimed at expanding access to HIV rapid testing and linking HIV-positive MSM to health services and treatment. AHA's approach included rapid HIV Testing Services (HTC) in one mobile testing unit (MTU); a local, gay-led, non-governmental organization (NGO); an existing government-run health facility (COA); and Internet-based HIV self-testing. The objectives of the paper were to compare a) number of MSM tested in each strategy, its positivity and linkage; b) social, demographic and behavioral characteristics of MSM accessing the different HTC and linkage services; and c) the costs of the individual strategies to diagnose and link MSM to services. METHODS: We used data for 2,681 MSM tested at COA, MTU and NGO from March 2015 to March 2017. This is a cross sectional comparison of the demographics and behavioral factors (age group, race/ethnicity, education, sexually transmitted diseases, knowledge of AHA services and previous HIV test). Absolute frequencies, percentage distributions and confidence intervals for the percentages were used, as well as unilateral statistical tests. RESULTS AND DISCUSSION: AHA performed 2,681 HIV tests among MSM across three in-person strategies: MTU, NGO, and COA; and distributed 4,752 HIV oral fluid tests through the self-testing platform. MTU, NGO and COA reported 365 (13.6%) HIV positive diagnoses among MSM, including 28 users with previous HIV diagnosis or on antiretroviral treatment for HIV. Of these, 89% of MSM were eligible for linkage-to-care services. Linkage support was accepted by 86% of positive MSM, of which 66.7% were linked to services in less than 90 days. The MTU resulted in the lowest cost per MSM tested ($137 per test), followed by self-testing ($247). CONCLUSIONS: AHA offered MSM access to HTC through innovative strategies operating in alternative sites and schedules. It presented the Curitiba HIV/AIDS community the opportunity to monitor HIV-positive MSM from diagnosis to treatment uptake. Self-testing emerged as a feasible strategy to increase MSM access to HIV-testing through virtual tools and anonymous test kit delivery and pick-up. Cost per test findings in both the MTU and self-testing support expansion to other regions with similar epidemiological contexts.

      4. Intersection of Syphilis and HIV Networks to Identify Opportunities to Enhance HIV Preventionexternal icon
        Dennis AM, Cressman A, Pasquale D, Frost SD, Kelly E, Guy J, Mobley V, Samoff E, Hurt CB, McNeil C, Hightow-Weidman L, Carry M, Hogben M, Seña AC.
        Clin Infect Dis. 2021 May 12.
        BACKGROUND: HIV and syphilis infection continue at disproportionate rates among minority men who have sex with men (MSM) in the United States. The integration of HIV genetic clustering with partner services can provide important insight into local epidemic trends to guide interventions and control efforts. METHODS: We evaluated contact networks of index persons defined as minority men and transgender women diagnosed with early syphilis and/or HIV infection between 2018-2020 in two North Carolina regions. HIV clusters were constructed from pol sequences collected through statewide surveillance. A combined "HIV-risk" network, which included persons with any links (genetic or sexual contact) to HIV-positive persons, was evaluated by component size, demographic factors, and HIV viral suppression. RESULTS: In total, 1,289 index persons were identified and 55% named 1,153 contacts. Most index persons were Black (88%) and young (median age 30 years); 70% had early syphilis and 43% had prevalent HIV infection. Most people with HIV (65%) appeared in an HIV cluster. The combined HIV-risk network (1,590 contact network and 1,500 cluster members) included 287 distinct components; however, 1,586 (51%) were in a single component. Fifty-five percent of network members with HIV had no evidence of viral suppression. Overall, fewer index persons needed to be interviewed to identify one HIV-positive member without viral suppression (1.3 versus 4.0 for contact tracing). CONCLUSIONS: Integration of HIV clusters and viral loads illuminate networks with high HIV prevalence, indicating recent and ongoing transmission. Interventions intensified towards these networks may efficiently reach persons for HIV prevention and care re-engagement.

      5. This evaluation describes an increase in reported drug-related risk behaviors (DRRBs) among females who are diagnosed with early syphilis over a 5-year span in New York State, excluding New York City. Integrating sexually transmitted infection prevention efforts with harm reduction services may help decrease syphilis rates in areas where DRRBs rates are high.

      6. Community-Based Testing for SARS-CoV-2 - Chicago, Illinois, May-November 2020external icon
        English K, Lei U, Shipman-Amuwo F, Burkey M, González JG, Richardson S, Chavez-Torres M, Arwady MA, Anderson C, Layden JE, Ruestow P, Pacilli M, Ghinai I.
        MMWR Morb Mortal Wkly Rep. 2021 May 14;70(19):707-711.
        On May 13, 2020, Chicago established a free community-based testing (CBT) initiative for SARS-CoV-2, the virus that causes COVID-19, using reverse transcription-polymerase chain reaction (RT-PCR). The initiative focused on demographic groups and geographic areas that were underrepresented in testing by clinical providers and had experienced high COVID-19 incidence, including Hispanic persons and those who have been economically marginalized. To assess the CBT initiative, the Chicago Department of Public Health (CDPH) compared demographic characteristics, economic marginalization, and test positivity between persons tested at CBT sites and persons tested in all other testing settings in Chicago. During May 13-November 14, a total of 253,904 SARS-CoV-2 RT-PCR tests were conducted at CBT sites. Compared with those tested in all other testing settings in Chicago, persons tested at CBT sites were more likely to live in areas that are economically marginalized (38.6% versus 32.0%; p<0.001) and to be Hispanic (50.9% versus 20.7%; p<0.001). The cumulative percentage of positive test results at the CBT sites was higher than that at all other testing settings (11.1% versus 7.1%; p<0.001). These results demonstrate the ability of public health departments to establish community-based testing initiatives that reach communities with less access to testing in other settings and that experience disproportionately higher incidences of COVID-19.

      7. Cruise ship travel in the era of COVID-19: A summary of outbreaks and a model of public health interventionsexternal icon
        Guagliardo SA, Prasad PV, Rodriguez A, Fukunaga R, Novak RT, Ahart L, Reynolds J, Griffin I, Wiegand R, Quilter LA, Morrison S, Jenkins K, Wall HK, Treffiletti A, White SB, Regan J, Tardivel K, Freeland A, Brown C, Wolford H, Johansson MA, Cetron MS, Slayton RB, Friedman CR.
        Clin Infect Dis. 2021 May 12.
        BACKGROUND: Cruise travel contributed to SARS-CoV-2 transmission when there were relatively few cases in the United States. By March 14, 2020, the Centers for Disease Control and Prevention (CDC) issued a No Sail Order suspending U.S. cruise operations; the last U.S. passenger ship docked on April 16. METHODS: We analyzed SARS-CoV-2 outbreaks on cruises in U.S. waters or carrying U.S. citizens and used regression models to compare voyage characteristics. We used compartmental models to simulate the potential impact of four interventions (screening for COVID-19 symptoms; viral testing on two days and isolation of positive persons; reduction of passengers by 40%, crew by 20%, and port visits to one) for 7-day and 14-day voyages. RESULTS: During January 19-April 16, 2020, 89 voyages on 70 ships had known SARS-CoV-2 outbreaks; 16 ships had recurrent outbreaks. There were 1,669 RT-PCR-confirmed SARS-CoV-2 infections and 29 confirmed deaths. Longer voyages were associated with more cases (adjusted incidence rate ratio, 1.10, 95% CI: 1.03-1.17, p < 0.0001). Mathematical models showed that 7-day voyages had about 70% fewer cases than 14-day voyages. On 7-day voyages, the most effective interventions were reducing the number of individuals onboard (43-49% reduction in total infections) and testing passengers and crew (42-43% reduction in total infections). All four interventions reduced transmission by 80%, but no single intervention or combination eliminated transmission. Results were similar for 14-day voyages. CONCLUSIONS: SARS-CoV-2 outbreaks on cruises were common during January-April 2020. Despite all interventions modeled, cruise travel still poses a significant SARS-CoV-2 transmission risk.

      8. Mitigation policies, community mobility, and COVID-19 case counts in Australia, Japan, Hong Kong, and Singaporeexternal icon
        Hakim AJ, Victory KR, Chevinsky JR, Hast MA, Weikum D, Kazazian L, Mirza S, Bhatkoti R, Schmitz MM, Lynch M, Marston BJ.
        Public Health. 2021 Feb 12;194:238-244.
        OBJECTIVES: The objective of the study was to characterize the timing and trends of select mitigation policies, changes in community mobility, and coronavirus disease 2019 (COVID-19) epidemiology in Australia, Japan, Hong Kong, and Singapore. STUDY DESIGN: Prospective abstraction of publicly available mitigation policies obtained from media reports and government websites. METHODS: Data analyzed include seven kinds of mitigation policies (mass gathering restrictions, international travel restrictions, passenger screening, traveler isolation/quarantine, school closures, business closures, and domestic movement restrictions) implemented between January 1 and April 26, 2020, changes in selected measures of community mobility assessed by Google Community Mobility Reports data, and COVID-19 epidemiology in Australia, Japan, Hong Kong, and Singapore. RESULTS: During the study period, community mobility decreased in Australia, Japan, and Singapore; there was little change in Hong Kong. The largest declines in mobility were seen in places that enforced mitigation policies. Across settings, transit-associated mobility declined the most and workplace-associated mobility the least. Singapore experienced an increase in cases despite the presence of stay-at-home orders, as migrant workers living in dormitories faced challenges to safely quarantine. CONCLUSIONS: Public policies may have different impacts on mobility and transmission of severe acute respiratory coronavirus-2 transmission. When enacting mitigation policies, decision makers should consider the possible impact of enforcement measures, the influence on transmission of factors other than movement restrictions, and the differential impact of mitigation policies on subpopulations.

      9. COVID-19 response by the Hopi Tribe: impact of systems improvement during the first wave on the second wave of the pandemicexternal icon
        Humeyestewa D, Burke RM, Kaur H, Vicenti D, Jenkins R, Yatabe G, Hirschman J, Hamilton J, Fazekas K, Leslie G, Sehongva G, Honanie K, Tu'tsi E, Mayer O, Rose MA, Diallo Y, Damon S, Zilversmit Pao L, McCraw HM, Talawyma B, Herne M, Nuvangyaoma TL, Welch S, Balajee SA.
        BMJ Glob Health. 2021 May;6(5).
        The Hopi Tribe is a sovereign nation home to ~7500 Hopi persons living primarily in 12 remote villages. The Hopi Tribe, like many other American Indian nations, has been disproportionately affected by COVID-19. On 18 May 2020, a team from the US Centers for Disease Control and Prevention (CDC) was deployed on the request of the tribe in response to increases in COVID-19 cases. Collaborating with Hopi Health Care Center (the reservation's federally run Indian Health Service health facility) and CDC, the Hopi strengthened public health systems and response capacity from May to August including: (1) implementing routine COVID-19 surveillance reporting; (2) establishing the Hopi Incident Management Authority for rapid coordination and implementation of response activities across partners; (3) implementing a community surveillance programme to facilitate early case detection and educate communities on COVID-19 prevention; and (4) applying innovative communication strategies to encourage mask wearing, hand hygiene and physical distancing. These efforts, as well as community adherence to mitigation measures, helped to drive down cases in August. As cases increased in September-November, the improved capacity gained during the first wave of the pandemic enabled the Hopi leadership to have real-time awareness of the changing epidemiological landscape. This prompted rapid response coordination, swift scale up of health communications and redeployment of the community surveillance programme. The Hopi experience in strengthening their public health systems to better confront COVID-19 may be informative to other indigenous peoples as they also respond to COVID-19 within the context of disproportionate burden.

