Issue 23, July 7, 2021

CDC Science Clips: Volume 13, Issue 23, July 7, 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
      • Gastric Cancer in Alaska Native and American Indian People Living in Alaska, 1990-2017external icon
        Nolen LD, Bressler S, Vindigni SM, Miller K, Nash S.
        Clin Transl Gastroenterol. 2021 Jun 23;12(7):e00374.
        INTRODUCTION: Alaska Native (AN) people experience a high burden of gastric cancer compared with other US Native and non-Native populations. Previous reports have suggested that gastric cancer in AN people occurs at a younger age and is a more aggressive pathologic type. We evaluated all cases of gastric cancer in AN people from 1990 to 2017 and compared the epidemiologic and pathologic characteristics with the gastric cancers that occurred in the same time in the US white (USW) population. METHODS: Cancer data were collected by the Alaska Native Tumor Registry and National Cancer Institute's Surveillance, Epidemiology, and End Results Program. Comparisons were performed looking at the age and sex distribution of the affected AN and USW people, as well as the cancer characteristics, including the location, stage, and pathology. RESULTS: The age distribution was significantly different between AN and USW patients (P < 0.001), with a greater proportion of AN people diagnosed younger than 40 years (11% vs 3%, P < 0.0001) and 40-59 years (37% vs 20%, P < 0.0001). In addition, a greater proportion of AN people were diagnosed with distant stage cancer (AN: 48% and USW: 35%, P < 0.0001). The age-adjusted rate of gastric cancer in the AN population was significantly higher than the USW population (20.8 vs 6.7 per 100,000 persons, P < 0.0001). Although there has been a significant decrease in the gastric cancer incidence rate in the USW population, no significant change in incidence was seen in the AN population. DISCUSSION: This study highlights the disproportionate burden of gastric cancer in the AN population. Further work is needed to address and understand this disparity.

    • Communicable Diseases
      • Taskforce report on the diagnosis and clinical management of COVID-19 associated pulmonary aspergillosisexternal icon
        Verweij PE, Brüggemann RJ, Azoulay E, Bassetti M, Blot S, Buil JB, Calandra T, Chiller T, Clancy CJ, Cornely OA, Depuydt P, Koehler P, Lagrou K, de Lange D, Lass-Flörl C, Lewis RE, Lortholary O, Liu PL, Maertens J, Nguyen MH, Patterson TF, Rijnders BJ, Rodriguez A, Rogers TR, Schouten JA, Wauters J, van de Veerdonk FL, Martin-Loeches I.
        Intensive Care Med. 2021 Jun 23:1-16.
        PURPOSE: Invasive pulmonary aspergillosis (IPA) is increasingly reported in patients with severe coronavirus disease 2019 (COVID-19) admitted to the intensive care unit (ICU). Diagnosis and management of COVID-19 associated pulmonary aspergillosis (CAPA) are challenging and our aim was to develop practical guidance. METHODS: A group of 28 international experts reviewed current insights in the epidemiology, diagnosis and management of CAPA and developed recommendations using GRADE methodology. RESULTS: The prevalence of CAPA varied between 0 and 33%, which may be partly due to variable case definitions, but likely represents true variation. Bronchoscopy and bronchoalveolar lavage (BAL) remain the cornerstone of CAPA diagnosis, allowing for diagnosis of invasive Aspergillus tracheobronchitis and collection of the best validated specimen for Aspergillus diagnostics. Most patients diagnosed with CAPA lack traditional host factors, but pre-existing structural lung disease and immunomodulating therapy may predispose to CAPA risk. Computed tomography seems to be of limited value to rule CAPA in or out, and serum biomarkers are negative in 85% of patients. As the mortality of CAPA is around 50%, antifungal therapy is recommended for BAL positive patients, but the decision to treat depends on the patients' clinical condition and the institutional incidence of CAPA. We recommend against routinely stopping concomitant corticosteroid or IL-6 blocking therapy in CAPA patients. CONCLUSION: CAPA is a complex disease involving a continuum of respiratory colonization, tissue invasion and angioinvasive disease. Knowledge gaps including true epidemiology, optimal diagnostic work-up, management strategies and role of host-directed therapy require further study.

    • Disease Reservoirs and Vectors
      • Permethrin resistance in Aedes aegypti: Genomic variants that confer knockdown resistance, recovery, and deathexternal icon
        Saavedra-Rodriguez K, Campbell CL, Lozano S, Penilla-Navarro P, Lopez-Solis A, Solis-Santoyo F, Rodriguez AD, Perera R, Black IV WC.
        PLoS Genet. 2021 Jun;17(6):e1009606.
        Pyrethroids are one of the few classes of insecticides available to control Aedes aegypti, the major vector of dengue, chikungunya, and Zika viruses. Unfortunately, evolving mechanisms of pyrethroid resistance in mosquito populations threaten our ability to control disease outbreaks. Two common pyrethroid resistance mechanisms occur in Ae. aegypti: 1) knockdown resistance, which involves amino acid substitutions at the pyrethroid target site-the voltage-gated sodium channel (VGSC)-and 2) enhanced metabolism by detoxification enzymes. When a heterogeneous population of mosquitoes is exposed to pyrethroids, different responses occur. During exposure, a proportion of mosquitoes exhibit immediate knockdown, whereas others are not knocked-down and are designated knockdown resistant (kdr). When these individuals are removed from the source of insecticide, the knocked-down mosquitoes can either remain in this status and lead to dead or recover within a few hours. The proportion of these phenotypic responses is dependent on the pyrethroid concentration and the genetic background of the population tested. In this study, we sequenced and performed pairwise genome comparisons between kdr, recovered, and dead phenotypes in a pyrethroid-resistant colony from Tapachula, Mexico. We identified single-nucleotide polymorphisms (SNPs) associated with each phenotype and identified genes that are likely associated with the mechanisms of pyrethroid resistance, including detoxification, the cuticle, and insecticide target sites. We identified high association between kdr and mutations at VGSC and moderate association with additional insecticide target site, detoxification, and cuticle protein coding genes. Recovery was associated with cuticle proteins, the voltage-dependent calcium channel, and a different group of detoxification genes. We provide a list of detoxification genes under directional selection in this field-resistant population. Their functional roles in pyrethroid metabolism and their potential uses as genomic markers of resistance require validation.

    • Epidemiology and Surveillance
      • Protecting Privacy and Transforming COVID-19 Case Surveillance Datasets for Public Useexternal icon
        Lee B, Dupervil B, Deputy NP, Duck W, Soroka S, Bottichio L, Silk B, Price J, Sweeney P, Fuld J, Weber JT, Pollock D.
        Public Health Rep. 2021 Jun 17:333549211026817.
        OBJECTIVES: Federal open-data initiatives that promote increased sharing of federally collected data are important for transparency, data quality, trust, and relationships with the public and state, tribal, local, and territorial partners. These initiatives advance understanding of health conditions and diseases by providing data to researchers, scientists, and policymakers for analysis, collaboration, and use outside the Centers for Disease Control and Prevention (CDC), particularly for emerging conditions such as COVID-19, for which data needs are constantly evolving. Since the beginning of the pandemic, CDC has collected person-level, de-identified data from jurisdictions and currently has more than 8 million records. We describe how CDC designed and produces 2 de-identified public datasets from these collected data. METHODS: We included data elements based on usefulness, public request, and privacy implications; we suppressed some field values to reduce the risk of re-identification and exposure of confidential information. We created datasets and verified them for privacy and confidentiality by using data management platform analytic tools and R scripts. RESULTS: Unrestricted data are available to the public through, and restricted data, with additional fields, are available with a data-use agreement through a private repository on PRACTICE IMPLICATIONS: Enriched understanding of the available public data, the methods used to create these data, and the algorithms used to protect the privacy of de-identified people allow for improved data use. Automating data-generation procedures improves the volume and timeliness of sharing data.

    • Health Disparities
      • Disparities in Incidence and Severity of Shigella Infections Among Children-Foodborne Diseases Active Surveillance Network (FoodNet), 2009-2018external icon
        Gharpure R, Marsh ZA, Tack DM, Collier SA, Strysko J, Ray L, Payne DC, Garcia-Williams AG.
        J Pediatric Infect Dis Soc. 2021 Jun 19.
        BACKGROUND: Shigella infections are an important cause of diarrhea in young children and can result in severe complications. Disparities in Shigella infections are well documented among US adults. Our objective was to characterize disparities in incidence and severity of Shigella infections among US children. METHODS: We analyzed laboratory-diagnosed Shigella infections reported to FoodNet, an active, population-based surveillance system in 10 US sites, among children during 2009-2018. We calculated the incidence rate stratified by sex, age, race/ethnicity, Shigella species, and disease severity. Criteria for severe classification were hospitalization, bacteremia, or death. The odds of severe infection were calculated using logistic regression. RESULTS: During 2009-2018, 10 537 Shigella infections were reported in children and 1472 (14.0%) were severe. The incidence rate was 9.5 infections per 100 000 child-years and the incidence rate of severe infections was 1.3 per 100 000 child-years. Incidence was highest among children aged 1-4 years (19.5) and lowest among children aged 13-17 years (2.3); however, children aged 13-17 years had the greatest proportion of severe infections (21.2%). Incidence was highest among Black (16.2 total; 2.3 severe), Hispanic (13.1 total; 2.3 severe), and American Indian/Alaska Native (15.2 total; 2.5 severe) children. Infections caused by non-sonnei species had higher odds of severity than infections caused by Shigella sonnei (adjusted odds ratio 2.58; 95% confidence interval 2.12-3.14). CONCLUSIONS: The incidence and severity of Shigella infections among US children vary by age, race/ethnicity, and Shigella species, warranting investigation of unique risk factors among pediatric subpopulations.

    • Health Economics
    • Immunity and Immunization
      • Impact and effectiveness of 13-valent pneumococcal conjugate vaccine on population incidence of vaccine and non-vaccine serotype invasive pneumococcal disease in Blantyre, Malawi, 2006-18: prospective observational time-series and case-control studiesexternal icon
        Bar-Zeev N, Swarthout TD, Everett DB, Alaerts M, Msefula J, Brown C, Bilima S, Mallewa J, King C, von Gottberg A, Verani JR, Whitney CG, Mwansambo C, Gordon SB, Cunliffe NA, French N, Heyderman RS.
        Lancet Glob Health. 2021 Jul;9(7):e989-e998.
        BACKGROUND: The population impact of pneumococcal conjugate vaccines (PCVs) depends on direct and indirect protection. Following Malawi's introduction of the 13-valent PCV (PCV13) in 2011, we examined its impact on vaccine and non-vaccine serotype invasive pneumococcal disease among vaccine-eligible-age and vaccine-ineligible-age children and adults. METHODS: We did a prospective observational time-series analysis and a case-control study. We used data from between Jan 1, 2006, and Dec 31, 2018, from laboratory-based surveillance at a government hospital in Malawi. This period included 6 years before and 7 years after introduction of PCV13. By use of negative-binomial regression, we evaluated secular trend-adjusted incidence rate ratio (IRR) in vaccine serotype and non-vaccine serotype invasive pneumococcal disease before and after introduction of PCV. We compared predicted counterfactual incidence in hypothetical absence of vaccine with empirically observed incidence following vaccine introduction. The case-control study assessed vaccine effectiveness, comparing PCV uptake among cases of vaccine-eligible-age invasive pneumococcal disease versus matched community controls. FINDINGS: Surveillance covered 10 281 476 person-years of observation, with 140 498 blood and 63 291 cerebrospinal fluid cultures. A reduction in total (vaccine serotype plus non-vaccine serotype) invasive pneumococcal disease incidence preceded introduction of PCV: 19% (IRR 0·81, 95% CI 0·74 to 0·88, p<0·0001) among infants (<1 year old), 14% (0·86, 0·80 to 0·93, p<0·0001) among children aged 1-4 years, and 8% (0·92, 0·83 to 1·01, p=0·084) among adolescents and adults (≥15 years old). Among children aged 5-14 years there was a 2% increase in total invasive pneumococcal disease (1·02, 0·93 to 1·11, p=0·72). Compared with the counterfactually predicted incidence, incidence of post-PCV13 vaccine serotype invasive pneumococcal disease was 74% (95% CI 70 to 78) lower among children aged 1-4 years and 79% (76 to 83) lower among children aged 5-14 years, but only 38% (37 to 40) lower among infants and 47% (44 to 51) lower among adolescents and adults. Although non-vaccine serotype invasive pneumococcal disease has increased in incidence since 2015, observed incidence remains low. The case-control study (19 cases and 76 controls) showed vaccine effectiveness against vaccine serotype invasive pneumococcal disease of 80·7% (-73·7 to 97·9). INTERPRETATION: In a high-mortality, high-HIV-prevalence setting in Africa, there were significant pre-vaccine reductions in the incidence of invasive pneumococcal disease. 7 years after PCV introduction, although vaccine-attributable impact among vaccine-eligible-age children was significant, indirect effects benefitting unvaccinated infants and adults were not. Policy decisions should consider multiple alternative strategies for reducing disease burden, including targeted vaccination outside infant Expanded Programme of Immunization to benefit vulnerable populations. FUNDING: Bill & Melinda Gates Foundation, Wellcome Trust, and National Institute for Health Research.

    • Informatics
      • Using supervised machine learning to identify efficient blocking schemes for record linkageexternal icon
        Campbell SR, Resnick DM, Cox CS, Mirel LB.
        Statistical Journal of the IAOS. 2021 ;37(2):673-680.
        Record linkage enables survey data to be integrated with other data sources, expanding the analytic potential of both sources. However, depending on the number of records being linked, the processing time can be prohibitive. This paper describes a case study using a supervised machine learning algorithm, known as the Sequential Coverage Algorithm (SCA). The SCA was used to develop the join strategy for two data sources, the National Center for Health Statistics' (NCHS) 2016 National Hospital Care Survey (NHCS) and the Center for Medicare & Medicaid Services (CMS) Enrollment Database (EDB), during record linkage. Due to the size of the CMS data, common record joining methods (i.e. blocking) were used to reduce the number of pairs that need to be evaluated to identify the vast majority of matches. NCHS conducted a case study examining how the SCA improved the efficiency of blocking. This paper describes how the SCA was used to design the blocking used in this linkage. © 2021-IOS Press. All rights reserved.

    • Injury and Violence
      • Factors associated with concussion symptom knowledge and attitudes towards concussion care-seeking among parents of children aged 5–10 yearsexternal icon
        Haarbauer-Krupa JK, Register-Mihalik JK, Nedimyer AK, Chandran A, Kay MC, Gildner P, Kerr ZY.
        J. Saf. Res.. 2021 .
        Background: Understanding parents’ concussion-related knowledge and attitudes will contribute to the development of strategies that aim to improve concussion prevention and sport safety for elementary school children. This study investigated the association between parent- and child-related factors and concussion symptom knowledge and care-seeking attitudes among parents of elementary school children (aged 5–10 years). Methods: Four hundred parents of elementary school children completed an online questionnaire capturing parental and child characteristics; concussion symptom knowledge (25 items, range = 0–50; higher = better knowledge); and concussion care-seeking attitudes (five 7-point scale items, range = 5–35; higher = more positive attitudes). Multivariable ordinal logistic regression models identified predictors of higher score levels. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) excluding 1.00 were deemed statistically significant. Results: Select parent and child characteristics were associated with higher score levels for both outcomes. For example, odds of better knowledge level in parents were higher with increased age (10-year increase aOR = 1.59; 95% CI = 1.10–2.28), among females (aOR = 3.90; 95% CI = 2.27–6.70), and among white/non-Hispanics (aOR = 1.79; 95%CI = 1.07–2.99). Odds of more positive concussion care-seeking attitude levels were higher among parents with a college degree (aOR = 1.98; 95%CI = 1.09–3.60). Child sports participation was not associated with higher score levels for either outcome. Conclusions: Certain elementary school parent characteristics were associated with parents’ concussion symptom knowledge and care-seeking attitudes. While the findings suggest providing parents with culturally and demographically relevant concussion education might be helpful, they also emphasize the importance of ensuring education/prevention regardless of their children's sports participation. Practical Applications: Pediatric healthcare providers and elementary schools offer an optimal community-centered location to reach parents with this information within various communities. © 2021

    • Maternal and Child Health
      • Advance Care Directives Among a Population-Based Sample of Young Adults with Congenital Heart Defects, CH STRONG, 2016-2019external icon
        Farr SL, Downing KF, Goudie A, Klewer SE, Andrews JG, Oster ME.
        Pediatr Cardiol. 2021 Jun 23.
        Little is known about advance care planning among young adults with congenital heart defects (CHD). Congenital Heart Survey to Recognize Outcomes, Needs, and well-beinG (CH STRONG) participants were born with CHD between 1980 and 1997, identified using active, population-based birth defects surveillance systems in Arkansas, Arizona and Atlanta, and Georgia, and surveyed during 2016-2019. We estimated the percent having an advance care directive standardized to the site, year of birth, sex, maternal race, and CHD severity of the 9312 CH STRONG-eligible individuals. We calculated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for characteristics associated with having advance care directives. Of 1541 respondents, 34.1% had severe CHD, 54.1% were female, and 69.6% were non-Hispanic white. After standardization, 7.3% had an advance care directive (range: 2.5% among non-Hispanic blacks to 17.4% among individuals with "poor" perceived health). Individuals with severe CHD (10.5%, aOR = 1.6, 95% CI: 1.1-2.3), with public insurance (13.1%, aOR = 1.7, 95% CI: 1.1-2.7), with non-cardiac congenital anomalies (11.1%, aOR = 1.9, 95% CI: 1.3-2.7), and who were hospitalized in the past year (13.3%, aOR = 1.8, 95% CI: 1.1-2.8) were more likely than their counterparts to have advance care directives. Individuals aged 19-24 years (6.6%, aOR = 0.4, 95% CI: 0.3-0.7) and 25-30 years (7.6%, aOR = 0.5, 95% CI: 0.3-0.8), compared to 31-38 years (14.3%), and non-Hispanic blacks (2.5%), compared to non-Hispanic whites (9.5%, aOR = 0.2, 95% CI: 0.1-0.6), were less likely to have advance care directives. Few young adults with CHD had advance care directives. Disparities in advance care planning may exist.

