Issue 25, July 20, 2021

CDC Science Clips: Volume 13, Issue 25, July 20, 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
      • COVID-19 impact on screening test volume through the National Breast and Cervical Cancer early detection program, January-June 2020, in the United Statesexternal icon
        DeGroff A, Miller J, Sharma K, Sun J, Helsel W, Kammerer W, Rockwell T, Sheu A, Melillo S, Uhd J, Kenney K, Wong F, Saraiya M, Richardson LC.
        Prev Med. 2021 Oct;151:106559.
        Women from racial and ethnic minority groups face a disproportionate burden of cervical and breast cancers in the United States. The Coronavirus Disease 2019 (COVID-19) pandemic might exacerbate these disparities as supply and demand for screening services are reduced. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides cancer screening services to women with low income and inadequate health insurance. We examined COVID-19's impact on NBCCEDP screening services during January-June 2020. We found the total number of NBCCEDP-funded breast and cervical cancer screening tests declined by 87% and 84%, respectively, during April 2020 compared with the previous 5-year averages for that month. The extent of declines varied by geography, race/ethnicity, and rurality. In April 2020, screening test volume declined most severely in Health and Human Services Region 2 - New York (96% for breast, 95% for cervical cancer screening) compared to the previous 5-year averages. The greatest declines were among American Indian/Alaskan Native women for breast cancer screening (98%) and Asian Pacific Islander women for cervical cancer screening (92%). Test volume began to recover in May and, by June 2020, NBCCEDP breast and cervical cancer screening test volume was 39% and 40% below the 5-year average for that month, respectively. However, breast cancer screening remained over 50% below the 5-year average among women in rural areas. NBCCEDP programs reported assisting health care providers resume screening.

    • Communicable Diseases
      • Mortality Among Persons Entering HIV Care Compared With the General U.S. Population : An Observational Studyexternal icon
        Edwards JK, Cole SR, Breger TL, Rudolph JE, Filiatreau LM, Buchacz K, Humes E, Rebeiro PF, D'Souza G, Gill MJ, Silverberg MJ, Mathews WC, Horberg MA, Thorne J, Hall HI, Justice A, Marconi VC, Lima VD, Bosch RJ, Sterling TR, Althoff KN, Moore RD, Saag M, Eron JJ.
        Ann Intern Med. 2021 Jul 6.
        BACKGROUND: Understanding advances in the care and treatment of adults with HIV as well as remaining gaps requires comparing differences in mortality between persons entering care for HIV and the general population. OBJECTIVE: To assess the extent to which mortality among persons entering HIV care in the United States is elevated over mortality among matched persons in the general U.S. population and trends in this difference over time. DESIGN: Observational cohort study. SETTING: Thirteen sites from the U.S. North American AIDS Cohort Collaboration on Research and Design. PARTICIPANTS: 82 766 adults entering HIV clinical care between 1999 and 2017 and a subset of the U.S. population matched on calendar time, age, sex, race/ethnicity, and county using U.S. mortality and population data compiled by the National Center for Health Statistics. MEASUREMENTS: Five-year all-cause mortality, estimated using the Kaplan-Meier estimator of the survival function. RESULTS: Overall 5-year mortality among persons entering HIV care was 10.6%, and mortality among the matched U.S. population was 2.9%, for a difference of 7.7 (95% CI, 7.4 to 7.9) percentage points. This difference decreased over time, from 11.1 percentage points among those entering care between 1999 and 2004 to 2.7 percentage points among those entering care between 2011 and 2017. LIMITATION: Matching on available covariates may have failed to account for differences in mortality that were due to sociodemographic factors rather than consequences of HIV infection and other modifiable factors. CONCLUSION: Mortality among persons entering HIV care decreased dramatically between 1999 and 2017, although those entering care remained at modestly higher risk for death in the years after starting care than comparable persons in the general U.S. population. PRIMARY FUNDING SOURCE: National Institutes of Health.

    • Disease Reservoirs and Vectors
      • A previously unrecognized Rickettsia species was isolated in 1976 from a pool of Ixodes pacificus ticks collected in 1967 from Tillamook County, Oregon, USA. The isolate produced low fever and mild scrotal oedema following intraperitoneal injection into male guinea pigs (Cavia porcellus). Subsequent serotyping characterized this isolate as distinct from recognized typhus and spotted fever group Rickettsia species; nonetheless, the isolate remained unevaluated by molecular techniques and was not identified to species level for the subsequent 30 years. Ixodes pacificus is the most frequently identified human-biting tick in the western United States, and as such, formal identification and characterization of this potentially pathogenic Rickettsia species is warranted. Whole-genome sequencing of the Tillamook isolate revealed a genome 1.43 Mbp in size with 32.4 mol% G+C content. Maximum-likelihood phylogeny of core proteins places it in the transitional group of Rickettsia basal to both Rickettsia felis and Rickettsia asembonensis. It is distinct from existing named species, with maximum average nucleotide identity of 95.1% to R. asembonensis and maximum digital DNA-DNA hybridization score similarity to R. felis at 80.1%. The closest similarity at the 16S rRNA gene (97.9%) and sca4 (97.5%/97.6% respectively) is to Candidatus 'Rickettsia senegalensis' and Rickettsia sp. cf9, both isolated from cat fleas (Ctenocephalides felis). We characterized growth at various temperatures and in multiple cell lines. The Tillamook isolate grows aerobically in Vero E6, RF/6A and DH82 cells, and growth is rapid at 28 °C and 32 °C. Using accepted genomic criteria, we propose the name Rickettsia tillamookensis sp. nov., with the type strain Tillamook 23. Strain Tillamook 23 is available from the Centers for Disease Control and Prevention Rickettsial Isolate Reference Collection (WDCM 1093), Atlanta, GA, USA (CRIRC accession number RTI001(T)) and the Collection de Souches de l'Unité des Rickettsies (WDCM 875), Marseille, France (CSUR accession number R5043). Using accepted genomic criteria, we propose the name Rickettsia tillamookensis sp. nov., with the type strain Tillamook 23 (=CRIRC RTI001=R5043).

    • Environmental Health
      • Impact of an Urban Sanitation Intervention on Enteric Pathogen Detection in Soilsexternal icon
        Capone D, Berendes D, Cumming O, Holcomb D, Knee J, Konstantinidis KT, Levy K, Nalá R, Risk BB, Stewart J, Brown J.
        Environ Sci Technol. 2021 Jul 8.
        Environmental fecal contamination is common in many low-income cities, contributing to a high burden of enteric infections and associated negative sequelae. To evaluate the impact of a shared onsite sanitation intervention in Maputo, Mozambique on enteric pathogens in the domestic environment, we collected 179 soil samples at shared latrine entrances from intervention (n = 49) and control (n = 51) compounds during baseline (preintervention) and after 24 months (postintervention) as part of the Maputo Sanitation Trial. We tested soils for the presence of nucleic acids associated with 18 enteric pathogens using a multiplex reverse transcription qPCR platform. We detected at least one pathogen-associated gene target in 91% (163/179) of soils and a median of 3 (IQR = 1, 5) pathogens. Using a difference-in-difference analysis and adjusting for compound population, visibly wet soil, sun exposure, wealth, temperature, animal presence, and visible feces, we estimate the intervention reduced the probability of detecting ≥1 pathogen gene by 15% (adjusted prevalence ratio, aPR = 0.85; 95% CI: 0.70, 1.0) and the total number of pathogens by 35% (aPR = 0.65; 0.44, 0.95) in soil 24 months following the intervention. These results suggest that the intervention reduced the presence of some fecal contamination in the domestic environment, but pathogen detection remained prevalent 24 months following the introduction of new latrines.

    • Healthcare Associated Infections
      • White Paper On Antimicrobial Stewardship In Solid Organ Transplant Recipientsexternal icon
        So M, Hand J, Forrest G, Pouch SM, Te H, Ardura MI, Bartash RM, Dadhania D, Edelman J, Ince D, Jorgenson MR, Kabbani S, Lease ED, Levine D, Ohler L, Patel G, Pisano J, Spinner ML, Abbo L, Verna EC, Husain S.
        Am J Transplant. 2021 Jul 1.
        Antimicrobial stewardship programs (ASPs) have made immense strides in optimizing antibiotic, antifungal, and antiviral use in clinical settings. However, while ASPs are required institutionally by regulatory agencies in the United States and Canada, they are not mandated for transplant centers or programs specifically. Despite the fact that solid-organ transplant recipients in particular are at increased risk of infections from multi-drug resistant organisms, due to host and donor factors and immunosuppressive therapy - there currently are little rigorous data regarding stewardship practices in solid organ transplant populations, and thus no transplant-specific requirements currently exist. Further complicating matters, transplant patients have a wide range of variability regarding their susceptibility to infection, as factors such as surgery of transplant, intensity of immunosuppression, and presence of drains or catheters in-situ, may modify the risk of infection. As such, it is not feasible to have a 'one-size-fits-all' style of stewardship for this patient population. The objective of this whitepaper is to identify opportunities, risk factors and ASP strategies that should be assessed with SOT recipients to optimize antimicrobial use, while producing an overall improvement in patient outcomes. We hope it may serve as a springboard for development of future guidance, and identification of research opportunities.

    • Injury and Violence
      • Victim and perpetrator characteristics in alcohol/drug-involved sexual violence victimization in the U.Sexternal icon
        Basile KC, Smith SG, Liu Y, Lowe A, Gilmore AK, Khatiwada S, Kresnow MJ.
        Drug Alcohol Depend. 2021 Jun 24;226:108839.
        The authors examine the prevalence and characteristics of sexual violence victimization - rape and being made to penetrate [MTP] (men only) - involving substances (alcohol or other drugs). Although it has been well-documented that perpetrators commit sexual violence against individuals who are using alcohol or drugs, more research is needed to describe the problem at a national level. Data are from the 2010-2012 National Intimate Partner and Sexual Violence Survey, a nationally representative random-digit-dial telephone survey of English- and Spanish-speaking adults in the United States (n = 41,174). Findings reveal that among victims of physically forced rape, 26.2 % of female and 30.0 % of male victims reported substance use; 44.5 % of male MTP victims reported substance use. The majority of forced rape and MTP victims reported the perpetrator was using alcohol or drugs. Among victims of alcohol/drug-facilitated rape, 29.7 % of female and 32.4 % of male victims reported involuntary use of substances, mostly drugs; 84.0 % of female and 82.6 % of male victims reported voluntary use. Among male victims of alcohol/drug-facilitated MTP, 14.6 % reported involuntary and 85.4 % reported voluntary use of substances. Female and male victims reported that the majority of intimate partner, acquaintance, and stranger perpetrators were using substances during the victimization. These findings suggest the importance of prevention efforts at the individual and community levels to reduce substance-involved sexual violence perpetration and risk reduction programs to reduce the likelihood of voluntary substance-facilitated sexual violence victimization.

    • Laboratory Sciences
      • Proinflammatory oscillations over the menstrual cycle drives bystander CD4 T cell recruitment and SHIV susceptibility from vaginal challengeexternal icon
        Swaims-Kohlmeier A, Sheth AN, Brody J, Hardnett FP, Sharma S, Bonning EW, Ofotokun I, Massud I, García-Lerma JG.
        EBioMedicine. 2021 Jul 2;69:103472.
        BACKGROUND: The menstrual cycle influences HIV infection-risk in women, although the timing and underlying mechanism are unclear. Here we investigated the contribution of the menstrual cycle to HIV susceptibility through evaluating immune behavior with infection-risk over time. METHODS: Blood and vaginal lavage samples were collected from 18 pig-tailed macaques to evaluate immune changes over reproductive cycles, and from 5 additional animals undergoing repeated vaginal exposures to simian HIV (SHIV). Peripheral blood mononuclear cell (PBMC) samples from healthy women (n = 10) were prospectively collected over the course of a menstrual cycle to profile T cell populations. Immune properties from PBMC and vaginal lavage samples were measured by flow cytometry. Plasma progesterone was measured by enzyme immunoassay. The oscillation frequency of progesterone concentration and CCR5 expression on CD4 T cells was calculated using the Lomb-Scargle periodogram. SHIV infection was monitored in plasma by RT-PCR. Immune measures were compared using generalized estimating equations (GEE). FINDINGS: Macaques cycle-phases were associated with fluctuations in systemic immune properties and a type-1 inflammatory T cell response with corresponding CCR5+ memory CD4 T cell (HIV target cell) infiltration into the vaginal lumen at the late luteal phase. Power spectral analysis identified CCR5 oscillation frequencies synchronized with reproductive cycles. In a repetitive low-dose vaginal challenge model, productive SHIV(163P3) infection only occurred during intervals of mounting type-1 T cell responses (n = 5/5). Finally, we identify similar type-1 inflammatory T cell responses over the menstrual cycle are occurring in healthy women. INTERPRETATION: These data demonstrate that periodic shifts in the immune landscape under menstrual cycle regulation drives bystander CCR5+ CD4 T cell recruitment and HIV susceptibility in the female reproductive tract. FUNDING: This study was supported by the U.S. Centers for Disease Control and Prevention, Atlanta, GA 30329 and NIH grants to Emory University (K23AI114407 to A.N.S., the Emory University Center for AIDS research [P30AI050409], and Atlanta Clinical and Translational Sciences Institute [KLR2TR000455, UL1TR000454]). DISCLAIMER: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the U.S. Centers for Disease Control and Prevention or the Department of Health and Human Services.