      10. Adverse pregnancy outcomes, maternal complications, and severe illness among U.S. delivery hospitalizations with and without a COVID-19 diagnosisexternal icon
        Ko JY, DeSisto CL, Simeone RM, Ellington S, Galang RR, Oduyebo T, Gilboa SM, Lavery AM, Gundlapalli AV, Shapiro-Mendoza CK.
        Clin Infect Dis. 2021 May 12.
        BACKGROUND: Evidence on risk for adverse outcomes from COVID-19 among pregnant women is still emerging. We examined the association between COVID-19 at delivery and adverse pregnancy outcomes, maternal complications, and severe illness, whether these associations differ by race/ethnicity; and described discharge status by COVID-19 diagnosis and maternal complications. METHODS: Data from 703 hospitals in the Premier Healthcare Database during March-September 2020 were included. Adjusted risk ratios overall and stratified by race/ethnicity were estimated using Poisson regression with robust standard errors. Proportion not discharged home was calculated by maternal complications, stratified by COVID-19 diagnosis. RESULTS: Among 489,471 delivery hospitalizations, 6,550 (1.3%) had a COVID-19 diagnosis. In adjusted models, COVID-19 was associated with increased risk for: acute respiratory distress syndrome (adjusted risk ratio [aRR] = 34.4), death (aRR = 17.0), sepsis (aRR = 13.6), mechanical ventilation (aRR = 12.7), shock (aRR = 5.1), intensive care unit admission (aRR = 3.6), acute renal failure (aRR = 3.5), thromboembolic disease (aRR = 2.7), adverse cardiac event/outcome (aRR = 2.2) and preterm labor with preterm delivery (aRR = 1.2). Risk for any maternal complications or for any severe illness did not significantly differ by race/ethnicity. Discharge status did not differ by COVID-19; however, among women with concurrent maternal complications, a greater proportion of those with (versus without) COVID-19 were not discharged home. CONCLUSIONS: These findings emphasize the importance of implementing recommended mitigation strategies to reduce risk for SARS-CoV-2 infection and further inform counseling and clinical care for pregnant women during the COVID-19 pandemic.

      11. Precore and Basal Core Promoter Hepatitis B Virus (HBV) Variants Are Present From a Young Age and Differ Across HBV Genotypesexternal icon
        Lau DT, Ganova-Raeva L, Wang J, Mogul D, Chung RT, Lisker-Melman M, Chang KM, Shaikh OS, Janssen HL, Wahed AS, Lok AS.
        Hepatology. 2021 May;73(5):1637-1651.
        BACKGROUND AND AIMS: Hepatitis B virus (HBV) precore (PC) and dual basal core promoter (BCP) mutations halt and down-regulate hepatitis B e antigen (HBeAg) production respectively. PC mutation is rarely associated with HBV genotype A. We sought to examine the association of these variants with HBV genotypes, age, and HBeAg status in a racially diverse population in North America. Prospective study included 1,036 (808 adults, 228 children) participants in the Hepatitis B Research Network. PC and BCP variants were determined by Sanger sequencing, and dominant HBV species (>50%) were reported. APPROACH AND RESULTS: Median age was 36.3 years (range, 2-80), 44.6% HBeAg(+), 74.2% Asians, 13.3% black, and 9.7% white. The dominant PC variant was present in 29.4% participants, including 20 with subgenotype A1 or A2. Seventeen of 20 participants with genotype A and PC had a compensatory C1858T mutation. In the HBeAg(+) cohort, the prevalence of PC and/or BCP variants increased from 14.4% in the first two decades to 51% after 40 years of age. Among those aged 2-18, 52% and 83% with dominant PC and BCP variants were HBeAg(+) compared to 3.8% and 29% in the >40 years age group. HBeAg clearance rates were significantly higher for those with dominant PC or BCP variants: 24.4 and 15.0 per 100 person-years compared to 6.0 in wild-type HBV (P < 0.0001). CONCLUSIONS: PC variants can be present in HBV genotype A and are usually associated with C1858T, which preserves the pregenome encapsidation sequence. Selection of PC and BCP variants occurred at a young age, with increasing prevalence across age groups. HBeAg(+) participants with dominant PC and BCP variants progressed to the HBeAg(-) phase of chronic HBV infection significantly faster. This finding has potential clinical and therapeutic implications.

      12. Communicability of varicella before rash onset: a literature reviewexternal icon
        Marin M, Leung J, Lopez AS, Shepersky L, Schmid DS, Gershon AA.
        Epidemiol Infect. 2021 May 7:1-18.

      13. BACKGROUND: Because most sources of administrative claims data do not contain laboratory result data, researchers rely on diagnosis codes to identify cases of disease. The validity of using diagnosis codes to identify chlamydial and gonococcal infections in administrative claims data remains largely uninvestigated. METHODS: We conducted a retrospective cohort analysis using OptumLabs® Data Warehouse, which includes de-identified medical (inpatient and outpatient) claims and laboratory test results. Among males and females aged 15-39 years during 2003-2017, we identified chlamydia and gonorrhea test results and corresponding diagnosis codes. Using test results as the gold standard, we calculated the sensitivity and specificity of chlamydia and gonorrhea diagnosis codes to identify laboratory confirmed infections. RESULTS: We identified 9.7 million chlamydia and gonorrhea test results among 3.1 million enrollees. Of the 176,241 positive chlamydia test results, only 11,515 had a corresponding diagnosis code, for a sensitivity of 6.5 (95% confidence interval [CI]: 6.4-6.7) and a specificity of 99.5 (95% CI: 99.5-99.5). Corresponding diagnosis codes were identified for 8,056 of the 31,766 positive gonorrhea test results for a sensitivity of 25.4 (95% CI: 24.9-25.8) and a specificity of 99.7 (95% CI: 99.7-99.7). CONCLUSIONS: Our findings indicate that using only ICD-CM diagnosis codes to identify chlamydial and gonococcal infections substantially underestimates the burden of these diseases and inaccurately classifies laboratory confirmed infections.

      14. SARS-CoV-2 transmission in intercollegiate athletics not fully mitigated with daily antigen testingexternal icon
        Moreno GK, Braun KM, Pray IW, Segaloff HE, Lim A, Poulsen K, Meiman J, Borcher J, Westergaard RP, Moll MK, Friedrich TC, O'Connor DH.
        Clin Infect Dis. 2021 May 12.
        BACKGROUND: High-frequency, rapid-turnaround SARS-CoV-2 testing continues to be proposed as a way of efficiently identifying and mitigating transmission in congregate settings. However, two SARS-CoV-2 outbreaks occurred among intercollegiate university athletic programs during the fall 2020 semester despite mandatory directly observed daily antigen testing. METHODS: During the fall 2020 semester, athletes and staff in both programs were tested daily using Quidel's Sofia SARS Antigen Fluorescent Immunoassay (FIA), with positive antigen results requiring confirmatory testing with real-time reverse transcription polymerase chain reaction (RT-PCR). We used genomic sequencing to investigate transmission dynamics in these two outbreaks. RESULTS: In Outbreak 1, 32 confirmed cases occurred within a university athletics program after the index patient attended a meeting while infectious despite a negative antigen test on the day of the meeting. Among isolates sequenced from Outbreak 1, 24 (92%) of 26 were closely related, suggesting sustained transmission following an initial introduction event. In Outbreak 2, 12 confirmed cases occurred among athletes from two university programs that faced each other in an athletic competition despite receiving negative antigen test results on the day of the competition. Sequences from both teams were closely related and distinct from viruses circulating in Team 1's community, suggesting transmission during intercollegiate competition in Team 2's community. CONCLUSIONS: These findings suggest that antigen testing alone, even when mandated and directly observed, may not be sufficient as an intervention to prevent SARS-CoV-2 outbreaks in congregate settings, and highlight the importance of supplementing serial antigen testing with appropriate mitigation strategies to prevent SARS-CoV-2 outbreak in congregate settings.

      15. Challenges in Surveillance for Streptococcal Toxic Shock Syndrome: Active Bacterial Core Surveillance, United States, 2014-2017external icon
        Nanduri SA, Onukwube J, Apostol M, Alden N, Petit S, Farley M, Harrison LH, Como-Sabetti K, Smelser C, Burzlaff K, Cieslak P, Schaffner W, Van Beneden CA.
        Public Health Rep. 2021 May 7.
        OBJECTIVES: Routine surveillance for streptococcal toxic shock syndrome (STSS), a severe manifestation of invasive group A Streptococcus (GAS) infections, likely underestimates its true incidence. The objective of our study was to evaluate routine identification of STSS in a national surveillance system for invasive GAS infections. METHODS: Active Bacterial Core surveillance (ABCs) conducts active population-based surveillance for invasive GAS disease in selected US counties in 10 states. We categorized invasive GAS cases with a diagnosis of STSS made by a physician as STSS-physician and cases that met the Council of State and Territorial Epidemiologists (CSTE) clinical criteria for STSS based on data in the medical record as STSS-CSTE. We evaluated agreement between the 2 methods for identifying STSS and compared the estimated national incidence of STSS when applying proportions of STSS-CSTE and STSS-physician among invasive GAS cases from this study with national invasive GAS estimates for 2017. RESULTS: During 2014-2017, of 7572 invasive GAS cases in ABCs, we identified 1094 (14.4%) as STSS-CSTE and 203 (2.7%) as STSS-physician, a 5.3-fold difference. Of 1094 STSS-CSTE cases, we identified only 132 (12.1%) as STSS-physician cases. Agreement between the 2 methods for identifying STSS was low (κ = 0.17; 95% CI, 0.14-0.19). Using ABCs data, we estimated 591 cases of STSS-physician and 3618 cases of STSS-CSTE occurred nationally in 2017. CONCLUSIONS: We found a large difference in estimates of incidence of STSS when applying different surveillance methods and definitions. These results should help with better use of currently available surveillance data to estimate the incidence of STSS and to evaluate disease prevention efforts, in addition to guiding future surveillance efforts for STSS.