    • Medicine
      • INTRODUCTION: Previous iterations of National Blood Collection and Utilization Survey (NBCUS) have demonstrated declines in blood collection and transfusion in the United States since 2008, including declines of 3.0% and 6.1% in red blood cell (RBC) collections and transfusions between 2015 and 2017, respectively. This study describes results of the 2019 NBCUS. METHODS: The survey was distributed to all US blood collection centers, all hospitals performing ≥1000 surgeries annually, and a 40% random sample of hospitals performing 100-999 surgeries annually. Weighting and imputation were used to generate national estimates for units of blood and components collected, distributed, transfused, and outdated. RESULTS: In 2019, 11,590,000 RBC units were collected (95% confidence interval [CI], 11,151,000-12,029,000 units), a 5.1% decrease compared with 2017, while 10,852,000 RBC units were transfused (95% CI, 10,444-11,259 units), a 2.5% increase from 2017. Between 2017 and 2019, platelet distributions (2,508,000 units; 95% CI, 2,375,000-2,641,000 units) decreased by 2.0%, and plasma distributions (2,679,000 units; 95% CI, 2,525,000-2,833,000 units) decreased by 16.5%. During the same time period, platelet transfusions (2,243,000 units; 95% CI, 1,846,000-2,147,000 units) increased by 15.8% and plasma transfusions (2,185,000 units; 95% CI, 2,068,000-2,301,000 units) decreased by 8.0%. CONCLUSION: Utilization of RBC in the United States might have reached a nadir. Between 2017 and 2019, RBC collections declined while RBC transfusions did not significantly change, suggesting a narrowing between blood supply and demand. Monitoring national blood collection and utilization data is integral to understanding trends in blood supply safety and availability.

    • Parasitic Diseases
      • Neurocysticercosis. A frequent cause of seizures, epilepsy, and other neurological morbidity in most of the worldexternal icon
        Bustos J, Gonzales I, Saavedra H, Handali S, Garcia HH.
        J Neurol Sci. 2021 Jun 17;427:117527.
        Neurocysticercosis is endemic in most of the world and in endemic areas it accounts for approximately 30% of cases of epilepsy. Appropriate diagnosis and management of neurocysticercosis requires understanding the diverse presentations of the disease since these will vary in regards to clinical manifestation, sensitivity of diagnostic tests, and most importantly, therapeutic approach. This review attempts to familiarize tropical neurology practitioners with the diverse types of neurocysticercosis and the more appropriate management approaches for each.

  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. Comprehensive Search for Novel Circulating miRNAs and Axon Guidance Pathway Proteins Associated with Risk of End Stage Kidney Disease in Diabetesexternal icon
        Satake E, Saulnier PJ, Kobayashi H, Gupta M, Looker H, Wilson J, Md Dom Z, Ihara K, O'Neil K, Krolewski B, Pipino C, Pavkov M, Nair V, Bitzer M, Niewczas M, Kretzler M, Mauer M, Doria A, Najafian B, Kulkarni R, Duffin K, Pezzolesi M, Kahn CR, Nelson R, Krolewski A.
        J Am Soc Nephrol. 2021 Jun 17.
        Background Mechanisms underlying the progression of diabetic kidney disease to end-stage kidney disease (ESKD) are not fully understood. Methods We performed global micro-RNA (miRNA) analysis in plasma in two cohorts encompassing 375 individuals with type 1 and type 2 diabetes with late diabetic kidney disease and targeted proteomics analysis in plasma in four cohorts encompassing 746 individuals with late and early diabetic kidney disease. We examined structural lesions in kidney biopsies from the 105 individuals with early diabetic kidney disease. Human umbilical vein endothelial cells were used to assess the effects of miRNA mimics or inhibitors on regulation of candidate proteins. Results In the late diabetic kidney disease cohorts, we identified 17 circulating miRNAs represented by four exemplars (miR-1287-5p, miR-197-5p, miR-339-5p, miR-328-3p), which were strongly associated with 10-year risk of ESKD. These miRNAs targeted proteins in the axon guidance pathway. Circulating levels of six of these proteins-most notably EFNA4 and EPHA2-were strongly associated with 10-year risk of ESKD in all cohorts. Furthermore, circulating levels of these proteins correlated with severity of structural lesions in kidney biopsies. In contrast, expression levels of genes encoding these proteins had no apparent effects on the lesions. In in vitro experiments, mimics of miR-1287-5p and miR-197-5p and inhibitors of miR-339-5p and miR328-3p upregulated concentrations of EPHA2 in either cell lysate, supernatant, or both. Conclusions This study reveals novel mechanisms involved in progression to ESKD and points to the importance of systemic factors in the development of diabetic kidney disease. Some circulating miRNAs and axon guidance pathway proteins represent potential targets for new therapies to prevent and treat this condition.

    • Communicable Diseases
      1. Juvenile-Onset Recurrent Respiratory Papillomatosis in the United States, Epidemiology and HPV Types-2015-2020external icon
        Amiling R, Meites E, Querec TD, Stone L, Singh V, Unger ER, Derkay CS, Markowitz LE.
        J Pediatric Infect Dis Soc. 2021 Jun 19.
        BACKGROUND: Juvenile-onset recurrent respiratory papillomatosis (JORRP) is a rare disease characterized by the growth of papillomas in the respiratory tract. In the United States, JORRP is not a nationally notifiable condition and current data are limited. METHODS: Children with JORRP aged <18 years were enrolled from 26 pediatric otolaryngology centers in 23 US states from January 2015 through August 2020. Demographic, birth information, and maternal vaccination history were collected from a parent/guardian. Clinical history was abstracted from medical records. Papilloma biopsies were tested for 28 human papillomavirus (HPV) types. Mothers who delivered in 2006 or later were considered age-eligible for HPV vaccination if aged ≤26 years in 2006. We described characteristics of enrolled children and their birth mothers and analyzed disease severity by diagnosis age and HPV type using multiple logistic regression. RESULTS: Among 215 children with JORRP, 88.8% were delivered vaginally; 64.2% were firstborn. Among 190 mothers, the median delivery age was 22 years. Among 114 (60.0%) age-eligible for HPV vaccination, 16 (14.0%) were vaccinated, 1 (0.9%) before delivery. Among 162 specimens tested, 157 (96.9%) had detectable HPV; all 157 had a vaccine-preventable type. Disease severity was associated with younger diagnosis age and HPV 11; adjusted analyses found only younger diagnosis age significant (adjusted odds ratio: 6.1; 95% confidence interval: 2.9, 12.8). CONCLUSIONS: Children with JORRP were commonly firstborn and delivered vaginally to young mothers; most of the mothers reported no HPV vaccination before delivery. Vaccine-preventable HPV was identified in all specimens with detectable HPV. Increasing preexposure HPV vaccination could substantially reduce or eliminate JORRP in the United States.

      2. Intensive Care Unit Admission, Mechanical Ventilation, and Mortality Among Patients With Type 1 Diabetes Hospitalized for COVID-19 in the U.Sexternal icon
        Barrett CE, Park J, Kompaniyets L, Baggs J, Cheng YJ, Zhang P, Imperatore G, Pavkov ME.
        Diabetes Care. 2021 Jun 22.
        OBJECTIVE: To assess whether risk of severe outcomes among patients with type 1 diabetes mellitus (T1DM) hospitalized for coronavirus disease 2019 (COVID-19) differs from that of patients without diabetes or with type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS: Using the Premier Healthcare Database Special COVID-19 Release records of patients discharged after COVID-19 hospitalization from U.S. hospitals from March to November 2020 (N = 269,674 after exclusion), we estimated risk differences (RD) and risk ratios (RR) of intensive care unit admission or invasive mechanical ventilation (ICU/MV) and of death among patients with T1DM compared with patients without diabetes or with T2DM. Logistic models were adjusted for age, sex, and race or ethnicity. Models adjusted for additional demographic and clinical characteristics were used to examine whether other factors account for the associations between T1DM and severe COVID-19 outcomes. RESULTS: Compared with patients without diabetes, T1DM was associated with a 21% higher absolute risk of ICU/MV (RD 0.21, 95% CI 0.19-0.24; RR 1.49, 95% CI 1.43-1.56) and a 5% higher absolute risk of mortality (RD 0.05, 95% CI 0.03-0.07; RR 1.40, 95% CI 1.24-1.57), with adjustment for age, sex, and race or ethnicity. Compared with T2DM, T1DM was associated with a 9% higher absolute risk of ICU/MV (RD 0.09, 95% CI 0.07-0.12; RR 1.17, 95% CI 1.12-1.22), but no difference in mortality (RD 0.00, 95% CI -0.02 to 0.02; RR 1.00, 95% CI 0.89-1.13). After adjustment for diabetic ketoacidosis (DKA) occurring before or at COVID-19 diagnosis, patients with T1DM no longer had increased risk of ICU/MV (RD 0.01, 95% CI -0.01 to 0.03) and had lower mortality (RD -0.03, 95% CI -0.05 to -0.01) in comparisons with patients with T2DM. CONCLUSIONS: Patients with T1DM hospitalized for COVID-19 are at higher risk for severe outcomes than those without diabetes. Higher risk of ICU/MV in patients with T1DM than in patients with T2DM was largely accounted for by the presence of DKA. These findings might further guide recommendations related to diabetes management and the prevention of COVID-19.

      3. COVID-19 Surveillance and Investigations in Workplaces - Seattle & King County, Washington, June 15-November 15, 2020external icon
        Bonwitt J, Deya RW, Currie DW, Lipton B, Huntington-Frazier M, Sanford SJ, Pallickaparambil AJ, Hood J, Rao AK, Kelly-Reif K, Luckhaupt SE, Pogosjans S, Lindquist S, Duchin J, Kawakami V.
        MMWR Morb Mortal Wkly Rep. 2021 Jun 25;70(25):916-921.
        Workplace activities involving close contact with coworkers and customers can lead to transmission of SARS-CoV-2, the virus that causes COVID-19 (1,2). Information on the approach to and effectiveness of COVID-19 workplace investigations is limited. In May 2020, Public Health - Seattle & King County (PHSKC), King County, Washington established a COVID-19 workplace surveillance and response system to enhance COVID-19 contact tracing and identify outbreaks in workplaces. During June 15-November 15, 2020, a total of 2,881 workplaces in King County reported at least one case of COVID-19. Among 1,305 (45.3%) investigated workplaces,* 524 (40.3%) met the definition of a workplace outbreak.(†) Among 306 (58.4%) workplaces with complete data,(§) an average of 4.4 employee COVID-19 cases(¶) (median = three; range = 1-65) were identified per outbreak, with an average attack rate among employees of 17.5%. PHSKC and the Washington State Department of Health optimized resources by establishing a classification scheme to prioritize workplace investigations as high, medium, or low priority based on workplace features observed to be associated with increased COVID-19 spread and workforce features associated with severe disease outcomes. High-priority investigations were significantly more likely than medium- and low-priority investigations to have two or more cases among employees (p<0.001), two or more cases not previously linked to the workplace (p<0.001), or two or more exposed workplace contacts not previously identified during case interviews (p = 0.002). Prioritization of workplace investigations allowed for the allocation of limited resources to effectively conduct workplace investigations to limit the potential workplace spread of COVID-19. Workplace investigations can also serve as an opportunity to provide guidance on preventing workplace exposures to SARS-CoV-2, facilitate access to vaccines, and strengthen collaborations between public health and businesses.

      4. Is Interview Length Associated With Blood Test Participation? Evidence From Three Population-Based HIV Impact Assessment Surveys Conducted From 2016 to 2017external icon
        Bray R, Palma AM, Philip NM, Brown K, Levin B, Thompson J, Ginindza C, Mulenga LB.
        J Acquir Immune Defic Syndr. 2021 Aug 1;87(Suppl 1):S57-s66.
        BACKGROUND: High response rates in surveys are critical to ensuring that findings are unbiased and representative of the target population. Questionnaire length affects response rates, with long interviews associated with partially complete surveys, higher item nonresponse ("don't know" and "refuse" responses), and willingness to participate in future surveys. Our aim is to determine the impact of questionnaire length on blood test participation in population-based HIV surveys. METHODS: Data are from population-based HIV impact assessments conducted in Zambia, Eswatini, and Lesotho in 2016-2017. The population-based HIV impact assessments consist of an interview followed by a blood draw. Consent for blood draw was obtained before the interview in Eswatini and after the interview in Zambia and Lesotho. Interview length was measured by the survey tablet as the time to complete the survey (interview duration) and the number of questions answered by the participant (questionnaire length). We assessed the effects of questionnaire length and interview duration on blood test participation using logistic regression. RESULTS: Across all 3 surveys, the median interview duration was 16 minutes and the median number of questions was 77. In adjusted analyses, there was a negative impact of interview duration on blood draw consent for individuals with unknown status in Lesotho and a positive relationship between questionnaire length and blood draw consent in Zambia for those with HIV-negative and unknown status. CONCLUSION: Although interview length is an important consideration to reduce respondent burden, a longer questionnaire does not necessarily result in lower consent rates for blood testing.

      5. High risk sexual behaviours associated with traditional beliefs about gender roles among men interested in medical male circumcision in South Africaexternal icon
        Chetty-Makkan CM, Grund JM, Muchiri E, Price MA, Latka MH, Charalambous S.
        AIDS Res Ther. 2021 Jun 22;18(1):33.
        BACKGROUND: Beliefs about gender roles and high-risk sexual behaviours underlie the human immunodeficiency virus (HIV) epidemic in South Africa. Yet, there is limited information on the relationships between beliefs about gender roles and risky sexual behaviours. Few studies have explored the association between beliefs about gender roles, high risk sexual behaviour, and health-seeking behaviour among men. METHODS: We investigated associations between gender beliefs (dichotomised as traditional or progressive) and high-risk sexual behaviour among South African men presenting for medical male circumcision (Apr 2014 to Nov 2015). RESULTS: Of 2792 enrolled men, 47.4% reported traditional gender beliefs. Participant ages ranged between 18-46 years (median age 26 years; interquartile range, 21-31 years). Most participants had at least one sex partner over the last 12 months (68.2%). Younger men (18-24 years old vs. 25-46 years old) (odds ratio [OR], 1.5 [95% confidence interval (CI) 1.0-2.0]), those with multiple partners ([OR], 1.5 (CI) 1.3-1.8]) and participants unsure of their last partner's HIV status (OR, 1.4 [95% CI 1.1-1.7]) were more likely to have traditional beliefs on gender roles. CONCLUSION: Young men with traditional beliefs on gender roles may be more likely to engage in high-risk sexual behaviour and could be good candidates for HIV prevention programmes. N = 206 (max 350) Trial registration Name of registry:; Trial registration number: NCT02352961; Date of registration: 30 January 2015 "Retrospectively registered"; URL of trial registry record:

      6. Identification of TB space-time clusters and hotspots in Ouest département, Haiti, 2011-2016external icon
        Dismer AM, Charles M, Dear N, Louis-Jean JM, Barthelemy N, Richard M, Morose W, Fitter DL.
        Public Health Action. 2021 Jun 21;11(2):101-107.
        BACKGROUND: Haiti has the highest incidence rate of TB in the Western Hemisphere, with an estimated 170 cases per 100,000 in 2019. Since 2010, control efforts have focused on targeted case-finding activities in urban areas, implementation of rapid molecular diagnostics at high-volume TB centers, and improved reporting. TB analyses are rarely focused on lower geographic units; thus, the major goal was to determine if there were focal areas of TB transmission from 2011 to 2016 at operational geographic levels useful for the National TB Control Program (PNLT). METHODS: We created a geocoder to locate TB cases at the smallest geographic level. Kulldorff's space-time permutation scan, Anselin Moran's I, and Getis-Ord Gi* statistics were used to determine the spatial distribution and clusters of TB. RESULTS: With 91% of cases linked using the geocoder, TB clusters were identified each year. Getis-Ord Gi* analysis revealed 14 distinct spatial clusters of high incidences in the Port-au-Prince metropolitan area. One hundred retrospective space-time clusters were detected. CONCLUSION: Our study confirms the presence of TB hotspots in the Ouest département, with most clusters in the Port-au-Prince metropolitan area. Results will help the PNLT and its partners better design case-finding strategies for these areas.

