Issue 31, August 31, 2021

CDC Science Clips: Volume 13, Issue 31, August 31, 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
      • Trends in gestational diabetes at first live birth by race and ethnicity in the US, 2011-2019external icon
        Shah NS, Wang MC, Freaney PM, Perak AM, Carnethon MR, Kandula NR, Gunderson EP, Bullard KM, Grobman WA, O'Brien MJ, Khan SS.
        Jama. 2021 Aug 17;326(7):660-669.
        IMPORTANCE: Gestational diabetes is associated with adverse maternal and offspring outcomes. OBJECTIVE: To determine whether rates of gestational diabetes among individuals at first live birth changed from 2011 to 2019 and how these rates differ by race and ethnicity in the US. DESIGN, SETTING, AND PARTICIPANTS: Serial cross-sectional analysis using National Center for Health Statistics data for 12 610 235 individuals aged 15 to 44 years with singleton first live births from 2011 to 2019 in the US. EXPOSURES: Gestational diabetes data stratified by the following race and ethnicity groups: Hispanic/Latina (including Central and South American, Cuban, Mexican, and Puerto Rican); non-Hispanic Asian/Pacific Islander (including Asian Indian, Chinese, Filipina, Japanese, Korean, and Vietnamese); non-Hispanic Black; and non-Hispanic White. MAIN OUTCOMES AND MEASURES: The primary outcomes were age-standardized rates of gestational diabetes (per 1000 live births) and respective mean annual percent change and rate ratios (RRs) of gestational diabetes in non-Hispanic Asian/Pacific Islander (overall and in subgroups), non-Hispanic Black, and Hispanic/Latina (overall and in subgroups) individuals relative to non-Hispanic White individuals (referent group). RESULTS: Among the 12 610 235 included individuals (mean [SD] age, 26.3 [5.8] years), the overall age-standardized gestational diabetes rate significantly increased from 47.6 (95% CI, 47.1-48.0) to 63.5 (95% CI, 63.1-64.0) per 1000 live births from 2011 to 2019, a mean annual percent change of 3.7% (95% CI, 2.8%-4.6%) per year. Of the 12 610 235 participants, 21% were Hispanic/Latina (2019 gestational diabetes rate, 66.6 [95% CI, 65.6-67.7]; RR, 1.15 [95% CI, 1.13-1.18]), 8% were non-Hispanic Asian/Pacific Islander (2019 gestational diabetes rate, 102.7 [95% CI, 100.7-104.7]; RR, 1.78 [95% CI, 1.74-1.82]), 14% were non-Hispanic Black (2019 gestational diabetes rate, 55.7 [95% CI, 54.5-57.0]; RR, 0.97 [95% CI, 0.94-0.99]), and 56% were non-Hispanic White (2019 gestational diabetes rate, 57.7 [95% CI, 57.2-58.3]; referent group). Gestational diabetes rates were highest in Asian Indian participants (2019 gestational diabetes rate, 129.1 [95% CI, 100.7-104.7]; RR, 2.24 [95% CI, 2.15-2.33]). Among Hispanic/Latina participants, gestational diabetes rates were highest among Puerto Rican individuals (2019 gestational diabetes rate, 75.8 [95% CI, 71.8-79.9]; RR, 1.31 [95% CI, 1.24-1.39]). Gestational diabetes rates increased among all race and ethnicity subgroups and across all age groups. CONCLUSIONS AND RELEVANCE: Among individuals with a singleton first live birth in the US from 2011 to 2019, rates of gestational diabetes increased across all racial and ethnic subgroups. Differences in absolute gestational diabetes rates were observed across race and ethnicity subgroups.

    • Communicable Diseases
      • Estimating under-recognized COVID-19 deaths, United States, March 2020-May 2021 using an excess mortality modelling approachexternal icon
        Iuliano AD, Chang HH, Patel NN, Threlkel R, Kniss K, Reich J, Steele M, Hall AJ, Fry AM, Reed C.
        Lancet Reg Health Am. 2021 Jul 13:100019.
        BACKGROUND: In the United States, Coronavirus Disease 2019 (COVID-19) deaths are captured through the National Notifiable Disease Surveillance System and death certificates reported to the National Vital Statistics System (NVSS). However, not all COVID-19 deaths are recognized and reported because of limitations in testing, exacerbation of chronic health conditions that are listed as the cause of death, or delays in reporting. Estimating deaths may provide a more comprehensive understanding of total COVID-19-attributable deaths. METHODS: We estimated COVID-19 unrecognized attributable deaths, from March 2020-April 2021, using all-cause deaths reported to NVSS by week and six age groups (0-17, 18-49, 50-64, 65-74, 75-84, and ≥85 years) for 50 states, New York City, and the District of Columbia using a linear time series regression model. Reported COVID-19 deaths were subtracted from all-cause deaths before applying the model. Weekly expected deaths, assuming no SARS-CoV-2 circulation and predicted all-cause deaths using SARS-CoV-2 weekly percent positive as a covariate were modelled by age group and including state as a random intercept. COVID-19-attributable unrecognized deaths were calculated for each state and age group by subtracting the expected all-cause deaths from the predicted deaths. FINDINGS: We estimated that 766,611 deaths attributable to COVID-19 occurred in the United States from March 8, 2020-May 29, 2021. Of these, 184,477 (24%) deaths were not documented on death certificates. Eighty-two percent of unrecognized deaths were among persons aged ≥65 years; the proportion of unrecognized deaths were 0•24-0•31 times lower among those 0-17 years relative to all other age groups. More COVID-19-attributable deaths were not captured during the early months of the pandemic (March-May 2020) and during increases in SARS-CoV-2 activity (July 2020, November 2020-February 2021). DISCUSSION: Estimating COVID-19-attributable unrecognized deaths provides a better understanding of the COVID-19 mortality burden and may better quantify the severity of the COVID-19 pandemic. FUNDING: None.

      • Pelvic inflammatory disease (PID) is a syndrome that causes substantial morbidity, including chronic pelvic pain, to women globally. While limited data are available from low- and middle-income countries, national databases from the United States and Europe suggest that PID incidence may be decreasing but the rate of decrease may differ by the etiologic cause. Recent studies of women with PID have reported that fewer than half of women receiving a diagnosis of PID have gonococcal or chlamydial infection, while Mycoplasma genitalium, respiratory pathogens, and the constellation of bacteria associated with bacterial vaginosis may account for a substantial fraction of PID cases. The clinical diagnosis of PID is nonspecific, creating an urgent need to develop noninvasive tests to diagnose PID. Advances in serologic testing for Chlamydia trachomatis and Neisseria gonorrhoeae could advance epidemiologic studies, while the development of vaccines against these sexually transmitted pathogens could affect incident PID and associated morbidity.

    • Environmental Health
      • Correlates of plasma concentrations of per- and poly-fluoroalkyl substances among reproductive-aged Black womenexternal icon
        Wise LA, Wesselink AK, Schildroth S, Calafat AM, Bethea TN, Geller RJ, Coleman CM, Fruh V, Henn BC, Botelho JC, Harmon QE, Thirkill M, Wegienka GR, Baird DD.
        Environ Res. 2021 Aug 14:111860.
        BACKGROUND: Per- and polyfluoroalkyl substances (PFAS) are synthetic chemicals used in commercial and consumer goods. Black women are underrepresented in studies of PFAS exposure. METHODS: We performed a cross-sectional analysis of correlates of plasma PFAS concentrations among 1499 Black women aged 23-35 participating in the Study of Environment, Lifestyle, and Fibroids (SELF), a Detroit-based cohort study. At baseline (2010-2012), participants provided questionnaire data on socio-demographics; behaviors; diet; and menstrual, contraceptive, and reproductive histories. Using mass spectrometry in non-fasting plasma samples collected at enrollment, we quantified several PFAS, including perfluorohexane sulfonate (PFHxS), perfluorooctane sulfonate (PFOS), perfluorooctanoate (PFOA), perfluorononanoate (PFNA), perfluorodecanoate (PFDA), perfluoroundecanoate (PFUnDA), and 2-N-methyl-perfluorooctane sulfonamido acetate (MeFOSAA). We used linear regression to calculate percentage differences (%D) and 95 % confidence intervals (CIs) for associations between selected correlates and PFAS concentrations, adjusting for all other correlates. RESULTS: PFHxS, PFOS, PFOA, and PFNA were detected in ≥97 % of women; PFDA in 86 %; MeFOSAA in 70 %; and PFUnDA in 52 %. Age, income, education, and intakes of water, alcohol, and seafood were positively associated with several PFAS. Current smoking was positively associated with MeFOSAA. Body mass index was inversely associated with most PFAS, except PFHxS. Strong inverse associations (%D; 95 % CI) were observed between parity (≥3 vs. 0 births) and PFHxS (-34.7; -43.0, -25.1) and PFOA (-33.1; -39.2, -26.3); breastfeeding duration (≥6 months vs. nulliparous) and PFOA (-31.1; -37.8, -23.7), PFHxS (-24.2; -34.5, -12.3), and PFOS (-18.4; -28.3, -7.1); recent birth (<2 years ago vs. nulliparous) and PFOA (-33.1; -39.6, -25.8), PFHxS (-29.3; -39.0, -18.1), PFNA (-25.2; -32.7, -16.8), and PFOS (-18.3; -28.3, -6.9); and intensity of menstrual bleed (heavy vs. light) and PFHxS (-18.8; -28.3, -8.2), PFOS (-16.4; -24.9, -7.1), PFNA (-10.5; -17.8, -2.6), and PFOA (-10.0; -17.2, -2.1). Current use of depot medroxyprogesterone acetate (DMPA) was positively associated with PFOS (20.2; 1.4, 42.5), PFOA (16.2; 1.5, 33.0), and PFNA (15.3; 0.4, 32.4). CONCLUSIONS: Reproductive factors that influence PFAS elimination showed strong associations with several PFAS (reduced concentrations with parity, recent birth, lactation, heavy menstrual bleeding; increased concentrations with DMPA use). These data contribute to the sparse literature on PFAS exposure among Black women.