      16. Postmortem Study of Cause of Death Among Children Hospitalized With Respiratory Illness in Kenyaexternal icon
        Njuguna HN, Zaki SR, Roberts DJ, Rogena EA, Walong E, Fligner CL, Keating MK, Gachii AK, Maleche-Obimbo E, Irimu G, Mathaiya J, Orata N, Lopokoiyit R, Michuki J, Emukule GO, Onyango CO, Gikunju S, Owuor C, Muturi PK, Bunei M, Gloria Carvalho M, Fields B, Mott JA, Widdowson MA, Chaves SS.
        Pediatr Infect Dis J. 2021 May 4.
        BACKGROUND: In resource-limited settings, acute respiratory infections continue to be the leading cause of death in young children. We conducted postmortem investigations in children <5 years hospitalized with a clinical diagnosis of respiratory disease at Kenya's largest referral hospital. METHODS: We collected respiratory and other tissues postmortem to examine pathologic processes using histology, molecular and immunohistochemistry assays. Nasopharyngeal, trachea, bronchi and lung specimens were tested using 21-target respiratory pathogen real-time reverse transcription polymerase chain reaction assays deployed on Taqman Array Cards. Expert panels reviewed all findings to determine causes of death and associated pathogens. RESULTS: From 2014 to 2015, we investigated 64 pediatric deaths (median age 7 months). Pneumonia was determined as cause of death in 70% (42/52) of cases where death was associated with an infectious disease process. The main etiologies of pneumonia deaths were respiratory syncytial virus (RSV) (n = 7, 19%), Pneumocystis jirovecii (n = 7, 19%), influenza A (n = 5, 14%) and Streptococcus pneumoniae (n = 5, 14%)-10% of cases had multi-pathogen involvement. Among the other 10 deaths associated with a nonpneumonia infectious process, 4 did not have an etiology assigned, the others were associated with miliary tuberculosis (2), cerebral thrombosis due to HIV (1), Enterobacteriaceae (1), rotavirus (1), and 1 case of respiratory infection with severe hypokalemia associated with RSV. CONCLUSIONS: In spite of well-established vaccination programs in Kenya, some deaths were still vaccine preventable. Accelerated development of RSV monoclonal antibodies and vaccines, introduction of seasonal influenza vaccination, and maintenance or improved uptake of existing vaccines can contribute to further reductions in childhood mortality.

      17. Adults Hospitalized with COVID-19 -United States, March-June and October-December 2020: Implications for the Potential Effects of COVID-19 Tier-1 Vaccination on Future Hospitalizations and Outcomesexternal icon
        Sami S, Tenforde MW, Talbot HK, Lindsell CJ, Steingrub JS, Shapiro NI, Ginde AA, Douin DJ, Prekker ME, Erickson HL, Brown SM, Peltan ID, Gong MN, Khan A, Exline MC, Files DC, Gibbs KW, Rice TW, Casey JD, Grijalva CG, Stubblefield WB, Womack KN, Hager DN, Qadir N, Chang SY, Henning DJ, Wilson JG, Self WH, Patel MM.
        Clin Infect Dis. 2021 May 12.
        BACKGROUND: Because of the increased risk for severe coronavirus disease 2019 (COVID-19), the Advisory Committee on Immunization Practices (ACIP) initially prioritized COVID-19 vaccination for persons in long-term care facilities (LTCF), persons aged ≥65 years, and persons aged 16-64 years with high-risk medical conditions when there is limited vaccine supply. We compared characteristics and severe outcomes of hospitalized patients with COVID-19 in the United States between early and later in the pandemic categorized by groups at higher risk of severe COVID-19. METHODS: Observational study of sampled patients aged ≥18 years who tested positive for SARS-CoV-2 and admitted to one of 14 academic hospitals in the United States during March-June and October-December 2020. Demographic and clinical information were gathered from electronic health record data. RESULTS: Among 647 patients, 91% met ≥1 of the following risk factors for severe COVID-19 [91% March-June (n=434); 90% October-December (n=213)]; 19% were LTCF residents, 45% were aged ≥65-years, and 84% had ≥1 high-risk condition. The proportion of patients who resided in a LTCF declined significantly (25% vs. 6%) from early to later pandemic periods. Compared with patients at lower risk for severe COVID-19, in-hospital mortality was higher among patients at high risk for severe COVID-19 (20% vs. 7%); these differences were consistently observed between March-June and October-December. CONCLUSIONS: Most adults hospitalized with COVID-19 were those recommended to be prioritized for vaccination based on risk for developing severe COVID-19. These findings highlight the urgency to vaccinate patients at high risk for severe COVID-19 and monitor vaccination impact on hospitalizations and outcomes.

      18. BACKGROUND: Despite advances in diagnosis and treatment, neonatal infection with herpes simplex virus (HSV) has a high case fatality rate. The national burden of neonatal HSV, and associated deaths, is unknown because this condition is not nationally notifiable. We investigated trends in HSV-related infant deaths, compared to infant deaths from congenital syphilis (CS) and human immunodeficiency virus (HIV). METHODS: Linked birth-death files for infant deaths during 1995-2017 were obtained from the National Center for Health Statistics. These files include infants who were born alive and died in the first 365 days of life and exclude stillbirths. We searched death certificates for disease codes indicating HSV, CS, or HIV, and calculated the frequency and rate of deaths for each infection, overall, by infant sex, and birthing parent age and race/ethnicity. RESULTS: Nationally, 1,591 deaths related to the infections of interest were identified: 1,271 related to HSV (79.9%), 234 HIV (14.7%), and 86 CS (5.4%). HSV-related deaths increased significantly from 0.83/100,000 live-births (95% CI:0.57-1.17) in 1995 to 1.77 (95% CI:1.37-2.24) in 2017. In contrast, HIV-related deaths declined: 1.64/100,000 (95% CI:1.27-2.10) in 1995 to 0.00 in 2017. There was a median of 3 CS-related deaths/year, with elevated frequencies in 1995-1996 and 2017 (n=8). HSV-related death rates were elevated among infants born to birthing parents aged <20 years (4.17/100,000; 95% CI:3.75-4.59) and to Black parents (2.86/100,000; 95% CI:2.58-3.15). CONCLUSIONS: Nationally, HSV-related infant deaths exceeded those caused by HIV and CS and appear to be increasing. Our findings underscore the need for an effective HSV vaccine, test technologies enabling rapid identification of infants exposed to HSV at delivery, and a focus on equity in prevention efforts.

      19. Seroprevalence of SARS-CoV-2 Among Frontline Healthcare Personnel During the First Month of Caring for Patients With COVID-19-Nashville, Tennesseeexternal icon
        Stubblefield WB, Talbot HK, Feldstein LR, Tenforde MW, Ur Rasheed MA, Mills L, Lester SN, Freeman B, Thornburg NJ, Jones ID, Ward MJ, Lindsell CJ, Baughman A, Halasa N, Grijalva CG, Rice TW, Patel MM, Self WH.
        Clin Infect Dis. 2021 May 4;72(9):1645-1648.
        Among 249 healthcare personnel who worked in hospital units with COVID-19 patients for 1 month, 19 (7.6%) tested positive for SARS-CoV-2 antibodies. Only 11 (57.9%) of the 19 personnel with positive serology reported symptoms of a prior illness, suggesting asymptomatic healthcare personnel could be an important source of SARS-CoV-2 transmission.

      20. Isoniazid preventive therapy use among adult people living with HIV in Zimbabweexternal icon
        Takamiya M, Takarinda K, Balachandra S, Godfrey M, Radin E, Hakim A, Pearson ML, Choto R, Sandy C, Maphosa T, Rogers JH.
        Int J STD AIDS. 2021 May 12:9564624211014404.
        We assessed the prevalence of isoniazid preventive therapy (IPT) uptake and explored factors associated with IPT non-uptake among people living with HIV (PLHIV) using nationally representative data from the Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) 2015-2016. This was a cross-sectional study of 3418 PLHIV ZIMPHIA participants eligible for IPT, aged ≥15 years and in HIV care. Logistic regression modeling was performed to assess factors associated with self-reported IPT uptake. All analyses accounted for multistage survey design. IPT uptake among PLHIV was 12.7% (95% confidence interval (CI): 11.4-14.1). After adjusting for sex, age, rural/urban residence, TB screening at the last clinic visit, and hazardous alcohol use, rural residence was the strongest factor associated with IPT non-uptake (adjusted OR (aOR): 2.39, 95% CI: 1.82-3.12). Isoniazid preventive therapy non-uptake having significant associations with no TB screening at the last HIV care (aOR: 2.07, 95% CI: 1.54-2.78) and with hazardous alcohol use only in urban areas (aOR: 10.74, 95% CI: 3.60-32.0) might suggest suboptimal IPT eligibility screening regardless of residence, but more so in rural areas. Self-reported IPT use among PLHIV in Zimbabwe was low, 2 years after beginning national scale-up. This shows the importance of good TB screening procedures for successful IPT implementation.

      21. Seasonal Influenza Prevention and Control Progress in Latin America and the Caribbean in the Context of the Global Influenza Strategy and the COVID-19 Pandemicexternal icon
        Vicari AS, Olson D, Vilajeliu A, Andrus JK, Ropero AM, Morens DM, Santos IJ, Azziz-Baumgartner E, Berman S.
        Am J Trop Med Hyg. 2021 May 10.
        Each year in Latin America and the Caribbean, seasonal influenza is associated with an estimated 36,500 respiratory deaths and 400,000 hospitalizations. Since the 2009 influenza A(H1N1) pandemic, the Region has made significant advances in the prevention and control of seasonal influenza, including improved surveillance systems, burden estimates, and vaccination of at-risk groups. The Global Influenza Strategy 2019-2030 provides a framework to strengthen these advances. Against the backdrop of this new framework, the University of Colorado convened in October 2020 its Immunization Advisory Group of Experts to review and discuss current surveillance, prevention, and control strategies for seasonal influenza in Latin America and the Caribbean, also in the context of the COVID-19 pandemic. This review identified five areas for action and made recommendations specific to each area. The Region should continue its efforts to strengthen surveillance and impact evaluations. Existing data on disease burden, seasonality patterns, and vaccination effectiveness should be used to inform decision-making at the country level as well as advocacy efforts for programmatic resources. Regional and country strategic plans should be prepared and include specific targets for 2030. Existing investments in influenza prevention and control, including for immunization programs, should be optimized. Finally, regional partnerships, such as the regional networks for syndromic surveillance and vaccine effectiveness evaluation (SARInet and REVELAC-i), should continue to play a critical role in continuous learning and standardization by sharing experiences and best practices among countries.