      7. Successful Use of Near Point-of-Care Early Infant Diagnosis in NAMPHIA to Improve Turnaround Times in a National Household Surveyexternal icon
        Domaoal RA, Sleeman K, Sawadogo S, Dzinamarira T, Frans N, Shatumbu SP, Kakoma LN, Shuumbwa TK, Cox MH, Stephens S, Nisbet L, Metz M, Saito S, Williams DB, Voetsch AC, Patel HK, Parekh BS, Duong YT.
        J Acquir Immune Defic Syndr. 2021 Aug 1;87(Suppl 1):S67-s72.
        BACKGROUND: In the population-based HIV impact assessment surveys, early infant diagnosis (EID) was provided to infants <18 months without a prior diagnosis. For the Namibia population-based HIV impact assessment (NAMPHIA), the GeneXpert platform was assessed for the feasibility of near POC EID testing compared with the standard Roche COBAS AmpliPrep/COBAS TaqMan (CAP/CTM) platform. Quality assurance measures and turnaround time were compared to improve EID results reporting. METHODS: NAMPHIA participants were screened for HIV exposure using Determine HIV-1/2 rapid test; samples reactive on Determine received EID testing on the GeneXpert instrument and Xpert HIV-1 Qual assay using whole blood. Results were confirmed at the Namibia Institute of Pathology using dried blood spots on the Roche CAP/CTM platform per national guidelines. RESULTS: Of the 762 screened infants, 61 (8.0%) were Determine-reactive and considered HIV-exposed. Of the 61 exposed infants, 2 were found to be HIV-infected whereas 59 were negative on both GeneXpert and Roche platforms, achieving 100% concordance. Average turnaround time was 3.4 days for the Xpert HIV-1 Qual assay, and average time from collection to testing was 1.0 days for GeneXpert compared with 10.7 days for Roche. No samples failed using GeneXpert whereas 1 sample failed using Roche and was repeated. CONCLUSION: Quality POC EID testing is feasible in a national survey through extensive training and external quality assurance measures. The use of decentralized POC EID for national testing would provide rapid diagnosis and improve TATs which may prevent loss to follow-up, ensure linkage to care, and improve clinical outcomes for infants.

      8. HIV Testing Trends Among Persons with Commercial Insurance or Medicaid - United States, 2014-2019external icon
        Henny KD, Zhu W, Huang YA, Townes A, Delaney KP, Hoover KW.
        MMWR Morb Mortal Wkly Rep. 2021 Jun 25;70(25):905-909.
        HIV testing is a critical component of effective HIV prevention and care. CDC recommends routine opt-out HIV testing in health care settings for all sexually active persons aged 13-64 years at least once in their lifetime and risk-based testing regardless of age for those who report behaviors associated with HIV acquisition (1). However, recent studies show low HIV testing rates in clinical settings; HIV testing rates at visits to physician offices did not increase during 2009-2016 (2). The objective of the current study is to estimate temporal trends in HIV testing among persons with commercial insurance or Medicaid from 2014 through 2019 and describe their demographic characteristics in 2019. Weighted data from the IBM MarketScan Commercial Claims and Encounters database* (commercial insurance) and from the Centers for Medicare & Medicaid Services (CMS) claims database(†) (Medicaid) were analyzed to estimate the proportions of persons with commercial insurance or Medicaid who received testing for HIV. Testing rates increased among male and nonpregnant female persons aged ≥13 years with either type of coverage. In 2019, only 4.0% of those with commercial insurance and 5.5% of those with Medicaid received testing for HIV. Testing rates were higher among non-Hispanic Black or African American (Black) persons and Hispanic or Latino (Hispanic) persons. Based on mathematical modeling studies, these annual testing rates would need to increase at least threefold and be sustained over several years (3,4) to achieve the Ending the HIV Epidemic (EHE) in the U.S. initiative goal of ≥95% of persons with HIV being aware of their infection by 2025.(§) Interventions need to be implemented to increase routine and risk-based HIV testing in clinical settings to higher levels that can help reduce disparities in HIV diagnoses between Black and Hispanic persons compared with non-Hispanic White (White) persons (5). Increased HIV testing is essential to achieve the goals of the EHE initiative and reduce disparities in HIV diagnoses; public health should partner with health care systems to implement interventions that support increased testing.

      9. Engagement in care promotes durable viral suppression among persons newly diagnosed with HIV infectionexternal icon
        Iqbal K, Mendoza MC, Patala AH, Neblett Fanfair R, Marks G.
        AIDS Care. 2021 Jun 23:1-5.
        We characterize the association between engagement in care and durable viral suppression among persons newly diagnosed with HIV infection. Persons newly diagnosed with HIV with unsuppressed viral loads when they initiated care at one of six HIV clinics in the US were observed for up to 24 months. We describe the percentage who achieved durable viral suppression and number of days to achieve durable viral suppression. These outcomes were examined by the proportion of scheduled primary care appointments kept and demographic variables. Overall, 62% of patients achieved durable viral suppression and it took 174 days for 50% of patients to reach the beginning of the event. As the proportion of kept medical appointments increased, the proportion who achieved durable viral suppression increased, with 84% of patients who kept >75% of their appointments achieving the outcome. Higher adherence to appointments shortened the time to the beginning of durable viral suppression. Age, race/ethnicity, and risk factor for acquiring HIV infection were correlated with the outcomes. Adherence to primary care appointments is strongly associated with achieving durable viral suppression in persons newly diagnosed with HIV. Identifying and addressing patient barriers and unmet needs may increase the number who achieve durable viral suppression.

      10. Lessons From Rapid Field Implementation of an HIV Population-Based Survey in Nigeria, 2018external icon
        Jahun I, Greby SM, Adesina T, Agbakwuru C, Dalhatu I, Yakubu A, Jelpe T, Okoye M, Ikpe S, Ehoche A, Abimiku A, Aliyu G, Charurat M, Greenwell G, Bronson M, Patel H, McCracken S, Voetsch AC, Parekh B, Swaminathan M, Adewole I, Aliyu S.
        J Acquir Immune Defic Syndr. 2021 Aug 1;87(Suppl 1):S36-s42.
        BACKGROUND: The need for accurate HIV annual program planning data motivated the compressed timeline for the 2018 Nigerian HIV/AIDS Indicator and Impact Survey (NAIIS). The survey team used stakeholder cooperation and responsive design, using survey process and paradata to refine survey implementation, to quickly collect high-quality data. We describe processes that led to generation of data for program and funding decisions, ensuring HIV services were funded in 2019. SETTING: Nigeria is the most populous country in Africa, with approximately 195 million people in 36 states and the Federal Capital Territory. Challenges include multiple security threats, poor infrastructure, seasonal rains, and varied health system capacity. METHODS: Stakeholders worked together to plan and implement NAIIS. Methods from other population-based HIV impact assessments were modified to meet challenges and the compressed timeline. Data collection was conducted in 6 webs. Responsive design included reviewing survey monitoring paradata and laboratory performance. Costs required to correct data errors, for example, staff time and transportation, were tracked. RESULTS: NAIIS data collection was completed in 23 weeks, ahead of the originally scheduled 24 weeks. Responsive design identified and resolved approximately 68,000 interview errors, affecting approximately 62,000 households, saving about US$4.4 million in costs. Biweekly field laboratory test quality control improved from 50% to 100% throughout NAIIS. CONCLUSIONS: Cooperation across stakeholders and responsive design ensured timely release of NAIIS results and informed planning for HIV epidemic control in Nigeria. Based on NAIIS results, funds were provided to place an additional 500,000 HIV-positive Nigerians on antiretroviral therapy by the end of 2020, pushing Nigeria toward epidemic control.

      11. Adolescent girls and young women (aged 15-24 years; AGYW) continue to carry a disproportionate burden of HIV in sub-Saharan Africa. Pre-exposure prophylaxis (PrEP) helps reduce the risk of acquiring HIV for persons at substantial risk, including AGYW. As countries plan for the rollout of PrEP across sub-Saharan Africa, PrEP policies and programs could address the unique needs of AGYW. The purpose of this analysis was to identify policy considerations to improve AGYW access to PrEP. After reviewing the literature, we identified 13 policy considerations that policymakers and stakeholders could evaluate when developing or reviewing PrEP-related policies. We sorted these considerations into five categories, which together comprise an AGYW Access to PrEP Framework: AGYW-friendly delivery systems, clinical eligibility and adherence support, legal barriers and facilitators, affordability, and community and AGYW outreach. We also reviewed policies in three countries (Kenya, South Africa, and Uganda) to explore how PrEP-related policies addressed these considerations. Some of these policies addressed some of the 13 policy considerations, but none of the policies directly addressed the unique needs of AGYW for accessing PrEP. To improve access to PrEP for AGYW, country policies could include specific components that address these 13 considerations. To reach AGYW effectively, each country could use the 13 considerations we have identified to analyze current policies to identify existing programmatic barriers to AGYW accessing HIV services and address these barriers in PrEP-related policies.

      12. Increase in Outpatient Ivermectin Dispensing in the US During the COVID-19 Pandemic: A Cross-Sectional Analysisexternal icon
        Lind JN, Lovegrove MC, Geller AI, Uyeki TM, Datta SD, Budnitz DS.
        J Gen Intern Med. 2021 Jun 18:1-3.

      13. Efficacy of universal masking for source control and personal protection from simulated cough and exhaled aerosols in a roomexternal icon
        Lindsley WG, Beezhold DH, Coyle J, Derk RC, Blachere FM, Boots T, Reynolds JS, McKinney WG, Sinsel E, Noti JD.
        J Occup Environ Hyg. 2021 Jun 23:1-15.
        Face masks reduce the expulsion of respiratory aerosols produced during coughs and exhalations ("source control"). Factors such as the directions in which people are facing (orientation) and separation distance also affect aerosol dispersion. However, it is not clear how the combined effects of masking, orientation, and distance affect the exposure of individuals to respiratory aerosols in indoor spaces. We placed a respiratory aerosol simulator ("source") and a breathing simulator ("recipient") in a 3 m x 3 m chamber and measured aerosol concentrations for different combinations of masking, orientation, and separation distance. When the simulators were front-to-front during coughing, masks reduced the 15-minute mean aerosol concentration at the recipient by 92% at 0.9 and 1.8 m separation. When the simulators were side-by-side, masks reduced the concentration by 81% at 0.9 m and 78% at 1.8 m. During breathing, masks reduced the aerosol concentration by 66% when front-to-front and 76% when side-by-side at 0.9 m. Similar results were seen at 1.8 m. When the simulators were unmasked, changing the orientations from front-to-front to side-by-side reduced the cough aerosol concentration by 59% at 0.9 m and 60% at 1.8 m. When both simulators were masked, changing the orientations did not significantly change the concentration at either distance during coughing or breathing. Increasing the distance between the simulators from 0.9 m to 1.8 m during coughing reduced the aerosol concentration by 25% when no masks were worn but had little effect when both simulators were masked. During breathing, when neither simulator was masked, increasing the separation reduced the concentration by 13%, which approached significance, while the change was not significant when both source and recipient were masked. Our results show that universal masking reduces exposure to respiratory aerosol particles regardless of the orientation and separation distance between the source and recipient.

      14. HIV viral exposure and mortality in a multicenter ambulatory HIV adult cohort, United States, 1995-2016external icon
        Palella FJ, Armon C, Cole SR, Hart R, Tedaldi E, Novak R, Battalora L, Purinton S, Li J, Buchacz K.
        Medicine (Baltimore). 2021 Jun 25;100(25):e26285.
        The aim of this study was to identify viral exposure (VE) measures and their relationship to mortality risk among persons with HIV.Prospective multicenter observational study to compare VE formulae.Eligible participants initiated first combination antiretroviral therapy (cART) between March 1, 1995 and June 30, 2015. We included 1645 participants followed for ≥6 months after starting first cART, with cART prescribed ≥75% of time, who underwent ≥2 plasma viral load (VL) and ≥1 CD4+ T-lymphocyte cell (CD4) measurement during observation. We evaluated all-cause mortality from 6 months after cART initiation until June 30, 2016. VE was quantified using 2 time-updated variables: viremia copy-years and percent of person-years (%PY) spent >200 or 50 copies/mL. Cox models were fit to estimate associations between VE and mortality.Participants contributed 10,453 person years [py], with median 14 VLs per patient. Median %PY >200 or >50 were 10% (interquartile range: 1%-47%) and 26% (interquartile range: 6%-72%), respectively. There were 115 deaths, for an overall mortality rate of 1.19 per 100 person years. In univariate models, each measure of VE was significantly associated with mortality risk, as were older age, public insurance, injection drug use HIV risk history, and lower pre-cART CD4. Based on model fit, most recent viral load and %PY >200 copies/mL provided the best combination of VE factors to predict mortality, although all VE combinations evaluated performed well.The combination of most recent VL and %PY >200 copies/mL best predicted mortality, although all evaluated VE measures performed well.

      15. HIV infection in Eastern and Southern Africa: Highest burden, largest challenges, greatest potentialexternal icon
        Parker E, Judge MA, Macete E, Nhampossa T, Dorward J, Langa DC, de Schacht C, Couto A, Vaz P, Vitoria M, Molfino L, Idowu RT, Bhatt N, Naniche D, Le Souëf PN.
        South. Afr. J. HIV Med.. 2021 ;22(1).
        Background: The burden of HIV is especially concerning for Eastern and Southern Africa (ESA), as despite expansion of test-and-treat programmes, this region continues to experience significant challenges resulting from high rates of morbidity, mortality and new infections. Hard-won lessons from programmes on the ground in ESA should be shared. Objectives: This report summarises relevant evidence and regional experts’ recommendations regarding challenges specific to ESA. Method: This commentary includes an in-depth review of relevant literature, progress against global goals and consensus opinion from experts. Results: Recommendations include priorities for essential research (surveillance data collection, key and vulnerable population education and testing, in-country testing trials and evidence-based support services to improve retention in care) as well as research that can accelerate progress towards the prevention of new infections and achieving ambitious global goals in ESA. Conclusion: The elimination of HIV in ESA will require continued investment, commitment to evidence-based programmes and persistence. Local research is critical to ensuring that responses in ESA are targeted, efficient and evaluated. © 2021. The Authors. Licensee: AOSIS.

      16. Kaposi Sarcoma Incidence, Burden and Prevalence in United States People with HIV, 2000-2015external icon
        Peprah S, Engels EA, Horner MJ, Monterosso A, Hall HI, Johnson AS, Pfeiffer RM, Shiels MS.
        Cancer Epidemiol Biomarkers Prev. 2021 Jun 23.
        BACKGROUND: The introduction of combination antiretroviral therapy (cART) has led to a significant reduction in Kaposi sarcoma (KS) incidence among people with HIV (PWH). However, it is unclear if incidence has declined similarly across key demographic and HIV transmission groups and the annual number of incident and prevalent KS cases remains unquantified. METHODS: Using population-based registry linkage data, we evaluated temporal trends in KS incidence using adjusted Poisson regression. Incidence and prevalence estimates were applied to CDC HIV surveillance data, to obtain the number of incident (2008-2015) and prevalent (2015) cases in the United States. RESULTS: Among PWH, KS rates were elevated 521-fold (95% confidence intervals [CI]: 498, 536) compared to the general population and declined from 109 per 100,000 person-years in 2000 to 47 per 100,000 person-years in 2015, at an annual percentage change of -6%. Rates declined substantially (p-trend<0∙005) across all demographic and HIV transmission groups. Of the 5,306 new cases estimated between 2008 and 2015, 89% occurred among men who have sex with men. At the end of 2015, 1,904 PWH (0.20%) had been diagnosed with KS in the previous 5 years. CONCLUSIONS: A consistent gradual decline in KS incidence has occurred among PWH in the United States during the current cART era. This decrease is uniform across key demographic and HIV transmission groups, though rates remain elevated relative to the general population. IMPACT: Continued efforts to control HIV through early cART initiation and retention in care need to be maintained and possibly expanded to sustain declines.

      17. HIV General Population Surveys: Shedding Light on the Status of HIV Epidemics and Informing Future Actionsexternal icon
        Porter L, Bello G, Nkambule R, Justman J.
        J Acquir Immune Defic Syndr. 2021 Aug 1;87(Suppl 1):S2-s5.
        Nationally representative household surveys of the general population can provide critical assessments of the status of HIV epidemics and the impact of national HIV programs. With lessons learned from earlier surveys, PEPFAR has supported HIV-focused surveys in high burden countries to measure known HIV status, access to HIV treatment, and viral suppression, and, by using novel HIV recency assays, to estimate HIV incidence. The results from the initial population-based HIV impact assessments have transformed global HIV programming, demonstrating unexpected progress in population viral suppression and the persistent burden of high HIV incidence among adolescent girls and young women. The findings highlight the importance of tailoring programs to engage men more effectively in HIV testing and treatment. The collection of manuscripts summarized in this overview of the Supplement describe the methods and selected key findings from the initial population-based HIV impact assessment surveys. Taken together, the efforts described in these manuscripts have advanced survey and laboratory capacity and guided HIV programs toward the goal of ending the global epidemic.