    • Genetics and Genomics
      • The genomic epidemiology of multi-drug resistant invasive non-typhoidal Salmonella in selected sub-Saharan African countriesexternal icon
        Park SE, Pham DT, Pak GD, Panzner U, Maria Cruz Espinoza L, von Kalckreuth V, Im J, Mogeni OD, Schütt-Gerowitt H, Crump JA, Breiman RF, Adu-Sarkodie Y, Owusu-Dabo E, Rakotozandrindrainy R, Bassiahi Soura A, Aseffa A, Gasmelseed N, Sooka A, Keddy KH, May J, Aaby P, Biggs HM, Hertz JT, Montgomery JM, Cosmas L, Olack B, Fields B, Sarpong N, Razafindrabe TJ, Raminosoa TM, Kabore LP, Sampo E, Teferi M, Yeshitela B, El Tayeb MA, Krumkamp R, Dekker DM, Jaeger A, Tall A, Gassama A, Niang A, Bjerregaard-Andersen M, Løfberg SV, Deerin JF, Park JK, Konings F, Carey ME, Van Puyvelde S, Ali M, Clemens J, Dougan G, Baker S, Marks F.
        BMJ Glob Health. 2021 Aug;6(8).
        BACKGROUND: Invasive non-typhoidal Salmonella (iNTS) is one of the leading causes of bacteraemia in sub-Saharan Africa. We aimed to provide a better understanding of the genetic characteristics and transmission patterns associated with multi-drug resistant (MDR) iNTS serovars across the continent. METHODS: A total of 166 iNTS isolates collected from a multi-centre surveillance in 10 African countries (2010-2014) and a fever study in Ghana (2007-2009) were genome sequenced to investigate the geographical distribution, antimicrobial genetic determinants and population structure of iNTS serotypes-genotypes. Phylogenetic analyses were conducted in the context of the existing genomic frameworks for various iNTS serovars. Population-based incidence of MDR-iNTS disease was estimated in each study site. RESULTS: Salmonella Typhimurium sequence-type (ST) 313 and Salmonella Enteritidis ST11 were predominant, and both exhibited high frequencies of MDR; Salmonella Dublin ST10 was identified in West Africa only. Mutations in the gyrA gene (fluoroquinolone resistance) were identified in S. Enteritidis and S. Typhimurium in Ghana; an ST313 isolate carrying bla (CTX-M-15) was found in Kenya. International transmission of MDR ST313 (lineage II) and MDR ST11 (West African clade) was observed between Ghana and neighbouring West African countries. The incidence of MDR-iNTS disease exceeded 100/100 000 person-years-of-observation in children aged <5 years in several West African countries. CONCLUSIONS: We identified the circulation of multiple MDR iNTS serovar STs in the sampled sub-Saharan African countries. Investment in the development and deployment of iNTS vaccines coupled with intensified antimicrobial resistance surveillance are essential to limit the impact of these pathogens in Africa.

    • Health Economics
      • Association of obesity and annual health care utilization and spending among long-term cancer survivorsexternal icon
        Han X, Jemal A, Zheng Z, Nogueira L, Khushalani J, Chen Z, Yabroff KR.
        Cancer. 2021 Aug 19.
        BACKGROUND: Obesity is associated with a substantial health and economic burden in the general population in the United States. This study estimates the excess health care utilization and medical spending associated with overweight and obesity among long-term cancer survivors. METHODS: Long-term cancer survivors (≥2 years after their diagnosis) aged ≥18 years (N = 12,547) were identified from the nationally representative 2008-2016 Medical Expenditure Panel Survey. A 2-part modeling approach was used to calculate the average annual care utilization and spending by service type. Excess care utilization and spending associated with overweight (25 kg/m(2) ≤ body mass index [BMI] < 30 kg/m(2) ), obesity (BMI ≥ 30 kg/m(2) ), and severe obesity (BMI ≥ 40 kg/m(2) ), in comparison with normal weight (18.5 kg/m(2) ≤ BMI < 25 kg/m(2) ), were estimated. RESULTS: Compared with normal-weight cancer survivors, overweight survivors had comparable care utilization and medical spending; survivors with obesity had an additional $3216 (95% CI, $1940-$4492) of medical spending, including $1243 (95% CI, $417-$2070) on hospital inpatient services and $1130 (95% CI, $756-$1504) on prescriptions per person per year. The excess annual medical spending associated with obesity among long-term cancer survivors translated to $19.7 billion in 2016 in the United States. The excess medical spending was magnified in cancer survivors with severe obesity ($5317 [95% CI, $2849-$7785], which translated to $6.7 billion in 2016). Excess care utilization and medical spending were mostly explained by comorbid conditions related to obesity. CONCLUSIONS: For long-term cancer survivors, obesity was associated with increased health care utilization and substantial excess medical spending. This suggests that policies and practices promoting a healthy lifestyle and achieving and maintaining a healthy body weight for cancer survivors may reduce their health care utilization and economic burden.

    • Healthcare Associated Infections
    • Laboratory Sciences
      • Characterizing the transport of aluminum-, silicon- and titanium-containing particles and nanoparticles in mainstream tobacco smokeexternal icon
        Fresquez MR, Watson CH, Valentin-Blasini L, Steven Pappas R.
        J Anal Toxicol. 2021 Aug 14;45(7):722-729.
        The most commonly observed forms of aluminum, silicon and titanium in tobacco products are aluminum silicates (e.g., kaolin), silica and titanium(IV) oxide. These compounds are neither water soluble nor volatile at cigarette combustion temperatures. Rather, they are transported in mainstream tobacco smoke as particles after being freed by combustion from the tobacco filler and can induce pulmonary inflammation when inhaled. Aluminum silicate particles are the most frequently observed particles in the pulmonary macrophages of smokers and have become known as 'smokers' inclusions'. A relatively new technique, single particle triple quadrupole inductively coupled plasma-mass spectrometry was used to analyze aluminum-, silicon- and titanium-containing particle deliveries in cigarette and little cigar mainstream tobacco smoke, and to collect information on solid inorganic particles. The mass concentration of aluminum-containing particles transmitted in mainstream smoke was low (0.89-0.56 ng/cigarette), which was not surprising because aluminum silicates are not volatile. Although the collective masses (ng/cigarette) of aluminum-, silicon- and titanium-containing particles under 100 nm diameter transported in mainstream smoke were low, an abundance of 'ultrafine' particles (particles < 100 nm or nanoparticles) was observed. Limitations of the particle background equivalent diameter (the smallest detectable particle size (MassHunter 4.5 Software) due to the environmentally ubiquitous silicon background restricted the determination of silica nanoparticles, but silica particles slightly below 200 nm diameter were consistently detected. Aluminum- and titanium-containing nanoparticles were observed in all cigarette and little cigar samples, with titanium(IV) oxide particle deliveries consistently fewer in number and smaller in diameter than the other two types of particles. The highest concentrations of aluminum-containing particles (as kaolin) were in the nanoparticle range with much lower concentrations extending to the larger particle sizes (>100 nm). The number and range of particle sizes determined in mainstream smoke is consistent with pulmonary deposition of aluminum silicates described by other researchers as contributing to the 'smokers' inclusions' observed in pulmonary macrophages.

    • Nutritional Sciences
      • Use of the electronic health record to assess prevalence of anemia and iron deficiency in pregnancyexternal icon
        Sharma AJ, Ford ND, Bulkley JE, Jenkins LM, Vesco KK, Williams AM.
        J Nutr. 2021 Aug 12.
        BACKGROUND: In the United States, the prevalence of anemia, iron deficiency (ID), and iron-deficiency anemia (IDA) during pregnancy remains largely unknown as data at the national or state level are limited or nonexistent, respectively. OBJECTIVES: In an effort to identify opportunities to improve maternal health surveillance, we assessed the feasibility of anemia, ID, and IDA surveillance among first-trimester pregnancies using electronic health records (EHRs). METHODS: We identified pregnancies among Kaiser Permanente Northwest members aged ≥18 y during 2005-2016 with first-trimester prenatal care (n = 41,991). Earliest laboratory test results for hemoglobin or hematocrit and ferritin were selected. We describe the proportion of pregnancies screened for and the prevalence of anemia, ID, and IDA; the concordance of anemia status by hemoglobin compared with hematocrit; and the proportion of pregnancies with laboratory-confirmed anemia that also had an International Classification of Diseases diagnostic code related to anemia. RESULTS: Identified pregnancies included women who were 73.1% non-Hispanic (NH) white, 11.5% Hispanic, 8.5% NH Asian/Pacific Islander, and 2.9% NH black. Hemoglobin and hematocrit results were available for 92.7% (n = 38,923) pregnancies. Anemia prevalence was 2.7% (n = 1045) based on hemoglobin <11.0 g/dL or hematocrit <33%;  45.2% of anemia cases had both low hemoglobin and low hematocrit. Among pregnancies with anemia, 18.9% (n = 197) had a ferritin result; of those, 48.2% had ID (ferritin <15 μg/L). In pregnancies without anemia, 3.4% (n = 1275) had a ferritin result; of those, 23.5% had ID. Based on 1472 pregnancies with both anemia and ID assessed, prevalence of ID and IDA was 26.8% and 6.5%, respectively; estimates likely represent selective screening. CONCLUSIONS: EHR data have potential to monitor anemia prevalence and trends in health systems where prenatal anemia screening is nearly universal. However, if iron assessment is not routine, then representative estimates of ID or IDA are unattainable.