      22. Where Are the Newly Diagnosed HIV Positives in Kenya? Time to Consider Geo-Spatially Guided Targeting at a Finer Scale to Reach the "First 90"external icon
        Waruru A, Wamicwe J, Mwangi J, Achia TN, Zielinski-Gutierrez E, Ng'ang'a L, Miruka F, Yegon P, Kimanga D, Tobias JL, Young PW, De Cock KM, Tylleskär T.
        Front Public Health. 2021 ;9:503555.
        Background: The UNAIDS 90-90-90 Fast-Track targets provide a framework for assessing coverage of HIV testing services (HTS) and awareness of HIV status - the "first 90." In Kenya, the bulk of HIV testing targets are aligned to the five highest HIV-burden counties. However, we do not know if most of the new HIV diagnoses are in these five highest-burden counties or elsewhere. Methods: We analyzed facility-level HTS data in Kenya from 1 October 2015 to 30 September 2016 to assess the spatial distribution of newly diagnosed HIV-positives. We used the Moran's Index (Moran's I) to assess global and local spatial auto-correlation of newly diagnosed HIV-positive tests and Kulldorff spatial scan statistics to detect hotspots of newly diagnosed HIV-positive tests. For aggregated data, we used Kruskal-Wallis equality-of-populations non-parametric rank test to compare absolute numbers across classes. Results: Out of 4,021 HTS sites, 3,969 (98.7%) had geocodes available. Most facilities (3,034, 76.4%), were not spatially autocorrelated for the number of newly diagnosed HIV-positives. For the rest, clustering occurred as follows; 438 (11.0%) were HH, 66 (1.7%) HL, 275 (6.9%) LH, and 156 (3.9%) LL. Of the HH sites, 301 (68.7%) were in high HIV-burden counties. Over half of 123 clusters with a significantly high number of newly diagnosed HIV-infected persons, 73(59.3%) were not in the five highest HIV-burden counties. Clusters with a high number of newly diagnosed persons had twice the number of positives per 1,000,000 tests than clusters with lower numbers (29,856 vs. 14,172). Conclusions: Although high HIV-burden counties contain clusters of sites with a high number of newly diagnosed HIV-infected persons, we detected many such clusters in low-burden counties as well. To expand HTS where most needed and reach the "first 90" targets, geospatial analyses and mapping make it easier to identify and describe localized epidemic patterns in a spatially dispersed epidemic like Kenya's, and consequently, reorient and prioritize HTS strategies.

      23. Can isoniazid preventive therapy be scaled up rapidly? Lessons learned in Kenya, 2014-2018external icon
        Weyenga H, Karanja M, Onyango E, Katana AK, Ng'Ang'A LW, Sirengo M, Ondondo RO, Wambugu C, Waruingi RN, Muthee RW, Masini E, Ngugi EW, Shah NS, Pathmanathan I, Maloney S, De Cock KM.
        Int J Tuberc Lung Dis. 2021 May 1;25(5):367-372.
        BACKGROUND: TB is the leading cause of mortality among people living with HIV (PLHIV), for whom isoniazid preventive therapy (IPT) has a proven mortality benefit. Despite WHO recommendations, countries have been slow in scaling up IPT. This study describes processes, challenges, solutions, outcomes and lessons learned during IPT scale-up in Kenya.METHODS: We conducted a desk review and analyzed aggregated Ministry of Health (MOH) IPT enrollment data from 2014 to 2018 to determine trends and impact of program activities. We further analyzed IPT completion reports for patients initiated from 2015 to 2017 in 745 MOH sites in Nairobi, Central, Eastern and Western Kenya.RESULTS: IPT was scaled up 75-fold from 2014 to 2018: the number of PLHIV covered increased from 9,981 to 749,890. The highest percentage increases in the cumulative number of PLHIV on IPT were seen in the quarters following IPT pilot projects in 2014 (49%), national launch in 2015 (54%), and HIV treatment acceleration in 2016 (158%). Among 250,069 patients initiating IPT from 2015 to 2017, 97.5% completed treatment, 0.2% died, 0.8% were lost to follow-up, 1.0% were not evaluated, and 0.6% discontinued treatment.CONCLUSIONS: IPT can be scaled up rapidly and effectively among PLHIV. Deliberate MOH efforts, strong leadership, service delivery integration, continuous mentorship, stakeholder involvement, and accountability are critical to program success.

    • Environmental Health
      1. The associations of phthalate biomarkers during pregnancy with later glycemia and lipid profilesexternal icon
        Wu H, Just AC, Colicino E, Calafat AM, Oken E, Braun JM, McRae N, Cantoral A, Pantic I, Pizano-Zárate ML, Tolentino MC, Wright RO, Téllez-Rojo MM, Baccarelli AA, Deierlein AL.
        Environ Int. 2021 May 6;155:106612.
        BACKGROUND: Pregnancy induces numerous cardiovascular and metabolic changes. Alterations in these sensitive processes may precipitate long-term post-delivery health consequences. Studies have reported associations between phthalates and metabolic complications of pregnancy, but no study has investigated metabolic outcomes beyond pregnancy. OBJECTIVES: To examine associations of exposure to phthalates during pregnancy with post-delivery metabolic health. DESIGN: We quantified 15 urinary phthalate biomarker concentrations during the second and third trimesters among 618 pregnant women from Mexico City. Maternal metabolic health biomarkers included fasting blood measures of glycemia [glucose, insulin, Homeostatic Model Assessment of Insulin Resistance [HOMA-IR], % hemoglobin A1c (HbA1c%)] and lipids (total, high-density lipoprotein (HDL), low-density lipoprotein (LDL) cholesterol, triglycerides), at 4-5 and 6-8 years post-delivery. To estimate the influence of the phthalates mixture, we used Bayesian weighted quantile sum regression and Bayesian kernel machine regression; for individual biomarkers, we used linear mixed models. RESULTS: As a mixture, higher urinary phthalate biomarker concentrations during pregnancy were associated with post-delivery concentrations of plasma glucose (interquartile range [IQR] difference: 0.13 SD, 95%CrI: 0.05, 0.20), plasma insulin (IQR difference: 0.06 SD, 95%CrI: -0.02, 0.14), HOMA-IR (IQR difference: 0.08 SD, 95% CrI: 0.01, 0.16), and HbA1c% (IQR difference: 0.15 SD, 95%CrI: 0.05, 0.24). Associations were primarily driven by mono-2-ethyl-5-carboxypentyl terephthalate (MECPTP) and the sum of dibutyl phthalate biomarkers (∑DBP). The phthalates mixture was associated with lower HDL (IQR difference: -0.08 SD, 95%CrI: -0.16, -0.01), driven by ∑DBP and monoethyl phthalate (MEP), and higher triglyceride levels (IQR difference: 0.15 SD, 95%CrI: 0.08, 0.22), driven by MECPTP and MEP. The overall mixture was not associated with total cholesterol and LDL. However, ∑DBP and MEP were associated with lower and higher total cholesterol, respectively, and MECPTP and ∑DBP were associated with lower LDL. CONCLUSIONS: Phthalate exposure during pregnancy is associated with adverse long-term changes in maternal metabolic health. A better understanding of timing of the exact biological changes and their implications on metabolic disease risk is needed.

    • Genetics and Genomics
      1. Genome Sequences of Neurotropic Lineage III Listeria monocytogenes Isolates UKVDL9 and 2010L-2198external icon
        Albrecht TM, Kucerova Z, D'Orazio SE.
        Microbiol Resour Announc. 2021 May 6;10(18).
        We report the whole-genome sequence of Listeria monocytogenes UKVDL9 and an edited draft genome sequence of L. monocytogenes 2010L-2198. Both are neurotropic lineage III strains; UKVDL9 was isolated from a sheep brain, and 2010L-2198 was isolated from a human subject with rhombencephalitis.

    • Health Disparities
      1. Indicators of poor mental health and stressors during the COVID-19 pandemic, by disability status: A cross-sectional analysisexternal icon
        Okoro CA, Strine TW, McKnight-Eily L, Verlenden J, Hollis ND.
        Disabil Health J. 2021 Apr 21:101110.
        BACKGROUND: Evidence from previous public health emergencies indicates that adults with disabilities have higher risk for morbidity (physical and mental) and mortality than adults without disabilities. OBJECTIVE: To provide estimates of mental health indicators and stressors for US adults by disability status during April and May 2020, shortly following the emergence of the COVID-19 pandemic. METHODS: We analyzed data from Porter Novelli View 360 opt-in Internet panel survey conducted during the weeks of April 20th and May 18th(,) 2020 among 1004 English-speaking adults aged ≥18 years without and with disabilities (serious difficulty with hearing, vision, cognition, or mobility; any difficulty with self-care or independent living). Weighted logistic regression was used to test for significant differences between calculated prevalence estimates at the P ≤ .05 level. RESULTS: One in four adults reported any disability. Adults with any disability were significantly more likely than adults without disability to report current depressive symptoms, frequent mental distress, suicidal ideation, and COVID-19-related initiated or increased substance use (all p values < .0001). Adults with disabilities also reported significantly higher levels of stressors, such as access to health care services (p < .0001), difficulty caring for their own (or another's) chronic condition (p < .0001), emotional or physical abuse from others (p < .001), and not having enough food (p < .01). CONCLUSIONS: The disproportionately high levels of poor mental health indicators among adults with disabilities as compared to those without highlight the importance of delivering timely mental health screening and treatment/intervention during and after the COVID-19 pandemic to persons with disabilities.

    • Health Economics
      1. Costs of Interventions to Increase Vaccination Coverage Among Children in the United States: A Systematic Reviewexternal icon
        Hong K, Leidner AJ, Tsai Y, Tang Z, Cho BH, Stokley S.
        Acad Pediatr. 2021 May-Jun;21(4s):S67-s77.
        BACKGROUND: The Community Preventive Services Task Force (CPSTF) has recommended several interventions that have been demonstrated to be effective at increasing vaccination coverage. OBJECTIVE: Conduct a systematic review to examine the costs of interventions designed to increase vaccination coverage among children and adolescents in the United States. DATA SOURCES: PubMed, EconLit, Embase, and Cochrane. STUDY ELIGIBILITY, PARTICIPANTS, AND INTERVENTIONS: Peer-reviewed articles from January 1, 2009 to August 31, 2019. APPRAISAL AND SYNTHESIS METHODS: Studies were identified with systematic searches of the literature, reviewed for inclusion criteria, abstracted for data on intervention, target population, costs, and risk of bias. Cost measures were reported as costs per child in the target population, costs per vaccinated child, incremental costs per vaccinated child, and costs per vaccine dose administered. Results were stratified by intervention type, vaccine, and age group. RESULTS: Thirty-seven studies were identified for full-text review. Across all interventions and age groups, the cost per child ranged from $0.10 to $537.38, and the incremental cost per vaccinated child ranged from $6.52 to $5,098.57. Provider assessment and feedback interventions had the lowest (median) cost per child ($0.17) and a healthcare system-based combined intervention with multiple components had the lowest (median) incremental cost per vaccinated child ($26.65). A community-based combined intervention with multiple components had the highest median cost per child ($537.38) and the highest median incremental cost per vaccinated child ($5,098.57). LIMITATIONS: A small number of included intervention types and inconsistent cost definition. CONCLUSIONS: There is substantial variability in the costs of CPSTF-recommended interventions.