      18. Improving Sampling Efficiency for Determining Pediatric HIV Prevalence in National Surveys: Evidence From 8 Sub-Saharan African Countriesexternal icon
        Reid G, Voetsch AC, Stupp P, McCracken S, Kalton G, Dlamini S, McOllogi Juma J, Kalua T, Kirungi W, Koto M, Mugurungi O, Mulenga L, Mutenda N, Marum L, Saito S.
        J Acquir Immune Defic Syndr. 2021 Aug 1;87(Suppl 1):S43-s51.
        BACKGROUND: Measurement of mother-to-child HIV transmission through population-based surveys requires large sample sizes because of low HIV prevalence among children. We estimate potential improvements in sampling efficiency resulting from a targeted sample design. SETTING: Eight countries in sub-Saharan Africa with completed Population-based HIV Impact Assessment (PHIA) surveys as of 2017. METHODS: The PHIA surveys used a geographically stratified 2-stage sample design with households sampled from randomly selected census enumeration areas. Children (0-14 years of age) were eligible for HIV testing within a random subsample of households (usually 50%). Estimates of child HIV prevalence in each country were calculated using jackknife replicate weights. We compared sample sizes and precision achieved using this design with a 2-phase disproportionate sample design applied to strata defined by maternal HIV status and mortality. RESULTS: HIV prevalence among children ranged from 0.4% (95% confidence interval: 0.2 to 0.6) in Tanzania to 2.8% (95% confidence interval: 2.2 to 3.4) in Eswatini with achieved relative standard errors between 11% and 21%. The expected precision improved in the targeted design in all countries included in the analysis, with proportionate reductions in mean squared error ranging from 27% in Eswatini to 61% in Tanzania, assuming an equal sample size. CONCLUSIONS: Population-based surveys of adult HIV prevalence that also measure child HIV prevalence should consider targeted sampling of children to reduce required sample size, increase precision, and increase the number of positive children tested. The findings from the PHIA surveys can be used as baseline data for informing future sample designs.

      19. Population-Based HIV Impact Assessments Survey Methods, Response, and Quality in Zimbabwe, Malawi, and Zambiaexternal icon
        Sachathep K, Radin E, Hladik W, Hakim A, Saito S, Burnett J, Brown K, Phillip N, Jonnalagadda S, Low A, Williams D, Patel H, Herman-Roloff A, Musuka G, Barr B, Wadondo-Kabonda N, Chipungu G, Duong Y, Delgado S, Kamocha S, Kinchen S, Kalton G, Schwartz L, Bello G, Mugurungi O, Mulenga L, Parekh B, Porter L, Hoos D, Voetsch AC, Justman J.
        J Acquir Immune Defic Syndr. 2021 Aug 1;87(Suppl 1):S6-s16.
        BACKGROUND: The population-based HIV impact assessment (population-based HIV impact assessments) surveys are among the first to estimate national adult HIV incidence, subnational prevalence of viral load suppression, and pediatric HIV prevalence. We summarize the survey methods implemented in Zimbabwe, Malawi, and Zambia, as well as response rates and quality metrics. METHODS: Each cross-sectional, household-based survey used a 2-stage cluster design. Survey preparations included sample design, questionnaire development, tablet programming for informed consent and data collection, community mobilization, establishing a network of satellite laboratories, and fieldworker training. Interviewers collected demographic, behavioral, and clinical information using tablets. Blood was collected for home-based HIV testing and counseling (HBTC) and point-of-care CD4+ T-cell enumeration with results immediately returned. HIV-positive blood samples underwent laboratory-based confirmatory testing, HIV incidence testing, RNA polymerase chain reaction (viral load), DNA polymerase chain reaction (early infant diagnosis), and serum antiretroviral drug detection. Data were weighted for survey design, and chi square automatic interaction detection-based methods were used to adjust for nonresponse. RESULTS: Each survey recruited a nationally representative, household-based sample of children and adults over a 6-10-month period in 2015 and 2016. Most (84%-90%) of the 12,000-14,000 eligible households in each country participated in the survey, with 77%-81% of eligible adults completing an interview and providing blood for HIV testing. Among eligible children, 59%-73% completed HIV testing. Across the 3 surveys, 97.8% of interview data were complete and had no errors. CONCLUSION: Conducting a national population-based HIV impact assessment with immediate return of HIV and other point-of-care test results was feasible, and data quality was high.

      20. Association Between Cytomegalovirus and Epstein-Barr Virus Viremia And Human Immunodeficiency Virus DNA Levels in the Reservoir of Kenyan Infants Receiving Antiretroviral Therapyexternal icon
        Slyker JA, Guthrie B, Pankau M, Tapia K, Wamalwa D, Benki-Nugent S, Ngugi E, Huang ML, Njuguna I, Langat A, John-Stewart G, Lehman D.
        J Infect Dis. 2021 Jun 4;223(11):1923-1927.
        Identifying determinants of human immunodeficiency virus (HIV) reservoir levels may inform novel viral eradication strategies. Cytomegalovirus (CMV) and Epstein-Barr virus (EBV) coinfections were assessed as predictors of HIV proviral DNA level in 26 HIV RNA-suppressed Kenyan children starting antiretroviral therapy before 7 months of age. Earlier acquisition of CMV and EBV and higher cumulative burden of systemic EBV DNA viremia were each associated with higher HIV DNA level in the reservoir after 24 months of antiretroviral therapy, independent of HIV RNA levels over time. These data suggest that delaying or containing CMV and EBV viremia may be novel strategies to limit HIV reservoir formation.

      21. BACKGROUND: There is a lack of information on high-risk sexual behaviors (HRSB) related to gender of sex partner and associated sexually transmitted infection (STI)/HIV testing among Medicaid enrollees. METHODS: We used the 2016 Centers for Medicare & Medicaid Services Medicaid claims data to identify enrollees aged 15 to 60 years with HRSB by International Classification of Disease, Tenth Revision codes (Z72.51, Z72.52, and Z72.53). Enrollees diagnosed with HRSB were classified into 2 groups:(1) with same-sex partners and (2) with opposite-sex partners. The date when the initial diagnosis for HRSB was documented was used to define as the index date. We assessed chlamydia, gonorrhea, syphilis, and HIV testing on the index date, in the 6-month period before and after the index date (excluded the index date). HIV testing was limited to enrollees without documented HIV infection. RESULTS: Of 50 million Medicaid enrollees aged 15 to 60 years, 1.2% were identified as enrollees with HRSB in 2016. Of those enrollees with HRSB, 2.7% were enrollees with same-sex partners and 0.71% had documented HIV infection. Chlamydia, gonorrhea, syphilis, and HIV testing rates were 82.4%, 81.9%, 33.2%, and 44.3%, respectively, at the index date. The chlamydia testing rate was ≥90% among enrollees who resided in the West compared with 53% to 61% across other regions. HIV testing was more likely among males and among those with same-sex partners. Sexually transmitted infection/HIV testing was <30% in the 6-month periods before and after the index date. CONCLUSIONS: Among Medicaid enrollees with HRSB, STI/HIV testing varied regionally. Many enrollees were not tested for STI/HIV at the index visit in which they were identified as HRSB.

      22. Phylogenomic analysis reveals persistence of gonococcal strains with reduced-susceptibility to extended-spectrum cephalosporins and mosaic penA-34external icon
        Thomas 4th JC, Joseph SJ, Cartee JC, Pham CD, Schmerer MW, Schlanger K, St Cyr SB, Kersh EN, Raphael BH.
        Nat Commun. 2021 Jun 21;12(1):3801.
        The recent emergence of strains of Neisseria gonorrhoeae associated with treatment failures to ceftriaxone, the foundation of current treatment options, has raised concerns over a future of untreatable gonorrhea. Current global data on gonococcal strains suggest that several lineages, predominately characterized by mosaic penA alleles, are associated with elevated minimum inhibitory concentrations (MICs) to extended spectrum cephalosporins (ESCs). Here we report on whole genome sequences of 813 N. gonorrhoeae isolates collected through the Gonococcal Isolate Surveillance Project in the United States. Phylogenomic analysis revealed that one persisting lineage (Clade A, multi-locus sequence type [MLST] ST1901) with mosaic penA-34 alleles, contained the majority of isolates with elevated MICs to ESCs. We provide evidence that an ancestor to the globally circulating MLST ST1901 clones potentially emerged around the early to mid-20th century (1944, credibility intervals [CI]: 1935-1953), predating the introduction of cephalosporins, but coinciding with the use of penicillin. Such results indicate that drugs with novel mechanisms of action are needed as these strains continue to persist and disseminate globally.

      23. HepCCATT: a multilevel intervention for hepatitis C among vulnerable populations in Chicagoexternal icon
        Tilmon S, Aronsohn A, Boodram B, Canary L, Goel S, Hamlish T, Kemble S, Lauderdale DS, Layden J, Lee K, Millman AJ, Nelson N, Ritger K, Rodriguez I, Shurupova N, Wolf J, Johnson D.
        J Public Health (Oxf). 2021 Jun 22.
        BACKGROUND: Hepatitis C infection could be eliminated. Underdiagnosis and lack of treatment are the barriers to cure, especially for vulnerable populations (i.e. unable to pay for health care). METHODS: A multilevel intervention from September 2014 to September 2019 focused on the providers and organizations in 'the safety net' (providing health care to populations unable to pay), including: (i) public education, (ii) training for primary care providers (PCPs) and case managers, (iii) case management for high-risk populations, (iv) policy advice and (v) a registry (Registry) for 13 health centers contributing data. The project tracked the number of PCPs trained and, among Registry sites, the number of people screened, engaged in care (i.e. clinical follow-up after diagnosis), treated and/or cured. RESULTS: In Chicago, 215 prescribing PCPs and 56 other health professionals, 86% of whom work in the safety net, were trained to manage hepatitis C. Among Registry sites, there was a 137% increase in antibody screening and a 32% increase in current hepatitis C diagnoses. Engagement in care rose by 18%. CONCLUSIONS: Hepatitis C Community Alliance to Test and Treat (HepCCATT) successfully targeted safety net providers and organizations with a comprehensive care approach. While there were challenges, HepCCATT observed increased hepatitis C screening, diagnosis and engagement in care in the Chicago community.

      24. Prevalence of human papillomavirus among females older than recommended age for vaccination by birth cohort, United States 2003‒2016external icon
        Vahle K, Gargano JW, Lewis RM, Querec TD, Unger ER, Bednarczyk RA, Markowitz LE.
        J Infect Dis. 2021 Jun 23.
        BACKGROUND: Apparent associations between HPV prevalence and age observed in cross-sectional studies could be misleading if cohort effects influence HPV detection. METHODS: Using data from 2003-2016 National Health and Nutrition Examination Surveys (NHANES), we evaluated overall and 10-year birth cohort-specific cervicovaginal HPV prevalence estimates (any, high-risk [HR], and non-HR) by 3-year age group among 27-59 year-old females born in 1950-1979. Average percent changes (APC) in HPV prevalence by 3-year age were calculated using prevalence ratios from log-binomial models. RESULTS: Overall, prevalence of any HPV declined from 49.9% in 27-29 year-olds to 33.8% in 57-59 year-olds [APC: -2.82% per 3-year age group, 95% confidence interval (CI): -4.02%, -1.60%] as did prevalence of HR-HPV [APC: -6.19% (95% CI: -8.09%, -4.26%)] and non-HR-HPV [APC: -2.00% (95% CI: -3.48%, -0.51%)]. By birth cohort, declines by age group were seen in prevalences of any HPV, HR-HPV, and non-HR-HPV for those born in the 1950s and 1970s and in any HPV and HR-HPV for those born in the 1960s (APC range: -14.08% - 0.06%). CONCLUSIONS: Declines in HPV prevalence with age in these cross-sectional surveys cannot be explained by birth cohort differences alone, as associations were observed across all birth cohorts. These findings are consistent with biological and behavioral explanations.

      25. HIV-1 Recent Infection Testing Algorithm With Antiretroviral Drug Detection to Improve Accuracy of Incidence Estimatesexternal icon
        Voetsch AC, Duong YT, Stupp P, Saito S, McCracken S, Dobbs T, Winterhalter FS, Williams DB, Mengistu A, Mugurungi O, Chikwanda P, Musuka G, Ndongmo CB, Dlamini S, Nuwagaba-Biribonwoha H, Pasipamire M, Tegbaru B, Eshetu F, Biraro S, Ward J, Aibo D, Kabala A, Mgomella GS, Malewo O, Mushi J, Payne D, Mengistu Y, Asiimwe F, Shang JD, Dokubo EK, Eno LT, Zoung-Kanyi Bissek AC, Kingwara L, Junghae M, Kiiru JN, Mwesigwa RC, Balachandra S, Lobognon R, Kampira E, Detorio M, Yufenyuy EL, Brown K, Patel HK, Parekh BS.
        J Acquir Immune Defic Syndr. 2021 Aug 1;87(Suppl 1):S73-s80.
        BACKGROUND: HIV-1 incidence calculation currently includes recency classification by HIV-1 incidence assay and unsuppressed viral load (VL ≥ 1000 copies/mL) in a recent infection testing algorithm (RITA). However, persons with recent classification not virally suppressed and taking antiretroviral (ARV) medication may be misclassified. SETTING: We used data from 13 African household surveys to describe the impact of an ARV-adjusted RITA on HIV-1 incidence estimates. METHODS: HIV-seropositive samples were tested for recency using the HIV-1 Limiting Antigen (LAg)-Avidity enzyme immunoassay, HIV-1 viral load, ARVs used in each country, and ARV drug resistance. LAg-recent result was defined as normalized optical density values ≤1.5. We compared HIV-1 incidence estimates using 2 RITA: RITA1: LAg-recent + VL ≥ 1000 copies/mL and RITA2: RITA1 + undetectable ARV. We explored RITA2 with self-reported ARV use and with clinical history. RESULTS: Overall, 357 adult HIV-positive participants were classified as having recent infection with RITA1. RITA2 reclassified 55 (15.4%) persons with detectable ARV as having long-term infection. Those with detectable ARV were significantly more likely to be aware of their HIV-positive status (84% vs. 10%) and had higher levels of drug resistance (74% vs. 26%) than those without detectable ARV. RITA2 incidence was lower than RITA1 incidence (range, 0%-30% decrease), resulting in decreased estimated new infections from 390,000 to 341,000 across the 13 countries. Incidence estimates were similar using detectable or self-reported ARV (R2 > 0.995). CONCLUSIONS: Including ARV in RITA2 improved the accuracy of HIV-1 incidence estimates by removing participants with likely long-term HIV infection.

      26. Global burden of acute lower respiratory infection associated with human parainfluenza virus in children younger than 5 years for 2018: a systematic review and meta-analysisexternal icon
        Wang X, Li Y, Deloria-Knoll M, Madhi SA, Cohen C, Arguelles VL, Basnet S, Bassat Q, Brooks WA, Echavarria M, Fasce RA, Gentile A, Goswami D, Homaira N, Howie SR, Kotloff KL, Khuri-Bulos N, Krishnan A, Lucero MG, Lupisan S, Mathisen M, McLean KA, Mira-Iglesias A, Moraleda C, Okamoto M, Oshitani H, O'Brien KL, Owor BE, Rasmussen ZA, Rath BA, Salimi V, Sawatwong P, Scott JA, Simões EA, Sotomayor V, Thea DM, Treurnicht FK, Yoshida LM, Zar HJ, Campbell H, Nair H.
        Lancet Glob Health. 2021 Jun 21.
        BACKGROUND: Human parainfluenza virus (hPIV) is a common virus in childhood acute lower respiratory infections (ALRI). However, no estimates have been made to quantify the global burden of hPIV in childhood ALRI. We aimed to estimate the global and regional hPIV-associated and hPIV-attributable ALRI incidence, hospital admissions, and mortality for children younger than 5 years and stratified by 0-5 months, 6-11 months, and 12-59 months of age. METHODS: We did a systematic review of hPIV-associated ALRI burden studies published between Jan 1, 1995, and Dec 31, 2020, found in MEDLINE, Embase, Global Health, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Global Health Library, three Chinese databases, and Google search, and also identified a further 41 high-quality unpublished studies through an international research network. We included studies reporting community incidence of ALRI with laboratory-confirmed hPIV; hospital admission rates of ALRI or ALRI with hypoxaemia in children with laboratory-confirmed hPIV; proportions of patients with ALRI admitted to hospital with laboratory-confirmed hPIV; or in-hospital case-fatality ratios (hCFRs) of ALRI with laboratory-confirmed hPIV. We used a modified Newcastle-Ottawa Scale to assess risk of bias. We analysed incidence, hospital admission rates, and hCFRs of hPIV-associated ALRI using a generalised linear mixed model. Adjustment was made to account for the non-detection of hPIV-4. We estimated hPIV-associated ALRI cases, hospital admissions, and in-hospital deaths using adjusted incidence, hospital admission rates, and hCFRs. We estimated the overall hPIV-associated ALRI mortality (both in-hospital and out-hospital mortality) on the basis of the number of in-hospital deaths and care-seeking for child pneumonia. We estimated hPIV-attributable ALRI burden by accounting for attributable fractions for hPIV in laboratory-confirmed hPIV cases and deaths. Sensitivity analyses were done to validate the estimates of overall hPIV-associated ALRI mortality and hPIV-attributable ALRI mortality. The systematic review protocol was registered on PROSPERO (CRD42019148570). FINDINGS: 203 studies were identified, including 162 hPIV-associated ALRI burden studies and a further 41 high-quality unpublished studies. Globally in 2018, an estimated 18·8 million (uncertainty range 12·8-28·9) ALRI cases, 725 000 (433 000-1 260 000) ALRI hospital admissions, and 34 400 (16 400-73 800) ALRI deaths were attributable to hPIVs among children younger than 5 years. The age-stratified and region-stratified analyses suggested that about 61% (35% for infants aged 0-5 months and 26% for 6-11 months) of the hospital admissions and 66% (42% for infants aged 0-5 months and 24% for 6-11 months) of the in-hospital deaths were in infants, and 70% of the in-hospital deaths were in low-income and lower-middle-income countries. Between 73% and 100% (varying by outcome) of the data had a low risk in study design; the proportion was 46-65% for the adjustment for health-care use, 59-77% for patient groups excluded, 54-93% for case definition, 42-93% for sampling strategy, and 67-77% for test methods. Heterogeneity in estimates was found between studies for each outcome. INTERPRETATION: We report the first global burden estimates of hPIV-associated and hPIV-attributable ALRI in young children. Globally, approximately 13% of ALRI cases, 4-14% of ALRI hospital admissions, and 4% of childhood ALRI mortality were attributable to hPIV. These numbers indicate a potentially notable burden of hPIV in ALRI morbidity and mortality in young children. These estimates should encourage and inform investment to accelerate the development of targeted interventions. FUNDING: Bill & Melinda Gates Foundation.