    • Parasitic Diseases
      • The effect of intermittent preventive treatment of malaria during pregnancy and placental malaria on infant risk of malariaexternal icon
        Andronescu LR, Sharma A, Peterson I, Kachingwe M, Kachepa W, Liang Y, Gutman JR, Mathanga DP, Chinkhumba J, Laufer MK.
        J Infect Dis. 2021 Jul 3.
        BACKGROUND: Intermittent preventive treatment of malaria during pregnancy (IPTp) with dihydroartemisinin-piperaquine (DP) provides greater protection from placental malaria than sulfadoxine-pyrimethamine (SP). Some studies suggest placental malaria alters the risk of malaria infection in infants, but few studies have quantified the effect of IPTp on infant susceptibility to malaria. METHODS: Infants born to pregnant women enrolled in a randomized clinical trial comparing IPTp-SP and IPTp-DP in Malawi were followed from birth to 24 months to assess effect of IPTp and placental malaria on time to first malaria episode and P. falciparum incidence. RESULTS: In total, 192 infants born to mothers randomized to IPTp-SP and 195 to mothers randomized to IPTp-DP were enrolled. Infants in the IPTp exposure groups did not differ significantly regarding incidence of clinical malaria (IRR= 1.03; 95% CI: 0.58 - 1.86) or incidence of infection (IRR= 1.18; 95% CI: 0.92-1.55). Placental malaria exposure was not associated with incidence of clinical malaria (IRR= 1.03; 95% CI: 0.66-1.59) or incidence of infection (IRR:= 1.15; 95% CI: 0.88-1.50). Infant sex, season of birth, and maternal gravidity did not confound results. CONCLUSIONS: We did not find evidence that IPTp regimen or placental malaria exposure influenced risk of malaria during infancy in this population.

      • Trypanosoma cruzi in Nonischemic Cardiomyopathy Patients, Houston, Texas, USAexternal icon
        Nolan MS, Aguilar D, Misra A, Gunter SM, Erickson T, Gorchakov R, Rivera H, Montgomery SP, Murray KO.
        Emerg Infect Dis. 2021 Jul;27(7):1958-1960.
        To investigate possible cardiac manifestations of Chagas disease, we tested 97 Latinx patients with nonischemic cardiomyopathy in Houston, Texas, USA, for Trypanosoma cruzi infection. We noted a high prevalence of underdiagnosed infection and discrepant results in clinical diagnostic assays. Latinx cardiac patients in the United States would benefit from laboratory screening for T. cruzi infection.

    • Physical Activity
      • Cross-sectional study of changes in physical activity behavior during the COVID-19 pandemic among US adultsexternal icon
        Watson KB, Whitfield GP, Huntzicker G, Omura JD, Ussery E, Chen TJ, Fanfair RN.
        Int J Behav Nutr Phys Act. 2021 Jul 7;18(1):91.
        BACKGROUND: Physical activity (PA) provides numerous health benefits relevant to the COVID-19 pandemic. However, concerns exist that PA levels may have decreased during the pandemic thus exacerbating health disparities. This study aims to determine changes in and locations for PA and reasons for decreased PA during the pandemic. METHODS: Reported percentage of changes in and locations for PA and reasons for decreased PA were examined in 3829 US adults who completed the 2020 SummerStyles survey. RESULTS: Overall, 30% reported less PA, and 50% reported no change or no activity during the pandemic; percentages varied across subgroups. Adults who were non-Hispanic Black (Black) or Hispanic (vs. non-Hispanic White, (White)) reported less PA. Fewer Black adults (vs. White) reported doing most PA in their neighborhood. Concern about exposure to the virus (39%) was the most common reason adults were less active. CONCLUSIONS: In June 2020, nearly one-third of US adults reported decreased PA; 20% reported increased PA. Decreased activity was higher among Black and Hispanic compared to White adults; these two groups have experienced disproportionate COVID-19 impacts. Continued efforts are needed to ensure everyone has access to supports that allow them to participate in PA while still following guidance to prevent COVID-19 transmission.

    • Public Health Law
      • A Legal Mapping Assessment of Cytomegalovirus-Related Laws in the United Statesexternal icon
        Yassine BB, Hulkower R, Dollard S, Cahill E, Lanzieri T.
        J Public Health Manag Pract. 2021 Jun 30.
        IMPORTANCE: Congenital cytomegalovirus (CMV) infection is the leading infectious cause of birth defects in the United States, affecting approximately 1 out of 200 newborns. Increasing awareness of congenital CMV infection among policy makers and the public is critical for advancing the evidence base for prevention and intervention strategies, including behavioral interventions for pregnant women, newborn screening to enable timely interventions, and garnering support for vaccine development. OBJECTIVE: To understand the current landscape of CMV-related statutes and regulations, we conducted a 50-state legal epidemiology study of laws expressly referencing "cytomegalovirus." EVIDENCE REVIEW: Our search yielded 101 statutes and regulations from 35 jurisdictions (34 states and District of Columbia). We systematically reviewed and coded the texts for themes. FINDINGS: Laws addressed 3 main themes: (1) CMV awareness and education; (2) testing and reporting; and (3) the provision of services. CONCLUSIONS AND RELEVANCE: State-level CMV laws have been enacted to increase CMV awareness and to implement CMV testing for infants at a higher risk for infection, such as those who do not pass newborn hearing screening. This study provides a complete legal assessment of existing ways law is used to address CMV infection in the United States.

    • Social and Behavioral Sciences
      • Fathers and Families: Risk and Resilience. An Introductionexternal icon
        Fitzgerald HE, Robinson LR, Cabrera N, Segal L.
        Advers Resil Sci. 2021 Jun 25:1-7.
        The articles in this special issue are informed by the historic changes in the twentieth century (i.e., decreasing family size, changing family roles, and youth demonstrating more independent behaviors) that propelled intensive study of fathers' impacts on child development. The papers are conceptualized within a developmental systems framework and focused on a father's presence rather than on his absence in the family, going beyond the study of merely father involvement. Papers reflect longitudinal and cross-sectional methods and examine issues related to paternal mental health, parenting behavior, cultural context, and children's physical and mental health.

  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. Effective control of hypertension at the population level is a global public health challenge. This study shows how improving population coverages at different hypertension care cascade levels could impact population-level hypertension management. We developed an analytical framework and a companion Excel model of multi-level hypertension care cascade entailing awareness, treatment, and control. The model estimates the prevalence of uncontrolled hypertension for different level of population coverages at certain cascade levels. We applied the model to data from Bangladesh and reported prevalence estimates associated with coverage interventions at different cascade levels. The model estimated that if 50% of the unaware hypertensive patients became aware of their hypertensive condition, the prevalence of uncontrolled hypertension would decrease by 1.8 and 1.3 percentage points (8.2% and 5.8% relative reduction), respectively, for constant and variable rates in the status quo setting. When 50% of the aware, but untreated individuals received treatment, the prevalence would decrease by around 0.7 percentage points (3.3% relative reduction). A 50% decrease in the share of treated individuals who did not have hypertension under control, would result in decreasing the prevalence by 2.8 percentage points (12.7% relative reduction). By providing an analytical tool that demonstrates the probable impact of population coverage interventions at certain hypertension care cascade levels, our study endows public health practitioners with vital information to identify gaps and design effective policies for hypertension management.

      2. AIMS: The extent that pre-diabetic fasting plasma glucose (FPG) levels influence the effectiveness of lifestyle interventions in preventing type 2 diabetes (T2DM) is uncertain. We aimed to determine if the outcome of lifestyle intervention in people with impaired glucose tolerance (IGT) differs in those with normal or impaired FPG levels. METHODS: Using data from the Da Qing Diabetes Prevention Outcome Study, a 30-year follow-up of a six-year randomized trial of lifestyle intervention in 576 people with IGT, we conducted a post-hoc analysis to compare the efficacy of intervention to reduce the incidence of T2DM and its complications in those with baseline FPG <100 mg/dL and FPG ≥100 mg/dL. RESULTS: Lifestyle intervention reduced the cumulative incidence of T2DM by 37-46% in those with baseline FPG <100 mg/dL and by 47-51% in those with FPG ≥100 mg/dL. The FPG <100 mg/dL group had a lower cumulative incidence of diabetes and 6.41 years median delay in its onset compared with 2.21 years delay in the FPG >100 mg/dL group. In those with FPG <100 mg/dL intervention was associated with at least as great a reduction in cardiovascular disease (CVD) and all-cause mortality as in the FPG >100 mg/dL group. CONCLUSIONS: Lifestyle intervention reduced the incidence of T2DM in people with IGT regardless of baseline FPG levels, and in those with FPG <100 mg/dL led to a substantial delay in its onset. All persons with IGT, with normal or impaired FPG levels, may benefit from lifestyle intervention to delay its onset and mitigate the incidence of T2DM. This article is protected by copyright. All rights reserved.

      3. Associations between baseline and longitudinal semi-automated quantitative joint space width at the hip and incident hip osteoarthritis: Data from a community-based cohortexternal icon
        Nelson AE, Smith JA, Alvarez C, Arbeeva L, Renner JB, Murphy LB, Jordan JM, Golightly YM, Duryea J.
        Arthritis Care Res (Hoboken). 2021 Jul 5.
        OBJECTIVE: To evaluate quantitative joint space width (qJSW, at 10-, 30-, and 50-degree locations) in relation to incident radiographic and symptomatic hip osteoarthritis (rHOA and sxHOA, respectively) in a community-based cohort. METHODS: Data were from Johnston County OA Project (JoCoOA) participants with supine hip radiographs at each of 4 timepoints; all had Kellgren-Lawrence grades (KLG) and qJSW. We assessed covariates (age, race, height, weight, body mass index [BMI]) associated with qJSW, and hip-level associations between qJSW and HOA, over time using sex-stratified and multivariable-adjusted linear mixed models. A cluster analysis with logistic regression estimated associations between qJSW trajectory groups and incident rHOA and sxHOA. RESULTS: At baseline, 397 participants (784 hips, 41% men, 24% Black, mean age=57 years) had a mean BMI=29 kilograms/meter(2) . Over a mean of 18 years, 20% and 12% developed incident KLG-defined rHOA or sxHOA, respectively. QJSW was more sensitive to changes over time at 50 degrees. Values were stable among men but declined over time in women. Heavier women lost more qJSW; changes in qJSW were not significantly associated with race, education, or injury in women or men. In women only, loss of qJSW over time was associated with 2-3 times higher odds of rHOA and sxHOA; among women and men, narrower baseline qJSW was associated with these outcomes. CONCLUSION: Hip qJSW demonstrates marked sex differences, with significant loss over time only in women. Loss of qJSW over time in women, and narrower baseline qJSW in men and women, was associated with incident rHOA and sxHOA.

      4. Early assessment of the first wave of the COVID-19 pandemic on cancer screening services: The International Cancer Screening Network COVID-19 surveyexternal icon
        Puricelli Perin DM, Elfström KM, Bulliard JL, Burón A, Campbell C, Flugelman AA, Giordano L, Kamineni A, Ponti A, Rabeneck L, Saraiya M, Smith RA, Broeders MJ.
        Prev Med. 2021 Oct;151:106642.
        Screening can decrease the burden of breast, cervical, and colorectal cancers. The COVID-19 pandemic led many countries to suspend cancer screening services as part of their response to the pandemic. The International Cancer Screening Network (ICSN) carried out an online survey to assess the effects of the first wave of the COVID-19 pandemic on cancer screening. A 33-item survey was distributed to 834 email addresses to gather information about settings and assess decision-making processes that led to cancer screening suspension. Information about communication, impact on resources, and patient follow-up was collected. Quantitative data was analyzed as frequencies overall and by setting, while a comment section under each survey item captured nuanced details. Responses were recategorized into 66 settings, representing 35 countries. Most settings suspended cancer screening services (n = 60, 90.9%) in March 2020 (n = 45, 68.2%), guided by a government decision (n = 51, 77.3%). Few settings made the decision whether to suspend services based on a preparedness plan (n = 17, 25.8%). In most settings, professionals were reassigned (n = 41, 62.1%) and infrastructure repurposed (n = 35, 53.0%). The first wave of the COVID-19 pandemic has had profound effects on cancer screening worldwide, including the suspension of services in almost all settings. Most settings were unprepared to deal with the scale of the pandemic but demonstrated flexibility in the response. These results contribute to inform, through experiences and lessons learned, the next steps for the global cancer screening community to further evaluate the impact of COVID-19 and prepare for future disruptions.

      5. BACKGROUND: Amyotrophic lateral sclerosis (ALS) is a neurological disease of largely unknown etiology with no cure. The National ALS Registry is a voluntary online system that collects demographic and reproductive history (females only) data from patients with ALS. We will examine the association between demographic and reproductive history among female patients aged >18 years and various ages of onset for ALS. METHODS: Data from a cross-sectional study were collected and examined for 1,018 female ALS patients. Patient characteristics examined were demographics including race, BMI, and familial history of ALS. Among patients, information on reproductive history, including age at menopause, ever pregnant, and age at first pregnancy was collected. Unadjusted and adjusted logistic regression models were used to estimate OR and 95% CI in this study. RESULTS: Women were more likely to be diagnosed with ALS before age 60 if they were nonwhite (p = 0.015), had attended college (p = 0.0012), had a normal BMI at age 40 (p < 0.0001), completed menopause before age 50 (p < 0.0001), and had never been pregnant (p = 0.046) in the univariate analysis. Women diagnosed with ALS before age 60 were also more likely to have limb site of onset (p < 0.0001). In the multivariate analysis, those who completed menopause before age 50 were more likely to be diagnosed with ALS before age 60 (OR = 1.8, 95% CI: 1.4-2.3) compared with women who completed menopause at or after age 50, after controlling for race, ever pregnant, age at first pregnancy, family history of ALS, education status, smoking history, and BMI at age 40. For women who were diagnosed with ALS before age 50, the odds of them entering menopause before age 50 climb to 48.7 (95% CI: 11.8, 200.9). The mean age of ALS diagnosis for women who completed menopause before age 50 was 58 years and 64 years for women who entered menopause after age 50 (p < 0.0001). CONCLUSION: Women who reported completing menopause before age 50 were significantly more likely to be diagnosed with ALS before age 60 compared with those who reported entering menopause after age 50. More research is needed to determine the relationship between female reproductive history, especially regarding endogenous estrogen exposure and early-onset ALS.