    • Healthcare Associated Infections
      1. Improving Delayed Antibiotic Prescribing for Acute Otitis Mediaexternal icon
        Frost HM, Monti JD, Andersen LM, Norlin C, Bizune DJ, Fleming-Dutra KE, Czaja CA.
        Pediatrics. 2021 May 12.
        OBJECTIVES: Acute otitis media (AOM) is the most-common indication for antibiotics in children. Delayed antibiotic prescribing for AOM can significantly reduce unnecessary antibiotic use and is recommended by the American Academy of Pediatrics for select children. We sought to improve delayed prescribing for AOM across 8 outpatient pediatric practices in Colorado. METHODS: Through a collaborative initiative with American Academy of Pediatrics and the Centers for Disease Control and Prevention, we implemented an economical 6-month antimicrobial stewardship intervention that included education, audit and feedback, online resources, and content expertise. Practices used The Model for Improvement and plan-do-study-act cycles to improve delayed antibiotic prescribing. Generalized estimating equations were used to generate relative risk ratios (RRRs) for outcomes at the intervention end and 3- and 6-months postintervention. Practice surveys were evaluated. RESULTS: In total, 69 clinicians at 8 practice sites implemented 27 plan-do-study-act cycles. Practices varied by size (range: 6-37 providers), payer type, and geographic setting. The rate of delayed antibiotic prescribing increased from 2% at baseline to 21% at intervention end (RRR: 8.96; 95% confidence interval [CI]: 4.68-17.17). Five practices submitted postintervention data. The rate of delayed prescribing at 3 months and 6 months postintervention remained significantly higher than baseline (3 months postintervention, RRR: 8.46; 95% CI: 4.18-17.11; 6 months postintervention, RRR: 6.69; 95% CI: 3.53-12.65) and did not differ from intervention end (3 months postintervention, RRR: 1.12; 95% CI: 0.62-2.05; 6-months postintervention, RRR: 0.89; 95% CI: 0.53-1.49). CONCLUSIONS: Baseline rate of delayed prescribing was low. A low-cost intervention resulted in a significant and sustained increase in delayed antibiotic prescribing across a diversity of settings.

      2. Associations of facility-level antibiotic use and hospital-onset Clostridioides difficile infection in US acute-care hospitals, 2012-2018external icon
        Kazakova SV, Baggs J, Yi SH, Reddy SC, Hatfield KM, Guh AY, Jernigan JA, McDonald LC.
        Infect Control Hosp Epidemiol. 2021 May 7:1-3.
        Previously reported associations between hospital-level antibiotic use and hospital-onset Clostridioides difficile infection (HO-CDI) were reexamined using 2012-2018 data from a new cohort of US acute-care hospitals. This analysis revealed significant positive associations between total, third-generation, and fourth-generation cephalosporin, fluoroquinolone, carbapenem, and piperacillin-tazobactam use and HO-CDI rates, confirming previous findings.

      3. Legionella antibiotic susceptibility testing: is it time for international standardization and evidence-based guidance?external icon
        Portal E, Descours G, Ginevra C, Mentasti M, Afshar B, Chand M, Day J, Echahidi F, Franzin L, Gaia V, Lück C, Meghraoui A, Moran-Gilad J, Ricci ML, Lina G, Uldum S, Winchell J, Howe R, Bernard K, Spiller OB, Chalker VJ, Jarraud S.
        J Antimicrob Chemother. 2021 Apr 13;76(5):1113-1116.
        Legionella pneumophila, a Gram-negative bacillus, is the causative agent of Legionnaire's disease, a form of severe community-acquired pneumonia. Infection can have high morbidity, with a high proportion of patients requiring ICU admission, and up to 10% mortality, which is exacerbated by the lack of efficacy of typical empirical antibiotic therapy against Legionella spp. The fastidious nature of the entire Legionellaceae family historically required inclusion of activated charcoal in the solid medium to remove growth inhibitors, which inherently interferes with accurate antimicrobial susceptibility determination, an acknowledged methodological shortfall, now rectified by a new solid medium that gives results comparable to those of microbroth dilution. Here, as an international Legionella community (with authors representing various international reference laboratories, countries and clinical stakeholders for diagnosis and treatment of legionellosis), we set out recommendations for the standardization of antimicrobial susceptibility testing methods, guidelines and reference strains to facilitate an improved era of antibiotic resistance determination.

      4. Positive correlation between Candida auris skin-colonization burden and environmental contamination at a ventilator-capable skilled nursing facility in Chicagoexternal icon
        Sexton DJ, Bentz ML, Welsh RM, Derado G, Furin W, Rose LJ, Noble-Wang J, Pacilli M, McPherson TD, Black S, Kemble SK, Herzegh O, Ahmad A, Forsberg K, Jackson B, Litvintseva AP.
        Clin Infect Dis. 2021 May 12.
        BACKGROUND: Candida auris is an emerging multidrug-resistant yeast that contaminates healthcare environments causing healthcare-associated outbreaks. The mechanisms facilitating contamination are not established. METHODS: C. auris was quantified in residents' bilateral axillary/inguinal composite skin swabs and environmental samples during a point-prevalence survey at a ventilator-capable skilled-nursing facility (vSNF A) with documented high colonization prevalence. Environmental samples were collected from all doorknobs, windowsills and handrails of each bed in 12 rooms. C. auris concentrations were measured using culture and C. auris-specific qPCR. The relationship between C. auris concentrations in residents' swabs and associated environmental samples were evaluated using Kendall's tau-b (τb) correlation coefficient. RESULTS: C. auris was detected in 70 /100 tested environmental samples and 31/ 57 tested resident skin swabs. The mean C. auris concentration in skin swabs was 1.22 x 10 5 cells/mL by culture and 1.08 x 10 6 cells/mL by qPCR. C. auris was detected on all handrails of beds occupied by colonized residents, as well as 10/24 doorknobs and 9/12 windowsills. A positive correlation was identified between the concentrations of C. auris in skin swabs and associated handrail samples based on culture (τb = 0.54, p = 0.0004) and qPCR (τb = 0.66, p = 3.83e -6). Two uncolonized residents resided in beds contaminated with C. auris. CONCLUSIONS: Colonized residents can have high C. auris burdens on their skin, which was positively related with contamination of their surrounding healthcare environment. These findings underscore the importance of hand hygiene, transmission-based precautions, and particularly environmental disinfection in preventing spread in healthcare facilities.

    • Immunity and Immunization
      1. Prediction of putative epitope-based vaccine against all corona virus strains for the Chinese population: Approach toward development of vaccineexternal icon
        Batool H, Batool S, Mahmood MS, Mushtaq N, Khan AU, Ali M, Sahibzada KI, Ashraf NM.
        Microbiol Immunol. 2021 Apr;65(4):154-160.
        Currently, the whole world is facing the coronavirus disease-19 pandemic. As of now, approximately 0.15 million people around the globe are infected with the novel coronavirus. In the last decade, two strains of the coronavirus family, severe acute respiratory syndrome-related coronavirus and Middle East respiratory syndrome coronavirus, also resulted in epidemics in south Asian and the Middle Eastern countries with high mortality rate. This scenario demands the development of a putative vaccine which may provide immunity against all current and new evolving coronavirus strains. In this study, we designed an epitope-based vaccine using an immunoinformatic approach. This vaccine may protect against all coronavirus strains. The vaccine is developed by considering the geographical distribution of coronavirus strains and host genetics (Chinese population). Nine experimentally validated epitopes sequences from coronavirus strains were used to derive the variants considering the conservancy in all strains. Further, the binding affinities of all derived variants were checked with most abundant human leukocyte antigen alleles in the Chinese population. Three major histocompatibility complex (MHC) Class I epitopes from spike glycoprotein and nucleoprotein showed sufficient binding while one MHC Class II epitope from spike glycoprotein was found to be an effective binder. A cocktail of these epitopes gave more than 95% population coverage in the Chinese population. Moreover, molecular dynamics simulation supported the aforementioned predictions. Further, in vivo studies are needed to confirm the immunogenic potential of these vaccines.

      2. Surveillance of Vaccination Coverage Among Adult Populations -United States, 2018external icon
        Lu PJ, Hung MC, Srivastav A, Grohskopf LA, Kobayashi M, Harris AM, Dooling KL, Markowitz LE, Rodriguez-Lainz A, Williams WW.
        MMWR Surveill Summ. 2021 May 14;70(3):1-26.
        PROBLEM/CONDITION: Adults are at risk for illness, hospitalization, disability and, in some cases, death from vaccine-preventable diseases, particularly influenza and pneumococcal disease. CDC recommends vaccinations for adults on the basis of age, health conditions, prior vaccinations, and other considerations. Updated vaccination recommendations from CDC are published annually in the U.S. Adult Immunization Schedule. Despite longstanding recommendations for use of many vaccines, vaccination coverage among U.S. adults remains low. REPORTING PERIOD: August 2017-June 2018 (for influenza vaccination) and January-December 2018 (for pneumococcal, herpes zoster, tetanus and diphtheria [Td]/tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis [Tdap], hepatitis A, hepatitis B, and human papillomavirus [HPV] vaccination). DESCRIPTION OF SYSTEM: The National Health Interview Survey (NHIS) is a continuous, cross-sectional national household survey of the noninstitutionalized U.S. civilian population. In-person interviews are conducted throughout the year in a probability sample of households, and NHIS data are compiled and released annually. NHIS's objective is to monitor the health of the U.S. population and provide estimates of health indicators, health care use and access, and health-related behaviors. Adult receipt of influenza, pneumococcal, herpes zoster, Td/Tdap, hepatitis A, hepatitis B, and at least 1 dose of HPV vaccines was assessed. Estimates were derived for a new composite adult vaccination quality measure and by selected demographic and access-to-care characteristics (e.g., age, race/ethnicity, indication for vaccination, travel history [travel to countries where hepatitis infections are endemic], health insurance status, contacts with physicians, nativity, and citizenship). Trends in adult vaccination were assessed during 2010-2018. RESULTS: Coverage for the adult age-appropriate composite measure was low in all age groups. Racial and ethnic differences in coverage persisted for all vaccinations, with lower coverage for most vaccinations among non-White compared with non-Hispanic White adults. Linear trend tests indicated coverage increased from 2010 to 2018 for most vaccines in this report. Few adults aged ≥19 years had received all age-appropriate vaccines, including influenza vaccination, regardless of whether inclusion of Tdap (13.5%) or inclusion of any tetanus toxoid-containing vaccine (20.2%) receipt was measured. Coverage among adults for influenza vaccination during the 2017-18 season (46.1%) was similar to the estimate for the 2016-17 season (45.4%), and coverage for pneumococcal (adults aged ≥65 years [69.0%]), herpes zoster (adults aged ≥50 years and aged ≥60 years [24.1% and 34.5%, respectively]), tetanus (adults aged ≥19 years [62.9%]), Tdap (adults aged ≥19 years [31.2%]), hepatitis A (adults aged ≥19 years [11.9%]), and HPV (females aged 19-26 years [52.8%]) vaccination in 2018 were similar to the estimates for 2017. Hepatitis B vaccination coverage among adults aged ≥19 years and health care personnel (HCP) aged ≥19 years increased 4.2 and 6.7 percentage points to 30.0% and 67.2%, respectively, from 2017. HPV vaccination coverage among males aged 19-26 years increased 5.2 percentage points to 26.3% from the 2017 estimate. Overall, HPV vaccination coverage among females aged 19-26 years did not increase, but coverage among Hispanic females aged 19-26 years increased 10.8 percentage points to 49.6% from the 2017 estimate. Coverage for the following vaccines was lower among adults without health insurance compared with those with health insurance: influenza vaccine (among adults aged ≥19 years, 19-49 years, and 50-64 years), pneumococcal vaccine (among adults aged 19-64 years at increased risk), Td vaccine (among all age groups), Tdap vaccine (among adults aged ≥19 years and 19-64 years), hepatitis A vaccine (among adults aged ≥19 years overall and among travelers aged ≥19 years), hepatitis B vaccine (among adults aged ≥19 years and 19-49 years and among travelers aged ≥19 years), herpes zoster vaccine (among adults aged ≥60 years), and HPV vaccine (among males and females aged 19-26 years). Adults who reported having a usual place for health care generally reported receipt of recommended vaccinations more often than those who did not have such a place, regardless of whether they had health insurance. Vaccination coverage was higher among adults reporting ≥1 physician contact during the preceding year compared with those who had not visited a physician during the preceding year, regardless of whether they had health insurance. Even among adults who had health insurance and ≥10 physician contacts during the preceding year, depending on the vaccine, 20.1%-87.5% reported not having received vaccinations that were recommended either for all persons or for those with specific indications. Overall, vaccination coverage among U.S.-born adults was significantly higher than that of foreign-born adults, including influenza vaccination (aged ≥19 years), pneumococcal vaccination (all ages), tetanus vaccination (all ages), Tdap vaccination (all ages), hepatitis B vaccination (aged ≥19 years and 19-49 years and travelers aged ≥19 years), herpes zoster vaccination (all ages), and HPV vaccination among females aged 19-26 years. Vaccination coverage also varied by citizenship status and years living in the United States. INTERPRETATION: NHIS data indicate that many adults remain unprotected against vaccine-preventable diseases. Coverage for the adult age-appropriate composite measures was low in all age groups. Individual adult vaccination coverage remained low as well, but modest gains occurred in vaccination coverage for hepatitis B (among adults aged ≥19 years and HCP aged ≥19 years), and HPV (among males aged 19-26 years and Hispanic females aged 19-26 years). Coverage for other vaccines and groups with Advisory Committee on Immunization Practices vaccination indications did not improve from 2017. Although HPV vaccination coverage among males aged 19-26 years and Hispanic females aged 19-26 years increased, approximately 50% of females aged 19-26 years and 70% of males aged 19-26 years remained unvaccinated. Racial/ethnic vaccination differences persisted for routinely recommended adult vaccines. Having health insurance coverage, having a usual place for health care, and having ≥1 physician contacts during the preceding 12 months were associated with higher vaccination coverage; however, these factors alone were not associated with optimal adult vaccination coverage, and findings indicate missed opportunities to vaccinate remained. PUBLIC HEALTH ACTIONS: Substantial improvement in adult vaccination uptake is needed to reduce the burden of vaccine-preventable diseases. Following the Standards for Adult Immunization Practice (, all providers should routinely assess adults' vaccination status at every clinical encounter, strongly recommend appropriate vaccines, either offer needed vaccines or refer their patients to another provider who can administer the needed vaccines, and document vaccinations received by their patients in an immunization information system.