      27. Unawareness of HIV Infection Among Men Aged 15-59 Years in 13 Sub-Saharan African Countries: Findings From the Population-Based HIV Impact Assessments, 2015-2019external icon
        West CA, Chang GC, Currie DW, Bray R, Kinchen S, Behel S, McCullough-Sanden R, Low A, Bissek A, Shang JD, Ndongmo CB, Dokubo EK, Balachandra S, Lobognon LR, Dube L, Nuwagaba-Biribonwoha H, Li M, Pasipamire M, Getaneh Y, Lulseged S, Eshetu F, Kingwara L, Zielinski-Gutierrez E, Tlhomola M, Ramphalla P, Kalua T, Auld AF, Williams DB, Remera E, Rwibasira GN, Mugisha V, Malamba SS, Mushi J, Jalloh MF, Mgomella GS, Kirungi WL, Biraro S, Awor A. C., Barradas DT, Mugurungi O, Rogers JH, Bronson M, Bodika SM, Ajiboye A, Gaffga N, Moore C, Patel HK, Voetsch AC.
        J Acquir Immune Defic Syndr. 2021 Aug 1;87(Suppl 1):S97-s106.
        BACKGROUND: Identifying men living with HIV in sub-Saharan Africa (SSA) is critical to end the epidemic. We describe the underlying factors of unawareness among men aged 15-59 years who ever tested for HIV in 13 SSA countries. METHODS: Using pooled data from the nationally representative Population-based HIV Impact Assessments, we fit a log-binomial regression model to identify characteristics related to HIV positivity among HIV-positive unaware and HIV-negative men ever tested for HIV. RESULTS: A total of 114,776 men were interviewed and tested for HIV; 4.4% were HIV-positive. Of those, 33.7% were unaware of their HIV-positive status, (range: 20.2%-58.7%, in Rwanda and Cote d'Ivoire). Most unaware men reported they had ever received an HIV test (63.0%). Age, region, marital status, and education were significantly associated with HIV positivity. Men who had HIV-positive sexual partners (adjusted prevalence ratio [aPR]: 5.73; confidence interval [95% CI]: 4.13 to 7.95) or sexual partners with unknown HIV status (aPR: 2.32; 95% CI: 1.89 to 2.84) were more likely to be HIV-positive unaware, as were men who tested more than 12 months compared with HIV-negative men who tested within 12 months before the interview (aPR: 1.58; 95% CI: 1.31 to 1.91). Tuberculosis diagnosis and not being circumcised were also associated with HIV positivity. CONCLUSION: Targeting subgroups of men at risk for infection who once tested negative could improve yield of testing programs. Interventions include improving partner testing, frequency of testing, outreach and educational strategies, and availability of HIV testing where men are accessing routine health services.

    • Disaster Control and Emergency Services
      1. 9/11 health updateexternal icon
        Cone JE, Santiago-Colón A, Lucchini R.
        International Journal of Environmental Research and Public Health. 2021 ;18(12).

      2. Asthma-Related Emergency Department Visits in North Carolina Following Hurricane Ireneexternal icon
        Cowan KN, Pennington AF, Sircar K, Flanders WD.
        Disaster Med Public Health Prep. 2021 Jun 21:1-4.
        OBJECTIVE: Previous research suggests that people with asthma may experience a worsening of symptoms following hurricanes due to changes in environmental exposures, discontinuity in chronic disease management, and stress. The objective of this study was to estimate changes in asthma-related emergency department (ED) visits in North Carolina following Hurricane Irene, which made landfall in August 2011. METHODS: Changes in asthma-related ED visits in September to December of 2010 and 2011 were examined using data from the Healthcare Cost and Utilization Project State Emergency Department and Inpatient Databases. A Poisson generalized linear model was used to estimate the association between Federal Emergency Management Agency disaster declarations following Hurricane Irene and county-level asthma-related ED visits controlling for month, year, and county. RESULTS: Following Hurricane Irene, disaster declarations were made for 38 of 100 counties in North Carolina. In September 2010, the rate of asthma-related ED visits for North Carolina was 6 per 10,000 person-months. In September 2011, rates of asthma-related ED visits were similar in counties with and without disaster declarations (7 and 5 per 10,000 person-months, respectively). When adjusting for covariates, there was little or no difference in the rate of asthma ED visits before and after the hurricane between counties with and without a disaster declaration (rate ratio {RR} [95% confidence interval {CI}] = 1.02[0.97, 1.08]). CONCLUSIONS: Although risk factors for asthma exacerbations increase following hurricanes, these results found little evidence of an increase in asthma-related ED visits in North Carolina following Hurricane Irene.

    • Disease Reservoirs and Vectors
      1. Evaluation of a Methoprene Aerial Application for the Control of Culiseta melanura (Diptera: Culicidae) in Wetland Larval Habitatsexternal icon
        Burtis JC, Poggi JD, Duval TB, Bidlack E, Shepard JJ, Matton P, Rossetti R, Harrington LC.
        J Med Entomol. 2021 Jun 18.
        Eastern equine encephalitis virus (EEEV) is an arbovirus endemic to the eastern United States. Human cases are rare but can be serious. The primary enzootic vector is Culiseta melanura (Coquillett) (Diptera: Culicidae), an ornithophagic mosquito. We conducted an aerial application of a granular methoprene formulation in Hockomock Swamp (Massachusetts), which represents a focus of EEEV transmission. Water collected from inside and outside Cs. melanura crypts was evaluated in bioassays of early fourth instar Cs. melanura larvae using treated and untreated water. Adult eclosion rates were 36% significantly lower in treated compared with untreated water (P < 0.05). Eclosion rates for water collected from inside crypts were significantly higher (62%) than rates from outside crypts (30%) (P < 0.05), indicating higher efficacy outside crypts. We tested whether reduced methoprene efficacy inside the crypts was due to reduced chemical penetration into this habitat. Chemical water analyses confirmed that methoprene concentrations were lower inside the crypts (0.1 ± 0.05 ppb) compared to water from outside crypts (1.79 ± 0.41 ppb). The susceptibility of Cs. melanura to methoprene was also determined to allow for comparison against concentrations observed in water collected from the field (LC-95: 1.95 ± 0.5 ppb). Overall, methoprene-treated water prevented mosquito development for up to 4 wk, but with a reduction in efficacy between 4- and 6-wk post-application. Our results suggest that aerial methoprene applications can effectively treat open water in wetlands but may not provide efficacious control of Cs. melanura due to an inability to penetrate larval habitats.

      2. High-throughput Detection of Eukaryotic Parasites and Arboviruses in Mosquitoesexternal icon
        Cannon MV, Bogale HN, Bhalerao D, Keita K, Camara D, Barry Y, Keita M, Coulibaly D, Kone AK, Doumbo OK, Thera MA, Plowe CV, Travassos MA, Irish SR, Yeroshefsky J, Dorothy J, Prendergast B, Laurent BS, Fritz ML, Serre D.
        Biol Open. 2021 Jun 22.
        Vector-borne pathogens cause many human infectious diseases and are responsible for high mortality and morbidity throughout the world. They can also cause livestock epidemics with dramatic social and economic consequences. Due to its high costs, vector-borne disease surveillance is often limited to current threats, and the investigation of emerging pathogens typically occurs after the reports of clinical cases. Here, we use high-throughput sequencing to detect and identify a wide range of parasites and viruses carried by mosquitoes from Cambodia, Guinea, Mali and Maryland. We apply this approach to individual Anopheles mosquitoes as well as pools of mosquitoes captured in traps; and compare the outcomes of this assay when applied to DNA or RNA. We identified known human and animal pathogens and mosquito parasites belonging to a wide range of taxa, as well as novel DNA sequences from previously uncharacterized organisms. Our results also revealed that analysis of the content of an entire trap could be an efficient approach to monitor and identify rare vector-borne pathogens in large surveillance studies. Overall, we describe a high-throughput and easy-to-customize assay to screen for a wide-range of pathogens and efficiently complement current vector-borne disease surveillance approaches.

      3. Tick extracellular vesicles enable arthropod feeding and promote distinct outcomes of bacterial infectionexternal icon
        Oliva Chávez AS, Wang X, Marnin L, Archer NK, Hammond HL, Carroll EE, Shaw DK, Tully BG, Buskirk AD, Ford SL, Butler LR, Shahi P, Morozova K, Clement CC, Lawres L, Neal AJ, Mamoun CB, Mason KL, Hobbs BE, Scoles GA, Barry EM, Sonenshine DE, Pal U, Valenzuela JG, Sztein MB, Pasetti MF, Levin ML, Kotsyfakis M, Jay SM, Huntley JF, Miller LS, Santambrogio L, Pedra JH.
        Nat Commun. 2021 Jun 17;12(1):3696.
        Extracellular vesicles are thought to facilitate pathogen transmission from arthropods to humans and other animals. Here, we reveal that pathogen spreading from arthropods to the mammalian host is multifaceted. Extracellular vesicles from Ixodes scapularis enable tick feeding and promote infection of the mildly virulent rickettsial agent Anaplasma phagocytophilum through the SNARE proteins Vamp33 and Synaptobrevin 2 and dendritic epidermal T cells. However, extracellular vesicles from the tick Dermacentor andersoni mitigate microbial spreading caused by the lethal pathogen Francisella tularensis. Collectively, we establish that tick extracellular vesicles foster distinct outcomes of bacterial infection and assist in vector feeding by acting on skin immunity. Thus, the biology of arthropods should be taken into consideration when developing strategies to control vector-borne diseases.

      4. Deer management (e.g., reduction) has been proposed as a tool to reduce the acarological risk of Lyme disease. There have been few opportunities to investigate Ixodes scapularis (blacklegged tick) and Borrelia burgdorferi sensu stricto dynamics in the absence of white-tailed deer (Odocoileus virginianus) in midwestern North America. A pair of islands in Lake Michigan presented a unique opportunity to study the role of alternative hosts for the adult stage of the blacklegged tick for maintaining a tick population as a deer herd exists on North Manitou Island but not on South Manitou Island, where coyotes (Canis latrans) and hares (Lepus americanus) are the dominant medium mammals. Additionally, we were able to investigate the maintenance of I. scapularis and B. burgdorferi in small mammal communities on both islands, which were dominated by eastern chipmunks (Tamias striatus). From 2011 to 2015, we surveyed both islands for blacklegged ticks by drag cloth sampling, bird mist netting, and small and medium-sized mammal trapping. We assayed questing ticks, on-host ticks, and mammal biopsies for the Lyme disease pathogen, B. burgdorferi. We detected all three life stages of the blacklegged tick on both islands. Of the medium mammals sampled, no snowshoe hares (Lepus americanus, 0/23) were parasitized by adult blacklegged ticks, but 2/2 coyotes (Canis latrans) sampled on South Manitou Island in 2014 were parasitized by adult blacklegged ticks, suggesting that coyotes played a role in maintaining the tick population in the absence of deer. We also detected I. scapularis ticks on passerine birds from both islands, providing support that birds contribute to maintaining as well as introducing blacklegged ticks and B. burgdorferi to the islands. We observed higher questing adult and nymphal tick densities, and higher B. burgdorferi infection prevalence in small mammals and in adult ticks on the island with deer as compared to the deer-free island. On the islands, we also found that 25% more chipmunks were tick-infested than mice, fed more larvae and nymphs relative to their proportional abundance compared to mice, and thus may play a larger role compared to mice in the maintenance of B. burgdorferi. Our investigation demonstrated that alternative hosts could maintain a local population of blacklegged ticks and an enzootic cycle of the Lyme disease bacterium in the absence of white-tailed deer. Thus, alternative adult blacklegged tick hosts should be considered when investigating deer-targeted management tools for reducing tick-borne disease risk, especially when the alternative host community may be abundant and diverse.

    • Food Safety
      1. Evaluation of Avocados as a Possible Source of Listeria monocytogenes Infections, United States, 2016 to 2019external icon
        Pomeroy M, Conrad A, Pettengill JB, Mc C, Wellman AA, Marus J, Huffman J, Wise M.
        J Food Prot. 2021 Jul 1;84(7):1122-1126.
        ABSTRACT: Outbreaks of Listeria monocytogenes infections have historically been associated with contaminated deli meats, but recent outbreaks have been linked to produce. To date, avocados have not been identified as the source of any outbreaks of L. monocytogenes infections in the United States, but avocado samples have yielded strains that were closely related genetically to clinical L. monocytogenes isolates. To determine whether avocados have been a source of listeriosis, we conducted a retrospective review of epidemiological data for clinical isolates that were genetically related to isolates from avocados. Using a national database, we identified clusters containing clinical and at least one avocado isolate. We then selected clusters based upon isolation dates, cluster and composition size, and available food history data. For each cluster, we assessed (i) whether avocado consumption was higher among case patients in the cluster than among those with sporadic illnesses and (ii) whether the only food isolates within the cluster were from avocados. If both conditions were met, the link was considered "likely," if one condition was met the link was considered "possible," and if neither condition was met evidence was "limited." Five of 15 clusters met the criteria for assessment. Of these, two were classified as having "limited" evidence for a link to avocados, two as "possible," and one as "likely." For the cluster considered "likely," avocado consumption was significantly higher among case patients in the cluster compared with sporadic illnesses (odds ratio, 8.5; 95% confidence interval, 1.5 to 86.5). We identified three clusters that were likely or possibly linked to avocados, which suggests that avocados could be a source of listeriosis in the United States. Messaging on safe handling might be warranted for groups at higher risk, but further research is first needed to better characterize the ecology of pathogens on avocados and the likelihood of internalization of L. monocytogenes.

    • Health Disparities
      1. BACKGROUND: Pneumonia, diarrhoea and malaria are responsible for over one third of all deaths in children under the age of 5 years in low and middle sociodemographic index countries; many of these deaths are also associated with malnutrition. We explore the co-occurrence and clustering of fever, acute respiratory infection, diarrhoea and wasting and their relationship with equity-relevant variables. METHODS: Multilevel, multivariate Bayesian logistic regression models were fitted to Demographic and Health Survey data from over 380,000 children in 39 countries. The relationship between outcome indicators (fever, acute respiratory infection, diarrhoea and wasting) and equity-relevant variables (wealth, access to health care and rurality) was examined. We quantified the geographical clustering and co-occurrence of conditions and a child's risk of multiple illnesses. RESULTS: The prevalence of outcomes was very heterogeneous within and between countries. There was marked spatial clustering of conditions and co-occurrence within children. For children in the poorest households and those reporting difficulties accessing healthcare, there were significant increases in the probability of at least one of the conditions in 18 of 21 countries, with estimated increases in the probability of up to 0.23 (95% CrI, 0.06-0.40). CONCLUSIONS: The prevalence of fever, acute respiratory infection, diarrhoea and wasting are associated with equity-relevant variables and cluster together. Via pathways of shared aetiology or risk, those children most disadvantaged disproportionately suffer from these conditions. This highlights the need for horizontal approaches, such as integrated community case management, with a focus on equity and targeted to those most at need.

    • Healthcare Associated Infections
      1. Sampling efficiency of Candida auris from healthcare surfaces: culture and nonculture detection methodsexternal icon
        Furin WA, Tran LH, Chan MY, Lyons AK, Noble-Wang J, Rose LJ.
        Infect Control Hosp Epidemiol. 2021 Jun 22:1-3.
        Sponges and swabs were evaluated for their ability to recover Candida auris dried 1 hour on steel and plastic surfaces. Culture recovery ranged from <0.1% (sponges) to 8.4% (swabs), and cells detected with an esterase activity assay revealed >50% recovery (swabs), indicating that cells may enter a viable but nonculturable state.