      6. A cross sectional study to compare cardiac structure and diastolic function in adolescents and young adults with youth-onset type 1 and type 2 diabetes: The SEARCH for Diabetes in Youth Studyexternal icon
        Shah AS, Isom S, Dabelea D, D'Agostino R, Dolan LM, Wagenknecht L, Imperatore G, Saydah S, Liese AD, Lawrence JM, Pihoker C, Urbina EM.
        Cardiovasc Diabetol. 2021 Jul 7;20(1):136.
        AIMS: To compare left ventricular structure (LV) and diastolic function in young adults with youth- onset diabetes by type, determine the prevalence of abnormal diastolic function by diabetes type using published values from age similar healthy controls, and examine the risk factors associated with diastolic function. METHODS: In a cross sectional analysis we compared LV structure and diastolic function from two dimensional echocardiogram in participants with type 1 (T1D) and type 2 diabetes (T2D) who participated in the SEARCH for Diabetes in Youth Study. Linear models were used to examine the risk factors associated with worse diastolic function. RESULTS: Of 479 participants studied, 258 had T1D (mean age 21.2 ± 5.2 years, 60.5% non-Hispanic white, 53.9% female) and 221 had T2D (mean age 24.8 ± 4.3 years, 24.4% non-Hispanic white, 73.8% female). Median diabetes duration was 11.6 years. Participants with T2D had greater LV mass index and worse diastolic function that persisted after adjustment for differences in risk factors compared with participants with T1D (all p < 0.05). Abnormal diastolic function, quantified using healthy controls, was pronounced in both groups but greater in those with T2D than T1D (T2D: 57.7% vs T1D: 47.2%, respectively), p < 0.05. Risk factors associated with worse diastolic function included older age at diabetes diagnosis, female sex, higher BP, heart rate and HbA1c and longer diabetes duration. CONCLUSIONS: LV structure and diastolic function is worse in individuals with T2D compared to T1D. However, abnormal diastolic function in seen in both groups compared to published values from age similar healthy controls.

    • Communicable Diseases
      1. Epidemiology of the Rhinovirus (RV) in African and Southeast Asian Children: A Case-Control Pneumonia Etiology Studyexternal icon
        Baillie VL, Moore DP, Mathunjwa A, Baggett HC, Brooks A, Feikin DR, Hammitt LL, Howie SR, Knoll MD, Kotloff KL, Levine OS, O'Brien KL, Scott AG, Thea DM, Antonio M, Awori JO, Driscoll AJ, Fancourt NS, Higdon MM, Karron RA, Morpeth SC, Mulindwa JM, Murdoch DR, Park DE, Prosperi C, Rahman MZ, Rahman M, Salaudeen RA, Sawatwong P, Somwe SW, Sow SO, Tapia MD, Simões EA, Madhi SA.
        Viruses. 2021 Jun 27;13(7).
        Rhinovirus (RV) is commonly detected in asymptomatic children; hence, its pathogenicity during childhood pneumonia remains controversial. We evaluated RV epidemiology in HIV-uninfected children hospitalized with clinical pneumonia and among community controls. PERCH was a case-control study that enrolled children (1-59 months) hospitalized with severe and very severe pneumonia per World Health Organization clinical criteria and age-frequency-matched community controls in seven countries. Nasopharyngeal/oropharyngeal swabs were collected for all participants, combined, and tested for RV and 18 other respiratory viruses using the Fast Track multiplex real-time PCR assay. RV detection was more common among cases (24%) than controls (21%) (aOR = 1.5, 95%CI:1.3-1.6). This association was driven by the children aged 12-59 months, where 28% of cases vs. 18% of controls were RV-positive (aOR = 2.1, 95%CI:1.8-2.5). Wheezing was 1.8-fold (aOR 95%CI:1.4-2.2) more prevalent among pneumonia cases who were RV-positive vs. RV-negative. Of the RV-positive cases, 13% had a higher probability (>75%) that RV was the cause of their pneumonia based on the PERCH integrated etiology analysis; 99% of these cases occurred in children over 12 months in Bangladesh. RV was commonly identified in both cases and controls and was significantly associated with severe pneumonia status among children over 12 months of age, particularly those in Bangladesh. RV-positive pneumonia was associated with wheezing.

      2. Incidence of Laboratory-Confirmed Influenza among HIV-Infected versus HIV-Uninfected Individuals in Two Districts of Ghana, 2014 to 2016external icon
        Balachandran N, Ntiri M, Duque J, Addo C, Edu-Quansah E, Badji E, Brightson K, Houphouet EE, Ndahwouh TN, Koram K, McMorrow M, Ampofo W.
        Am J Trop Med Hyg. 2021 Jul 6.
        Influenza is known to cause severe respiratory illness in HIV-infected adults, but there are few data describing the relationship between HIV infection and influenza in West African countries such as Ghana. We conducted a prospective cohort study in the Shai-Osudoku and Ningo Prampram districts of Ghana from 2014 to 2016. Beginning May 2014, 266 HIV-infected and 510 HIV-uninfected participants age 18 to 73 years were enrolled and monitored for 12 months. We observed 4 and 11 laboratory-confirmed influenza cases among HIV-infected and HIV-uninfected persons, respectively. The overall rate of laboratory-confirmed influenza among HIV-infected participants was 15.0 per 1,000 person years (PY) (95% CI, 0.3-29.80 per 1,000 PY), whereas that among HIV-uninfected participants was 21.6 per 1,000 PY (95% CI, 8.8-34.3 per 1,000 PY) (incidence density ratio, 0.70; P = 0.56). Our study found no significant difference in the incidence of laboratory-confirmed influenza-associated illness among HIV-infected and HIV-uninfected individuals in Ghana.

      3. Estimating the HIV Effective Reproduction Number in the United States and Evaluating HIV Elimination Strategiesexternal icon
        Chen YH, Farnham PG, Hicks KA, Sansom SL.
        J Public Health Manag Pract. 2021 Jun 30.
        CONTEXT: The reproduction number is a fundamental epidemiologic concept used to assess the potential spread of infectious diseases and whether they can be eliminated. OBJECTIVE: We estimated the 2017 United States HIV effective reproduction number, Re, the average number of secondary infections from an infected person in a partially infected population. We analyzed the potential effects on Re of interventions aimed at improving patient flow rates along different stages of the HIV care continuum. We also examined these effects by individual transmission groups. DESIGN: We used the HIV Optimization and Prevention Economics (HOPE) model, a compartmental model of disease progression and transmission, and the next-generation matrix method to estimate Re. We then projected the impact of changes in HIV continuum-of-care interventions on the continuum-of-care flow rates and the estimated Re in 2020. SETTING: United States. PARTICIPANTS: The HOPE model simulated the sexually active US population and persons who inject drugs, aged 13 to 64 years, which was stratified into 195 subpopulations by transmission group, sex, race/ethnicity, age, male circumcision status, and HIV risk level. MAIN OUTCOME MEASURES: The estimated value of Re in 2017 and changes in Re in 2020 from interventions affecting the continuum-of-care flow rates. RESULTS: Our estimated HIV Re in 2017 was 0.92 [0.82, 0.94] (base case [min, max across calibration sets]). Among the interventions considered, the most effective way to reduce Re substantially below 1.0 in 2020 was to maintain viral suppression among those receiving HIV treatment. The greatest impact on Re resulted from changing the flow rates for men who have sex with men (MSM). CONCLUSIONS: Our results suggest that current prevention and treatment efforts may not be sufficient to move the country toward HIV elimination. Reducing Re to substantially below 1.0 may be achieved by an ongoing focus on early diagnosis, linkage to care, and sustained viral suppression especially for MSM.

      4. Improving Services for HIV-Exposed Infants in Zambia and Cameroon Using a Quality Improvement Collaborative Approachexternal icon
        Dougherty G, Abena T, Abesselo JP, Banda JN, Biyaga TP, Boccanera R, Boyd MA, Ebogo M, Hamomba L, Jed S, Kakanou ZF, Kasonde P, Kasonka SC, Lungwebungu R, Madevu-Matson C, Mayer MM, Mwamba M, Panya M, Sakanda P, Tsiouris F, Walker L, Rabkin M.
        Glob Health Sci Pract. 2021 Jun 30;9(2):399-411.
        INTRODUCTION: Early infant diagnosis (EID) and rapid antiretroviral therapy (ART) initiation are lifesaving interventions for HIV-infected infants. In Cameroon and Zambia, EID coverage for HIV-exposed infants (HEIs) is suboptimal and the time to ART initiation for infants infected with HIV often exceeds national standards despite numerous policy and training initiatives. METHODS: ICAP at Columbia University supported the Cameroon and Zambia Ministries of Health (MOHs) and local partners to implement quality improvement collaboratives (QICs) to improve EID coverage and ART initiation at 17 health facilities (HFs) in Cameroon (March 2016 to June 2017) and 15 HFs in Zambia (March 2017 to June 2018). In each country, MOH led project design and site selection. MOH and ICAP provided quality improvement training and monthly supportive supervision, which enabled HF teams to conduct root cause analyses, design and implement contextually appropriate interventions, conduct rapid tests of change, analyze monthly progress, and convene at quarterly learning sessions to compare performance and share best practices. RESULTS: In Cameroon, EID testing coverage improved from 57% (113/197 HEIs tested) during the 5-month baseline period to 80% (165/207) in the 5-month endline period. In Zambia, EID testing coverage improved from 77% (4,773/6,197) during the 12-month baseline period to 89% (2,144/2,420) during the 3-month endline period. In a comparison of the same baseline and endline periods, the return of positive test results to caregivers improved from 18% (36/196 caregivers notified) to 86% (182/211) in Cameroon and from 44% (94/214) to 79% (44/56) in Zambia. ART initiation improved from 44% (94/214 HIV-infected infants) to 80% (45/56) in Zambia; the numbers of HIV-infected infants in Cameroon were too small to detect meaningful differences. CONCLUSIONS: QICs improved coverage of timely EID and ART initiation in both countries. In addition to building quality improvement capacity and improving outcomes, the QICs resulted in a "change package" of successful initiatives that were disseminated within each country.

      5. Association Between Caseload Surge and COVID-19 Survival in 558 U.S. Hospitals, March to August 2020external icon
        Kadri SS, Sun J, Lawandi A, Strich JR, Busch LM, Keller M, Babiker A, Yek C, Malik S, Krack J, Dekker JP, Spaulding AB, Ricotta E, Powers Iii JH, Rhee C, Klompas M, Athale J, Boehmer TK, Gundlapalli AV, Bentley W, Datta SD, Danner RL, Demirkale CY, Warner S.
        Ann Intern Med. 2021 Jul 6.
        BACKGROUND: Several U.S. hospitals had surges in COVID-19 caseload, but their effect on COVID-19 survival rates remains unclear, especially independent of temporal changes in survival. OBJECTIVE: To determine the association between hospitals' severity-weighted COVID-19 caseload and COVID-19 mortality risk and identify effect modifiers of this relationship. DESIGN: Retrospective cohort study. ( NCT04688372). SETTING: 558 U.S. hospitals in the Premier Healthcare Database. PARTICIPANTS: Adult COVID-19-coded inpatients admitted from March to August 2020 with discharge dispositions by October 2020. MEASUREMENTS: Each hospital-month was stratified by percentile rank on a surge index (a severity-weighted measure of COVID-19 caseload relative to pre-COVID-19 bed capacity). The effect of surge index on risk-adjusted odds ratio (aOR) of in-hospital mortality or discharge to hospice was calculated using hierarchical modeling; interaction by surge attributes was assessed. RESULTS: Of 144 116 inpatients with COVID-19 at 558 U.S. hospitals, 78 144 (54.2%) were admitted to hospitals in the top surge index decile. Overall, 25 344 (17.6%) died; crude COVID-19 mortality decreased over time across all surge index strata. However, compared with nonsurging (<50th surge index percentile) hospital-months, aORs in the 50th to 75th, 75th to 90th, 90th to 95th, 95th to 99th, and greater than 99th percentiles were 1.11 (95% CI, 1.01 to 1.23), 1.24 (CI, 1.12 to 1.38), 1.42 (CI, 1.27 to 1.60), 1.59 (CI, 1.41 to 1.80), and 2.00 (CI, 1.69 to 2.38), respectively. The surge index was associated with mortality across ward, intensive care unit, and intubated patients. The surge-mortality relationship was stronger in June to August than in March to May (slope difference, 0.10 [CI, 0.033 to 0.16]) despite greater corticosteroid use and more judicious intubation during later and higher-surging months. Nearly 1 in 4 COVID-19 deaths (5868 [CI, 3584 to 8171]; 23.2%) was potentially attributable to hospitals strained by surging caseload. LIMITATION: Residual confounding. CONCLUSION: Despite improvements in COVID-19 survival between March and August 2020, surges in hospital COVID-19 caseload remained detrimental to survival and potentially eroded benefits gained from emerging treatments. Bolstering preventive measures and supporting surging hospitals will save many lives. PRIMARY FUNDING SOURCE: Intramural Research Program of the National Institutes of Health Clinical Center, the National Institute of Allergy and Infectious Diseases, and the National Cancer Institute.