      3. Influenza Vaccination in Health Centers during the COVID-19 Pandemic-United States, November 7-27, 2020external icon
        Marks SM, Clara A, Fiebelkorn AP, Le X, Armstrong PA, Campbell S, Van Alstyne JM, Price S, Bolton J, Sandhu PK, Bombard JM, Strona FV.
        Clin Infect Dis. 2021 May 12.
        BACKGROUND: Influenza vaccination is the most effective way to prevent influenza and influenza-associated complications including those leading to hospitalization. Resources otherwise used for influenza could support caring for patients with Coronavirus Disease 2019 (COVID-19). The Health Resources and Services Administration (HRSA) Health Center Program serves 30 million people annually by providing comprehensive primary health care, including influenza vaccination, to demographically diverse and historically underserved communities. As racial and ethnic minority groups have been disproportionately impacted by COVID-19, the objective of this analysis was to assess disparities in influenza vaccination at HRSA-funded health centers during the COVID-19 pandemic. METHODS: The Centers for Disease Control and Prevention (CDC) and HRSA analyzed cross-sectional data on influenza vaccinations from a weekly, voluntary Health Center COVID-19 survey after addition of an influenza-related question covering November 7-27, 2020. RESULTS: During the three-week period, 1,126 (81%) of 1385 health centers responded to the survey. Most of the 811,738 influenza vaccinations took place in urban areas and in the Western US Region. There were disproportionately more health center influenza vaccinations among racial and ethnic minorities in comparison with county demographics, except among Non-Hispanic Blacks and American Indian/Alaska Natives. CONCLUSIONS: HRSA-funded health centers were able to quickly vaccinate large numbers of mostly racial or ethnic minority populations, disproportionately more than county demographics. However, additional efforts might be needed to reach specific racial populations and persons in rural areas. Success in influenza vaccination efforts can support success in SARS-CoV-2 vaccination efforts.

      4. National introduction of human papillomavirus (HPV) vaccine in Tanzania: Programmatic decision-making and implementationexternal icon
        Mphuru A, Li AJ, Kyesi F, Mwengee W, Mazige F, Nshunju R, Shayo B, Giattas MR, Loharikar A, Lyimo D.
        Vaccine. 2021 May 4.
        BACKGROUND: Cervical cancer is the leading cause of cancer among women in Tanzania, with approximately 10,000 new cases and 7,000 deaths annually. In April 2018, the Government of Tanzania introduced 2 doses of human papillomavirus (HPV) vaccine nationally to adolescent girls to prevent cervical cancer, following a successful 2-year pilot introduction of the vaccine in the Kilimanjaro Region. METHODS: We interviewed key informants at the national level in Tanzania from February to November 2019, using a semi-structured tool to better understand national decision-making and program implementation. We conducted a comprehensive desk review of HPV vaccine introduction materials and reviewed administrative coverage data. RESULTS: Ten key informants were interviewed from the Ministry of Health, Community Development, Gender, Elderly, and Children, the World Health Organization, and other partners, and HPV vaccine planning documents and administrative coverage data were reviewed during the desk review. Tanzania introduced HPV vaccine to a single-age cohort of 14-year-old girls, with the decision-making process involving the Tanzania Immunization Technical Advisory Group and the national Interagency Coordination Committee. HPV vaccine was integrated into the routine immunization delivery strategy, available at health facilities and through outreach services at community sites, community mobile sites (>10 km from the health facility), and primary and secondary schools. Pre-introduction activities included trainings and microplanning workshops for health workers and school personnel at the national, regional, council, and health facility levels. Over 6,000 health workers and 22,000 school personnel were trained nationwide. Stakeholder and primary health care committee meetings were also conducted at the national level and in each of the regions as part of the advocacy and communication strategy. Administrative coverage of the first dose of HPV vaccine at the end of 2019 was 78%, and second dose coverage was 49%. No adverse events following HPV vaccination were reported to the national level. DISCUSSION: Tanzania successfully introduced HPV vaccine nationally targeting 14-year-old girls, using routine delivery strategies. Continued monitoring of vaccination coverage will be important to ensure full 2-dose vaccination of eligible girls. Tanzania can consider periodic intensified vaccination and targeted social mobilization efforts, as needed.

      5. Current Challenges and Future Possibilities for Immunization Information Systemsexternal icon
        Scharf LG, Coyle R, Adeniyi K, Fath J, Harris L, Myerburg S, Kurilo MB, Abbott E.
        Acad Pediatr. 2021 May-Jun;21(4s):S57-s64.
        Immunizations have proven to be an important tool for public health and for reducing the impact of vaccine preventable diseases. To realize the maximum benefits of immunizations, a coordinated effort between public policy, health care providers and health systems is required to increase vaccination coverage and to ensure high-quality data are available to inform clinical and public health interventions. Immunization information systems (IIS) are confidential, population-based, computerized databases that record all immunization doses administered by participating providers to persons residing within a given geopolitical area. The key output of an IIS is high-quality data for use in targeting and monitoring immunization program activities and providing clinical decision support at the point of care. To be truly effective, IISs need to form a nationwide network and repository of immunization data. Since the early 2000s Centers for Disease Control and Prevention has made strides to help IIS move toward a nationwide network through efforts focused on improving infrastructure and functionality, such as the IIS Minimum Functional Standards, and the IIS Annual Report, a self-reported data collection of IIS progress toward achieving the functional standards. While these efforts have helped immunization programs achieve more functional standards, there is a need to shift focus from infrastructure and functionality improvements to high data quality through objective measurement of IIS performance and evaluating critical outcomes. Additionally, realizing the vision of a nationwide repository of high-quality immunization data requires tackling the many challenges that impact data quality and availability including those related to policy, data sharing, data use, aging IIS technology, sustainability, and participation in the IIS. This paper describes the current state of IIS in the United States, critical challenges impacting the quality of data in IIS, and potential components of a future IIS model to address these challenges.

      6. Implementing Effective Vaccination Interventions Into Sustainable 'Real World' Practiceexternal icon
        Stockwell MS, Stokley S, Kempe A.
        Acad Pediatr. 2021 May-Jun;21(4s):S78-s80.

      7. Improving Pediatric Vaccination Coverage in the United Statesexternal icon
        Stokley S, Kempe A, Stockwell MS, Szilagyi PG.
        Acad Pediatr. 2021 May-Jun;21(4s):S1-s2.

      8. Demographic and Social Factors Associated with COVID-19 Vaccination Initiation Among Adults Aged ≥65 Years - United States, December 14, 2020-April 10, 2021external icon
        Whiteman A, Wang A, McCain K, Gunnels B, Toblin R, Lee JT, Bridges C, Reynolds L, Murthy BP, Qualters J, Singleton JA, Fox K, Stokley S, Harris L, Gibbs-Scharf L, Abad N, Brookmeyer KA, Farrall S, Pingali C, Patel A, Link-Gelles R, Dasgupta S, Gharpure R, Ritchey MD, Barbour KE.
        MMWR Morb Mortal Wkly Rep. 2021 May 14;70(19):725-730.
        Compared with other age groups, older adults (defined here as persons aged ≥65 years) are at higher risk for COVID-19-associated morbidity and mortality and have therefore been prioritized for COVID-19 vaccination (1,2). Ensuring access to vaccines for older adults has been a focus of federal, state, and local response efforts, and CDC has been monitoring vaccination coverage to identify and address disparities among subpopulations of older adults (2). Vaccine administration data submitted to CDC were analyzed to determine the prevalence of COVID-19 vaccination initiation among adults aged ≥65 years by demographic characteristics and overall. Characteristics of counties with low vaccination initiation rates were quantified using indicators of social vulnerability data from the 2019 American Community Survey.* During December 14, 2020-April 10, 2021, nationwide, a total of 42,736,710 (79.1%) older adults had initiated vaccination. The initiation rate was higher among men than among women and varied by state. On average, counties with low vaccination initiation rates (<50% of older adults having received at least 1 vaccine dose), compared with those with high rates (≥75%), had higher percentages of older adults without a computer, living in poverty, without Internet access, and living alone. CDC, state, and local jurisdictions in partnerships with communities should continue to identify and implement strategies to improve access to COVID-19 vaccination for older adults, such as assistance with scheduling vaccination appointments and transportation to vaccination sites, or vaccination at home if needed for persons who are homebound.(†) Monitoring demographic and social factors affecting COVID-19 vaccine access for older adults and prioritizing efforts to ensure equitable access to COVID-19 vaccine are needed to ensure high coverage among this group.