      2. Integrated genomic, epidemiologic investigation of Candida auris skin colonization in a skilled nursing facilityexternal icon
        Proctor DM, Dangana T, Sexton DJ, Fukuda C, Yelin RD, Stanley M, Bell PB, Baskaran S, Deming C, Chen Q, Conlan S, Park M, Welsh RM, Vallabhaneni S, Chiller T, Forsberg K, Black SR, Pacilli M, Kong HH, Lin MY, Schoeny ME, Litvintseva AP, Segre JA, Hayden MK.
        Nat Med. 2021 Jun 21.
        Candida auris is a fungal pathogen of high concern due to its ability to cause healthcare-associated infections and outbreaks, its resistance to antimicrobials and disinfectants and its persistence on human skin and in the inanimate environment. To inform surveillance and future mitigation strategies, we defined the extent of skin colonization and explored the microbiome associated with C. auris colonization. We collected swab specimens and clinical data at three times points between January and April 2019 from 57 residents (up to ten body sites each) of a ventilator-capable skilled nursing facility with endemic C. auris and routine chlorhexidine gluconate (CHG) bathing. Integrating microbial-genomic and epidemiologic data revealed occult C. auris colonization of multiple body sites not targeted commonly for screening. High concentrations of CHG were associated with suppression of C. auris growth but not with deleterious perturbation of commensal microbes. Modeling human mycobiome dynamics provided insight into underlying alterations to the skin fungal community as a possible modifiable risk factor for acquisition and persistence of C. auris. Failure to detect the extensive, disparate niches of C. auris colonization may reduce the effectiveness of infection-prevention measures that target colonized residents, highlighting the importance of universal strategies to reduce C. auris transmission.

      3. The landscape of candidemia during the COVID-19 pandemicexternal icon
        Seagle EE, Jackson BR, Lockhart SR, Georgacopoulos O, Nunnally NS, Roland J, Barter DM, Johnston HL, Czaja CA, Kayalioglu H, Clogher P, Revis A, Farley MM, Harrison LH, Davis SS, Phipps EC, Tesini BL, Schaffner W, Markus TM, Lyman MM.
        Clin Infect Dis. 2021 Jun 18.
        BACKGROUND: The COVID-19 pandemic has resulted in unprecedented healthcare challenges, and COVID-19 has been linked to secondary infections. Candidemia, a fungal healthcare-associated infection, has been described in patients hospitalized with severe COVID-19. However, studies of candidemia and COVID-19 co-infection have been limited in sample size and geographic scope. We assessed differences in patients with candidemia with and without a COVID-19 diagnosis. METHODS: We conducted a case-level analysis using population-based candidemia surveillance data collected through the Centers for Disease Control and Prevention's Emerging Infections Program during April-August 2020 to compare characteristics of candidemia patients with and without a positive test for COVID-19 in the 30 days before their Candida culture using chi-square or Fisher exact tests. RESULTS: Of the 251 candidemia patients included, 64 (25.5%) were positive for SARS-CoV-2. Liver disease, solid organ malignancies, and prior surgeries were each >3 times more common in patients without COVID-19 co-infection, whereas intensive care unit-level care, mechanical ventilation, having a central venous catheter, and receipt of corticosteroids and immunosuppressants were each >1.3 times more common in patients with COVID-19. All cause in-hospital fatality was two times higher among those with COVID-19 (62.5%) than without (32.1%). CONCLUSIONS: One quarter of candidemia patients had COVID-19. These patients were less likely to have certain underlying conditions and recent surgery commonly associated with candidemia and more likely to have acute risk factors linked to COVID-19 care, including immunosuppressive medications. Given the high mortality, it is important for clinicians to remain vigilant and take proactive measures to prevent candidemia in patients with COVID-19.

    • Immunity and Immunization
      1. COVID-19 Vaccination Coverage and Intent Among Adults Aged 18-39 Years - United States, March-May 2021external icon
        Baack BN, Abad N, Yankey D, Kahn KE, Razzaghi H, Brookmeyer K, Kolis J, Wilhelm E, Nguyen KH, Singleton JA.
        MMWR Morb Mortal Wkly Rep. 2021 Jun 25;70(25):928-933.
        Since April 19, 2021, all persons aged ≥16 years in the United States have been eligible to receive a COVID-19 vaccine. As of May 30, 2021, approximately one half of U.S. adults were fully vaccinated, with the lowest coverage and lowest reported intent to get vaccinated among young adults aged 18-39 years (1-4). To examine attitudes toward COVID-19 vaccination and vaccination intent among adults in this age group, CDC conducted nationally representative household panel surveys during March-May 2021. Among respondents aged 18-39 years, 34.0% reported having received a COVID-19 vaccine. A total of 51.8% were already vaccinated or definitely planned to get vaccinated, 23.2% reported that they probably were going to get vaccinated or were unsure about getting vaccinated, and 24.9% reported that they probably or definitely would not get vaccinated. Adults aged 18-24 years were least likely to report having received a COVID-19 vaccine and were most likely to report being unsure about getting vaccinated or that they were probably going to get vaccinated. Adults aged 18-39 years with lower incomes, with lower educational attainment, without health insurance, who were non-Hispanic Black, and who lived outside of metropolitan areas had the lowest reported vaccination coverage and intent to get vaccinated. Concerns about vaccine safety and effectiveness were the primary reported reasons for not getting vaccinated. Vaccination intent and acceptance among adults aged 18-39 years might be increased by improving confidence in vaccine safety and efficacy while emphasizing that vaccines are critical to prevent the spread of COVID-19 to friends and family and for resuming social activities (5).

      2. COVID-19 Vaccination Coverage Among Adults - United States, December 14, 2020-May 22, 2021external icon
        Diesel J, Sterrett N, Dasgupta S, Kriss JL, Barry V, Vanden Esschert K, Whiteman A, Cadwell BL, Weller D, Qualters JR, Harris L, Bhatt A, Williams C, Fox LM, Meaney Delman D, Black CL, Barbour KE.
        MMWR Morb Mortal Wkly Rep. 2021 Jun 25;70(25):922-927.
        The U.S. COVID-19 vaccination program launched on December 14, 2020. The Advisory Committee on Immunization Practices recommended prioritizing COVID-19 vaccination for specific groups of the U.S. population who were at highest risk for COVID-19 hospitalization and death, including adults aged ≥75 years*; implementation varied by state, and eligibility was gradually expanded to persons aged ≥65 years beginning in January 2021. By April 19, 2021, eligibility was expanded to all adults aged ≥18 years nationwide.(†) To assess patterns of COVID-19 vaccination coverage among U.S. adults, CDC analyzed data submitted on vaccinations administered during December 14, 2020-May 22, 2021, by age, sex, and community-level characteristics. By May 22, 2021, 57.0% of persons aged ≥18 years had received ≥1 COVID-19 vaccine dose; coverage was highest among persons aged ≥65 years (80.0%) and lowest among persons aged 18-29 years (38.3%). During the week beginning February 7, 2021, vaccination initiation among adults aged ≥65 years peaked at 8.2%, whereas weekly initiation among other age groups peaked later and at lower levels. During April 19-May 22, 2021, the period following expanded eligibility to all adults, weekly initiation remained <4.0% and decreased for all age groups, including persons aged 18-29 years (3.6% to 1.9%) and 30-49 years (3.5% to 1.7%); based on the current rate of weekly initiation (as of May 22), younger persons will not reach the same levels of coverage as older persons by the end of August. Across all age groups, coverage (≥1 dose) was lower among men compared with women, except among adults aged ≥65 years, and lower among persons living in counties that were less urban, had higher social vulnerabilities, or had higher percentages of social determinants of poor health. Continued efforts to improve vaccination confidence and alleviate barriers to vaccination initiation, especially among adults aged 18-49 years, could improve vaccination coverage.

      3. Sensitivity of Self-reported HPV Vaccination History among 18-26 year-old Men Who Have Sex with Men - Seattle, Washington, 2016-2018external icon
        Forward T, Meites E, Lin J, Hughes JP, Unger ER, Markowitz LE, Golden M, Swanson F, Faestel PM, Winer RL.
        Sex Transm Dis. 2021 Jun 22.
        BACKGROUND: We assessed sensitivity of self-reported HPV vaccination among young adult men who have sex with men (MSM) with documented HPV vaccination. METHODS: During 2016-2018, MSM and transgender women aged 18-26 years were enrolled in Seattle, Washington. HPV vaccination history was assessed via self-administered survey, clinic electronic medical records (EMR), and the Washington State Immunization Information System (WAIIS). We assessed self-report sensitivity among participants with documented prior HPV vaccination (≥1 dose) in either the EMR or WAIIS, and used logistic regression to compare sensitivity by age, number of doses, and time since first dose. RESULTS: Of 292 participants with ≥1 documented HPV vaccine dose, 243 self-reported ≥1 dose (sensitivity = 83.2%,95%CI:78.4%-87.3%). Compared to participants whose first dose was <1 year ago, likelihood of self-report was lower among those with ≥3 years since first dose (adjusted odds ratio (aOR) = 0.2,95%CI:0.1-0.5). Furthermore, compared to participants with only 1 documented HPV vaccine dose, likelihood of self-reporting ≥1 dose was higher among those with 2 (aOR = 2.4,95%CI:1.0-5.5) or ≥ 3 doses (aOR = 6.2,95%CI:2.7-14.4). Among 115 participants with ≥3 documented doses, sensitivity for recalling ≥3 doses was 69.6% (95%CI:60.3%-77.8%). CONCLUSIONS: Most young adult MSM with a documented history of HPV vaccination self-reported prior HPV vaccination. Although recall was highest in those with ≥3 doses, 30% of this fully-vaccinated subgroup did not correctly recall the number of doses received, highlighting limitations of self-reporting. Furthermore, results indicating reduced recall with ≥3 years since first dose suggest that sensitivity of self-report among young adult MSM may decline over time as adolescent vaccination coverage increases.

      4. INTRODUCTION: Zimbabwe introduced human papillomavirus (HPV) vaccine nationally in May 2018, targeting multiple cohorts (girls aged 10-14 years) through a school-based vaccination campaign. One year later, the second dose was administered to the multiple cohorts concurrently with the first dose given to a new single cohort of girls in grade 5. We conducted cross-sectional surveys among health workers, school personnel, and community members to assess feasibility of implementation, training, social mobilization, and community acceptability. METHODS: Thirty districts were selected proportional to the volume of the HPV vaccine doses delivered in 2018; two health facilities were randomly selected within each district. One health worker, school health coordinator, village health worker, and community leader were surveyed at each selected health facility and surrounding area during January-February 2020, using standard questionnaires. Descriptive analysis was completed across groups. RESULTS: There were 221 interviews completed. Over 60% of health workers reported having enough staff to carry out vaccination sessions in schools while maintaining routine vaccination services in health facilities. All school health coordinators felt the HPV vaccine should be delivered in schools in the future. Knowledge of the correct target cohort eligibility decreased from 91% in 2018 to 50% in 2020 among health workers. Understanding of HPV infection and use of HPV vaccine for cervical cancer prevention was above 90% for all respondents. Forty-two percent of respondents reported hearing rumors about the HPV vaccine, primarily regarding infertility and safety. CONCLUSIONS: Findings demonstrate the presence of highly knowledgeable staff at health facilities and schools, strong community acceptance, and a school-based HPV program considered feasible to implement in Zimbabwe. However, misunderstandings regarding target eligibility and rumors persist, which can impact vaccine uptake and coverage. Continued social mobilization efforts to maintain community demand and training on eligibility were recommended. Integration, partnerships, and resource mobilization are also needed to ensure program sustainability.

      5. Estimation of the correlates of protection of the rVSVG-ZEBOV-GP Zaire ebolavirus vaccine: a post-hoc analysis of data from phase 2/3 clinical trialsexternal icon
        Grais RF, Kennedy SB, Mahon BE, Dubey SA, Grant-Klein RJ, Liu K, Hartzel J, Coller BA, Welebob C, Hanson ME, Simon JK.
        Lancet Microbe. 2021 ;2(2):e70-e78.
        Background: Establishment of immune correlates of protection can provide a measurable criterion for assessing protection against infection or disease. For some vaccines, such as the measles vaccine, antibodies serve as the correlate of protection, but for others, such as human papillomavirus, the correlate of protection remains unknown. Merck & Co, Kenilworth, NJ, USA, in collaboration with multiple partners, developed a live recombinant vesicular stomatitis virus vaccine (rVSVG-ZEBOV-GP [ERVEBO]) containing the Zaire ebolavirus glycoprotein (GP) in place of the recombinant vesicular stomatitis virus GP to prevent Ebola virus disease. Seroresponse, defined as post-vaccination GP-ELISA of 200 ELISA units (EU) per mL or higher and two-times or more above baseline, was proposed; however, correlates of protection have not been determined. The objective of this post-hoc analysis was to infer possible correlates of protection for rVSVG-ZEBOV-GP.

      6. OBJECTIVE: Pregnant women are at increased risk of serious complications from influenza and are recommended to receive an influenza vaccination during pregnancy. The objective of this study was to assess trends, timing patterns, and associated factors of influenza vaccination among pregnant women. METHODS: We used 2010-2018 MarketScan data on 1 286 749 pregnant women aged 15-49 who were privately insured to examine trends and timing patterns of influenza vaccination coverage. We examined descriptive statistics and identified factors associated with vaccination uptake by using multivariate log-binomial and Cox proportional hazard models. RESULTS: In-plan influenza vaccination coverage before delivery increased from 22.0% during the 2010-2011 influenza season to 33.2% during the 2017-2018 influenza season. About two-thirds of vaccinated women received the vaccine in September or October during each influenza season. For women who delivered in September through May, influenza vaccination coverage increased rapidly at the beginning of influenza season and flattened after October. For women who delivered in June through August, influenza vaccination coverage increased gradually until February and flattened thereafter. Most vaccinated women who delivered before January received the vaccine in the third trimester. Increased likelihood of being vaccinated was associated with age 31-40, living in a metropolitan statistical area, living outside the South, enrollment in a consumer-driven or high-deductible health plan, being spouses or dependents of policy holders, and delivery in November through January. CONCLUSIONS: Despite increases during the past several years, vaccination uptake is still suboptimal, particularly after October. Health care provider education on timing of vaccination and recommendations throughout influenza seasons are needed to improve influenza vaccination coverage among pregnant women.

      7. Population impact and effectiveness of sequential 13-valent pneumococcal conjugate and monovalent rotavirus vaccine introduction on infant mortality: prospective birth cohort studies from Malawiexternal icon
        King C, Bar-Zeev N, Phiri T, Beard J, Mvula H, Crampin A, Heinsbroek E, Hungerford D, Lewckya S, Verani J, Whitney C, Costello A, Mwansambo C, Cunliffe N, Heyderman R, French N.
        BMJ Glob Health. 2020 Sep;5(9).
        BACKGROUND: Pneumococcal conjugate vaccine (PCV) and rotavirus vaccine (RV) are key tools for reducing common causes of infant mortality. However, measurement of population-level mortality impact is lacking from sub-Saharan Africa. We evaluated mortality impact and vaccine effectiveness (VE) of PCV13 introduced in November 2011, with subsequent RV1 roll-out in October 2012, in Malawi. METHODS: We conducted two independent community-based birth cohort studies. Study 1, in northern Malawi (40000population), evaluated population impact using change-point analysis and negative-binomial regression of non-traumatic 14-51-week infant mortality preintroduction (1 January 2004 to 31 September 2011) and postintroduction (1 October 2011 to 1 July 2019), and against three-dose coverage. Study 2, in central Malawi (465 000 population), was recruited from 24 November 2011 to 1 June 2015. In the absence of preintroduction data, individual three-dose versus zero-dose VE was estimated using individual-level Cox survival models. In both cohorts, infants were followed with household visits to ascertain vaccination, socioeconomic and survival status. Verbal autopsies were conducted for deaths. RESULTS: Study 1 included 20 291 live births and 216 infant deaths. Mortality decreased by 28.6% (95% CI: 15.3 to 39.8) post-PCV13 introduction. A change point was identified in November 2012. Study 2 registered 50 731 live births, with 454 deaths. Infant mortality decreased from 17 to 10/1000 live births during the study period. Adjusted VE was 44.6% overall (95% CI: 23.0 to 59.1) and 48.3% (95% CI: -5.9 to 74.1) against combined acute respiratory infection, meningitis and sepsis-associated mortality. CONCLUSION: These data provide population-level evidence of infant mortality reduction following sequential PCV13 and RV1 introduction into an established immunisation programme in Malawi. These data support increasing coverage of vaccine programmes in high-burden settings.