      6. SARS-CoV-2 Variants of Interest and Concern naming scheme conducive for global discourseexternal icon
        Konings F, Perkins MD, Kuhn JH, Pallen MJ, Alm EJ, Archer BN, Barakat A, Bedford T, Bhiman JN, Caly L, Carter LL, Cullinane A, de Oliveira T, Druce J, El Masry I, Evans R, Gao GF, Gorbalenya AE, Hamblion E, Herring BL, Hodcroft E, Holmes EC, Kakkar M, Khare S, Koopmans MP, Korber B, Leite J, MacCannell D, Marklewitz M, Maurer-Stroh S, Rico JA, Munster VJ, Neher R, Munnink BO, Pavlin BI, Peiris M, Poon L, Pybus O, Rambaut A, Resende P, Subissi L, Thiel V, Tong S, van der Werf S, von Gottberg A, Ziebuhr J, Van Kerkhove MD.
        Nat Microbiol. 2021 Jul;6(7):821-823.

      7. Efficacy of Portable Air Cleaners and Masking for Reducing Indoor Exposure to Simulated Exhaled SARS-CoV-2 Aerosols - United States, 2021external icon
        Lindsley WG, Derk RC, Coyle JP, Martin SB, Mead KR, Blachere FM, Beezhold DH, Brooks JT, Boots T, Noti JD.
        MMWR Morb Mortal Wkly Rep. 2021 Jul 9;70(27):972-976.
        SARS-CoV-2, the virus that causes COVID-19, can be spread by exposure to droplets and aerosols of respiratory fluids that are released by infected persons when they cough, sing, talk, or exhale. To reduce indoor transmission of SARS-CoV-2 between persons, CDC recommends measures including physical distancing, universal masking (the use of face masks in public places by everyone who is not fully vaccinated), and increased room ventilation (1). Ventilation systems can be supplemented with portable high efficiency particulate air (HEPA) cleaners* to reduce the number of infectious particles in the air and provide enhanced protection from transmission between persons (2); two recent reports found that HEPA air cleaners in classrooms could reduce overall aerosol particle concentrations by ≥80% within 30 minutes (3,4). To investigate the effectiveness of portable HEPA air cleaners and universal masking at reducing exposure to exhaled aerosol particles, the investigation team used respiratory simulators to mimic a person with COVID-19 and other, uninfected persons in a conference room. The addition of two HEPA air cleaners that met the Environmental Protection Agency (EPA)-recommended clean air delivery rate (CADR) (5) reduced overall exposure to simulated exhaled aerosol particles by up to 65% without universal masking. Without the HEPA air cleaners, universal masking reduced the combined mean aerosol concentration by 72%. The combination of the two HEPA air cleaners and universal masking reduced overall exposure by up to 90%. The HEPA air cleaners were most effective when they were close to the aerosol source. These findings suggest that portable HEPA air cleaners can reduce exposure to SARS-CoV-2 aerosols in indoor environments, with greater reductions in exposure occurring when used in combination with universal masking.

      8. Cluster of Oseltamivir-Resistant and Hemagglutinin Antigenically Drifted Influenza A(H1N1)pdm09 Viruses, Texas, USA, January 2020external icon
        Mohan T, Nguyen HT, Kniss K, Mishin VP, Merced-Morales AA, Laplante J, St George K, Blevins P, Chesnokov A, De La Cruz JA, Kondor R, Wentworth DE, Gubareva LV.
        Emerg Infect Dis. 2021 Jul;27(7):1953-1957.
        Four cases of oseltamivir-resistant influenza A(H1N1)pdm09 virus infection were detected among inhabitants of a border detention center in Texas, USA. Hemagglutinin of these viruses belongs to 6B.1A5A-156K subclade, which may enable viral escape from preexisting immunity. Our finding highlights the necessity to monitor both drug resistance and antigenic drift of circulating viruses.

      9. BACKGROUND: To describe changes in reported sexually transmitted diseases (STDs) during the U.S. coronavirus disease 2019 pandemic, we compared the weekly number of reported nationally notifiable STDs in 2020 to 2019. METHODS: We reviewed cases of chlamydia, gonorrhea, and primary & secondary (P&S) syphilis reported to the U.S. National Notifiable Disease Surveillance System in 2020. For each STD, we compare the number of 2020 cases reported for a given Morbidity and Mortality Weekly Report (MMWR) week to the number of 2019 cases reported in the same week, expressing 2020 cases as a percentage of 2019 cases. We also calculated the percent difference between 2020 and 2019 cumulative case totals as of MMWR week 50 (week of December 9). RESULTS: During MMWR weeks 1-11 (week of December 29, 2019-March 11, 2020), the weekly number of cases of STDs reported in 2020 as a percentage of the cases in the same week in 2019 were similar. However, 2020 numbers were much lower than 2019 numbers in week 15 (week of April 8; chlamydia, 49.8%; gonorrhea, 71.2%; and P&S syphilis, 63.7%). As of week 50, the 2020 cumulative totals compared to 2019 were 14.0% lower for chlamydia, 7.1% higher for gonorrhea, and 0.9% lower for P&S syphilis. CONCLUSION: During March-April 2020, national case reporting for STDs dramatically decreased compared to 2019. However, resurgence in reported gonorrhea and syphilis cases later in the year suggest STD reporting may have increased during 2020, underscoring the importance of continued STD prevention and care activities.

      10. Latent tuberculosis infection: Misperceptions among non-U.S.-born-populations from countries where tuberculosis is commonexternal icon
        Parmer J, Macario E, Tatum K, Brackett A, Allen L, Picard R, DeLuca N, Dowling M.
        Glob Public Health. 2021 Jul 6:1-15.
        ABSTRACTThe Centers for Disease Control and Prevention works to eliminate tuberculosis (TB) disease by finding and treating cases of TB disease and expanding latent tuberculosis infection (LTBI) testing and treatment to prevent TB disease. Approximately 70% of reported TB cases in the United States occur among non-U.S.-born persons. We conducted 15 focus groups with U.S. residents born in the six most common countries of birth among non-U.S.-born TB patients: Mexico, the Philippines, India, Vietnam, China and Guatemala. Participants reacted to 39 messages on LTBI and TB disease risk factors, the Bacille Calmette-Guérin (BCG) vaccine, and LTBI testing and treatment. There was low awareness of LTBI, the TB blood test, and how the TB blood test is not affected by prior BCG vaccination. Several participants thought TB disease is contracted by sharing kitchenware. Some felt negatively targeted when presented with information about countries where TB disease is more common than the U.S. Findings highlight the need for communication aimed at increasing LTBI testing and treatment to include messages framed in ways that will be resonant and actionable to populations at risk. Focus groups revealed LTBI misconceptions which highlight areas for targeted education to decrease TB stigma and increase LTBI testing and treatment.

      11. Time From HIV Infection to Diagnosis in the U.S., 2014-2018external icon
        Peruski AH, Wu B, Linley L, Delaney KP, DiNenno EA, Johnson AS.
        Am J Prev Med. 2021 Jun 30.
        INTRODUCTION: Understanding the role of sociologic, structural, and biomedical factors that influence the length of time from HIV infection to diagnosis and reducing the time from infection to diagnosis are critical for achieving the goals of the Ending the HIV Epidemic initiative. In a retrospective analysis, the length of time from HIV infection to diagnosis and its association with individual- and facility-level attributes are determined. METHODS: Data reported by December 2019 to the U.S. National HIV Surveillance System for people with HIV diagnosed during 2014-2018 were analyzed during December 2020. A CD4 depletion model was used to estimate the time from HIV infection to diagnosis. RESULTS: During 2018, the median time from HIV infection to diagnosis was shortest for those infections diagnosed using the rapid testing algorithm (30.3 days, 95% CI=25.5, 34.5) than those diagnosed using the recommended (41.0 days, 95% CI=39.5, 42.0), traditional (37.0 days, 95% CI=29.5, 43.5), or other (35.5 days, 95% CI=32.5, 38.0) diagnostic testing algorithms. From 2014 to 2018, the time from HIV infection to diagnosis remained stable overall for all testing methods except for the traditional diagnostic testing algorithm. In multivariate analyses, those more likely to have HIV diagnosed closer to the time of infection were younger, were White, had transmission risk factors of injection drug use or heterosexual contact (for female individuals) or male-to-male sexual contact and injection drug use, or had HIV diagnosed at a correctional or screening facility (p<0.01). CONCLUSIONS: Providing access to expanded testing, including rapid testing in nonclinical settings, is likely to result in a decrease in the length of time a person is unaware of their HIV infection and thus reduce onward transmission of HIV infection.

      12. Acceptability of household practices to prevent boils in rural Alaskaexternal icon
        Plumb ID, Dobson J, Seeman S, Bruce MG, Reasonover A, Lefferts B, Rudolph KM, Klejka J, Hennessy TW.
        J Environ Health. 2021 ;84(1):26-34.
        Boils are a major health problem affecting rural Alaska Native communities. Boils result from transmission of Staphylococcus aureus from steam bath surfaces, infected skin, and household environments. To assess the acceptability of practices to prevent boils within one community, we surveyed 57 households before and after distribution of supplies and educational materials. Before distribution, 64% of households cleaned steam baths with bleach (23/36), 72% used steam bath seat barriers (41/57), 74% did not share scrubbers (42/57), 35% added recommended bleach to laundry (20/57), and 30% used hand sanitizer (17/57). After distribution, 75% households used new scrubbers (43/57), 88% used new seat barriers (50/57), and 25% used new antiseptic skin cleanser (14/57). Additionally, after the intervention, more households used seat barriers in steam baths (from 72% to 86%, p = .046) and hand sanitizer (from 30% to 60%, p < .001). This study supports development of a household-based intervention as a potential strategy to prevent boils in Alaska Native communities.

      13. Outcomes Among Patients Referred to Outpatient Rehabilitation Clinics After COVID-19 diagnosis - United States, January 2020-March 2021external icon
        Rogers-Brown JS, Wanga V, Okoro C, Brozowsky D, Evans A, Hopwood D, Cope JR, Jackson BR, Bushman D, Hernandez-Romieu AC, Bonacci RA, McLeod T, Chevinsky JR, Goodman AB, Dixson MG, Lufty C, Rushmore J, Koumans E, Morris SB, Thompson W.
        MMWR Morb Mortal Wkly Rep. 2021 Jul 9;70(27).
        As of June 30, 2021, 33.5 million persons in the United States had received a diagnosis of COVID-19 (1). Although most patients infected with SARS-CoV-2, the virus that causes COVID-19, recover within a few weeks, some experience post-COVID-19 conditions. These range from new or returning to ongoing health problems that can continue beyond 4 weeks. Persons who were asymptomatic at the time of infection can also experience post-COVID-19 conditions. Data on post-COVID-19 conditions are emerging and information on rehabilitation needs among persons recovering from COVID-19 is limited. Using data acquired during January 2020-March 2021 from Select Medical* outpatient rehabilitation clinics, CDC compared patient-reported measures of health, physical endurance, and health care use between patients who had recovered from COVID-19 (post-COVID-19 patients) and patients needing rehabilitation because of a current or previous diagnosis of a neoplasm (cancer) who had not experienced COVID-19 (control patients). All patients had been referred to outpatient rehabilitation. Compared with control patients, post-COVID-19 patients had higher age- and sex-adjusted odds of reporting worse physical health (adjusted odds ratio [aOR] = 1.8), pain (aOR = 2.3), and difficulty with physical activities (aOR = 1.6). Post-COVID-19 patients also had worse physical endurance, measured by the 6-minute walk test(†) (6MWT) (p<0.001) compared with control patients. Among patients referred to outpatient rehabilitation, those recovering from COVID-19 had poorer physical health and functional status than those who had cancer, or were recovering from cancer but not COVID-19. Patients recovering from COVID-19 might need additional clinical support, including tailored physical and mental health rehabilitation services.

      14. Pneumococcal Disease Outbreak at a State Prison, Alabama, USA, September 1-October 10, 2018(1)external icon
        Sanchez GV, Bourne CL, Davidson SL, Ellis M, Feldstein LR, Fay K, Brown NE, Geeter EF, Foster LL, Gilmore C, McIntyre MG, Taylor B, Velusamy S, Chochua S, Matanock AM.
        Emerg Infect Dis. 2021 Jul;27(7):1949-1952.
        A pneumococcal disease outbreak caused by Streptococcus pneumoniae serotype 12F occurred in a state prison in Alabama, USA. Among 1,276 inmates, 40 cases were identified (3 confirmed, 2 probable, 35 suspected). Close living quarters, substance use, and underlying conditions likely contributed to disease risk. Prophylaxis for close contacts included azithromycin and 23-valent pneumococcal polysaccharide vaccine.

      15. Epidemiologic, immunologic, and virus characteristics in patients with paired SARS-CoV-2 serology and reverse transcription polymerase chain reaction testingexternal icon
        Shragai T, Smith-Jeffcoat SE, Koh M, Schechter MC, Rebolledo PA, Kasinathan V, Wang Y, Hoffman A, Miller H, Tejada-Strop A, Jain S, Tamin A, Harcourt JL, Thornburg NJ, Wong P, Medrzycki M, Folster JM, Semenova V, Steward-Clark E, Drobenuic J, Biedron C, Stewart RJ, da Silva J, Kirking HL, Tate JE.
        J Infect Dis. 2021 Jul 3.
        BACKGROUND: The natural history and clinical progression of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections can be better understood using combined serological and reverse transcription polymerase chain reaction (RT-PCR) testing. METHODS: Nasopharyngeal swabs and serum were collected at a single time-point from patients at an urban, public hospital August - November 2020 and tested for SARS-CoV-2 using RT-PCR, viral culture, and anti-Spike pan-Ig antibody testing. Participant demographics and symptoms were collected through interview. Chi-squared and Fisher's exact tests were used to identify associations between RT-PCR and serology results with presence of viable virus and frequency of symptoms. RESULTS: Among 592 participants, 129 (21.8%) had evidence of SARS-CoV-2 infection by RT-PCR or serology. Presence of SARS-CoV-2 antibodies was strongly associated with lack of viable virus (p-value=0.016). COVID-19 symptom frequency was similar for patients testing RT-PCR positive/seronegative and patients testing RT-PCR positive/seropositive. Patients testing RT-PCR positive/seronegative reported headaches, fatigue, diarrhea and vomiting at rates not statistically significantly different from those testing RT-PCR negative/seropositive. CONCLUSIONS: While patients testing SARS-CoV-2 seropositive were unlikely to test positive for viable virus and were therefore low-risk for forward transmission, COVID-19 symptoms were common. Paired SARS-CoV-2 RT-PCR and antibody testing provides more nuanced understanding of patients' COVID-19 status.