    • Laboratory Sciences
      1. Implementation of Rapid Diagnostics Assays for Detection of Histoplasmosis and Cryptococcosis in Central American People Living with HIVexternal icon
        Caceres DH, Arauz AB, Flores C, Santiago E, Montoya S, Saenz C, Torres-Meneses FA, Peralta H, Zuniga-Moya JC, Lainez Arteaga IZ, Garcia A, Abdo J, Verweij PE, Chiller TM, Forno D.
        Mycoses. 2021 May 9.
        OBJECTIVES: Histoplasmosis and cryptococcosis are important public health problems in people living with HIV (PLHIV) in Central America. Conventional laboratory assays, based on microscopy and culture, are not optimal for the diagnosis of either disease. However, antigen (Ag) assays are rapid and highly accurate for the diagnosis of these infections. METHODS: Laboratory surveillance of PLHIV was carried out in four hospitals in Panama, Honduras, and Nicaragua, between 2015 and 2019. Detection of Histoplasma antigens in urine was performed by enzyme immunoassay (EIA), and Cryptococcus antigen detection in sera and cerebrospinal fluid specimens was performed by lateral flow assay (LFA). RESULTS: A total of 4,453 PLHIV with clinical suspicion of histoplasmosis (n=1,343) or cryptococcosis (n=3,110; 2,721 sera and 389 CSF) were tested. Of 1,343 patients suspected of having histoplasmosis, 269 (20%) were Histoplasma Ag positive. Of 3,110 patients tested using the Cryptococcus Ag assay, 329 (11%) were positive. Honduras reported the highest positivity rates (32% for Histoplasma Ag, and 16% for Cryptococcus Ag); Panama reported the largest number of patients testing positive using the Histoplasma Ag assay (n=201); and Nicaragua reported the largest number of patients testing positive using the Cryptococcus Ag assay (n=170). CONCLUSION: Here we show how the implementation of rapid diagnostics assays impacted case detection and were useful for the care of people with advanced HIV. Rapid and accurate diagnosis could reduce mortality associated with histoplasmosis and cryptococcosis in PLHIV.

      2. The Specificity of the Persistent IgM Neutralizing Antibody Response in Zika Viral Infections Among Individuals with Prior Dengue Virus Exposureexternal icon
        Calvert AE, Horiuchi K, Boroughs KL, Ong YT, Anderson KM, Biggerstaff BJ, Stone M, Simmons G, Busch MP, Huang CY.
        J Clin Microbiol. 2021 May 12.
        Dengue viruses (DENV) and Zika virus (ZIKV) are related mosquito-borne flaviviruses with similar disease manifestations, vector ecology and geographic range. The ability to differentiate these viruses serologically is vital due to the teratogenic nature of ZIKV and the potential confounding of pre-existing cross-reactive anti-DENV antibodies. Here we illustrate the kinetics of the IgM neutralizing antibody (NAb) response using longitudinal samples ranging from acute ZIKV infection to late convalescence from individuals with evidence of prior DENV infection. By serially depleting antibody isotypes prior to neutralization assay, we determined that IgM contributes predominantly to ZIKV neutralization, and it is less cross-reactive than the IgG NAb. The IgM NAb peaked around 14 days (95% CI: 13-15) with a median duration of 257 days (95% CI: 133-427). These results demonstrate the persistence of IgM NAb after ZIKV infections and imply its potential role in diagnosis, vaccine evaluation, serosurveillance, and research of flaviviral-host interactions.

      3. Detection of CTX-M-27 β-lactamase genes on two distinct plasmid types in ST38 Escherichia coli from three US statesexternal icon
        Cameron A, Mangat R, Taffner S, Wang J, Dumyati G, Stanton RA, Daniels JB, Campbell D, Lutgring JD, Pecora ND.
        Antimicrob Agents Chemother. 2021 May 10.
        Infections caused by extended-spectrum β-lactamase (ESBL)-producing Escherichia coli are a significant cause of morbidity and healthcare costs. Globally, the prevailing clonal type is ST131 in association with the blaCTX-M-15 β-lactamase gene. However, other ESBLs such as blaCTX-M-14 and blaCTX-M-27 can also be prevalent in some regions. We identified ST38 ESBL-producing E. coli from different regions in the US which carry blaCTX-M-27 embedded on two distinct plasmid types, suggesting the potential emergence of new ESBL lineages.

      4. Rapid development of neutralizing and diagnostic SARS-COV-2 mouse monoclonal antibodiesexternal icon
        Chapman AP, Tang X, Lee JR, Chida A, Mercer K, Wharton RE, Kainulainen M, Harcourt JL, Martines RB, Schroeder M, Zhao L, Bryksin A, Zhou B, Bergeron E, Bollweg BC, Tamin A, Thornburg N, Wentworth DE, Petway D, Bagarozzi DA, Finn MG, Goldstein JM.
        Sci Rep. 2021 May 6;11(1):9682.
        The need for high-affinity, SARS-CoV-2-specific monoclonal antibodies (mAbs) is critical in the face of the global COVID-19 pandemic, as such reagents can have important diagnostic, research, and therapeutic applications. Of greatest interest is the ~ 300 amino acid receptor binding domain (RBD) within the S1 subunit of the spike protein because of its key interaction with the human angiotensin converting enzyme 2 (hACE2) receptor present on many cell types, especially lung epithelial cells. We report here the development and functional characterization of 29 nM-affinity mouse SARS-CoV-2 mAbs created by an accelerated immunization and hybridoma screening process. Differing functions, including binding of diverse protein epitopes, viral neutralization, impact on RBD-hACE2 binding, and immunohistochemical staining of infected lung tissue, were correlated with variable gene usage and sequence.

      5. Broadly neutralizing antibody-mediated protection of macaques against repeated intravenous exposures to simian-human immunodeficiency virusexternal icon
        Garber DA, Guenthner P, Mitchell J, Ellis S, Gazumyan A, Nason M, Seaman MS, McNicholl JM, Nussenzweig MC, Heneine W.
        Aids. 2021 May 5.
        OBJECTIVE: The opioid epidemic has increased parentally acquired HIV infection. To inform the development of a long-acting prevention strategy, we evaluated the protective efficacy of broadly neutralizing antibodies (bNAbs) against intravenous SHIV infection in macaques. DESIGN: Five cynomolgus macaques were injected once subcutaneously with 10-1074 and 3BNC117 (10 mg each kg-1) and were repeatedly challenged intravenously once weekly with SHIVAD8-EO (130 TCID50), until infection was confirmed via plasma viral load assay. Two control macaques, which received no antibody, were challenged identically. METHODS: Plasma viremia was monitored via RT-qPCR assay. bNAb concentrations were determined longitudinally in plasma samples via TZM-bl neutralization assays using virions pseudotyped with 10-1074-sensitive (X2088_c9) or 3BNC117-sensitive (Q769.d22) HIV envelope proteins. RESULTS: Passively immunized macaques were protected against a median of five weekly intravenous SHIV challenges, as compared to untreated controls, which were infected following a single challenge. Of the two bNAbs, 10-1074 exhibited relatively longer persistence in vivo. The median plasma level of 10-1074 at SHIV breakthrough was 1.1 μg ml-1 (range: 0.6-1.6 μg ml-1), whereas 3BNC117 was undetectable. Probit modeling estimated that 6.6 μg ml-1 of 10-1074 in plasma corresponded to a 99% reduction in per-challenge infection probability, as compared to controls. CONCLUSIONS: Significant protection against repeated intravenous SHIV challenges was observed following administration of 10-1074 and 3BNC117 and was due primarily to 10-1074. Our findings extend preclinical studies of bNAb-mediated protection against mucosal SHIV acquisition and support the possibility that intermittent subcutaneous injections of 10-1074 could serve as long-acting pre-exposure prophylaxis for persons who inject drugs.

      6. BACKGROUND: The genus Candida includes about 200 different species, but only a few are able to produce disease in humans. The species responsible for the highest proportion of human infections is Candida albicans. However, in the last two decades there has been an increase in the proportion of infections caused by other Candida species, including C. glabrata (Nakaseomyces glabrata), C. parapsilosis, C. tropicalis, C. krusei (Pichia kudriavzevi) and more recently C. auris. Decolonization of patients has been used as an infection control strategy for bacterial infections, but information about decolonization products used in clinical practice for Candida and other fungal pathogens is limited. Compounds with antimicrobial activity, such as triclosan (TR), boric acid (BA) and zinc oxide (ZO), are mainly used in personal care products. These products can be used for long periods of time without an abrasive skin effect and are a possible alternative for patient decolonization in health care settings. OBJECTIVE: The aim of this study was to evaluate the antifungal activity of boric acid (BA), triclosan (TR) and zinc oxide (ZO), individually and combined, against clinically relevant Candida species. MATERIALS AND METHODS: Compounds to be screened for antifungal activity were evaluated at different concentrations, alone, and combined, using a well diffusion assay. The statistical evaluation was performed using analysis of variance (ANOVA) and a post hoc analysis using the multiple comparisons method. RESULTS: Individually, BA and TR showed antifungal activity against all Candida species evaluated but ZO did not show any antifungal activity. Mixtures of BA [5%] - TR [0.2%]; BA [5%] - TR [0.3%]; BA [5%] - TR [0.2%] - ZO [8.6%]; and BA [5%] - TR [0.2%] - ZO [25%] yielded the highest antifungal activity. An increased antifungal effect was observed in some mixtures when compared with individual compounds. CONCLUSIONS: We demonstrated antifungal activity of BA and TR against multiple Candida species, including against a clade of the emerging healthcare-associated pathogen C. auris. Additionally, this study shows enhancement of the antifungal effect and no antagonism among the mixtures of these compounds. Further research is needed to determine whether these compounds can reduce the burden of Candida on skin.

      7. Impact of Kenya's Frontline Epidemiology Training Program on Outbreak Detection and Surveillance Reporting: A Geographical Assessment, 2014-2017external icon
        Macharia D, Jinnai Y, Hirai M, Galgalo T, Lowther SA, Ekechi CO, Widdowson MA, Turcios-Ruiz R, Williams SG, Baggett HK, Bunnell RE, Oyugi E, Langat D, Makayotto L, Gura Z, Cassell CH.
        Health Secur. 2021 May 10.
        Rapid detection and response to infectious disease outbreaks requires a robust surveillance system with a sufficient number of trained public health workforce personnel. The Frontline Field Epidemiology Training Program (Frontline) is a focused 3-month program targeting local ministries of health to strengthen local disease surveillance and reporting capacities. Limited literature exists on the impact of Frontline graduates on disease surveillance completeness and timeliness reporting. Using routinely collected Ministry of Health data, we mapped the distribution of graduates between 2014 and 2017 across 47 Kenyan counties. Completeness was defined as the proportion of complete reports received from health facilities in a county compared with the total number of health facilities in that county. Timeliness was defined as the proportion of health facilities submitting surveillance reports on time to the county. Using a panel analysis and controlling for county-fixed effects, we evaluated the relationship between the number of Frontline graduates and priority disease reporting of measles. We found that Frontline training was correlated with improved completeness and timeliness of weekly reporting for priority diseases. The number of Frontline graduates increased by 700%, from 57 graduates in 2014 to 456 graduates in 2017. The annual average rates of reporting completeness increased from 0.8% in 2014 to 55.1% in 2017. The annual average timeliness reporting rates increased from 0.1% in 2014 to 40.5% in 2017. These findings demonstrate how global health security implementation progress in workforce development may influence surveillance and disease reporting.