      8. Prevalence and characterization of pertactin deficient Bordetella pertussis strains in Brazil, a whole-cell vaccine countryexternal icon
        Leite D, Camargo CH, Kashino SS, Polatto R, Martins LM, Pereira JC, Pawloski L, Tondella ML, Oliveira RS, Vaz de Lima LR.
        Vaccine: X. 2021 ;8.
        Many countries have reported antigenic divergence among circulating Bordetella pertussis strains, mainly in those countries which introduced the acellular pertussis (aP) vaccine. This phenomenon can be seen, for example, with the recent rise of pertactin (Prn)-deficient B. pertussis strains, one of the antigens included in aP vaccine formulas. The whole cell pertussis (wP) vaccine has been used in Brazil since 1977 for the primary pertussis, diphtheria and tetanus immunization series. In 2014, the aP vaccine was recommended for women during pregnancy to protect infants in the first months of life. Our objective was to determine the prevalence of Prn-deficiency in 511 isolates of B. pertussis collected in Brazil during 2010–2016. All isolates were characterized, through PFGE and serotyping, and screened for the loss of Prn by ELISA. Prn-deficiency was confirmed by immunoblotting, and identification of the possible genetic markers was performed with PCR and Sanger sequencing. Results indicate that 110 PFGE profiles are currently circulating, with five profiles representing the majority, and the predominant serotype 3, has been gradually replaced by serotype 2 and serotype 2,3. ELISA screening and immunoblotting identified three Prn-deficient isolates. Genotypic characterization by PCR and sequencing indicated that one isolate had a promoter mutation in prn, while the other two did not have an obvious genetic explanation for their deficiency. While the lack of Prn was identified in a few isolates, this study did not detect a relevant occurrence of Prn-deficiency, until 2016, confirming previous observations that Prn-deficiency is likely aP vaccine-driven. © 2021

      9. Vaccine Safety Datalink infrastructure enhancements for evaluating the safety of maternal vaccinationexternal icon
        Naleway AL, Crane B, Irving SA, Bachman D, Vesco KK, Daley MF, Getahun D, Glenn SC, Hambidge SJ, Jackson LA, Klein NP, McCarthy NL, McClure DL, Panagiotakopoulos L, Panozzo CA, Vazquez-Benitez G, Weintraub ES, Zerbo O, Kharbanda EO.
        Ther. Adv. Drug Saf.. 2021 ;12.
        Background: Identifying pregnancy episodes and accurately estimating their beginning and end dates are imperative for observational maternal vaccine safety studies using electronic health record (EHR) data. Methods: We modified the Vaccine Safety Datalink (VSD) Pregnancy Episode Algorithm (PEA) to include both the International Classification of Disease, ninth revision (ICD-9 system) and ICD-10 diagnosis codes, incorporated additional gestational age data, and validated this enhanced algorithm with manual medical record review. We also developed the new Dynamic Pregnancy Algorithm (DPA) to identify pregnancy episodes in real time. Results: Around 75% of the pregnancy episodes identified by the enhanced VSD PEA were live births, 12% were spontaneous abortions (SABs), 10% were induced abortions (IABs), and 0.4% were stillbirths (SBs). Gestational age was identified for 99% of live births, 89% of SBs, 69% of SABs, and 42% of IABs. Agreement between the PEA-assigned and abstractor-identified pregnancy outcome and outcome date was 100% for live births, but was lower for pregnancy losses. When gestational age was available in the medical record, the agreement was higher for live births (97%), but lower for pregnancy losses (75%). The DPA demonstrated strong concordance with the PEA and identified pregnancy episodes ⩾6 months prior to the outcome date for 89% of live births. Conclusion: The enhanced VSD PEA is a useful tool for identifying pregnancy episodes in EHR databases. The DPA improves the timeliness of pregnancy identification and can be used for near real-time maternal vaccine safety studies. Plain Language Summary: Improving identification of pregnancies in the Vaccine Safety Datalink electronic medical record databases to allow for better and faster monitoring of vaccination safety during pregnancy Introduction: It is important to monitor of the safety of vaccines after they have been approved and licensed by the Food and Drug Administration, especially among women vaccinated during pregnancy. The Vaccine Safety Datalink (VSD) monitors vaccine safety through observational studies within large databases of electronic medical records. Since 2012, VSD researchers have used an algorithm called the Pregnancy Episode Algorithm (PEA) to identify the medical records of women who have been pregnant. Researchers then use these medical records to study whether receiving a particular vaccine is linked to any negative outcomes for the woman or her child. Methods: The goal of this study was to update and enhance the PEA to include the full set of medical record diagnostic codes [both from the older International Classification of Disease, ninth revision (ICD-9 system) and the newer ICD-10 system] and to incorporate additional sources of data about gestational age. To ensure the validity of the PEA following these enhancements, we manually reviewed medical records and compared the results with the algorithm. We also developed a new algorithm, the Dynamic Pregnancy Algorithm (DPA), to identify women earlier in pregnancy, allowing us to conduct more timely vaccine safety assessments. Results: The new version of the PEA identified 2,485,410 pregnancies in the VSD database. The enhanced algorithm more precisely estimated the beginning of pregnancies, especially those that did not result in live births, due to the new sources of gestational age data. Conclusion: Our new algorithm, the DPA, was successful at identifying pregnancies earlier in gestation than the PEA. The enhanced PEA and the new DPA will allow us to better evaluate the safety of current and future vaccinations administered during or around the time of pregnancy. © The Author(s), 2021.

      10. TIPICO X: report of the 10th interactive infectious disease workshop on infectious diseases and vaccinesexternal icon
        Rivero-Calle I, Gómez-Rial J, Bont L, Gessner BD, Kohn M, Dagan R, Payne DC, Bruni L, Pollard AJ, García-Sastre A, Faustman DL, Osterhaus A, Butler R, Giménez Sánchez F, Álvarez F, Kaforou M, Bello X, Martinón-Torres F.
        Hum Vaccin Immunother. 2021 Mar 4;17(3):759-772.
        TIPICO is an expert meeting and workshop that aims to provide the most recent evidence in the field of infectious diseases and vaccination. The 10th Interactive Infectious Disease TIPICO workshop took place in Santiago de Compostela, Spain, on November 21-22, 2019. Cutting-edge advances in vaccination against respiratory syncytial virus, Streptococcus pneumoniae, rotavirus, human papillomavirus, Neisseria meningitidis, influenza virus, and Salmonella Typhi were discussed. Furthermore, heterologous vaccine effects were updated, including the use of Bacillus Calmette-Guérin (BCG) vaccine as potential treatment for type 1 diabetes. Finally, the workshop also included presentations and discussion on emergent virus and zoonoses, vaccine resilience, building and sustaining confidence in vaccination, approaches to vaccine decision-making, pros and cons of compulsory vaccination, the latest advances in decoding infectious diseases by RNA gene signatures, and the application of big data approaches.

    • Informatics
      1. Data Architecture to Support Real-Time Data Analytics for the Population-Based HIV Impact Assessmentsexternal icon
        Metz M, Smith R, Mitchell R, Duong YT, Brown K, Kinchen S, Lee K, Ogollah FM, Dzinamarira T, Maliwa V, Moore C, Patel H, Chung H, Mtengo H, Saito S.
        J Acquir Immune Defic Syndr. 2021 Aug 1;87(Suppl 1):S28-s35.
        BACKGROUND AND SETTING: Electronic data capture facilitates timely use of data. Population-based HIV impact assessments (PHIAs) were led by host governments, with funding from the President's Emergency Plan for AIDS Relief, technical assistance from the Centers for Disease Control, and implementation support from ICAP at Columbia University. We described data architectures, code-based processes, and resulting data volume and quality for 14 national PHIA surveys with concurrent timelines and varied country-level data governance (2015-2020). METHODS: PHIA project data were collected through tablets, point-of-care and laboratory testing instruments, and inventory management systems, using open-source software, vendor solutions, and custom-built software. Data were securely uploaded to the PHIA data warehouse daily or weekly and then used to populate survey-monitoring dashboards and return timely laboratory-based test results on an ongoing basis. Automated data processing allowed timely reporting of survey results. RESULTS: Fourteen data architectures were successfully established, and data from more than 450,000 participants in 30,000 files across 13 countries with completed PHIAs, and blood draws producing approximately 6000 aliquots each week per country, were securely collected, transmitted, and processed by 17 full-time equivalent staff. More than 25,600 viral load results were returned to clinics of participants' choice. Data cleaning was not needed for 98.5% of household and 99.2% of individual questionnaires. CONCLUSION: The PHIA data architecture permitted secure, simultaneous collection and transmission of high-quality interview and biomarker data across multiple countries, quick turnaround time of laboratory-based biomarker results, and rapid dissemination of survey outcomes to guide President's Emergency Plan for AIDS Relief epidemic control.

    • Injury and Violence
      1. Importance: Adverse Childhood Experiences (ACEs) are prevalent, preventable, and a public health issue that cycles from one generation to the next with serious implications for health and wellbeing, particularly. Research is needed to identify factors, including those related to economic position (i.e., wage, net family wealth, home ownership), that break the cycle of ACEs and inform decisions about policies, practices, and programs. Objective: To determine whether economic position moderates the association between mother's ACE score and child's ACE score and whether these pathways differ by race and ethnicity. Design: Conducted regression and moderation analysis using mother-child dyadic data from panel surveys, stratified by race. The simple slopes for the interactions were probed to determine the magnitude and significance of the interaction. Setting: Secondary data analysis utilizing data from two cohorts of the National Longitudinal Surveys: 1) National Longitudinal Survey of Youth 1979; and 2) National Longitudinal Survey of Youth 1979 Children and Young Adults. Participants: The sample included 6,261 children and 2,967 matched mothers. Main Outcomes (s) and Measure(s): The outcome variable was the child's ACE score. Mother's ACE score was the independent variable. Three economic position moderators were examined: mother's and her spouse's average wage and salary, average net family wealth, and percent of time owning a home during her child's first five years of life. Results: Mother's ACE score was positively associated with her child's ACE score. Economic position was a significant moderator for Black families. Higher wages and net family wealth during children's first five years were associated with weakened associations between mother and child ACEs for Black families. For Hispanic families, higher wages and salary were significantly associated with weakened associations. Among White families, higher net family wealth was associated with stronger ACEs transmission. Conclusions and Relevance: Taken together, these findings highlight the important role that economic position may play on breaking the cycle of ACEs. This information can inform decisions about what public assistance policies, practices, and programs may be used to improve economic stability among families as an effective ACEs prevention strategy, and for whom these strategies might be most effective at reducing the cycle of ACEs. © 2021

      2. Background: Many healthcare providers do not consistently implement recommendations contained in clinical guidelines on mild traumatic brain injury (mTBI). As such, the Centers for Disease Control and Prevention (CDC) created the HEADS UP to Healthcare Providers online training to promote uptake of five key recommendations in the CDC Pediatric mTBI Guideline. Methods: Using data from modules in the CDC HEADS UP to Healthcare Providers online training, healthcare providers’ self-reported knowledge and self-efficacy prior to and immediately following completion of the training was analyzed. Results: Improvements for 8 out of the 10 knowledge questions had a high level of practical significance. The knowledge question with the highest level of practical significance pre- to post-test improvement was for the key guideline recommendation on neuroimaging (pre-test correct: 70.2%; post-test correct: 87.8%; (p < 0.0001, Cohen's g = 0.39). Four out of the six questions had a self-efficacy level increase of a high level of practical significance (r > 0.50) between the pre- and post-tests. The self-efficacy question with pre- to post-test improvement with the highest level of practical significance was “I am confident in my ability to manage the return to sports progression for my patients” (p < 0.001; r = 0.54). Conclusions: The HEADS UP to Healthcare Providers online training led to significant improvements in knowledge and self-efficacy related to mTBI diagnosis and management. Expanded use of this training among healthcare providers who commonly provide care for pediatric patients with mTBI may be beneficial. Practical Applications: This study highlights several factors guideline developers may take into consideration when creating an implementation tool, such as using health behavior theories, working with partners and key stakeholders, and focusing on digital-based tools. © 2021

    • Laboratory Sciences
      1. Evidence of False Positivity for Vibrio Species Tested by Gastrointestinal Multiplex PCR Panels, Minnesota, 2016-2018external icon
        Decuir M, Fowler RC, Cebelinski E, Smith K, Boxrud D, Medus C.
        Open Forum Infect Dis. 2021 Jun;8(6):ofab247.
        BACKGROUND: Syndromic gastrointestinal multiplex polymerase chain reaction (PCR) panels (GMPPs) are used by an increasing number of clinical laboratories to identify enteric pathogens. Vibrio species are included on GMPPs, but because of the low prevalence of vibriosis, performance characteristics for these panels have been difficult to measure. METHODS: All Vibrio spp. cases identified by GMPPs in Minnesota during 2016-2018 (n = 100) were assessed to identify differences between culture-confirmed cases and those that were PCR-positive only. RESULTS: Overall, 47% of cases had Vibrio species recovered by culture. Two GMPPs were used in Minnesota, Verigene EPT and FilmArray GIP, and the recovery rate of Vibrio spp. was significantly different between these platforms (Verigene EPT 63%, compared with FilmArray GIP 28%). No distinct seasonality was identified among GMPP-positive, culture-negative cases, whereas culture-confirmed case incidence peaked during July and August. Among cases with no other pathogen detected by the GMPP, confirmed cases reported a lower rate of bloody diarrhea (odds ratio [OR], 0.7; P = .004) and were less likely to have a symptom duration >14 days (OR, 0.3; P = .04). Confirmed cases were also more likely to include reports of consuming food items typically associated with Vibrio spp. infection or to have another likely source of infection (eg, international travel or contact with an untreated body of fresh or salt water or marine life; OR, 9.6; P = .001). CONCLUSIONS: The combined findings indicate that cases identified by GMPP that did not have culture confirmation were less likely to include symptoms or exposures consistent with vibriosis. These findings emphasize the need for improvements to testing platform specificity and the importance of combining clinical and exposure information when diagnosing an infection. This study underscores the importance of maintaining the ability to culture Vibrio species to aid in accurate diagnoses.

      2. A comparison of performance metrics for cloth masks as source control devices for simulated cough and exhalation aerosolsexternal icon
        Lindsley WG, Blachere FM, Beezhold DH, Law BF, Derk RC, Hettick JM, Woodfork K, Goldsmith WT, Harris JR, Duling MG, Boutin B, Nurkiewicz T, Boots T, Coyle J, Noti JD.
        Aerosol Sci. Technol.. 2021 .
        Universal mask wearing is recommended to help control the spread of COVID-19. Masks reduce the expulsion of aerosols of respiratory fluids into the environment (called source control) and offer some protection to the wearer. Masks are often characterized using filtration efficiency, airflow resistance, and manikin or human fit factors, which are standard metrics used for personal protective devices. However, none of these metrics are direct measurements of how effectively a mask blocks coughed and exhaled aerosols. We studied the source control performance of 15 cloth masks (face masks, neck gaiters, and bandanas), two medical masks, and two N95 filtering facepiece respirators by measuring their ability to block aerosols ≤7 µm expelled during simulated coughing and exhalation (called source control collection efficiency). These measurements were compared with filtration efficiencies, airflow resistances, and fit factors measured on manikin headforms and humans. Collection efficiencies for the cloth masks ranged from 17% to 71% for coughing and 35% to 66% for exhalation. Filtration efficiencies for the cloth masks ranged from 1.4% to 98%, while the fit factors were 1.3 to 7.4 on headforms and 1.0 to 4.0 on human subjects. The Spearman’s rank correlation coefficients between the source control collection efficiencies and the standard metrics ranged from 0.03 to 0.68 and were significant in all but two cases. However, none of the standard metrics were strongly correlated with source control performance. A better understanding of the relationships between source control collection efficiency, filtration efficiency, airflow resistance, and fit factor is needed. ©, This work was authored as part of the Contributor's official duties as an Employee of the United States Government and is therefore a work of the United States Government. In accordance with 17 USC. 105, no copyright protection is available for such works under US Law.

      3. A Comprehensive Approach to Assuring Quality of Laboratory Testing in HIV Surveys: Lessons Learned From the Population-Based HIV Impact Assessment Projectexternal icon
        Patel HK, Duong YT, Birhanu S, Dobbs T, Lupoli K, Moore C, Detorio M, Sleeman K, Manjengwa J, Wray-Gordon F, Yavo D, Jackson K, Domaoal RA, Yufenyuy EL, Vedapuri S, Ndongmo CB, Ogollah FM, Dzinamarira T, Rubinstein P, Sachathep KK, Metz M, Longwe H, Saito S, Brown K, Voetsch AC, Parekh BS.
        J Acquir Immune Defic Syndr. 2021 Aug 1;87(Suppl 1):S17-s27.
        BACKGROUND: Conducting HIV surveys in resource-limited settings is challenging because of logistics, limited availability of trained personnel, and complexity of testing. We described the procedures and systems deemed critical to ensure high-quality laboratory data in the population-based HIV impact assessments and large-scale household surveys. METHODS: Laboratory professionals were engaged in every stage of the surveys, including protocol development, site assessments, procurement, training, quality assurance, monitoring, analysis, and reporting writing. A tiered network of household, satellite laboratories, and central laboratories, accompanied with trainings, optimized process for blood specimen collection, storage, transport, and real-time monitoring of specimen quality, and test results at each level proved critical in maintaining specimen integrity and high-quality testing. A plausibility review of aggregate merged data was conducted to confirm associations between key variables as a final quality check for quality of laboratory results. RESULTS: Overall, we conducted a hands-on training for 3355 survey staff across 13 surveys, with 160-387 personnel trained per survey on biomarker processes. Extensive training and monitoring demonstrated that overall, 99% of specimens had adequate volume and 99.8% had no hemolysis, indicating high quality. We implemented quality control and proficiency testing for testing, resolved discrepancies, verified >300 Pima CD4 instruments, and monitored user errors. Aggregate data review for plausibility further confirmed the high quality of testing. CONCLUSIONS: Ongoing engagement of laboratory personnel to oversee processes at all levels of the surveys is critical for successful national surveys. High-quality population-based HIV impact assessments laboratory data ensured reliable results and demonstrated the impact of HIV programs in 13 countries.