    • Occupational Safety and Health
      • Introduction: Chronic obstructive pulmonary disease is the fourth leading cause of death in the U.S. Workplace exposures are important modifiable contributors to the burden of chronic obstructive pulmonary disease. Among U.S. workers, 19% of chronic obstructive pulmonary disease cases are attributable to workplace exposures. This study examines the trends in chronic obstructive pulmonary disease prevalence during 2012–2018 among workers and assesses the population attributable fraction for chronic obstructive pulmonary disease associated with work by smoking status, industry, and occupation. Methods: The 2012–2018 National Health Interview Survey data for workers aged ≥18 years employed during the 12 months before the interview were analyzed in 2019. Annual trends were examined using the Poisson regression model. Multivariate logistic regression was used to calculate adjusted prevalence ORs. Results: During 2012–2018, an estimated age-adjusted annual average of 4.1% of workers had chronic obstructive pulmonary disease, and prevalence varied by industry and occupation. Overall, chronic obstructive pulmonary disease prevalence increased by an estimated annual average of 1.5% (p<0.05). The prevalence trends increased significantly among workers in the merchant wholesale nondurable and the arts, entertainment, and recreation industries and among financial specialists; supervisors, other food services workers; supervisors, building grounds workers, and maintenance workers; personal care and services workers; supervisors and office and administrative support workers; and motor-vehicle operators and material moving workers. The proportion of chronic obstructive pulmonary disease cases attributable to work was 27.3% among all workers and 24.0% among never smokers. Conclusions: Public health efforts to increase the awareness and understanding of chronic obstructive pulmonary disease associated with occupational risk factors are needed to prevent chronic obstructive pulmonary disease among workers, especially among those employed in industries and occupations with increasing prevalence trends. © 2021

      • Potential risks to hearing functions of service members from exposure to jet fuelsexternal icon
        Morata TC, Hungerford M, Konrad-Martin D.
        Am J Audiol. 2021 Aug 18:1-6.
        Purpose Several military occupations, particularly those within the U.S. Air Force, require working with or around jet fuels. Jet fuels contain components that are known to affect central nervous function, yet effects of these fuels on auditory function, specifically auditory processing of sound, are not well understood at this time. Animal studies have demonstrated that exposure to jet fuels prior to noise exposure can exacerbate the noise exposure's effects, and service members exposed to jet fuels are at risk of noise exposure within their work environments. The purpose of this article was to give a brief synopsis of the evidence on the ototoxic effects due to jet fuel exposure to aid audiologists in their decision making when providing care for populations who are occupationally exposed to fuels or while during military service. Conclusions Exposure to jet fuels impacts central nervous function and, in combination with noise exposure, may have detrimental auditory effects that research has yet to fully explain. Additional longitudinal research is needed to explain the relationships, which have clinical implications for service members and others exposed to jet fuels. In the meantime, audiologists can gain useful information by screening for chemical exposures when obtaining patient case histories. If jet fuel exposure is suspected, the Lifetime Exposure to Noise and Solvents Questionnaire can be used to estimate a noise exposure ranking and identify other potentiating agents such as jet fuel and industrial chemicals. A history of jet fuel exposure should inform the selection of hearing tests in the audiometric evaluation and when devising the treatment plan.

    • Substance Use and Abuse
      • State-specific prevalence of current e-cigarette use by disability status and disability type-United States, BRFSS 2016-2018external icon
        Zhang QC, Courtney-Long EA, Sinclair LB, Reese S, Armour BS, Shapira SK.
        Disabil Health J. 2021 Aug 8:101182.
        BACKGROUND: Cigarette smoking is the leading cause of preventable disease and death in the United States. The tobacco product landscape has diversified to include electronic cigarettes (e-cigarettes). Adults with disabilities are more likely than adults without disabilities to smoke cigarettes, but within the current body of literature, there is limited information on the use of e-cigarettes among adults with disabilities. OBJECTIVE: To assess overall and state-specific prevalence of current e-cigarette use among adults by disability status, disability type, sex, and age. METHODS: Disability was defined as having serious difficulty with vision, hearing, mobility, cognition, or any difficulty with self-care or independent living. The Behavioral Risk Factor Surveillance System cross-sectional survey data (2016-2018; n = 1,150,775) were used to estimate state and District of Columbia prevalence of current e-cigarette use among adults (aged ≥18 years) with and without disabilities, overall and by disability type, sex, and age group. RESULTS: Median prevalence of current e-cigarette use was higher among adults with than without disabilities (6.5% vs. 4.3%, P < 0.05). Among adults with disabilities, use varied from 2.5% in DC to 10.0% in Colorado; median use was highest among those with cognitive disabilities (10.0%) and those aged 18-24 years (18.7%). CONCLUSIONS: Prevalence of current e-cigarette use was higher among adults with than without disabilities and varied across states by disability status, type, and age group. The findings underscore the need to monitor e-cigarette use among adults with disabilities and specifically include them in tobacco control policies and programs addressing e-cigarette use.

  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. Association of anti-thyroid antibodies with radiographic knee osteoarthritis and chondrocalcinosis: a NHANES III studyexternal icon
        Tagoe CE, Wang W, Wang S, Barbour KE.
        Ther Adv Musculoskelet Dis. 2021 ;13:1759720x211035199.
        OBJECTIVES: To examine the relationships between radiographic knee osteoarthritis (RKOA), symptomatic radiographic knee osteoarthritis (sRKOA), and chondrocalcinosis, as outcome variables, and the autoimmune thyroid disease (AITD) autoantibodies, anti-thyroid peroxidase antibody (TPOAb) and anti-thyroglobulin antibody (TgAb), in the Third National Health and Nutrition Examination Survey (NHANES III) data source. METHODS: NHANES III provided data on 2291 persons over the age of 60 years that included the osteoarthritis variables of interest RKOA, sRKOA and chondrocalcinosis, and the thyroid autoantibodies TPOAb and TgAb. A log-binomial regression model was fit to examine the relationships between anti-thyroid autoantibodies and RKOA. Modified Poisson regression models were employed for the thyroid autoantibodies compared to sRKOA and chondrocalcinosis. RESULTS: Patients with higher levels of TPOAb were more likely to have chondrocalcinosis [prevalence ratio (PR) 1.247, 95% confidence interval (CI) 1.051, 1.479, p = 0.012]. A piecewise regression analysis indicated that this relationship between TPOAb and chondrocalcinosis was only observed when TPOAb was above 35 IU/ml (PR 1.482, 95% CI 1.233, 1.781, p < 0.001). Levels equal to or below 35 IU/ml were not associated with chondrocalcinosis. TPOAb was not associated with RKOA or sRKOA, and TgAb was not significantly related to any of the outcomes. CONCLUSION: There was no association of AITD autoantibodies TPOAb and TgAb with RKOA or sRKOA. However, there may be an association of TPOAb with the presence of chondrocalcinosis.

      2. The bidirectional longitudinal association between depressive symptoms and HbA(1c) : a systematic review and meta-analysisexternal icon
        Beran M, Muzambi R, Geraets A, Albertorio J, Adriaanse MC, Iversen MM, Kokoszka A, Nefs G, Nouwen A, Pouwer F, Huber JW, Schmitt A, Schram MT.
        Diabet Med. 2021 Aug 18:e14671.
        AIM: To investigate whether there is a bidirectional longitudinal association of depression with HbA(1c) . METHODS: We conducted a systematic literature search in PubMed, PsycINFO, CINAHL and EMBASE for observational, longitudinal studies published from January 2000 to September 2020, assessing the association between depression and HbA(1c) in adults. We assessed study quality with the Newcastle-Ottawa-Scale. Pooled effect estimates were reported as partial correlation coefficients (r(p) ) or odds ratios (OR). RESULTS: We retrieved 1,642 studies; 26 studies were included in the systematic review and eleven in the meta-analysis. Most studies (16/26) focused on type 2 diabetes. Study quality was rated as good (n=19), fair (n=2) and poor (n=5). Of the meta-analysed studies, six investigated the longitudinal association between self-reported depressive symptoms and HbA(1c) and five the reverse longitudinal association, with a combined sample size of n=48,793 and a mean follow-up of 2 years. Higher levels of baseline depressive symptoms were associated with subsequent higher levels of HbA(1c) (partial r=0.07;[95%CI0.03,0.12]; I(2) 38%). Higher baseline HbA(1c) values were also associated with 18% increased risk of (probable) depression (OR=1.18;[95%CI1.12,1.25]; I(2) 0.0%). CONCLUSIONS: Our findings support a bidirectional longitudinal association between depressive symptoms and HbA(1c) . However, the observed effect sizes were small and future research in large-scale longitudinal studies is needed to confirm this association. Future studies should investigate the role of type of diabetes and depression, diabetes distress and diabetes self-management behaviours. Our results may have clinical implications, as depressive symptoms and HbA(1c) levels could be targeted concurrently in the prevention and treatment of diabetes and depression.

      3. COVID-19 pandemic and quality of care and outcomes of acute stroke hospitalizations: the Paul Coverdell National Acute Stroke Programexternal icon
        Tong X, King SM, Asaithambi G, Odom E, Yang Q, Yin X, Merritt RK.
        Prev Chronic Dis. 2021 Aug 19;18:E82.
        INTRODUCTION: Studies documented significant reductions in emergency department visits and hospitalizations for acute stroke during the COVID-19 pandemic. A limited number of studies assessed the adherence to stroke performance measures during the pandemic. We examined rates of stroke hospitalization and adherence to stroke quality-of-care measures before and during the early phase of pandemic. METHODS: We identified hospitalizations with a clinical diagnosis of acute stroke or transient ischemic attack among 406 hospitals who contributed data to the Paul Coverdell National Acute Stroke Program. We used 10 performance measures to examine the effect of the pandemic on stroke quality of care. We compared data from 2 periods: pre-COVID-19 (week 11-24 in 2019) and COVID-19 (week 11-24 in 2020). We used χ(2) tests for differences in categorical variables and the Wilcoxon-Mann-Whitney rank test or Kruskal-Wallis test for continuous variables. RESULTS: We identified 64,461 hospitalizations. We observed a 20.2% reduction in stroke hospitalizations (from 35,851 to 28,610) from the pre-COVID-19 period to the COVID-19 period. Hospitalizations among patients aged 85 or older, women, and non-Hispanic White patients declined the most. A greater percentage of patients aged 18 to 64 were hospitalized with ischemic stroke during COVID-19 than during pre-COVID-19 (34.4% vs 32.5%, P < .001). Stroke severity was higher during COVID-19 than during pre-COVID-19 for both hemorrhagic stroke and ischemic stroke, and in-hospital death among patients with ischemic stroke increased from 4.3% to 5.0% (P = .003) during the study period. We found no differences in rates of receiving care across stroke type during the study period. CONCLUSION: Despite a significant reduction in stroke hospitalizations, more severe stroke among hospitalized patients, and an increase in in-hospital death during the pandemic period, we found no differences in adherence to quality of stroke care measures.

      4. Persons with dementia and informal caregivers prioritizing care: A mixed-methods studyexternal icon
        Wammes JD, Labrie NH, Agogo GO, Monin JK, de Bekker-Grob EW, MacNeil Vroomen JL.
        Alzheimers Dement (N Y). 2021 ;7(1):e12193.
        INTRODUCTION: More persons with dementia are residing in the community as many countries shift from residential care to home and community care. Although there are many forms of care and support available to avoid crisis situations and prolong community living, it remains unclear how these are valued by community-dwelling persons with dementia and their informal caregivers. Understanding perspectives of persons with dementia and informal caregivers on care characteristics is a vital step in valuing care services. This study aims to prioritize care characteristics for community-dwelling persons with dementia and informal caregivers with the use of an innovative mixed-methods approach. METHODS: Six mixed focus groups were conducted in The Netherlands with persons with dementia (n = 23) and informal caregivers (n = 20), including a quantitative ranking exercise that prioritized seven care and support characteristics from "most important" to "least important," followed by a group discussion about the prioritization. Audio recordings were transcribed and analyzed using thematic analysis. RESULTS: The ranking exercise and discussion showed that persons with dementia favored in-home care, help with daily activities, and social activities, whereas informal caregivers favored social activities, information about dementia, navigating the health care system, and emotional support. DISCUSSION: Persons with dementia prioritized day-to-day activities, whereas informal caregivers preferred assistance with organizing care and coping with caregiving. This study created a method to capture the care preferences of persons with dementia and informal caregivers.