      16. Logically Inferred Tuberculosis Transmission (LITT): A Data Integration Algorithm to Rank Potential Source Casesexternal icon
        Winglee K, McDaniel CJ, Linde L, Kammerer S, Cilnis M, Raz KM, Noboa W, Knorr J, Cowan L, Reynolds S, Posey J, Sullivan Meissner J, Poonja S, Shaw T, Talarico S, Silk BJ.
        Front Public Health. 2021 ;9:667337.
        Understanding tuberculosis (TB) transmission chains can help public health staff target their resources to prevent further transmission, but currently there are few tools to automate this process. We have developed the Logically Inferred Tuberculosis Transmission (LITT) algorithm to systematize the integration and analysis of whole-genome sequencing, clinical, and epidemiological data. Based on the work typically performed by hand during a cluster investigation, LITT identifies and ranks potential source cases for each case in a TB cluster. We evaluated LITT using a diverse dataset of 534 cases in 56 clusters (size range: 2-69 cases), which were investigated locally in three different U.S. jurisdictions. Investigators and LITT agreed on the most likely source case for 145 (80%) of 181 cases. By reviewing discrepancies, we found that many of the remaining differences resulted from errors in the dataset used for the LITT algorithm. In addition, we developed a graphical user interface, user's manual, and training resources to improve LITT accessibility for frontline staff. While LITT cannot replace thorough field investigation, the algorithm can help investigators systematically analyze and interpret complex data over the course of a TB cluster investigation. Code available at:;

      17. Coverage of maternal viral load monitoring during pregnancy in South Africa: Results from the 2019 national Antenatal HIV Sentinel Surveyexternal icon
        Woldesenbet SA, Kufa-Chakezha T, Lombard C, Manda S, Cheyip M, Ayalew K, Puren A.
        HIV Med. 2021 Jul 1.
        OBJECTIVES: South Africa has made remarkable progress in increasing the coverage of antiretroviral therapy (ART) among pregnant women; however, viral suppression among pregnant women receiving ART is reported to be low. Access to routine viral load testing is crucial to identify women with unsuppressed viral load early in pregnancy and to provide timely intervention to improve viral suppression. This study aimed to determine the coverage of maternal viral load monitoring nationally, focusing on viral load testing, documentation of viral load test results, and viral suppression (viral load < 50 copies/mL). At the time of this study, the first-line regimen for women initiating ART during pregnancy was non-nucleoside reverse transcriptase (NNRTI)-based regimen. METHODS: Between 1 October and 15 November 2019, a cross-sectional survey was conducted among 15- to 49-year-old pregnant women attending antenatal care in 1589 nationally representative public health facilities. Data on ART status, viral load testing and viral load test results were extracted from medical records. Logistic regression was used to examine factors associated with coverage of viral load testing. RESULTS: Of 8112 participants eligible for viral load testing, 81.7% received viral load testing, and 94.1% of the viral load test results were documented in the medical records. Of those who had viral load test results documented, 74.1% were virally suppressed. Women initiated on ART during pregnancy and who received ART for three months had lower coverage of viral load testing (73%) and viral suppression (56.8%) compared with women initiated on ART before pregnancy (82.8% and 76.1%, respectively). Initiating ART during pregnancy rather than before pregnancy was associated with a lower likelihood of receiving a viral load test during pregnancy (adjusted odds ratio = 1.6, 95% confidence interval: 1.4-1.8). CONCLUSIONS: Viral load result documentation was high; viral load testing could be improved especially among women initiating ART during pregnancy. The low viral suppression among women who initiated ART during pregnancy despite receiving ART for three months highlights the importance of enhanced adherence counselling during pregnancy. Our finding supports the WHO recommendation that a Dolutegravir-containing regimen be the preferred regimen for women who are newly initiating ART during pregnancy for more rapid viral suppression.

    • Disease Reservoirs and Vectors
      1. Genetic Characterization of Cryptosporidium cuniculus from Rabbits in Egyptexternal icon
        Naguib D, Roellig DM, Arafat N, Xiao L.
        Pathogens. 2021 Jun 20;10(6).
        Rabbits are increasingly farmed in Egypt for meat. They are, however, known reservoirs of infectious pathogens. Currently, no information is available on the genetic characteristics of Cryptosporidium spp. in rabbits in Egypt. To understand the prevalence and genetic identity of Cryptosporidium spp. in these animals, 235 fecal samples were collected from rabbits of different ages on nine farms in El-Dakahlia, El-Gharbia, and Damietta Provinces, Egypt during the period from July 2015 to April 2016. PCR-RFLP analysis of the small subunit rRNA gene was used to detect and genotype Cryptosporidium spp. The overall detection rate was 11.9% (28/235). All 28 samples were identified as Cryptosporidium cuniculus. The 16 samples successfully subtyped by the sequence analysis of the partial 60 kDa glycoprotein gene belonged to two subtypes, VbA19 (n = 1) and VbA33 (n = 15). As C. cuniculus is increasingly recognized as a cause of human cryptosporidiosis, Cryptosporidium spp. in rabbits from Egypt have zoonotic potential.

    • Environmental Health
      1. Features and Practicability of the Next-Generation Sensors and Monitors for Exposure Assessment to Airborne Pollutants: A Systematic Reviewexternal icon
        Fanti G, Borghi F, Spinazzè A, Rovelli S, Campagnolo D, Keller M, Cattaneo A, Cauda E, Cavallo DM.
        Sensors (Basel). 2021 Jun 30;21(13).
        In the last years, the issue of exposure assessment of airborne pollutants has been on the rise, both in the environmental and occupational fields. Increasingly severe national and international air quality standards, indoor air guidance values, and exposure limit values have been developed to protect the health of the general population and workers; this issue required a significant and continuous improvement in monitoring technologies to allow the execution of proper exposure assessment studies. One of the most interesting aspects in this field is the development of the "next-generation" of airborne pollutants monitors and sensors (NGMS). The principal aim of this review is to analyze and characterize the state of the art and of NGMS and their practical applications in exposure assessment studies. A systematic review of the literature was performed analyzing outcomes from three different databases (Scopus, PubMed, Isi Web of Knowledge); a total of 67 scientific papers were analyzed. The reviewing process was conducting systematically with the aim to extrapolate information about the specifications, technologies, and applicability of NGMSs in both environmental and occupational exposure assessment. The principal results of this review show that the use of NGMSs is becoming increasingly common in the scientific community for both environmental and occupational exposure assessment. The available studies outlined that NGMSs cannot be used as reference instrumentation in air monitoring for regulatory purposes, but at the same time, they can be easily adapted to more specific applications, improving exposure assessment studies in terms of spatiotemporal resolution, wearability, and adaptability to different types of projects and applications. Nevertheless, improvements needed to further enhance NGMSs performances and allow their wider use in the field of exposure assessment are also discussed.

      2. Prenatal and childhood exposure to per- and polyfluoroalkyl substances (PFAS) and child executive function and behavioral problemsexternal icon
        Harris MH, Oken E, Rifas-Shiman SL, Calafat AM, Bellinger DC, Webster TF, White RF, Sagiv SK.
        Environ Res. 2021 Jul 5:111621.
        Early life exposure to per- and polyfluoroalkyl substances (PFAS) may adversely impact neurodevelopment, but epidemiological findings are inconsistent. In the Project Viva pre-birth cohort, we examined associations of prenatal and childhood PFAS plasma concentrations with parent and teacher assessments of children's behavior problems [Strengths and Difficulties Questionnaire (SDQ)] and executive function abilities [Behavior Rating Inventory of Executive Function (BRIEF)] at age 6-10 years (sample sizes 485-933). PFAS concentrations in pregnant Project Viva mothers (in 1999-2002) and children at ages 6-10 (in 2007-10) were similar to concentrations at similar time points in women and children in the nationally representative U.S. National Health and Nutrition Examination Survey. We observed no consistent associations of prenatal PFAS concentrations with behavior or executive function. Childhood concentrations of perfluorooctanoate (PFOA), perfluorooctane sulfonate (PFOS), perfluorohexane sulfonate (PFHxS), perfluorononanoate (PFNA) and perfluorodecanoate (PFDA) were associated with higher parent-rated SDQ Total Difficulties scores (mean = 6.7, standard deviation (SD) = 4.9), suggesting greater behavioral problems (top (Q4) versus bottom (Q1) quartile PFOA: 1.5, 95% confidence interval (CI): 0.3, 2.7; PFOS: 1.4, 95% CI: 0.3, 2.5; PFHxS: 1.2, 95% CI: 0.1, 2.3; PFNA: 1.2, 95% CI: 0.1, 2.2; PFDA: 1.1, 95% CI: 0.0, 1.1); teacher-rated SDQ scores did not show associations. Higher childhood PFOS was associated with higher (indicating more problems) parent-rated BRIEF General Executive Composite (GEC) scores (standardized to mean = 50, SD = 10) (Q4 vs. Q1: 2.4, 95% CI: 0.2, 4.6), while teacher BRIEF GEC scores indicated more problems among children with higher PFHxS (Q4 vs. Q1: 3.5, 95% CI: -0.8, 6.3). There were no consistent patterns of sexual dimorphism in associations. In a cohort of U.S. children, we observed cross-sectional associations of childhood PFAS concentrations with greater behavioral and executive function problems, but no consistent associations with prenatal PFAS.

      3. INTRODUCTION: Among U.S. adolescents, the knowledge that air pollution can impact health is relatively high and varies by the demographics of the respondents and the places they live, but the influence of asthma status is unknown. This study assesses the role of asthma in U.S. adolescents' awareness, perceptions, and behaviors related to air pollution. METHODS: In 2020, data were analyzed from 817 adolescents aged 12-17 years who responded to the 2020 Porter Novelli Public Services YouthStyles survey, a nationally representative survey of U.S. adolescents. Respondents self-reported having or having had asthma in the past year and their awareness, perceptions, and behaviors related to air pollution. For each aspect of air quality awareness, perception, and behavior, weighted percentages of responses were calculated by asthma status. RESULTS: Overall, an estimated 11.5% of U.S. adolescents self-reported asthma. Awareness that air pollution can impact health, awareness that respondents can limit their air pollution exposure, and having heard or read about air quality alerts were similar among adolescents with and without asthma, with some differences reported in where they heard or read about air quality alerts. Those with asthma reported discussing with a health professional about ways to limit exposure more frequently than those without asthma. CONCLUSIONS: Despite the well-known risk of asthma exacerbations from air pollution exposure, air quality awareness was similar among adolescents with and without asthma. These findings reveal the areas in which air quality awareness and behaviors to reduce exposure can be improved among adolescents with and without asthma.

    • Health Economics
      1. Data Needs for Economic Evaluations of Screening in Pediatric Primary Care: A Research Frameworkexternal icon
        Grosse SD, Kemper AR, Prosser LA.
        Pediatrics. 2021 Jul;148(Suppl 1):s45-s50.

      2. Estimating the economic burden of pneumococcal meningitis and pneumonia in northern Ghana in the African meningitis belt post-PCV13 introductionexternal icon
        Kobayashi M, Abdul-Karim A, Milucky JL, Zakariah A, Leidner AJ, Asiedu-Bekoe F, Opare D, Eleeza JB, Ofosu W, Walker C, Whitney CG, Lessa FC.
        Vaccine. 2021 Jul 1.
        BACKGROUND: Ghana introduced 13-valent pneumococcal conjugate vaccine (PCV13) into the routine infant immunization program in 2012, using a three-dose primary series without a booster. Despite ≥ 88% reported three-dose vaccination coverage since 2013, PCV13-type pneumococcal meningitis outbreaks have occurred. We estimated the ongoing economic burden of PCV13-type pneumococcal meningitis and pneumonia in northern Ghana, an area within the African meningitis belt with seasonal increases of pneumococcal meningitis post-PCV13 introduction, to inform PCV13 vaccination policy. METHODS: We performed a cross-sectional survey among patients with pneumonia or meningitis at three hospitals in northern Ghana to determine patient-level costs (direct medical and nonmedical, indirect patient and caregiver costs) incurred in household, outpatient, and inpatient settings. Pneumonia burden was estimated using 2017-2018 administrative records. Pneumococcal meningitis burden was estimated using 2017-2018 case-based surveillance data. Economic burden was reported in 2019 U.S. dollars ($) from the societal perspective. RESULTS: For an area with a total population of 5,068,521, our model estimated 6,441 PCV13-type pneumonia cases and 286 PCV13-type meningitis cases occurred in a typical year post-PCV13. In the base case scenario, the total economic burden was $5,230,035 per year ($777 per case). By age group, cost per PCV13-type pneumonia case was $423 (<5 years), $911 (5-14 years), and $784 (≥15 years); cost per PCV13-type meningitis case was $2,128 (<5 years), $3,247 (5-14 years), and $2,883 (≥15 years). Most (78.0-93.4%) of the total societal cost was due to indirect costs related to deaths from PCV13-type diseases. CONCLUSIONS: The estimated economic burden of PCV13-type disease in northern Ghana remains substantial, especially in older children and adults who were expected to have benefited from indirect effects from infant immunization. Additional interventions such as changes in the infant immunization schedule, reactive vaccination, or catch-up PCV13 vaccination may be needed to control remaining vaccine-type disease.