    • Occupational Safety and Health
      1. Work-Related Risk Factors for Rotator Cuff Syndrome in a Prospective Study of Manufacturing and Healthcare Workersexternal icon
        Meyers AR, Wurzelbacher SJ, Krieg EF, Ramsey JG, Crombie K, Christianson AL, Luo L, Burt S.
        Hum Factors. 2021 Jun 20:187208211022122.
        OBJECTIVE: This prospective study assessed the risk of developing rotator cuff syndrome (RCS) with separate or specific combinations of biomechanical exposures measures, controlling for individual confounders. BACKGROUND: Compared with other musculoskeletal disorders, rates of work-related shoulder musculoskeletal disorders have been declining more slowly. METHOD: We conducted up to 2 years of individual, annual assessments of covariates, exposures, and health outcomes for 393 U.S. manufacturing and healthcare workers without RCS at baseline. Task-level biomechanical exposures assessed exposure to forceful exertions (level, exertion rates, duty cycles), vibration, and upper arm postures (flexion, abduction). Hazard ratios (HRs) were calculated with Cox proportional hazard models. RESULTS: We observed 39 incident RCS cases in 694 person-years (incidence rate = 5.62 per 100 person-years). Adjusting for confounders, we found increased risk of incident RCS associated with forceful hand exertions per minute for three upper arm posture tertiles: flexion ≥45° (≥28.2% time, HR = 1.11, CI [1.01, 1.22]), abduction ≥30° (11.9-21.2%-time, HR = 1.18, CI [1.04, 1.34]), and abduction >60° (≥4.8% time, HR = 1.16, CI [1.04, 1.29]). We failed to observe statistically significant effects for other interactions or any separate measures of biomechanical exposure. CONCLUSION: This study highlights the importance of assessing combinations of exposure to forceful repetition and upper arm elevation when developing interventions for preventing RCS. APPLICATION: Based on these results, interventions that reduce exposure to forceful repetition (i.e., lower force levels and/or slower exertion rates) may reduce the risk of RCS, especially when upper arm elevation cannot be avoided.

      2. Additive Manufacturing for Occupational Hygiene: A Comprehensive Review of Processes, Emissions, & Exposuresexternal icon
        Stefaniak AB, Du Preez S, Du Plessis JL.
        J Toxicol Environ Health B Crit Rev. 2021 Jun 17:1-50.
        This comprehensive review introduces occupational (industrial) hygienists and toxicologists to the seven basic additive manufacturing (AM) process categories. Forty-six articles were identified that reported real-world measurements for all AM processes, except sheet lamination. Particles released from powder bed fusion (PBF), material jetting (MJ), material extrusion (ME), and directed energy deposition (DED) processes exhibited nanoscale to submicron scale; real-time particle number (mobility sizers, condensation nuclei counters, miniDiSC, electrical diffusion batteries) and surface area monitors (diffusion chargers) were generally sufficient for these processes. Binder jetting (BJ) machines released particles up to 8.5 µm; optical particle sizers (number) and laser scattering photometers (mass) were sufficient for this process. PBF and DED processes (powdered metallic feedstocks) released particles that contained respiratory irritants (chromium, molybdenum), central nervous system toxicants (manganese), and carcinogens (nickel). All process categories, except those that use metallic feedstocks, released organic gases, including (but not limited to), respiratory irritants (toluene, xylenes), asthmagens (methyl methacrylate, styrene), and carcinogens (benzene, formaldehyde, acetaldehyde). Real-time photoionization detectors for total volatile organics provided useful information for processes that utilize polymer feedstock materials. More research is needed to understand 1) facility-, machine-, and feedstock-related factors that influence emissions and exposures, 2) dermal exposure and biological burden, and 3) task-based exposures. Harmonized emissions monitoring and exposure assessment approaches are needed to facilitate inter-comparison of study results. Improved understanding of AM process emissions and exposures is needed for hygienists to ensure appropriate health and safety conditions for workers and for toxicologists to design experimental protocols that accurately mimic real-world exposure conditions.ABBREVIATIONS ABS : acrylonitrile butadiene styrene; ACGIH® TLV® : American Conference of Governmental Industrial Hygienists Threshold Limit Value; ACH : air change per hour; AM : additive manufacturing; ASA : acrylonitrile styrene acrylate; AVP : acetone vapor polishing; BJ : binder jetting; CAM-LEM : computer-aided manufacturing of laminated engineering materials; CNF : carbon nanofiber; CNT : carbon nanotube; CP : co-polyester; CNC : condensation nuclei counter; CVP : chloroform vapor polishing; DED : directed energy deposition; DLP : digital light processing; EBM : electron beam melting; EELS : electron energy loss spectrometry; EDB : electrical diffusion batteries; EDX : energy dispersive x-ray analyzer; ER : emission rate; FDM™ : fused deposition modeling; FFF : fused filament fabrication; IAQ : indoor air quality; LSP : laser scattering photometer; LCD : liquid crystal display; LDSA : lung deposited particle surface area; LOD : limit of detection; LOM : laminated object manufacturing; LOQ : limit of quantitation; MCE : mixed cellulose ester filter; ME : material extrusion; MJ : material jetting; OEL : occupational exposure limit; OPS : optical particle sizer; PBF : powder bed fusion; PBZ : personal breathing zone; PC : polycarbonate; PEEK : poly ether ether ketone; PET : polyethylene terephthalate; PETG : Polyethylene terephthalate glycol; PID : photoionization detector; PLA : polylactic acid; PM(1) : particulate matter with aerodynamic diameter less than 1 µm; PM(2.5) : particulate matter with aerodynamic diameter less than 2.5 µm; PM(10) : particulate matter with aerodynamic diameter less than 10 µm; PSL : plastic sheet lamination; PVA : polyvinyl alcohol; REL : recommended exposure limit; SDL : selective deposition lamination; SDS : safety data sheet; SEM : scanning electron microscopy; SL : sheet lamination; SLA : stereolithography; SLM : selective laser melting; SMPS : scanning mobility particle sizer; SVOC : semi-volatile organic compound; TEM : transmission electron microscopy; TGA : thermal gravimetric analysis; TPU : thermo polyurethane; UAM : ultrasonic additive manufacturing; UC : ultrasonic consolidation; TVOC : total volatile organic compounds; TWA : time-weighted average; VOC : volatile organic compound; VP : vat photopolymerization.

    • Parasitic Diseases
      1. Community-based delivery of intermittent preventive treatment of malaria in pregnancy in Burkina Faso: a qualitative studyexternal icon
        Burke D, Tiendrebeogo J, Emerson C, Youll S, Gutman J, Badolo O, Savadogo Y, Vibbert K, Wolf K, Brieger W.
        Malar J. 2021 Jun 23;20(1):277.
        BACKGROUND: Burkina Faso is among ten countries with the highest rates of malaria cases and deaths in the world. Delivery and coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) is insufficient in Burkina Faso; In a 2016 survey, only 22% of eligible women had received their third dose of IPTp. It is also an extremely rural country and one with an established cadre of community healthcare workers (CHWs). To better meet the needs of pregnant women, an enhanced programme was established to facilitate distribution of IPTp at the community level by CHWs. METHODS: In order to assess the perceptions of CHWs and facility healthcare workers (HCWs) involved in this programme rollout, semi-structured interviews were conducted at three high malaria burden health districts in Burkina Faso. Interviews were conducted at baseline with 104 CHWs and 35 HCWs prior to the introduction of community based IPTp (c-IPTp) to assess capacity and any areas of concern. At endline, interviews were conducted with 29 CHWs and 21 HCWs to identify key facilitators and suggestions for further implementation of the c-IPTp programme. RESULTS: CHWs reported feeling capable of supporting c-IPTp delivery and facilitating linkage to antenatal care (ANC). They noted that the opportunity for enhanced training and close and ongoing connections with facility HCWs and supportive supervision were imperative. Both CHWs and HCWs perceived this approach as acceptable to community members and noted the importance of close community engagement, monthly meetings between CHWs and facility HCWs, and maintaining regular supplies of sulfadoxine-pyrimethamine (SP). Those interviewed noted that it was beneficial to have the involvement of both female and male CHWs. CONCLUSIONS: Community-based delivery of IPTp was feasible and acceptable to both facility HCWs and CHWs. This approach has the potential to strengthen delivery and uptake of IPTp and ANC both in Burkina Faso and across the region.

    • Reproductive Health
      1. Need for Contraceptive Services Among Women of Reproductive Age - 45 Jurisdictions, United States, 2017-2019external icon
        Zapata LB, Pazol K, Curtis KM, Kane DJ, Jatlaoui TC, Folger SG, Okoroh EM, Cox S, Whiteman MK.
        MMWR Morb Mortal Wkly Rep. 2021 Jun 25;70(25):910-915.
        Ensuring access to contraceptive services is an important strategy for preventing unintended pregnancies, which account for nearly one half of all U.S. pregnancies (1) and are associated with adverse maternal and infant health outcomes (2). Equitable, person-centered contraceptive access is also important to ensure reproductive autonomy (3). Behavioral Risk Factor Surveillance System (BRFSS) data collected during 2017-2019 were used to estimate the proportion of women aged 18-49 years who were at risk for unintended pregnancy* and had ongoing or potential need for contraceptive services.(†) During 2017-2019, in the 45 jurisdictions(§) from which data were collected, 76.2% of women aged 18-49 years were considered to be at risk for unintended pregnancy, ranging from 67.0% (Alaska) to 84.6% (Georgia); 60.7% of women had ongoing or potential need for contraceptive services, ranging from 45.3% (Puerto Rico) to 73.7% (New York). For all jurisdictions combined, the proportion of women who were at risk for unintended pregnancy and had ongoing or potential need for contraceptive services varied significantly by age group, race/ethnicity, and urban-rural status. Among women with ongoing or potential need for contraceptive services, 15.2% used a long-acting reversible method (intrauterine device or contraceptive implant), 25.0% used a short-acting reversible method (injectable, pill, transdermal patch, or vaginal ring), and 29.5% used a barrier or other reversible method (diaphragm, condom, withdrawal, cervical cap, sponge, spermicide, fertility-awareness-based method, or emergency contraception). In addition, 30.3% of women with ongoing or potential need were not using any method of contraception. Data in this report can be used to help guide jurisdictional planning to deliver contraceptive services, reduce unintended pregnancies, ensure that the contraceptive needs of women and their partners are met, and evaluate efforts to increase access to contraception.

    • Statistics as Topic
      1. In this paper, an improved Interior-Point Method (IPM) for solving symmetric optimization problems is presented. Symmetric optimization (SO) problems are linear optimization problems over symmetric cones. In particular, the method can be efficiently applied to an important instance of SO, a Controlled Tabular Adjustment (CTA) problem which is a method used for Statistical Disclosure Limitation (SDL) of tabular data. The presented method is a full Nesterov-Todd step infeasible IPM for SO. The algorithm converges to ε-approximate solution from any starting point whether feasible or infeasible. Each iteration consists of the feasibility step and several centering steps, however, the iterates are obtained in the wider neighborhood of the central path in comparison to the similar algorithms of this type which is the main improvement of the method. However, the currently best known iteration bound known for infeasible short-step methods is still achieved.

    • Substance Use and Abuse
      1. Evaluation of Five Data-to-Action Workshops to Enhance Capacity for Tobacco Controlexternal icon
        Garcia de Quevedo I, Tripp A, Twentyman E, Smith R, Ahluwalia IB.
        Health Promot Pract. 2021 Jun 22:15248399211019984.
        BACKGROUND: Five data-to-action workshops were conducted during 2016-2019 with participants from 38 countries. The purpose of the workshops is to use data to inform and disseminate tobacco prevention and control strategies. We evaluated the workshops using the Kirkpatrick Model for evaluation of trainings. METHODS: We evaluated the data-to-action workshops in three topic areas: (1) if the workshop was clear, useful, engaging, and relevant to the participant's work, (2) self-reported knowledge and skills for tobacco control topics, and (3) intention to apply the knowledge learned. We used nonparametric tests (one-sided Wilcoxon signed-rank test) and conducted descriptive analysis to assess the difference between pre- and postworkshop scores in each topic area. Free text data from open-ended responses were analyzed in Excel using thematic content analysis. RESULTS: Participants reported the workshop had a clear purpose (93.6%, n = 73), was well organized (94.9%, n = 74), and relevant to their work (96.2%, n = 76). There was a statistically significant increase in median learning scores across all three knowledge and five skills topic areas (p < 0.05); more than 95% of participants intended to apply the knowledge they obtained during the workshop and planned to perform new skills learned in the workshop. CONCLUSIONS: Programs interested in replicating a similar successful model may incorporate a mix of modes of instruction and hands-on experiences, as well as focus on the selection of the right audience, for their workshops. These workshops pose an opportunity for countries to enhance use and dissemination of their tobacco control data.

      2. Increasing rates of methamphetamine/amphetamine-involved overdose hospitalizations in Washington State, 2010-2017external icon
        Njuguna H, Gong J, Hutchinson K, Ndiaye M, Sabel J, Wasserman C.
        Addict Behav Rep. 2021 Dec;14:100353.
        BACKGROUND AND AIMS: In the United States, overdose deaths resulting from methamphetamine and other amphetamine-type stimulants (METH/AMPH) have been increasing. We describe rates and characterize patients hospitalized after a METH/AMPH-involved overdose in Washington State, to guide prevention and control measures. DESIGN SETTING PARTICIPANTS: We conducted a trend analysis of hospitalized Washington State residents aged ≥15 years who received a METH/AMPH-involved overdose diagnosis in Washington's civilian hospitals and reported in the Comprehensive Hospital Abstract Reporting System. MEASUREMENTS: We used Joinpoint regression analysis to study trends in rates of hospitalized patients who received a METH/AMPH-involved overdose diagnosis during 2010-2017. We used 2016-2017 data to describe characteristics of patients with nonfatal and fatal outcomes and used chi-square test (for categorical variables) and Wilcoxon rank-sum test (for continuous variables) to compare characteristics of patients by outcome. FINDINGS: During 2010-2017, 3587 patients were hospitalized and received a METH/AMPH-involved overdose diagnosis. The age-adjusted rate for METH/AMPH-involved overdose hospitalization increased from 6.3/100,000 persons in 2010 to 8.5/100,000 persons in 2017. Patients aged ≥55 years had the greatest increase in rate of overdose hospitalizations. Among these patients, 86% also had a substance use disorder diagnosis involving substances other than METH/AMPH, and 35% experienced a polysubstance overdose. CONCLUSIONS: We observed increasing rates of METH/AMPH-involved overdose hospitalizations in Washington State, particularly among persons aged ≥55 years. Approximately a third of patients also experienced a polysubstance overdose, which can be considered when designing interventions to address increasing rates of overdose hospitalizations in Washington State.

    • Zoonotic and Vectorborne Diseases
      1. Tick bite prevention practices, knowledge of Lyme disease (LD) symptoms and transmission, and patterns of LD diagnoses among Hispanic persons have been reported but not comprehensively evaluated. In 2014, CDC examined questions from a prospective nationwide survey of U.S. Hispanic adults conducted via the Offerwise QueOpinas panel regarding ticks and LD. From October to November, a total of 2,649 surveys were released and 1,006 completed surveys returned. Overall, 44% of respondents reported routinely practising at least one form of personal protection against tick bites, and wearing repellent was the most commonly reported method (29%). Approximately 6% of respondents reported a tick bite for either themselves or someone in their household during the previous 12 months. An individual or household diagnosis of LD in the previous year was reported by 2% of respondents, with the highest proportion of diagnoses reported by respondents from high LD incidence states. The annual incidence of healthcare provider-diagnosed LD in the survey population was higher than national surveillance estimates for reported LD among U.S. Hispanic persons during 2000-2013. As annual incidence of LD continues to increase, it is important to ensure equitable access to information about LD, including disease transmission, manifestations, and prevention recommendations. Results from this survey can help inform public health outreach focused on effective tick bite prevention methods and early recognition of LD.

      2. Use of partial N-gene sequences as a tool to monitor progress on rabies control and elimination efforts in Ethiopiaexternal icon
        Binkley L, Deressa A, Shi M, Jara M, Escobar LE, Mauldin MR, Matheny A, O'Quin J, Pieracci EG, Kling C, Hartloge C, Yimer G, Abate E, Gebreyes W, Reynolds M, Belay E, Shiferaw M, Nakazawa Y, Velasco-Villa A.
        Acta Trop. 2021 Jun 20:106022.
        Ethiopia is one of the African countries most affected by rabies. A coarse catalog of rabies viruses (RABV) was created as a benchmark to assess the impact of control and elimination activities. We evaluated a 726 bp amplicon at the end of the N-gene to infer viral lineages in circulation using maximum likelihood and Bayesian methods for phylogenetic reconstruction. We sequenced 228 brain samples from wild and domestic animals collected in five Ethiopian regions during 2010-2017. Results identified co-circulating RABV lineages that are causing recurrent spillover infections into wildlife and domestic animals. We found no evidence of importation of RABVs from other African countries or vaccine-induced cases in the area studied. A divergent RABV lineage might be involved in an independent rabies cycle in jackals. This investigation provides a feasible approach to assess rabies control and elimination efforts in resource-limited countries.

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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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