      5. Population-level approaches to preventing type 2 diabetes globallyexternal icon
        Siegel KR, Albright AL.
        Endocrinol Metab Clin North Am. 2021 Sep;50(3):401-414.
        Type 2 diabetes (T2DM) is increasingly considered an epidemic rooted in modern society as much as in individual behavior. Addressing the T2DM burden thus involves a dual approach, simultaneously addressing high-risk individuals and whole populations. Within this context, this article summarizes the evidence base, in terms of effectiveness and cost-effectiveness, for population-level approaches to prevent T2DM: (1) modifications to the food environment; (2) modifications to the built environment and physical activity; and (3) programs and policies to address social and economic factors. Existing knowledge gaps are also discussed.

    • Communicable Diseases

      1. The burden of and trends in pelvic inflammatory disease in the United States, 2006-2016external icon
        Kreisel KM, Llata E, Haderxhanaj L, Pearson WS, Tao G, Wiesenfeld HC, Torrone EA.
        J Infect Dis. 2021 Aug 16;224(Supplement_2):S103-s112.
        BACKGROUND: Pelvic inflammatory disease (PID) is an infection of the upper genital tract that has important reproductive consequences to women. We describe the burden of and trends in PID among reproductive-aged women in the United States during 2006-2016. METHODS: We used data from 2 nationally representative probability surveys collecting self-reported PID history (National Health and Nutrition Examination Survey, National Survey of Family Growth); 5 datasets containing International Classification of Diseases, Ninth/Tenth Revision codes indicating diagnosed PID (Healthcare Utilization Project; National Hospital Ambulatory Medical Care Survey, emergency department component; National Ambulatory Medical Care Survey; National Disease Therapeutic Index; MarketScan); and data from a network of sexually transmitted infection (STI) clinics (Sexually Transmitted Disease Surveillance Network). Trends during 2006-2016 were estimated overall, by age group and, if available, race/ethnicity, region, and prior STIs. RESULTS: An estimated 2 million reproductive-aged women self-reported a history of PID. Three of 4 nationally representative data sources showed overall declines in a self-reported PID history, and PID emergency department and physician office visits, with small increases observed in nearly all data sources starting around 2015. CONCLUSIONS: The burden of PID in the United States is high. Despite declines in burden over time, there is evidence of an increase in recent years.

      2. Advancing the understanding of pelvic inflammatory disease (PID) requires access to advanced diagnostic approaches for evaluating reproductive sequelae of sexually transmitted infections (STIs). Current limitations of clinical criteria and advanced imaging technologies for diagnosing reproductive sequelae make diagnosis and surveillance of PID a challenge. We summarize and comment on major challenges in diagnostic evaluation of reproductive sequelae: limited point-of-care clinical diagnostic options for reproductive sequelae, economic and geographical obstacles to accessing state-of-the-art diagnostics, an expanding list of STIs that may cause reproductive sequelae and the complexities in evaluating them, and the need for coordinated research efforts to systematically evaluate biomarkers with gold-standard, well-defined specimens and associated clinical data. The future use of biomarkers in readily accessible mucosal or blood-derived specimens as a noninvasive approach to determining STI etiologies may be fruitful and requires more research. Biomarkers under consideration include cytokines, STI-specific antibody responses, and mRNA transcriptional profiles of inflammatory markers.

      3. Current and past immunodeficiency are associated with higher hospitalization rates among persons on virologically suppressive antiretroviral therapy for up to 11 yearsexternal icon
        Davy-Mendez T, Napravnik S, Eron JJ, Cole SR, van Duin D, Wohl DA, Hogan BC, Althoff KN, Gebo KA, Moore RD, Silverberg MJ, Horberg MA, Gill MJ, Mathews WC, Klein MB, Colasanti JA, Sterling TR, Mayor AM, Rebeiro PF, Buchacz K, Li J, Nanditha NG, Thorne JE, Nijhawan A, Berry SA.
        J Infect Dis. 2021 Aug 16;224(4):657-666.
        BACKGROUND: Persons with human immunodeficiency virus (PWH) with persistently low CD4 counts despite efficacious antiretroviral therapy could have higher hospitalization risk. METHODS: In 6 US and Canadian clinical cohorts, PWH with virologic suppression for ≥1 year in 2005-2015 were followed until virologic failure, loss to follow-up, death, or study end. Stratified by early (years 2-5) and long-term (years 6-11) suppression and lowest presuppression CD4 count <200 and ≥200 cells/µL, Poisson regression models estimated hospitalization incidence rate ratios (aIRRs) comparing patients by time-updated CD4 count category, adjusted for cohort, age, gender, calendar year, suppression duration, and lowest presuppression CD4 count. RESULTS: The 6997 included patients (19 980 person-years) were 81% cisgender men and 40% white. Among patients with lowest presuppression CD4 count <200 cells/μL (44%), patients with current CD4 count 200-350 vs >500 cells/μL had aIRRs of 1.44 during early suppression (95% confidence interval [CI], 1.01-2.06), and 1.67 (95% CI, 1.03-2.72) during long-term suppression. Among patients with lowest presuppression CD4 count ≥200 (56%), patients with current CD4 351-500 vs >500 cells/μL had an aIRR of 1.22 (95% CI, .93-1.60) during early suppression and 2.09 (95% CI, 1.18-3.70) during long-term suppression. CONCLUSIONS: Virologically suppressed patients with lower CD4 counts experienced higher hospitalization rates and could potentially benefit from targeted clinical management strategies.

      4. Deaths in children and adolescents associated with COVID-19 and MIS-C in the United Statesexternal icon
        McCormick DW, Richardson LC, Young PR, Viens LJ, Gould CV, Kimball A, Pindyck T, Rosenblum HG, Siegel DA, Vu QM, Komatsu K, Venkat H, Openshaw JJ, Kawasaki B, Siniscalchi AJ, Gumke M, Leapley A, Tobin-D'Angelo M, Kauerauf J, Reid H, White K, Ahmed FS, Richardson G, Hand J, Kirkey K, Larson L, Byers P, Garcia A, Ojo M, Zamcheck A, Lash MK, Lee EH, Reilly KH, Wilson E, de Fijter S, Naqvi OH, Harduar-Morano L, Burch AK, Lewis A, Kolsin J, Pont SJ, Barbeau B, Bixler D, Reagan-Steiner S, Koumans EH.
        Pediatrics. 2021 Aug 12.

      5. Demographic and clinical factors associated with death among persons <21 Years old with multisystem inflammatory syndrome in children-United States, February 2020-March 2021external icon
        Bowen A, Miller AD, Zambrano LD, Wu MJ, Oster ME, Godfred-Cato S, Belay ED, Campbell AP.
        Open Forum Infect Dis. 2021 Aug;8(8):ofab388.
        Multisystem inflammatory syndrome in children (MIS-C) occurs among persons aged <21 years following severe acute respiratory syndrome coronavirus 2 infection. Among 2818 MIS-C cases, 35 (1.2%) deaths were reported, primarily affecting racial/ethnic minority persons. Being 16-20 years old or having comorbidities was associated with death. Targeting coronavirus disease 2019 prevention among these groups and their caregivers might prevent MIS-C-related deaths.

      6. Description of adverse events among adult men following voluntary medical male circumcision: Findings from a circumcision programme in two provinces of South Africaexternal icon
        Muchiri E, Charalambous S, Ginindza S, Maraisane M, Maringa T, Vranken P, Loykissoonlal D, Muturi-Kioi V, Chetty-Makkan CM.
        PLoS One. 2021 ;16(8):e0253960.
        BACKGROUND: Clinical trials showed strong evidence that voluntary medical male circumcision (VMMC) reduces the acquisition of HIV among heterosexual men by up to 60%. However, VMMC uptake in East and Southern Africa remains suboptimal, with safety concerns identified as a barrier to uptake. We investigated the occurrence and severity of adverse events (AEs) in a routine VMMC programme implemented in Gauteng and North West provinces of South Africa. METHODS: We describe the frequency and characteristics of AEs using routinely collected data from a VMMC programme implemented between 01 May 2013 and 31 December 2014. The surgical procedure was provided at fixed clinics and mobile units in three districts. Adult men undertaking the procedure were referred for follow-up appointments where AEs were monitored. RESULTS: A total of 7,963 adult men were offered the VMMC service with 7,864 (98.8%) met the age and consent requirements for inclusion in a research follow-up after the surgical procedure and were followed-up for potential AEs. In total, 37 (0.5%) patients reported AEs post-surgery with infection [11 (29.7%)] and excessive bleeding [11 (29.7%)] commonly reported AEs. In terms of severity, 14 (37.8%) were classified as mild, 13 (35.1%) as moderate, and 10 (27.0%) as severe. Further, 32 (86.5%) of the AEs were classified as definitely related to the surgical procedure, with 36 (97.5%) of all AEs resolving without sequelae. CONCLUSION: The VMMC programme was able to reach adult men at high risk of HIV acquisition. Reported AEs in the programme were minimal, with the observed safety profile comparable to clinical trial settings, suggesting that VMMC can be safely administered in a programmatic setting.