      3. Promoting, seeking, and reaching vaccination services: A systematic review of costs to immunization programs, beneficiaries, and caregiversexternal icon
        Yemeke TT, Mitgang E, Wedlock PT, Higgins C, Chen HH, Pallas SW, Abimbola T, Wallace A, Bartsch SM, Lee BY, Ozawa S.
        Vaccine. 2021 Jul 1.
        INTRODUCTION: Understanding the costs to increase vaccination demand among under-vaccinated populations, as well as costs incurred by beneficiaries and caregivers for reaching vaccination sites, is essential to improving vaccination coverage. However, there have not been systematic analyses documenting such costs for beneficiaries and caregivers seeking vaccination. METHODS: We searched PubMed, Scopus, and the Immunization Delivery Cost Catalogue (IDCC) in 2019 for the costs for beneficiaries and caregivers to 1) seek and know how to access vaccination (i.e., costs to immunization programs for social mobilization and interventions to increase vaccination demand), 2) take time off from work, chores, or school for vaccination (i.e., productivity costs), and 3) travel to vaccination sites. We assessed if these costs were specific to populations that faced other non-cost barriers, based on a framework for defining hard-to-reach and hard-to-vaccinate populations for vaccination. RESULTS: We found 57 studies describing information, education, and communication (IEC) costs, social mobilization costs, and the costs of interventions to increase vaccination demand, with mean costs per dose at $0.41 (standard deviation (SD) $0.83), $18.86 (SD $50.65) and $28.23 (SD $76.09) in low-, middle-, and high-income countries, respectively. Five studies described productivity losses incurred by beneficiaries and caregivers seeking vaccination ($38.33 per person; SD $14.72; n = 3). We identified six studies on travel costs incurred by beneficiaries and caregivers attending vaccination sites ($11.25 per person; SD $9.54; n = 4). Two studies reported social mobilization costs per dose specific to hard-to-reach populations, which were 2-3.5 times higher than costs for the general population. Eight studies described barriers to vaccination among hard-to-reach populations. CONCLUSION: Social mobilization/IEC costs are well-characterized, but evidence is limited on costs incurred by beneficiaries and caregivers getting to vaccination sites. Understanding the potential incremental costs for populations facing barriers to reach vaccination sites is essential to improving vaccine program financing and planning.

    • Healthcare Associated Infections
      1. BACKGROUND: Although most norovirus outbreaks in high-income countries occur in healthcare facilities, information on associations between control measures and outbreak outcomes in these settings are lacking. METHODS: We conducted a systematic review/meta-analysis of published papers to assess associations between norovirus outbreak control measures and outcomes in hospitals and long-term care facilities (LTCFs), globally. Using regression analyses stratified by setting (hospital/LTCF), we compared durations, attack rates and case counts for outbreaks in which control measures were reportedly implemented to those in which they were not. RESULTS: We identified 102 papers describing 162 norovirus outbreaks. Control measures were reportedly implemented in 118 (73%) outbreaks and were associated with 0.6 (95% CI: 0.3-1.1) times smaller patient case counts and 0.7 (95% CI: 0.4, 1.0) times shorter durations in hospitals but 1.5 (95% CI: 1.1, 2.2), 1.5 (95% CI: 1.0-2.1) and 1.6 (95% CI: 1.0-2.6) times larger overall, resident and staff case counts, respectively, and 1.4 (95% CI: 1.0-2.0) times longer durations in LTCFs. CONCLUSIONS: Reported implementation of control measures was associated with smaller/shorter outbreaks in hospitals but larger/longer outbreaks in LTCFs. Control measures were likely implemented in response to larger/longer outbreaks in LTCFs, rather than causing them. Prospective observational or intervention studies are needed to determine effectiveness.

      2. Unexpected Hepatitis B Virus Infection After Liver Transplantation - United States, 2014-2019external icon
        Bixler D, Annambhotla P, Montgomery MP, Mixon-Hayden T, Kupronis B, Michaels MG, La Hoz RM, Basavaraju SV, Kamili S, Moorman A.
        MMWR Morb Mortal Wkly Rep. 2021 Jul 9;70(27):961-966.
        Unexpected donor-derived hepatitis B virus (HBV) infection is defined as a new HBV infection in a recipient of a transplanted organ from a donor who tested negative for total antihepatitis B core antibody (total anti-HBc), hepatitis B surface antigen (HBsAg), and HBV DNA* before organ procurement. Such infections are rare and are associated with injection drug use among deceased donors (1). During 2014-2019, CDC received 20 reports of HBV infection among recipients of livers from donors who had no evidence of past or current HBV infection. Investigation included review of laboratory data and medical records. Fourteen of these new HBV infections were detected during 2019 alone; infections were detected a median of 38 (range = 5-116) weeks after transplantation. Of the 14 donors, 13 were hepatitis C virus (HCV)-seropositive(†) and had a history of injection drug use within the year preceding death, a positive toxicology result, or both. Because injection drug use is the most commonly reported risk factor for hepatitis C,(§) providers caring for recipients of organs from donors who are HCV-seropositive or recently injected drugs should maintain awareness of infectious complications of injection drug use and monitor recipients accordingly (2). In addition to testing for HBV DNA at 4-6 weeks after transplantation, clinicians caring for liver transplant recipients should consider testing for HBV DNA 1 year after transplantation or at any time if signs and symptoms of viral hepatitis develop, even if previous tests were negative (2).

      3. Trends in Antibiotic Use in United States Hospitals During the Coronavirus Disease 2019 Pandemicexternal icon
        Rose AN, Baggs J, Wolford H, Neuhauser MM, Srinivasan A, Gundlapalli AV, Reddy S, Kompaniyets L, Pennington AF, Grigg C, Kabbani S.
        Open Forum Infect Dis. 2021 Jun;8(6):ofab236.
        We described antibiotic use among inpatients with coronavirus disease 2019 (COVID-19). Most COVID-19 inpatients received antibiotic therapy. We also described hospital-wide antibiotic use during 2020 compared with 2019, stratified by hospital COVID-19 burden. Although total antibiotic use decreased between years, certain antibiotic use increased with higher COVID-19 burden.

    • Immunity and Immunization
      1. Use of mRNA COVID-19 Vaccine After Reports of Myocarditis Among Vaccine Recipients: Update from the Advisory Committee on Immunization Practices - United States, June 2021external icon
        Gargano JW, Wallace M, Hadler SC, Langley G, Su JR, Oster ME, Broder KR, Gee J, Weintraub E, Shimabukuro T, Scobie HM, Moulia D, Markowitz LE, Wharton M, McNally VV, Romero JR, Talbot HK, Lee GM, Daley MF, Oliver SE.
        MMWR Morb Mortal Wkly Rep. 2021 Jul 9;70(27):977-982.
        In December 2020, the Food and Drug Administration (FDA) issued Emergency Use Authorizations (EUAs) for the Pfizer-BioNTech COVID-19 (BNT162b2) vaccine and the Moderna COVID-19 (mRNA-1273) vaccine,(†) and the Advisory Committee on Immunization Practices (ACIP) issued interim recommendations for their use in persons aged ≥16 years and ≥18 years, respectively.(§) In May 2021, FDA expanded the EUA for the Pfizer-BioNTech COVID-19 vaccine to include adolescents aged 12-15 years; ACIP recommends that all persons aged ≥12 years receive a COVID-19 vaccine. Both Pfizer-BioNTech and Moderna vaccines are mRNA vaccines encoding the stabilized prefusion spike glycoprotein of SARS-CoV-2, the virus that causes COVID-19. Both mRNA vaccines were authorized and recommended as a 2-dose schedule, with second doses administered 21 days (Pfizer-BioNTech) or 28 days (Moderna) after the first dose. After reports of myocarditis and pericarditis in mRNA vaccine recipients,(¶) which predominantly occurred in young males after the second dose, an ACIP meeting was rapidly convened to review reported cases of myocarditis and pericarditis and discuss the benefits and risks of mRNA COVID-19 vaccination in the United States. Myocarditis is an inflammation of the heart muscle; if it is accompanied by pericarditis, an inflammation of the thin tissue surrounding the heart (the pericardium), it is referred to as myopericarditis. Hereafter, myocarditis is used to refer to myocarditis, pericarditis, or myopericarditis. On June 23, 2021, after reviewing available evidence including that for risks of myocarditis, ACIP determined that the benefits of using mRNA COVID-19 vaccines under the FDA's EUA clearly outweigh the risks in all populations, including adolescents and young adults. The EUA has been modified to include information on myocarditis after receipt of mRNA COVID-19 vaccines. The EUA fact sheets should be provided before vaccination; in addition, CDC has developed patient and provider education materials about the possibility of myocarditis and symptoms of concern, to ensure prompt recognition and management of myocarditis.

      2. Tanzania's human papillomavirus (HPV) vaccination program: Community awareness, feasibility, and acceptability of a national HPV vaccination program, 2019external icon
        Li AJ, Manzi F, Kyesi F, Makame Y, Mwengee W, Fleming M, Mkopi A, Mmbaga S, Lyimo D, Loharikar A.
        Vaccine. 2021 Jul 3.
        BACKGROUND: In April 2018, Tanzania introduced the human papillomavirus (HPV) vaccine nationally to 14-year-old girls, utilizing routine delivery strategies (i.e. vaccinating girls at health facilities and community outreach, including schools). We sought to assess awareness, feasibility, and acceptability of the HPV vaccination program among health workers and community-level stakeholders. METHODS: We conducted cross-sectional in-person surveys among health workers, school personnel, community leaders, and council leaders in 18 council areas across six regions of Tanzania in October-November 2019. Regions were purposively selected to provide demographic, geographic, and vaccination coverage variability; sub-regional levels used random or stratified random sampling. Surveys included questions on HPV vaccine training and knowledge, delivery strategy, target population, and vaccine and program acceptability. Descriptive analysis was completed for all variables stratified by respondent groups. RESULTS: Across the 18 councils, there were 461 respondents, including health workers (165), school personnel (135), community leaders (143), and council leaders (18). Over half of each respondent group (50-78%) attended a training or orientation on HPV vaccine. Almost 75% of the health workers and school personnel respondent groups, and less than half (45%) of community leaders correctly identified the target age group for HPV vaccine. Most (80%) of the health workers indicated HPV vaccination was available at health facilities and schools; most (79%) indicated that the majority of girls receive HPV vaccine in school. Approximately half (52%) of all respondents reported hearing misinformation about HPV vaccine, but 97% of all respondents indicated that HPV vaccine was either "very accepted" or "somewhat accepted" in their community. CONCLUSION: The HPV vaccination program in Tanzania was well accepted by community stakeholders in 18 councils; adequate knowledge of HPV vaccine and the HPV vaccination program was demonstrated by health workers and school personnel. However, continued technical support for integration of HPV vaccination as a routine immunization activity and reinforcement of basic knowledge about HPV vaccine in specific community groups is needed. The Tanzania experience provides an example of how this vaccine can be integrated into routine immunization delivery strategies and can be a useful resource for countries planning to introduce HPV vaccine as well as informing global partners on how to best support to countries in operationalizing their HPV vaccine introduction plans.

      3. Influenza Illness and Partial Vaccination in the First Two Years of Lifeexternal icon
        Wagner AL, Gresh L, Sanchez N, Kuan G, Kubale J, Lopez R, Ojeda S, Azziz-Baumgartner E, Balmaseda A, Gordon A.
        Vaccines (Basel). 2021 Jun 20;9(6).
        More information about influenza in low- and middle-income countries could guide the establishment of pediatric influenza vaccine programs. This study (1) characterizes the burden of influenza in infants, and (2) compares signs and symptoms by prior influenza vaccination or influenza illness. Newborns from Managua, Nicaragua, were followed for two years. Data came from primary medical appointments, PCR testing, and parents' daily symptom diaries. Logistic regression models estimated associations between preceding vaccination or illness and influenza incidence. Linear models compared duration of illness by prior vaccination or influenza illness. Among 833 infants, 31% had PCR-positive influenza, and 28% were vaccinated against influenza. Four (<0.5%) were fully vaccinated. Overall, influenza incidence was 21.0 (95% confidence interval (CI): 18.8, 23.2) per 100 person-years. Incidence was lower among those with prior influenza compared with those without preceding illness or vaccination (OR: 0.64, 95% CI: 0.44, 0.94). Partially vaccinated children had 1 day less fever than those without prior illness or vaccination (p = 0.049). A large proportion of children <2 years in Nicaragua contract influenza. Illness was attenuated for those partially vaccinated. Since few children were fully vaccinated, future studies will need to consider the effectiveness of a two-dose vaccination schedule.

    • Laboratory Sciences
      1. Liquid wastes (LW) disposed in hospital handwashing sinks may affect colonization of sink P-traps by carbapenemase-producing Klebsiella pneumoniae (CPKP), causing CPKP dispersal into the patient care environment. This study aimed to determine the effect of LW on biofilm formation and CPKP colonization in a P-Trap model (PTM). PTMs containing polymicrobial biofilms grown in autoclaved municipal tap water (ATW) supplemented with 5% dextrose in water (D5W), nutritional shake (Shake), sugar-based soft drink (Soda), or ATW were inoculated with K. pneumoniae ST258 KPC+ (ST258) or K. pneumoniae CAV1016 (CAV1016) and sampled after 7, 14, and 21 d. Biofilm bio-volume, mean thickness, and heterotrophic plate counts were significantly reduced and roughness coefficient significantly increased by Soda compared with D5W, Shake, or ATW. CPKP were significantly reduced by Soda but significantly amplified by D5W (ST258; CAV1016, 7 d) and Shake (ST258) suggesting that reducing LW disposal in sinks may reduce CPKP dispersal into patient care environments.