      8. Harmonization of acronyms for volatile organic compound metabolites using a standardized naming systemexternal icon
        Tevis DS, Flores SR, Kenwood BM, Bhandari D, Jacob P, Liu J, Lorkiewicz PK, Conklin DJ, Hecht SS, Goniewicz ML, Blount BC, De Jesús VR.
        Int J Hyg Environ Health. 2021 May 4;235:113749.
        Increased interest in volatile organic compound (VOC) exposure has led to an increased need for consistent, systematic, and informative naming of VOC metabolites. As analytical methods have expanded to include many metabolites in a single assay, the number of acronyms in use for a single metabolite has expanded in an unplanned and inconsistent manner due to a lack of guidance or group consensus. Even though the measurement of VOC metabolites is a well-established means to investigate exposure to VOCs, a formal attempt to harmonize acronyms amongst investigators has not been published. The aim of this work is to establish a system of acronym naming that provides consistency in current acronym usage and a foundation for creating acronyms for future VOC metabolites.

    • Nutritional Sciences
      1. BACKGROUND: Elevated plasma methylmalonic acid (MMA) and/or total homocysteine (tHcy), as well as low serum vitamin B12 and/or holotranscobalamin (holoTC) are indicative of vitamin B12 deficiency. Combined indicators (cB12), which pool some or all 4 markers into an index, may be a more reliable diagnostic tool to overcome inconclusive diagnoses with individual markers. OBJECTIVES: We aimed to describe different cB12 score combinations and estimate the prevalence of low or transitional vitamin B12 status compared with individual markers. DESIGN: Using cross-sectional data for B12, MMA, and tHcy in persons ≥20 y participating in NHANES 1999-2004 (n = 12,335), we examined raw and covariate-adjusted regression models to assess determinants of 3cB12 (all 3 markers) and combinations of 2cB12 (2 markers). RESULTS: 3cB12 was significantly associated with B12 (Spearman r = 0.75), MMA (r = -0.70), and tHcy (r = -0.59). The 3cB12 reference interval (2.5th to 97.5th percentile) was -0.538 to 1.60. In covariate-adjusted models, we found no association of 3cB12 with age; adult females and users of B12 supplements had higher, while adults with advanced chronic kidney disease had lower 3cB12 levels regardless of race-Hispanic origin group (self-reported). Only 2.7% of adults had low or transitional vitamin B12 status using the proposed cB12 cutoff of ≤-0.5, while the prevalence of low (or low-normal) status depended on the selected individual marker and its cutoff: 2.2% and 13% for B12 < 148 and 148-222 pmol/L, respectively; 6.0% for MMA exceeding an age-specific cutoff (250-320 nmol/L); and 8.4% for tHcy > 13 µmol/L. The reference intervals for B12, MMA, and tHcy overlapped from the low (<-2.5) to the transitional (-2.5 to -0.5) and to the adequate (>-0.5) cB12 categories. CONCLUSIONS: Vitamin B12 deficiency may be overestimated among US adults when individual, conventional markers are used. When only 2 markers are available, the combination of B12 and MMA provides results comparable to 3cB12.

      2. Receiving Advice from a Health Professional and Action Taken to Reduce Dietary Sodium Intake among Adultsexternal icon
        Woodruff RC, Overwyk KJ, Cogswell ME, Fang J, Jackson SL.
        Public Health Nutr. 2021 May 11:1-17.
        OBJECTIVE: Population reductions in sodium intake could prevent hypertension, and current guidelines recommend that clinicians advise patients to reduce intake. This study aimed to estimate the prevalence of taking action and receiving advice from a health professional to reduce sodium intake in 10 US jurisdictions, including the first-ever data in New York state and Guam. DESIGN: weighted prevalence and 95% confidence intervals (CI) overall and by location, demographic group, health status, and receipt of provider advice using self-reported data from the 2017 Behavioral Risk Factor Surveillance System optional sodium module. SETTING: seven states, the District of Columbia, Puerto Rico, and Guam. PARTICIPANTS: adults aged ≥18 years. RESULTS: Overall, 53.6% (CI: 52.7, 54.5) of adults reported taking action to reduce sodium intake, including 54.8% (CI: 52.8, 56.7) in New York and 61.2% (CI: 57.6, 64.7) in Guam. Prevalence varied by demographic and health characteristics and was higher among adults who reported having hypertension (72.5%; CI: 71.2, 73.7) vs. those who did not report having hypertension (43.9%; CI: 42.7, 45.0). Among those who reported receiving sodium reduction advice from a health professional, 82.6% (CI: 81.3, 83.9) reported action vs. 44.4% (CI: 43.4, 45.5) among those who did not receive advice. However, only 24.0% (CI: 23.3, 24.7) of adults reported receiving advice from a health professional to reduce sodium intake. CONCLUSIONS: The majority of adults report taking action to reduce sodium intake. Results highlight an opportunity to increase sodium reduction advice from health professionals during clinical visits to better align with existing guidelines.

    • Occupational Safety and Health
      1. Slide guard effectiveness on steep-sloped roofsexternal icon
        Bobick TG, McKenzie EA, Powers JR.
        Prof Saf. 2021 Feb;66(2):28-33.
        Key Takeaways: 1) Roofing contractors should consider using a slide guard as a supplemental means of fall protection when working on roof slopes that are 34 degrees (8 in 12) or less, but a slide guard should never be considered as the sole means to achieve work site fall protection compliance. 2) Using a slide guard on a 45 degree roof slope (12 in 12) would not be an effective fall protection supplement to comply with OSHA's fall protection requirements. 3) Contractors should consider purchasing and using synthetic underlayment materials with higher coefficient-of-friction values. This type of information may be available from the suppliers of underlayment materials that are used on steep-sloped roofs.

    • Occupational Safety and Health - Mining
      1. Quantifying elemental and organic carbon in diesel particulate matter by mid-infrared spectrometryexternal icon
        Parks DA, Griffiths PR, Weakley AT, Miller AL.
        Aerosol Sci Tech. 2021 May:[Epub ahead of print].
        A method for the quantification of airborne organic carbon (OC) and elemental carbon (EC) within aerosolized diesel particulate matter (DPM) is described in this article. DPM is a known carcinogen encountered in many industrial workplaces (notably mining) and in the ambient atmosphere. The method described here collects DPM particles onto a quartz fiber filter, after which reflection-mode infrared spectra are measured on a mid-infrared Fourier transform (FT-IR) spectrometer. Several infrared absorption bands are investigated for their efficacy in quantifying OC and EC. The thermo-optical (T-O) method is used to calibrate a linear regression model to predict OC and EC from the infrared spectra. The calibrated model, generated from laboratory DPM samples, is then utilized to quantify OC and EC in mine samples obtained from two metal mine locations under a variety of operating conditions. The feasibility of further improving these results by partial least squares (PLS) regression was investigated. A single calibration that is broadly applicable would be considered an improvement over currently available portable instruments, which require aerosol-specific calibration.

    • Parasitic Diseases
      1. Since the announcement of the coronavirus disease (COVID-19) pandemic in January 30th 2020, 68 countries reported to the World Health Organization that they were experiencing disruptions in malaria diagnosis and treatment. This situation had the potential to lead to delays in diagnosis and treatment, which could result in an increase in severe cases and deaths. This analysis was based on findings from a field visit, carried out between June 30th and July 1st, 2020, to a warehouse, to two health facilities, and a meeting with a community health worker, and an descriptive epidemiologic data analysis of health information system (HIS) to evaluate trends of the number of people tested for malaria and number of malaria cases reported, by comparing data from 2018, 2019 and 2020 for the period between January and May. The two health facilities and the warehouse had about two months of stock of antimalarial drugs, and patients with malaria symptoms were being tested for malaria at the COVID-19 screening site. The HIS data showed that the number of reported malaria cases decreased by 3.0% (177.646/172.246) in April, and 7.0% (173.188/161.812) in May, when comparing 2019 and 2020 data. People tested for malaria in community increased by 39.0% (190.370/264.730), between 2019 and 2020. The COVID-19 may have had a negative impact on the diagnosis and treatment of malaria in HF. The decrease in people tested for malaria in the health facilities may have overwhelmed the activities of the community.

    • Zoonotic and Vectorborne Diseases
      1. Building the Sierra Leone Ebola Database: organization and characteristics of data systematically collected during 2014-2015 Ebola epidemicexternal icon
        Agnihotri S, Alpren C, Bangura B, Bennett S, Gorina Y, Harding JD, Hersey S, Kamara AS, Kamara MA, Klena JD, McLysaght F, Patel N, Presser L, Redd JT, Samba TT, Taylor AK, Vandi MA, Van Heest S.
        Ann Epidemiol. 2021 May 6.
        BACKGROUND: During the 2014-2016 Ebola outbreak in West Africa, the Sierra Leone Ministry of Health and Sanitation (MoHS), the US Centers for Disease Control and Prevention, and responding partners under the coordination of the National Ebola Response Center (NERC) and the MoHS's Emergency Operation Center (EOC) systematically recorded information from the 117 Call Center system and district alert phone lines, case investigations, laboratory sample testing, clinical management, and safe and dignified burial records. Since 2017, CDC assisted MoHS in building and managing the Sierra Leone Ebola Database (SLED) to consolidate these major data sources. The primary objectives of the project were helping families to identify the location of graves of their loved ones who died at the time of the Ebola epidemic through the SLED Family Reunification Program and creating a data source for epidemiological research. The objective of this paper is to describe the process of consolidating epidemic records into a useful and accessible data collection and to summarize data characteristics, strength, and limitations of this unique information source for public health research. METHODS: Because of the unprecedented conditions during the epidemic, most of the records collected from responding organizations required extensive processing before they could be used as a data source for research or the humanitarian purpose of locating burial sites. This process required understanding how the data were collected and used during the outbreak. To manage the complexity of processing the data obtained from various sources, the Sierra Leone Ebola Database (SLED) Team used an organizational strategy that allowed tracking of the data provenance and lifecycle. RESULTS: The SLED project brought raw data into one consolidated data collection. It provides researchers with secure and ethical access to the SLED data and serves as a basis for the research capacity building in Sierra Leone. The SLED Family Reunification Program allowed Sierra Leonean families to identify location of the graves of loved ones who died during the Ebola epidemic. DISCUSSION: The SLED project consolidated and utilized epidemic data recorded during the Sierra Leone Ebola Virus Disease outbreak that were collected and contributed to SLED by national and international organizations. This project has provided a foundation for developing a method of ethical and secure SLED data access while preserving the host nation's data ownership. SLED serves as a data source for the SLED Family Reunification Program and for epidemiological research. It presents an opportunity for building research capacity in Sierra Leone and provides a foundation for developing a relational database. Large outbreak data systems such as SLED provide a unique opportunity for researchers to improve responses to epidemics and indicate the need to include data management preparedness in the plans for emergency response.

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

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