      7. BACKGROUND: WHO recommends use of rapid dual HIV/syphilis tests for screening pregnant women (PW) during antenatal care to prevent mother-to-child transmission. Scale-up of testing implies a need to accurately forecast and procure benzathine penicillin (BPG) to treat the additionally identified PW with syphilis. METHODS: Country-reported ANC coverage, PW syphilis screening and treatment coverage values in 2019 were scaled linearly to EMTCT targets by 2030 (constant increasing slope from 2019 figures to 95% in 2030) for 11 focus countries. Antenatal syphilis screening coverage was substituted with HIV screening coverage to estimate potential contribution of rapid dual HIV/syphilis tests in identifying additional PW with syphilis. BPG demand was calculated for 2019-2030 accordingly. RESULTS: The estimated demand for BPG (in 2.4 million unit vials) using current maternal syphilis prevalence and treatment coverage will increase from a baseline of 414,459 doses in 2019 to 683,067 doses (+65%) in 2021 assuming immediate replacement of single HIV test kits with rapid dual HIV/syphilis tests for these 11 countries. Continued scale up of syphilis screening and treatment coverage to reach elimination coverage of 95% will result in an estimated demand increase of 160%, (663,969 doses) from 2019 baseline for a total demand of 1,078,428 BPG doses by 2030. CONCLUSIONS: Demand for BPG will increase following adoption of rapid dual HIV/syphilis test kits due to increases in maternal diagnoses of syphilis. To eliminate congenital syphilis, MNCH clinical programs will need to synergize with disease surveillance programs to accurately forecast BPG demand with scale up of antenatal syphilis screening to ensure adequate treatment is available for pregnant women diagnosed with syphilis.

      8. Etiology and diagnosis of pelvic inflammatory disease: Looking beyond gonorrhea and chlamydiaexternal icon
        Mitchell CM, Anyalechi GE, Cohen CR, Haggerty CL, Manhart LE, Hillier SL.
        J Infect Dis. 2021 Aug 16;224(Supplement_2):S29-s35.
        Pelvic inflammatory disease (PID) is a clinical syndrome that has been associated with a wide range of potential causal pathogens. Three broad groups of organisms have been isolated from the genital tract of people with PID: sexually transmitted organisms such as Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis; bacterial vaginosis (BV)-associated species and genera such as Atopobium vaginae, Sneathia, and Megasphaera; and genera and species usually associated with the gastrointestinal or respiratory tracts such as Bacteroides, Escherichia coli, Streptococcus, or Haemophilus influenza. Although PID is often considered to be synonymous with gonorrhea or chlamydia, these pathogens are found in only one quarter to one third of people with PID, suggesting that broader screening and diagnostic and treatment strategies need to be considered to reduce the burden of PID and its associated sequelae.

      9. Global distribution of sporadic sapovirus infections: A systematic review and meta-analysisexternal icon
        Diez Valcarce M, Kambhampati AK, Calderwood LE, Hall AJ, Mirza SA, Vinjé J.
        PLoS One. 2021 ;16(8):e0255436.
        Acute gastroenteritis (AGE), characterized by diarrhea and vomiting, is an important cause of global mortality, accounting for 9% of all deaths in children under five years of age. Since the reduction of rotavirus in countries that have included rotavirus vaccines in their national immunization programs, other viruses such as norovirus and sapovirus have emerged as more common causes of AGE. Due to widespread use of real-time RT-PCR testing, sapovirus has been increasingly reported as the etiologic agent in both AGE outbreaks and sporadic AGE cases. We aimed to assess the role of sapovirus as a cause of endemic AGE worldwide by conducting a systematic review of published studies that used molecular diagnostics to assess the prevalence of sapovirus among individuals with AGE symptoms. Of 106 articles included, the pooled sapovirus prevalence was 3.4%, with highest prevalence among children <5 years of age (4.4%) and among individuals in community settings (7.1%). Compared to studies that used conventional RT-PCR, RT-qPCR assays had a higher pooled prevalence (5.6%). Among individuals without AGE symptoms, the pooled sapovirus prevalence was 2.7%. These results highlight the relative contribution of sapovirus to cases of AGE, especially in community settings and among children <5 years of age.

      10. Incidence, clinical characteristics, and risk factors of SARS-CoV-2 infection among pregnant individuals in the United Statesexternal icon
        Dawood FS, Varner M, Tita A, Newes-Adeyi G, Gyamfi-Bannerman C, Battarbee A, Bruno A, Daugherty M, Reichle L, Vorwaller K, Vargas C, Parks M, Powers E, Lucca-Susana M, Gibson M, Subramaniam A, Cheng YJ, Feng PJ, Ellington S, Galang RR, Meece J, Flygare C, Stockwell MS.
        Clin Infect Dis. 2021 Aug 19.
        BACKGROUND: Data about the risk of SARS-CoV-2 infection among pregnant individuals are needed to inform infection prevention guidance and counseling for this population. METHODS: We prospectively followed a cohort of pregnant individuals during August 2020-March 2021 at three U.S. sites. The three primary outcomes were incidence rates of any SARS-CoV-2 infection, symptomatic infection, and asymptomatic infection, during pregnancy during periods of SARS-CoV-2 circulation. Participants self-collected weekly mid-turbinate nasal swabs for SARS-CoV-2 RT-PCR testing, completed weekly illness symptom questionnaires, and submitted additional swabs with COVID-19-like symptoms. An overall SARS-CoV-2 infection incidence rate weighted by population counts of women of reproductive age in each state was calculated. RESULTS: Among 1098 pregnant individuals followed for a mean of 10 weeks, nine percent (99/1098) had SARS-CoV-2 infections during the study. Population weighted incidence rates of SARS-CoV-2 infection were 10.0 per 1,000 (95% confidence interval [CI] 5.7-14.3) person-weeks for any infection, 5.7 per 1,000 (95% CI 1.7-9.7) for symptomatic infections, and 3.5 per 1,000 (95% CI 0-7.1) for asymptomatic infections. Among 96 participants with SARS-CoV-2 infection and symptom data, the most common symptoms were nasal congestion (72%), cough (64%), headache (59%), and change in taste or smell (54%); 28% had measured or subjective fever. The median symptom duration was 10 days (IQR6-16 days). CONCLUSION: Pregnant individuals had a 1% risk of SARS-CoV-2 infection per week. Study findings provide information about SARS-CoV-2 infection risk during pregnancy to inform counseling for pregnant individuals about infection prevention practices, including COVID-19 vaccination.

      11. Investigation of a large diphtheria outbreak and cocirculation of Corynebacterium pseudodiphtheriticum among forcibly displaced Myanmar nationals, 2017-2019external icon
        Weil LM, Williams MM, Shirin T, Lawrence M, Habib ZH, Aneke JS, Tondella ML, Zaki Q, Cassiday PK, Lonsway D, Farrque M, Hossen T, Feldstein LR, Cook N, Maldonado-Quiles G, Alam AN, Muraduzzaman AK, Akram A, Conklin L, Doan S, Friedman M, Acosta AM, Hariri S, Fox LM, Tiwari TS, Flora MS.
        J Infect Dis. 2021 Jul 15;224(2):318-325.
        BACKGROUND: Diphtheria, a life-threatening respiratory disease, is caused mainly by toxin-producing strains of Corynebacterium diphtheriae, while nontoxigenic corynebacteria (eg, Corynebacterium pseudodiphtheriticum) rarely causes diphtheria-like illness. Recently, global diphtheria outbreaks have resulted from breakdown of health care infrastructures, particularly in countries experiencing political conflict. This report summarizes a laboratory and epidemiological investigation of a diphtheria outbreak among forcibly displaced Myanmar nationals in Bangladesh. METHODS: Specimens and clinical information were collected from patients presenting at diphtheria treatment centers. Swabs were tested for toxin gene (tox)-bearing C. diphtheriae by real-time polymerase chain reaction (RT-PCR) and culture. The isolation of another Corynebacterium species prompted further laboratory investigation. RESULTS: Among 382 patients, 153 (40%) tested tox positive for C. diphtheriae by RT-PCR; 31 (20%) PCR-positive swabs were culture confirmed. RT-PCR revealed 78% (298/382) of patients tested positive for C. pseudodiphtheriticum. Of patients positive for only C. diphtheriae, 63% (17/27) had severe disease compared to 55% (69/126) positive for both Corynebacterium species, and 38% (66/172) for only C. pseudodiphtheriticum. CONCLUSIONS: We report confirmation of a diphtheria outbreak and identification of a cocirculating Corynebacterium species. The high proportion of C. pseudodiphtheriticum codetection may explain why many suspected patients testing negative for C. diphtheriae presented with diphtheria-like symptoms.

      12. Norovirus and other viral causes of medically attended acute gastroenteritis across the age spectrum: Results from the Medically Attended Acute Gastroenteritis Study in the United Statesexternal icon
        Burke RM, Mattison CP, Marsh Z, Shioda K, Donald J, Salas SB, Naleway AL, Biggs C, Schmidt MA, Hall AJ.
        Clin Infect Dis. 2021 Aug 16;73(4):e913-e920.
        BACKGROUND: Acute gastroenteritis (AGE) causes a substantial burden in the United States, but its etiology frequently remains undetermined. Active surveillance within an integrated healthcare delivery system was used to estimate the prevalence and incidence of medically attended norovirus, rotavirus, sapovirus, and astrovirus. METHODS: Active surveillance was conducted among all enrolled members of Kaiser Permanente Northwest during July 2014-June 2016. An age-stratified, representative sample of AGE-associated medical encounters were recruited to provide a stool specimen to be tested for norovirus, rotavirus, sapovirus, and astrovirus. Medically attended AGE (MAAGE) encounters for a patient occurring within 30 days were grouped into 1 episode, and all-cause MAAGE incidence was calculated. Pathogen- and healthcare setting-specific incidence estimates were calculated using age-stratified bootstrapping. RESULTS: The overall incidence of MAAGE was 40.6 episodes per 1000 person-years (PY), with most episodes requiring no more than outpatient care. Norovirus was the most frequently detected pathogen, with an incidence of 5.5 medically attended episodes per 1000 PY. Incidence of norovirus MAAGE was highest among children aged < 5 years (20.4 episodes per 1000 PY), followed by adults aged ≥ 65 years (4.5 episodes per 1000 PY). Other study pathogens showed similar patterns by age, but lower overall incidence (sapovirus: 2.4 per 1000 PY; astrovirus: 1.3 per 1000 PY; rotavirus: 0.5 per 1000 PY). CONCLUSIONS: Viral enteropathogens, particularly norovirus, are important contributors to MAAGE, especially among children < 5 years of age. The present findings underline the importance of judicious antibiotics use for pediatric AGE and suggest that an effective norovirus vaccine could substantially reduce MAAGE.