      2. tinselR-an R Shiny Application for Annotating Phylogenetic Treesexternal icon
        Hamlin JA, Nakov T, Williams-Newkirk A.
        Microbiol Resour Announc. 2021 Jul 8;10(27):e0022721.
        Public health laboratories obtain whole-genome sequences of pathogens to confirm outbreaks and identify transmission routes. Here, we present tinselR, an open-source and user-friendly application for visualization and annotation of relatedness among pathogens with phylogenetic trees. By combining annotation and phylogenetics, we simplify one critical step in the pathogen analysis workflow.

      3. Nanoparticles as a Tool in Neuro-Oncology Theranosticsexternal icon
        Klein AL, Nugent G, Cavendish J, Geldenhuys WJ, Sriram K, Porter D, Fladeland R, Lockman PR, Sherman JH.
        Pharmaceutics. 2021 Jun 24;13(7).
        The rapid growth of nanotechnology and the development of novel nanomaterials with unique physicochemical characteristics provides potential for the utility of nanomaterials in theranostics, including neuroimaging, for identifying neurodegenerative changes or central nervous system malignancy. Here we present a systematic and thorough review of the current evidence pertaining to the imaging characteristics of various nanomaterials, their associated toxicity profiles, and mechanisms for enhancing tropism in an effort to demonstrate the utility of nanoparticles as an imaging tool in neuro-oncology. Particular attention is given to carbon-based and metal oxide nanoparticles and their theranostic utility in MRI, CT, photoacoustic imaging, PET imaging, fluorescent and NIR fluorescent imaging, and SPECT imaging.

      4. Accurate assembly of minority viral haplotypes from next-generation sequencing through efficient noise reductionexternal icon
        Knyazev S, Tsyvina V, Shankar A, Melnyk A, Artyomenko A, Malygina T, Porozov YB, Campbell EM, Switzer WM, Skums P, Mangul S, Zelikovsky A.
        Nucleic Acids Res. 2021 Jul 2.
        Rapidly evolving RNA viruses continuously produce minority haplotypes that can become dominant if they are drug-resistant or can better evade the immune system. Therefore, early detection and identification of minority viral haplotypes may help to promptly adjust the patient's treatment plan preventing potential disease complications. Minority haplotypes can be identified using next-generation sequencing, but sequencing noise hinders accurate identification. The elimination of sequencing noise is a non-trivial task that still remains open. Here we propose CliqueSNV based on extracting pairs of statistically linked mutations from noisy reads. This effectively reduces sequencing noise and enables identifying minority haplotypes with the frequency below the sequencing error rate. We comparatively assess the performance of CliqueSNV using an in vitro mixture of nine haplotypes that were derived from the mutation profile of an existing HIV patient. We show that CliqueSNV can accurately assemble viral haplotypes with frequencies as low as 0.1% and maintains consistent performance across short and long bases sequencing platforms.

      5. Molecular characterization of Giardia duodenalis and evidence for cross-species transmission in Northern Argentinaexternal icon
        Kuthyar S, Kowalewski MM, Seabolt M, Roellig DM, Gillespie TR.
        Transbound Emerg Dis. 2021 Jul 5.
        Anthropogenic activities, such as human population expansion and land-use change, create ecological overlap between humans, domesticated animals, and wildlife and can exacerbate the zoonotic transmission of parasites. To improve our understanding of this dynamic, we employed multi-locus genotyping to conduct a cross-sectional study of the potential for zoonotic transmission of the protozoan parasite Giardia duodenalis among humans, household associated livestock and dogs, and black and gold howler monkeys (Alouatta caraya) in the Corrientes Province of Argentina. We found Giardia prevalence to be highest in howler monkeys (90.3% (47/52)), followed by humans (61.1% (22/36)), dogs (44.4% (16/36)), and cattle (41.9% (18/43)). We further established that howler monkeys exclusively harbored strains of assemblage B (100%) while humans were infected with either assemblage A (13.3%) or B (80%) or A and B (6.7%), and cattle and dogs were infected with either assemblage A (cattle, 94.1%; dogs, 80%)), A and C (10%), or their host-adapted assemblage (cattle, 5.9%; dogs, 10%). Our finding of G. duodenalis in both humans and domesticated animals (assemblage A) and humans and wild primates (assemblage B) suggests that cross-species transmission of multiple assemblages of G. duodenalis may occur in rural complexes such as northern Argentina where people, domesticated animals, and wildlife overlap. We further highlight the need to investigate the implications of these results for human health, the economics of livestock production, and wildlife conservation in this and similar systems. This article is protected by copyright. All rights reserved.

      6. Two-tail t test statistical analyses of International Organization for Standardization nonintense and Canadian Intense mainstream smoke yields of total particulate matter, tar, nicotine, and carbon monoxide from cigarettes show that mean quantities are generally higher for a linear smoking machine at a 95% confidence level but a rotary smoking machine has better precision. A novel "super pad" analysis concept combines four smaller filter pads from a linear smoking machine, resulting in increased mean constituent yields and reduced variability. Although measurement variability is still greater than that of rotary machines, super padding may be useful to reduce the variance caused by linear smoking machines.

      7. Multiplex Real-Time Reverse Transcription PCR for Influenza A Virus, Influenza B Virus, and Severe Acute Respiratory Syndrome Coronavirus 2external icon
        Shu B, Kirby MK, Davis WG, Warnes C, Liddell J, Liu J, Wu KH, Hassell N, Benitez AJ, Wilson MM, Keller MW, Rambo-Martin BL, Camara Y, Winter J, Kondor RJ, Zhou B, Spies S, Rose LE, Winchell JM, Limbago BM, Wentworth DE, Barnes JR.
        Emerg Infect Dis. 2021 ;27(7):1821-1830.
        Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in late 2019, and the outbreak rapidly evolved into the current coronavirus disease pandemic. SARS-CoV-2 is a respiratory virus that causes symptoms similar to those caused by influenza A and B viruses. On July 2, 2020, the US Food and Drug Administration granted emergency use authorization for in vitro diagnostic use of the Influenza SARS-CoV-2 Multiplex Assay. This assay detects influenza A virus at 10(2.0), influenza B virus at 10(2.2), and SARS-CoV-2 at 10(0.3) 50% tissue culture or egg infectious dose, or as few as 5 RNA copies/reaction. The simultaneous detection and differentiation of these 3 major pathogens increases overall testing capacity, conserves resources, identifies co-infections, and enables efficient surveillance of influenza viruses and SARS-CoV-2.

      8. Changes to virus taxonomy and to the International Code of Virus Classification and Nomenclature ratified by the International Committee on Taxonomy of Viruses (2021)external icon
        Walker PJ, Siddell SG, Lefkowitz EJ, Mushegian AR, Adriaenssens EM, Alfenas-Zerbini P, Davison AJ, Dempsey DM, Dutilh BE, García ML, Harrach B, Harrison RL, Hendrickson RC, Junglen S, Knowles NJ, Krupovic M, Kuhn JH, Lambert AJ, Łobocka M, Nibert ML, Oksanen HM, Orton RJ, Robertson DL, Rubino L, Sabanadzovic S, Simmonds P, Smith DB, Suzuki N, Van Dooerslaer K, Vandamme AM, Varsani A, Zerbini FM.
        Arch Virol. 2021 Jul 6.
        This article reports the changes to virus taxonomy approved and ratified by the International Committee on Taxonomy of Viruses (ICTV) in March 2021. The entire ICTV was invited to vote on 290 taxonomic proposals approved by the ICTV Executive Committee at its meeting in October 2020, as well as on the proposed revision of the International Code of Virus Classification and Nomenclature (ICVCN). All proposals and the revision were ratified by an absolute majority of the ICTV members. Of note, ICTV mandated a uniform rule for virus species naming, which will follow the binomial 'genus-species' format with or without Latinized species epithets. The Study Groups are requested to convert all previously established species names to the new format. ICTV has also abolished the notion of a type species, i.e., a species chosen to serve as a name-bearing type of a virus genus. The remit of ICTV has been clarified through an official definition of 'virus' and several other types of mobile genetic elements. The ICVCN and ICTV Statutes have been amended to reflect these changes.

      9. Screening and Identification of Lujo Virus Inhibitors Using a Recombinant Reporter Virus Platformexternal icon
        Welch SR, Spengler JR, Genzer SC, Chatterjee P, Flint M, Bergeron É, Montgomery JM, Nichol ST, Albariño CG, Spiropoulou CF.
        Viruses. 2021 Jun 28;13(7).
        Lujo virus (LUJV), a highly pathogenic arenavirus, was first identified in 2008 in Zambia. To aid the identification of effective therapeutics for LUJV, we developed a recombinant reporter virus system, confirming reporter LUJV comparability with wild-type virus and its utility in high-throughput antiviral screening assays. Using this system, we evaluated compounds with known and unknown efficacy against related arenaviruses, with the aim of identifying LUJV-specific and potential new pan-arenavirus antivirals. We identified six compounds demonstrating robust anti-LUJV activity, including several compounds with previously reported activity against other arenaviruses. These data provide critical evidence for developing broad-spectrum antivirals against high-consequence arenaviruses.

    • Maternal and Child Health
      1. Clinical presentation and management of childhood intussusception in South Africaexternal icon
        Cox S, Withers A, Arnold M, Chitnis M, de Vos C, Kirsten M, le Grange SM, Loveland J, Machaea S, Maharaj A, Madhi SA, Tate JE, Parashar UD, Groome MJ.
        Pediatr Surg Int. 2021 Jul 2.
        PURPOSE: We assessed management and outcomes for intussusception at nine academic hospitals in South Africa. METHODS: Patients ≤ 3 years presenting with intussusception between September 2013 and December 2017 were prospectively enrolled at all sites. Additionally, patients presenting between July 2012 and August 2013 were retrospectively enrolled at one site. Demographics, clinical information, diagnostic modality, reduction methods, surgical intervention and outcomes were reviewed. RESULTS: Four hundred seventy-six patients were enrolled, [54% males, median age 6.5 months (IQR 2.6-32.6)]. Vomiting (92%), bloody stool (91%), abdominal mass (57%), fever (32%) and a rectal mass (29%) represented advanced disease: median symptom duration was 3 days (IQR 1-4). Initial reduction attempts included pneumatic reduction (66%) and upfront surgery (32%). The overall non-surgical reduction rate was 28% and enema perforation rate was 4%. Surgery occurred in 334 (70%), 68 (20%) patients had perforated bowel, bowel resection was required in 61%. Complications included recurrence (2%) and nosocomial sepsis (4%). Length of stay (LOS) was significantly longer in patients who developed complications. Six patients died-a mortality rate of 1%. There was a significant difference in reduction rates, upfront surgery, bowel resection, LOS and mortality between centres with shorter symptom duration compared longer symptom duration. CONCLUSION: Delayed presentation was common and associated with low success for enema reduction, higher operative rates, higher rates of bowel resection and increased LOS. Improved primary health-care worker education and streamlining referral pathways might facilitate timely management.

    • Occupational Safety and Health
      1. Occupational Histoplasmosis: Epidemiology and Prevention Measuresexternal icon
        de Perio MA, Benedict K, Williams SL, Niemeier-Walsh C, Green BJ, Coffey C, Di Giuseppe M, Toda M, Park JH, Bailey RL, Nett RJ.
        J Fungi (Basel). 2021 Jun 26;7(7).
        In areas where Histoplasma is endemic in the environment, occupations involving activities exposing workers to soil that contains bird or bat droppings may pose a risk for histoplasmosis. Occupational exposures are frequently implicated in histoplasmosis outbreaks. In this paper, we review the literature on occupationally acquired histoplasmosis. We describe the epidemiology, occupational risk factors, and prevention measures according to the hierarchy of controls.

      2. Health-Related Exposures and Conditions among US Fishermenexternal icon
        Doza S, Bovbjerg VE, Vaughan A, Nahorniak JS, Case S, Kincl LD.
        J Agromedicine. 2021 Jul 6:1-8.
        Commercial fishing is a high-risk occupation, yet there is a lack of surveillance documenting health conditions, health behaviors, and health care coverage among US fishermen. We used publicly available data sources to identify exposures and health outcomes common among fishermen. We utilized the National Institute for Occupational Safety and Health-Worker Health Charts to estimate the prevalence of general exposures, psychosocial exposures, health behaviors, and health conditions from the national surveys National Health Interview Survey - Occupational Health Supplement (NHIS-OHS, 2015) and Behavioral Risk Factor Surveillance System (BRFSS) (2013-2015). We compared fishing workers with both agricultural workers and all-workers. Fishermen commonly reported general exposures, psychosocial exposures, non-standard work arrangements, frequent night shifts, and shift work. The prevalence of musculoskeletal conditions such as carpal tunnel syndrome (33%) and severe low-back pain (27%) was also high. Smoking (45%) and second-hand smoke exposure (25%) were widespread, and 21% reported no health care coverage. National household surveys such as NHIS-OHS, and BRFSS can be utilized to describe the health status of fishermen. This workforce would benefit from increased access to health care and health promotion programs. More comprehensive evaluations of existing data can help to identify occupation-specific health challenges.