      13. Outcomes of traditional and enhanced gonorrhea partner services in the strengthening the US Response to Resistant Gonorrhea Project, 2017- 2019external icon
        Learner ER, Schlanger K, Mauk K, Pham CD, Mukai R, Mulleavey L, Kerani RP, Albano T, Sessoms B, Holderman JL, Toro B, Sankaran M, Kirkcaldy RD.
        Sex Transm Dis. 2021 Aug 16.
        INTRODUCTION: The CDC implemented Strengthening the U.S. Response to Resistant Gonorrhea (SURRG) to build local detection and response capacity and evaluate responses to antibiotic-resistant gonorrhea outbreaks, including partner services for gonorrhea. We evaluated outcomes of traditional partner services conducted under SURRG, which involved (1) counseling index patients and eliciting sexual partners, (2) interviewing, testing and treating partners, and (3) providing partner services to partners newly diagnosed with gonorrhea. We also evaluated outcomes of enhanced partner services, which additionally involved interviewing and testing partners of persons who tested negative, and social contacts of index patients and partners. METHODS: We analyzed partner services investigation data from eight jurisdictions participating in SURRG from 2017 through 2019. We summed total index patients, partners from traditional partner services, and partners and contacts from enhanced partner services, and calculated partner services outcomes among partners and contacts. We also visualized sexual networks from partner services data. RESULTS: Of 1,242 index patients identified, 506 named at least one sexual partner. Traditional partner services yielded 1,088 sexual partners and 105 were newly diagnosed with gonorrhea. Enhanced partner services yielded an additional 59 sexual partners and 52 social contacts. Of those partners and contacts, 3 were newly diagnosed with gonorrhea. Network visualization revealed sparse networks with few complex partnership clusters. CONCLUSIONS: Traditional partner services for gonorrhea may be useful for eliciting, notifying, and diagnosing partners of index patients in an outbreak setting. Enhanced partner services are unlikely to be effective for eliciting, notifying, and diagnosing a substantial number of additional people.

      14. Point-of-care antigen test for SARS-CoV-2 in asymptomatic college studentsexternal icon
        Tinker SC, Szablewski CM, Litvintseva AP, Drenzek C, Voccio GE, Hunter MA, Briggs S, Heida DE, Folster J, Shewmaker PL, Medrzycki M, Bowen MD, Bohannon C, Bagarozzi D, Petway M, Rota PA, Kuhnert-Tallman W, Thornburg N, Prince-Guerra JL, Barrios LC, Tamin A, Harcourt JL, Honein MA.
        Emerg Infect Dis. 2021 Aug 16;27(10).
        We used the BinaxNOW COVID-19 Ag Card to screen 1,540 asymptomatic college students for severe acute respiratory syndrome coronavirus 2 in a low-prevalence setting. Compared with reverse transcription PCR, BinaxNOW showed 20% overall sensitivity; among participants with culturable virus, sensitivity was 60%. BinaxNOW provides point-of-care screening but misses many infections.

      15. Pressure to use HIV self-tests among men who have sex with men, United States, 2015-2016external icon
        Gwynn M, Chavez PR, Borkowf CB, Raiford JL, Gravens L, MacGowan RJ.
        AIDS Behav. 2021 Aug 18.
        To assess whether pressuring others to use HIV self-tests is prevalent among US men who have sex with men (MSM), we analyzed data from a randomized controlled trial of HIV self-testing. Among 752 online-recruited MSM who received HIV self-tests and responded to a 12-month survey, 8.5% (60/709) reported pressuring someone to use an HIV self-test: 29 pressured a friend, 28 pressured a sexual partner, and 1 pressured a family member. Conversely, 2.1% (15/715) reported being pressured to self-test: 12 by a sexual partner and 3 by a friend. No physical harm was reported. HIV prevention programs that use HIV self-tests to reach populations at risk for HIV may be reassured by our findings because, despite reports of pressure to use HIV self-tests, no physical abuse was reported between sex partners. These programs should, however, include messages emphasizing the voluntary use of HIV self-tests and be prepared to address concerns of persons who have been pressured to use HIV self-tests. This trial is registered at (NCT02067039) and the date of registration is February 5, 2014.

      16. A qualitative study of injection and sexual risk behavior among unstably housed people who inject drugs in the context of an HIV outbreak in Northeast Massachusetts, 2018external icon
        Board A, Alpren C, Hernandez B, Murray A, Dawson EL, Drumhiller K, Burrage A, Jaeger JL, Buchacz K, Klevens RM, Agnew-Brune C.
        Int J Drug Policy. 2021 Aug 11;95:103368.
        BACKGROUND: To investigate the underlying causes of a sudden increase in HIV among people who inject drugs (PWID) and initiate an appropriate response to the outbreak, we engaged in in-depth qualitative interviews with members of the PWID community in Lawrence and Lowell, Massachusetts. METHODS: We interviewed 34 PWID who were currently or recently unstably housed, then transcribed interviews and coded transcripts, grouping codes into categories from which we identified key themes. RESULTS: Participants described a heightened threat of overdose prompting PWID to inject together, increasing opportunities for sharing injection equipment. There were misunderstandings about safe injection practices to prevent HIV transmission and a low threshold for injection-related risk taking. Stigma regarding HIV prevented conversations about HIV status. Less thought was given to sexual risks than injection-related risks for HIV transmission. CONCLUSIONS: We found multiple facilitators of HIV transmission. Additional HIV education and prevention interventions focusing on both injection and sexual risk practices would benefit this population, in addition to structural interventions such as increased access and availability of syringe service programs.

      17. Reaching racial/ethnic and sexual and gender minorities with HIV prevention information via social marketingexternal icon
        Marshall B, Salabarría-Peña Y, Johnson W, Moore L.
        Eval Program Plann. 2021 Jul 30:101982.
        The Pre-exposure Prophylaxis, Data to Care, Implementation, and Evaluation (PrIDE) multi-site demonstration project utilized a cluster evaluation approach and identified six funding recipients that evaluated similar media evaluation questions (Baltimore, Los Angeles County, Lousiana, Michigan, New York City, and Virginia). All of the evaluated social marketing campaigns were developed in collaboration with health department staff, external marketing firms, and community advisory boards (CAB) aiming to produce changes in PrEP outcomes by reaching racial/ethnic and sexual and gender minorities. Jurisdictions demonstrated changes in PrEP awareness, knowledge, willingness to take PrEP, and/or PrEP literacy following initiation of the campaigns. In data from four sites, PrEP awareness significantly increased from 72 % at baseline to 86 % at mid-project, and to 90 % post-campaigns. The campaigns illustrate the importance of partnerships and stakeholder engagement, audience segmentation, and intentional evaluation planning. As PrEP services mature, evaluating PrEP demand and PrEP use resulting from campaigns, will be necessary. Also, future campaigns for racial/ethnic and sexual and gender minorities should identify the best channels to reach each group based on their input, disaggregate data by priority group, and determine campaign effectiveness.

      18. Use of rapid antigen testing for SARS-CoV-2 in remote communities - Yukon-Kuskokwim Delta Region, Alaska, September 15, 2020-March 1, 2021external icon
        Hodges E, Lefferts B, Bates E, Desnoyers C, Bruden D, Bruce M, McLaughlin J.
        MMWR Morb Mortal Wkly Rep. 2021 Aug 20;70(33):1120-1123.
        Controlling the spread of SARS-CoV-2, the virus that causes COVID-19, in Alaska is challenging. Alaska includes many remote and isolated villages with small populations (ranging from 15 to >1,000 persons) that are accessible only by air from larger communities. Until rapid point-of-care testing became widely available, a primary challenge in the diagnosis of COVID-19 in rural Alaska was slow turnaround times for SARS-CoV-2 test results, attributable to the need to transport specimens to testing facilities. To provide more timely test results and isolation of cases, the Yukon Kuskokwim Health Corporation (YKHC) introduced Abbott BinaxNOW COVID-19 Ag rapid antigen test (BinaxNOW) on November 9, 2020, in the rural Yukon-Kuskokwim Delta region in southwestern Alaska. To evaluate the impact of implementing antigen testing, YKHC reviewed the results of 54,981 antigen and molecular tests for SARS-CoV-2 performed in the Yukon-Kuskokwim Delta during September 15, 2020-March 1, 2021. Introduction of rapid, point-of-care testing was followed by a more than threefold reduction in daily SARS-CoV-2 case rates during approximately 1 month before the introduction of COVID-19 vaccination. The median turnaround time for SARS-CoV-2 test results decreased by >30%, from 6.4 days during September 15-November 8, 2020, to 4.4 days during November 9, 2020-March 1, 2021 (p<0.001). Daily incidence decreased 65% after the introduction of BinaxNOW, from 342 cases per 100,000 population during the week of November 9 to 119 during the week of December 13 (p<0.001). These findings indicate that point-of-care rapid antigen testing can be a valuable tool in reducing turnaround times in rural communities where local access to laboratory-based nucleic acid amplification testing (NAAT) is not readily available and could thereby reduce transmission by facilitating rapid isolation of infected persons, contact tracing, and implementation of local mitigation strategies.

      19. The utility of evaluation in optimizing implementation and improvement of HIV prevention programmingexternal icon
        Marshall B, Salabarría-Peña Y, Douglas C, Nakelsky S, Pichon LC.
        Eval Program Plann. 2021 Jul 27:101980.
        The objective of this article is to describe Project PrIDE (PrEP Implementation, Data to Care, and Evaluation) through the lens of Evaluation Utilization and provide examples of how twelve funded health departments (HD) utilized evaluation findings to make decisions related to improving PrEP awareness and uptake, and/or enhancing capacity for data to care (D2C) activities. Each HD conducted a local evaluation (LE) and reported ongoing and planned utilization of evaluation findings in the final LE reports. Information from all reports was abstracted for qualitative analysis to identify main evaluation utilization themes. Findings showed that program evaluation was incorporated as early as the project development phase and designed with the goal of improving, and not just demonstrating the efficacy of the programs. Evaluation data were effectively utilized to improve PrEP and D2C activities, for example, by increasing community engagement throughout LEs, enhancing social media implementation, prioritizing the most effective referral sources at re-linking clients into HIV care, reducing client wait time between receiving PrEP referral and obtaining appointment with provider, and incorporating evaluation findings into program planning and development. Project PrIDE highlights the importance of a planned evaluation in providing ongoing improvements to HIV prevention services to better serve priority populations.

      20. What can serology tell us about the burden of infertility in women caused by chlamydia?external icon
        Horner PJ, Anyalechi GE, Geisler WM.
        J Infect Dis. 2021 Aug 16;224(Supplement_2):S80-s85.
        Chlamydia trachomatis (CT) causes pelvic inflammatory disease, which may result in tubal factor infertility (TFI) in women. Serologic assays may be used to determine the proportion of women with and without TFI who have had previous CT infection and to generate estimates of infertility attributable to chlamydia. Unfortunately, most existing CT serologic assays are challenged by low sensitivity and, sometimes, specificity for prior CT infection; however, they are currently the only available tests available to detect prior CT infection. Modeling methods such as finite mixture modeling may be a useful adjunct to quantitative serologic data to obtain better estimates of CT-related infertility. In this article, we review CT serological assays, including the use of antigens preferentially expressed during upper genital tract infection, and suggest future research directions. These methodologic improvements, coupled with creation of new biomarkers for previous CT infection, should improve our understanding of chlamydia's contribution to female infertility.

    • Disease Reservoirs and Vectors
      1. Isolation and genetic characterization of a relapsing fever spirochete isolated from Ornithodoros puertoricensis collected in central Panamaexternal icon
        Bermúdez SE, Armstrong BA, Domínguez L, Krishnavajhala A, Kneubehl AR, Gunter SM, Replogle A, Petersen JM, Lopez JE.
        PLoS Negl Trop Dis. 2021 Aug 16;15(8):e0009642.
        Tick-borne relapsing fever (TBRF) spirochetes are likely an overlooked cause of disease in Latin America. In Panama, the pathogens were first reported to cause human disease in the early 1900s. Recent collections of Ornithodoros puertoricensis from human dwellings in Panama prompted our interest to determine whether spirochetes still circulate in the country. Ornithodoros puertoricensis ticks were collected at field sites around the City of Panama. In the laboratory, the ticks were determined to be infected with TBRF spirochetes by transmission to mice, and we report the laboratory isolation and genetic characterization of a species of TBRF spirochete from Panama. Since this was the first isolation of a species of TBRF spirochete from Central America, we propose to designate the bacteria as Borrelia puertoricensis sp. nov. This is consistent with TBRF spirochete species nomenclature from North America that are designated after their tick vector. These findings warrant further investigations to assess the threat B. puertoricensis sp. nov. may impose on human health.

      2. Pathology and One Health implications of fatal Leptospira interrogans infection in an urbanized, free-ranging, black-tufted marmoset (Callithrix penicillata) in Brazilexternal icon
        Wilson TM, Ritter JM, Martines RB, Gonçalves AA, Fair P, Galloway R, Weiner Z, Romano AP, Costa GR, de Melo CB, Zaki SR, de Castro MB.
        Transbound Emerg Dis. 2021 Aug 13.
        Leptospirosis is a zoonotic neglected disease of worldwide public health concern. Leptospira species can infect a wide range of wild and domestic mammals and can lead to a spectrum of disease, including severe and fatal forms. Herein, we report for the first time a fatal Leptospira interrogans infection in a free-ranging nonhuman primate (NHP), a black-tufted marmoset. Icterus, pulmonary hemorrhage, interstitial nephritis and hepatocellular dissociation were the main findings raising the suspicion of leptospirosis. Diagnostic confirmation was based on specific immunohistochemical and PCR assays for Leptospira species. Immunolocalization of leptospiral antigens and identification of pathogenic species (L. interrogans species) were important for better understanding the pathogenesis of disease. One Health related implications of free-ranging NHPs in anthropized areas and transmission dynamics of human and animal leptospirosis are discussed. This article is protected by copyright. All rights reserved.

    • Environmental Health
      1. The 32-mile Detroit River and surrounding tributaries have been designated as a Great Lakes Area of Concern due to pollution from decades of municipal and industrial discharges, sewer overflows and urban development. The Agency for Toxic Substances and Disease Registry and the Michigan Department of Health and Human Services conducted a biomonitoring study to assess exposures to persistent toxic substances in Detroit urban shoreline anglers who may be at high exposure risk due to consumption of locally caught fish. Using a modified venue-based sampling approach, 287 adult shoreline anglers along the Detroit River were recruited and participated in the program. Study participants provided blood and urine specimens and completed a questionnaire interview. In this report, we examine percentile estimates for blood lead, blood manganese, urine arsenic, urine mercury, urine cadmium, organochlorine pesticides in serum (mirex, hexachlorobenzene, chlordane), and serum polybrominated biphenyl 153 (PBB 153) concentrations among study participants. Multiple linear regression was used to identify predictors of contaminant concentrations. The Detroit urban anglers' blood lead concentrations were 2 times higher than the general adult U.S. population (median (95% CI): 2.9 μg/dL (1.8-2.3) vs. 0.94 μg/dL (0.90-0.98)). PBB 153 levels were 1.8 times higher than the general adult U.S. population at the 95th percentile (95th percentile, 95% CI: 62.7 ng/g of lipid, 53.2-75.2 vs. 34.6 ng/g of lipid, 12.8-66.8). Percentile estimates of the other study pollutants were similar to background levels found in the general U.S. population. Eating more locally caught fish was not associated with increased body burdens for any of the contaminants examined in this report. Higher blood lead was associated with increased age, male sex, current smoking, residing in a home built before 1960, an annual income less than $25,000, and a work history of lead paint removal. Evidence of PBB exposure in our study cohort likely reflects the continued effect of a widespread contamination of livestock feed in 1973 among Michigan's lower peninsula population. These study results help determine if the pollutants examined warrant further consideration in subsequent population-based biomonitoring of frequent consumers of fish from the Detroit River and surrounding waterways. The biomonitoring data from this study also served to inform public health officials regarding the potential need for environmental public health actions to reduce harmful exposures.

    • Epidemiology and Surveillance
      1. Fit for purpose in action: Design, implementation, and evaluation of the National Internet Flu Surveyexternal icon
        Dever JA, Amaya A, Srivastav A, Lu PJ, Roycroft J, Stanley M, Stringer MC, Bostwick MG, Greby SM, Santibanez TA, Williams WW.
        J Surv Stat Methodol. 2021 ;9(3):449-476.
        Researchers strive to design and implement high-quality surveys to maximize the utility of the data collected. The definitions of quality and usefulness, however, vary from survey to survey and depend on the analytic needs. Survey teams must evaluate the trade-offs of various decisions, such as when results are needed and their required level of precision, in addition to practical constraints like budget, before finalizing the design. Characteristics within the concept of fit for purpose (FfP) can provide the framework for considering the trade-offs. Furthermore, this tool can enable an evaluation of quality for the resulting estimates. Implementation of a FfP framework in this context, however, is not straightforward. In this article, we provide the reader with a glimpse of a FfP framework in action for obtaining estimates on early season influenza vaccination coverage estimates and on knowledge, attitudes, behaviors, and barriers related to influenza and influenza prevention among civilian noninstitutionalized adults aged 18 years and older in the United States. The result is the National Internet Flu Survey (NIFS), an annual, two-week internet survey sponsored by the US Centers for Disease Control and Prevention. In addition to critical design decisions, we use the established NIFS FfP framework to discuss the quality of the NIFS in meeting the intended objectives. We highlight aspects that work well and other survey traits requiring further evaluation. Differences found in comparing the NIFS to the National Flu Survey, the National Health Interview Survey, and Behavioral Risk Factor Surveillance System are discussed via their respective FfP characteristics. The findings presented here highlight the importance of the FfP framework for designing surveys, defining data quality, and providing a set a metrics used to advertise the intended use of the survey data and results. © 2019 The Author(s). Published by Oxford University Press on behalf of the American Association for Public Opinion Research. All rights reserved.

    • Genetics and Genomics
      1. Creation of an expert curated variant list for clinical genomic test development and validation: A ClinGen and GeT-RM Collaborative Projectexternal icon
        Wilcox E, Harrison SM, Lockhart E, Voelkerding K, Lubin IM, Rehm HL, Kalman L, Funke B.
        J Mol Diagn. 2021 Aug 9.
        Modern genomic sequencing tests often interrogate large numbers of genes. Identification of appropriate reference materials for development, validation studies, and quality assurance of these tests poses a significant challenge for laboratories. It is difficult to develop and maintain expert knowledge to identify all variants that must be validated to assure analytic and clinical validity. Additionally, it is usually not possible to procure appropriate and characterized genomic DNA reference materials containing the number and scope of variants required. To address these challenges, the Centers for Disease Control and Prevention's Genetic Testing Reference Material Program (GeT-RM) has partnered with the Clinical Genome Resource (ClinGen) to develop a publicly available list of expert curated, clinically important variants. ClinGen Variant Curation Expert Panels nominated 546 variants found in 84 disease associated genes, including common pathogenic and difficult to detect variants. Variant types nominated included 346 SNVs, 104 deletions, 37 CNVs, 25 duplications, 18 deletion-insertions, 5 inversions, 4 insertions, 2 complex rearrangements, 3 in difficult to sequence regions, and 2 fusions. This expert-curated variant list is a resource that provides a foundation for designing comprehensive validation studies and for creating in silico reference materials for clinical genomic test development and validation.

      2. Host genetic risk factors for Chlamydia trachomatis-related infertility in womenexternal icon
        Zheng X, Zhong W, O'Connell CM, Liu Y, Haggerty CL, Geisler WM, Anyalechi GE, Kirkcaldy RD, Wiesenfeld HC, Hillier SL, Steinkampf MP, Hammond KR, Fine J, Li Y, Darville T.
        J Infect Dis. 2021 Aug 16;224(Supplement_2):S64-s71.
        BACKGROUND: Chlamydia trachomatis (Ct) infection ascending to the upper genital tract can cause infertility. Direct association of genetic variants as contributors is challenging because infertility may not be diagnosed until years after infection. Investigating the intermediate trait of ascension bridges this gap. METHODS: We identified infertility genome-wide association study (GWAS) loci using deoxyribonucleic acid from Ct-seropositive cisgender women in a tubal factor infertility study and Ct-infected cisgender women from a longitudinal pelvic inflammatory disease cohort with known fertility status. Deoxyribonucleic acid and blood messenger ribonucleic acid from 2 additional female cohorts with active Ct infection and known endometrial infection status were used to investigate the impact of infertility single-nucleotide polymorphisms (SNPs) on Ct ascension. A statistical mediation test examined whether multiple infertility SNPs jointly influenced ascension risk by modulating expression of mediator genes. RESULTS: We identified 112 candidate infertility GWAS loci, and 31 associated with Ct ascension. The SNPs altered chlamydial ascension by modulating expression of 40 mediator genes. Mediator genes identified are involved in innate immune responses including type I interferon production, T-cell function, fibrosis, female reproductive tract health, and protein synthesis and degradation. CONCLUSIONS: We identified Ct-related infertility loci and their potential functional effects on Ct ascension.