      3. BACKGROUND: Commercial fishing consistently has among the highest workforce injury and fatality rates in the United States. Data related to commercial fishing incidents are routinely collected by multiple organizations which do not currently coordinate or automatically link data. Each data set has the potential to generate a more complete picture to inform prevention efforts. Our objective was to examine the utility of using statistical data linkage methods to link commercial fishing incident data when personally identifiable information is not available. METHODS: In this feasibility study, we identified true matches and discrepancies between de-identified data sets using the Python Record Linkage Toolkit. Four commercial fishing data sets from Oregon and Washington were linked: the Commercial Fishing Incident Database, the Vessel Casualty Database, the Nonfatal Injuries Database, and the Oregon Trauma Registry. The data sets each covered different date ranges within 2000-2017, containing 458, 524, 184, and 11 cases respectively. Several data linkage classifiers were evaluated. RESULTS: The Naïve-Bayes classifier returned the highest number of true matches between these small data sets. A total of 41 true matches and 8 close matches were identified, of which 29 were determined to be duplicates. In addition, linkage highlighted 4 records that were not commercial fishing cases from Oregon and Washington. The optimum match parameters were the date, state, vessel official number, and number of people on board. CONCLUSIONS: Statistical data linkage enables accurate, routine matching for small de-identified injury and fatality data sets such as those in commercial fishing. It provides information needed to improve the accuracy of existing data records. It also enables expanding and sharpening details of individual incidents in support of occupational safety research.

    • Parasitic Diseases
      1. A case report of primary amebic meningoencephalitis in North Floridaexternal icon
        Anjum SK, Mangrola K, Fitzpatrick G, Stockdale K, Matthias L, Ali IK, Cope JR, O'Laughlin K, Collins S, Beal SG, Saccoccio FM.
        IDCases. 2021 ;25.
        Primary amebic meningoencephalitis is a rare, usually fatal disease, caused by Naegleria fowleri. This case highlights the challenging clinicopathologic diagnosis in a 13-year-old boy who swam in freshwater in northern Florida where a previous case had exposure to a body of water on the same property in 2009. © 2021

      2. Plasmodium falciparum kelch 13 Mutations, 9 Countries in Africa, 2014-2018external icon
        Schmedes SE, Patel D, Dhal S, Kelley J, Svigel SS, Dimbu PR, Adeothy AL, Kahunu GM, Nkoli PM, Beavogui AH, Kariuki S, Mathanga DP, Koita O, Ishengoma D, Mohamad A, Hawela M, Moriarty LF, Samuels AM, Gutman J, Plucinski MM, Udhayakumar V, Zhou Z, Lucchi NW, Venkatesan M, Halsey ES, Talundzic E.
        Emerg Infect Dis. 2021 Jul;27(7):1902-1908.
        The spread of drug resistance to antimalarial treatments poses a serious public health risk globally. To combat this risk, molecular surveillance of drug resistance is imperative. We report the prevalence of mutations in the Plasmodium falciparum kelch 13 propeller domain associated with partial artemisinin resistance, which we determined by using Sanger sequencing samples from patients enrolled in therapeutic efficacy studies from 9 sub-Saharan countries during 2014-2018. Of the 2,865 samples successfully sequenced before treatment (day of enrollment) and on the day of treatment failure, 29 (1.0%) samples contained 11 unique nonsynonymous mutations and 83 (2.9%) samples contained 27 unique synonymous mutations. Two samples from Kenya contained the S522C mutation, which has been associated with delayed parasite clearance; however, no samples contained validated or candidate artemisinin-resistance mutations.

    • Social and Behavioral Sciences
      1. Recent Incarceration and Other Correlates of Psychological Distress Among African American and Latino Men Who Have Sex with Menexternal icon
        White JJ, Zaller ND, Fernandez MI, Spikes P, Flores S, Latkin CA, Yang C.
        Community Ment Health J. 2021 Jul 3.
        There is a dearth of research on the intersection of incarceration and psychological distress among men who have sex with men including African American (AAMSM) and Latino MSM (LMSM), populations which bear a large burden of HIV in the U.S. Recent incarceration is an important context to examine psychological distress given the critical implications it has on health outcomes. Using baseline data from the Latino and African American Men's Project (LAAMP), a multi-site randomized HIV behavioral intervention trial, this paper examined the association between previous incarceration within the past three months (i.e., recent incarceration) and psychological distress in the past four weeks, assessed by the Kessler Psychological Distress Scale (K10). Among 1482 AAMSM and LMSM (AAMSM: 911, LMSM: 571), we found 768 (52%) were previously incarcerated, but not in past three months and 138 (9.3%) had been recently incarcerated. After adjusting for race, education, access to resources, current living arrangement, HIV status, and substance use, participants who had been recently incarcerated were more likely to have mild psychological distress i.e., K10 score 20-24 (aRRR:1.43, 95% CI 1.20, 1.71) or severe psychological distress, i.e., K10 score > 30 (aRRR: 1.89, 95% CI 1.22, 2.93) in the past four weeks than those never incarcerated and those previously incarcerated, but not in past three months. Our findings have implications for mental health and HIV prevention services for AAMSM and LMSM with previous incarceration within the past three months.

    • Substance Use and Abuse
      1. Characterization of Total and Unprotonated (Free) Nicotine Content of Nicotine Pouch Productsexternal icon
        Stanfill S, Tran H, Tyx R, Fernandez C, Zhu W, Marynak K, King B, Valentín-Blasini L, Blount BC, Watson C.
        Nicotine Tob Res. 2021 May 26.
        INTRODUCTION: Nicotine pouch products, oral smokeless products that contain nicotine but no tobacco leaf material, have recently entered the US marketplace. Available data indicate sales of these products in the United States have increased since 2018; however, the extent of use among US youth and adults is uncertain. METHODS: To assay the chemistry of these emerging tobacco products, we analyzed 37 nicotine pouch brands from six total manufacturers. Almost all of the products had flavor descriptors (36 of 37), such as mint, licorice, coffee, cinnamon, and fruit. The amount of free nicotine, the form most easily absorbed, was calculated for each product using total nicotine, product pH, the appropriate pKa, and the Henderson-Hasselbalch equation. RESULTS: Nicotine pouch products varied in pouch content mass, moisture content (1.12%‒47.2%), alkalinity (pH 6.86‒10.1), and % free nicotine (7.7%‒99.2%). Total nicotine content ranged from 1.29 to 6.11 mg/pouch, whereas free nicotine ranged from 0.166 to 6.07 mg/pouch. These findings indicate that nicotine and pH levels found in some of these nicotine pouches are similar to conventional tobacco products, such as moist snuff and snus, and that most of these pouch products are flavored. CONCLUSIONS: Although these products likely lack many tobacco-related chemicals, each product analyzed contained nicotine, which is both addictive and can harm human health. Given that nicotine pouches may appeal to a spectrum of users, from novice to experienced users, it is important to include these emerging tobacco products in tobacco control research, policy, and practice. IMPLICATIONS: These "tobacco-free" nicotine pouches have similar pH and nicotine content to conventional tobacco products, such as moist snuff and snus. Although they lack many tobacco-related chemicals, most are highly flavored which could increase experimentation from new users. Given that nicotine pouches may appeal to a spectrum of users, from novice to experienced users, in terms of their flavors and nicotine content, it is important to examine and include these emerging tobacco products as they relate to tobacco control research, policy, and practice.

    • Veterinary Medicine
      1. The Gombe Ecosystem Health Project: 16 years of program evolution and lessons learnedexternal icon
        Lonsdorf EV, Travis DA, Raphael J, Kamenya S, Lipende I, Mwacha D, Collins DA, Wilson M, Mjungu D, Murray C, Bakuza J, Wolf TM, Parsons MB, Deere JR, Lantz E, Kinsel MJ, Santymire R, Pintea L, Terio KA, Hahn BH, Pusey AE, Goodall J, Gillespie TR.
        Am J Primatol. 2021 Jul 5:e23300.
        Infectious disease outbreaks pose a significant threat to the conservation of chimpanzees (Pan troglodytes) and all threatened nonhuman primates. Characterizing and mitigating these threats to support the sustainability and welfare of wild populations is of the highest priority. In an attempt to understand and mitigate the risk of disease for the chimpanzees of Gombe National Park, Tanzania, we initiated a long-term health-monitoring program in 2004. While the initial focus was to expand the ongoing behavioral research on chimpanzees to include standardized data on clinical signs of health, it soon became evident that the scope of the project would ideally include diagnostic surveillance of pathogens for all primates (including people) and domestic animals, both within and surrounding the National Park. Integration of these data, along with in-depth post-mortem examinations, have allowed us to establish baseline health indicators to inform outbreak response. Here, we describe the development and expansion of the Gombe Ecosystem Health project, review major findings from the research and summarize the challenges and lessons learned over the past 16 years. We also highlight future directions and present the opportunities and challenges that remain when implementing studies of ecosystem health in a complex, multispecies environment.

    • Zoonotic and Vectorborne Diseases
      1. New Mixed Methods Approach for Monitoring Community Perceptions of Ebola and Response Efforts in the Democratic Republic of the Congoexternal icon
        Earle-Richardson G, Erlach E, Walz V, Baggio O, Kurnit M, Camara CA, Craig C, Dios LR, Yee D, Soke GN, Voahary I, Prue CE.
        Glob Health Sci Pract. 2021 Jun 30;9(2):332-343.
        BACKGROUND: Efforts to contain the spread of Ebola in the eastern Democratic Republic of the Congo (DRC) during the 2018-2020 epidemic faced challenges in gaining community trust and participation. This affected implementation of community alerts, early isolation, contact tracing, vaccination, and safe and dignified burials. To quickly understand community perspectives and improve community engagement, collaborators from the DRC Red Cross, the International Federation of the Red Cross, and the U.S. Centers for Disease Control and Prevention explored a new method of collecting, coding, and quickly analyzing community feedback. METHODS: Over 800 DRC Red Cross local volunteers recorded unstructured, free-text questions and comments from community members during community Ebola awareness activities. Comments were coded and analyzed using a text-coding system developed by the collaborators. Coded comments were then aggregated and qualitatively grouped into major themes, and time trends were examined. RESULTS: Communities reported a lack of information about the outbreak and the response, as well as concerns about the Ebola vaccination program and health care quality. Some doubted that Ebola was real. The response used the feedback to revise some community engagement approaches. For example, 2 procedural changes that were followed by drops in negative community responses were: using transparent body bags, which allayed fears that bodies or organs were being stolen, and widening the eligibility criteria for Ebola vaccination, which addressed concerns that selectively vaccinating individuals within Ebola-affected communities was unfair. DISCUSSION: This system is unique in that unstructured feedback collected by local volunteers in the course of their work was rapidly coded, analyzed, and given to health authorities for use in making course corrections throughout the response. It provides a platform for local voices to be heard throughout an emergency response and provides a mechanism for assessing the effects of program adjustments on community sentiments.

      2. Fatal Human Infection with Evidence of Intrahost Variation of Eastern Equine Encephalitis Virus, Alabama, USA, 2019external icon
        Hughes HR, Velez JO, Davis EH, Laven J, Gould CV, Panella AJ, Lambert AJ, Staples JE, Brault AC.
        Emerg Infect Dis. 2021 Jul;27(7):1886-1892.
        Eastern equine encephalitis virus (EEEV) is an arbovirus in the family Togaviridae, genus Alphavirus, found in North America and associated with freshwater/hardwood swamps in the Atlantic, Gulf Coast, and Great Lakes regions. EEEV disease in humans is rare but causes substantial illness and death. To investigate the molecular epidemiology and microevolution of EEEV from a fatal case in Alabama, USA, in 2019, we used next-generation sequencing of serum and cerebrospinal fluid (CSF). Phylogenetic inference indicated that the infecting strain may be closely related to isolates from Florida detected during 2010-2014, suggesting potential seeding from Florida. EEEV detected in serum displayed a higher degree of variability with more single-nucleotide variants than that detected in the CSF. These data refine our knowledge of EEEV molecular epidemiologic dynamics in the Gulf Coast region and demonstrate potential quasispecies bottlenecking within the central nervous system of a human host.

      3. Assessing clinicians' Post-Exposure Prophylaxis recommendations for rabies virus exposures in Hunan Province, Chinaexternal icon
        Li Y, Rainey JJ, Yang H, Tran CH, Huai Y, Liu R, Zhu H, Wang Z, Mu D, Yin W, Guo C, Shiferaw M, Chen Q, Hu S, Li Z.
        PLoS Negl Trop Dis. 2021 Jul 6;15(7):e0009564.
        BACKGROUND: Timely and appropriate administration of post-exposure prophylaxis (PEP) is an essential component of human rabies prevention programs. We evaluated patient care at rabies clinics in a high-risk county in Hunan Province, China to inform strategies needed to achieve dog-mediated human rabies elimination by 2030. METHODS: We collected information on PEP, staff capacity, and service availability at the 17 rabies clinics in the high-risk county during onsite visits and key staff interviews. Additionally, we conducted observational assessments at five of these clinics, identified through purposive sampling to capture real-time information on patient care during a four-week period. Wound categories assigned by trained observers were considered accurate per national guidelines for comparison purposes. We used the kappa statistic and an alpha level of 0.05 to assess agreement between observers and clinic staff. RESULTS: In 2015, the 17 clinics provided PEP to 5,261 patients. Although rabies vaccines were available at all 17 clinics, rabies immune globulin (RIG) was only available at the single urban clinic in the county. During the assessment period in 2016, 196 patients sought care for possible rabies virus exposures. According to observers, 88 (44%) patients had category III wounds, 104 (53%) had category II wounds and 4 (2%) had category I wounds. Observers and PEP clinic staff agreed on approximately half of the assigned wound categories (kappa = 0.55, p-value< 0.001). Agreement for the urban county-level CDC clinic (kappa = 0.93, p-value<0.001) was higher than that of the rural township clinics (kappa = 0.16, p-value = 0.007). Using observer assigned wound categories, 142 (73%) patients received rabies vaccinations and RIG as outlined in the national guidelines. CONCLUSION: Rabies PEP services were available at each town of the project county; however, gaps between clinical practice of PEP and recommendations of national rabies guidelines were identified. We used these findings to develop and implement a training to rabies clinic staff on wound categorization, wound care, and appropriate use of PEP. Additional risk-based approaches for evaluating human rabies virus exposures may be needed as China progresses towards elimination.

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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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