    • Health Disparities

      1. Disparities in excess mortality associated with COVID-19 - United States, 2020external icon
        Rossen LM, Ahmad FB, Anderson RN, Branum AM, Du C, Krumholz HM, Li SX, Lin Z, Marshall A, Sutton PD, Faust JS.
        MMWR Morb Mortal Wkly Rep. 2021 Aug 20;70(33):1114-1119.
        The COVID-19 pandemic has disproportionately affected Hispanic or Latino, non-Hispanic Black (Black), non-Hispanic American Indian or Alaska Native (AI/AN), and non-Hispanic Native Hawaiian or Other Pacific Islander (NH/PI) populations in the United States. These populations have experienced higher rates of infection and mortality compared with the non-Hispanic White (White) population (1-5) and greater excess mortality (i.e., the percentage increase in the number of persons who have died relative to the expected number of deaths for a given place and time) (6). A limitation of existing research on excess mortality among racial/ethnic minority groups has been the lack of adjustment for age and population change over time. This study assessed excess mortality incidence rates (IRs) (e.g., the number of excess deaths per 100,000 person-years) in the United States during December 29, 2019-January 2, 2021, by race/ethnicity and age group using data from the National Vital Statistics System. Among all assessed racial/ethnic groups (non-Hispanic Asian [Asian], AI/AN, Black, Hispanic, NH/PI, and White populations), excess mortality IRs were higher among persons aged ≥65 years (426.4 to 1033.5 excess deaths per 100,000 person-years) than among those aged 25-64 years (30.2 to 221.1) and those aged <25 years (-2.9 to 14.1). Among persons aged <65 years, Black and AI/AN populations had the highest excess mortality IRs. Among adults aged ≥65 years, Black and Hispanic persons experienced the highest excess mortality IRs of >1,000 excess deaths per 100,000 person-years. These findings could help guide more tailored public health messaging and mitigation efforts to reduce disparities in mortality associated with the COVID-19 pandemic in the United States,* by identifying the racial/ethnic groups and age groups with the highest excess mortality rates.

      2. Evaluating for health equity among a cluster of health departments implementing PrEP servicesexternal icon
        Carter JW, Salabarría-Peña Y, Fields EL, Robinson WT.
        Eval Program Plann. 2021 Jul 27:101981.
        African American/Black and Hispanic/Latino sexual and gender minority populations are disproportionately affected by HIV in the United States and continue to experience HIV-related disparities. CDC funded project PrIDE to support 12 health departments (HD) with implementing pre-exposure prophylaxis (PrEP) strategies for men who have sex with men (MSM) and transgender persons, with a health-equity focus established by HDs. Each HD conducted mixed-methods evaluation of at least one local strategy. CDC employed a cluster evaluation approach to maximize cross validation. As a result, this cluster evaluation focused on three HDs that evaluated health equity-focused PrEP implementation strategies. Findings suggest that integrating health equity strategies such as storytelling and healthcare worker (HCW) trainings can help reduce HIV-related disparities. Storytelling improved HCW's understanding of clients' experiences of stigma due to racial, gender, and sexual identities. Provider training increased competencies on culturally appropriate care and the use of clinic services by Black and Hispanic MSM and transgender persons. Good practices included community engagement, seeking leadership buy-in, and integration of programmatic staff in health equity and evaluation activities. Evaluating strategies and training policies addressing social determinants of health that adversely affect HIV outcomes may help mitigate barriers Black and Hispanic MSM and transgender populations encounter in their HIV prevention seeking efforts.

      3. Geographic associations between social factors and SARS-CoV-2 testing early in the COVID-19 pandemic, February-June 2020, Massachusettsexternal icon
        Troppy S, Wilt GE, Whiteman A, Hallisey E, Crockett M, Sharpe JD, Haney G, Cranston K, Klevens RM.
        Public Health Rep. 2021 Aug 13.
        OBJECTIVES: Widespread SARS-CoV-2 testing is critical to identify infected people and implement public health action to interrupt transmission. With SARS-CoV-2 testing supplies and laboratory capacity now widely available in the United States, understanding the spatial heterogeneity of associations between social determinants and the use of SARS-CoV-2 testing is essential to improve testing availability in populations disproportionately affected by SARS-CoV-2. METHODS: We assessed positive and negative results of SARS-CoV-2 molecular tests conducted from February 1 through June 17, 2020, from the Massachusetts Virtual Epidemiologic Network, an integrated web-based surveillance and case management system in Massachusetts. Using geographically weighted regression and Moran's I spatial autocorrelation tests, we quantified the associations between SARS-CoV-2 testing rates and 11 metrics of the Social Vulnerability Index in all 351 towns in Massachusetts. RESULTS: Median SARS-CoV-2 testing rates decreased with increasing percentages of residents with limited English proficiency (median relative risk [interquartile range] = 0.96 [0.95-0.99]), residents aged ≥65 (0.97 [0.87-0.98]), residents without health insurance (0.96 [0.95-1.04], and people residing in crowded housing conditions (0.89 [0.80-0.94]). These associations differed spatially across Massachusetts, and localized models improved the explainable variation in SARS-CoV-2 testing rates by 8% to 12%. CONCLUSION: Indicators of social vulnerability are associated with variations in SARS-CoV-2 testing rates. Accounting for the spatial heterogeneity in these associations may improve the ability to explain and address the SARS-CoV-2 pandemic at substate levels.

    • Health Economics
      1. Patient costs for prevention of mother-to-child HIV transmission and antiretroviral therapy services in public health facilities in Zimbabweexternal icon
        Chingombe I, Mapingure MP, Balachandra S, Chipango TN, Gambanga F, Mushavi A, Apollo T, Suraratdecha C, Rogers JH, Ruangtragool L, Gonese E, Musuka GN, Mugurungi OM, Harris TG.
        PLoS One. 2021 ;16(8):e0256291.
        Zimbabwe has made large strides in addressing HIV. To ensure a continued robust response, a clear understanding of costs associated with its HIV program is critical. We conducted a cross-sectional evaluation in 2017 to estimate the annual average patient cost for accessing Prevention of Mother-To-Child Transmission (PMTCT) services (through antenatal care) and Antiretroviral Treatment (ART) services in Zimbabwe. Twenty sites representing different types of public health facilities in Zimbabwe were included. Data on patient costs were collected through in-person interviews with 414 ART and 424 PMTCT adult patients and through telephone interviews with 38 ART and 47 PMTCT adult patients who had missed their last appointment. The mean and median annual patient costs were examined overall and by service type for all participants and for those who paid any cost. Potential patient costs related to time lost were calculated by multiplying the total time to access services (travel time, waiting time, and clinic visit duration) by potential earnings (US$75 per month assuming 8 hours per day and 5 days per week). Mean annual patient costs for accessing services for the participants was US$20.00 [standard deviation (SD) = US$80.42, median = US$6.00, range = US$0.00-US$12,18.00] for PMTCT and US$18.73 (SD = US$58.54, median = US$8.00, range = US$0.00-US$ 908.00) for ART patients. The mean annual direct medical costs for PMTCT and ART were US$9.78 (SD = US$78.58, median = US$0.00, range = US$0.00-US$ 90) and US$7.49 (SD = US$60.00, median = US$0.00) while mean annual direct non-medical cost for US$10.23 (SD = US$17.35, median = US$4.00) and US$11.23 (SD = US$25.22, median = US$6.00, range = US$0.00-US$ 360.00). The PMTCT and ART costs per visit based on time lost were US$3.53 (US$1.13 to US$8.69) and US$3.43 (US$1.14 to US$8.53), respectively. The mean annual patient costs per person for PMTCT and ART in this evaluation will impact household income since PMTCT and ART services in Zimbabwe are supposed to be free.

      2. Projecting the prevalence and costs of metastatic breast cancer from 2015 through 2030external icon
        Gogate A, Wheeler SB, Reeder-Hayes KE, Ekwueme DU, Fairley TL, Drier S, Trogdon JG.
        JNCI Cancer Spectr. 2021 Aug;5(4):pkab063.
        BACKGROUND: This study projected the number of metastatic breast cancer (mBC) cases and costs (medical and productivity) attributable to mBC through 2030 among 3 age groups: younger (aged 18-44 years), midlife (aged 45-64 years), and older women (aged 65 years and older). METHODS: We developed a stock/flow model in which women enter the mBC population at initial diagnosis (de novo stage IV) or through progression of an earlier-stage cancer. Women exit the mBC population through death. Input parameters by age and phase of treatment came from the US Census, Surveillance, Epidemiology, and End Results and peer-reviewed literature. RESULTS: In 2030, we estimated there would be 246 194 prevalent cases of mBC, an increase of 54.8% from the 2015 estimate of 158 997. We estimated total costs (medical and productivity) of mBC across all age groups and phases of care were $63.4 billion (95% sensitivity range = $59.4-$67.4 billion) in 2015 and would increase to $152.4 billion (95% sensitivity range = $111.6-$220.4 billion) in 2030, an increase of 140%. Trends in estimated costs were higher for younger and midlife women than for older women. CONCLUSIONS: The cost of mBC could increase substantially in the coming decade, especially among younger and midlife women. Although accounting for trends in incidence, progression, and survival, our model did not attempt to forecast structural changes such as technological innovations in breast cancer treatment and health-care delivery reforms. These findings can motivate early detection activities, direct value-driven mBC treatment, and provide a useful baseline against which to measure the effect of prevention and treatment efforts.

    • Immunity and Immunization
      1. The purpose of this study was to determine the amount of time elementary and middle-school students spend away from the classroom and clinic time required to administer vaccines in school-located vaccination (SLV) clinics. We conducted a time study and estimated average time away from class and time to administer vaccine by health department (HD), student grade level, vaccine type, and vaccination process for SLV clinics during the 2012-2013 school year. Average time away from classroom was 10 min (sample: 688 students, 15 schools, three participating HD districts). Overall, time to administer intranasally administered influenza vaccine was nearly half the time to administer injected vaccine (52.5 vs. 101.7 s) (sample: 330 students, two HDs). SLV administration requires minimal time outside of class for elementary and middle-school students. SLV clinics may be an efficient way to administer catch-up vaccines to children who missed routine vaccinations during the coronavirus disease-2019 pandemic.

      2. Detection and clinical implications of monovalent rotavirus vaccine-derived virus strains in children with gastroenteritis in Alberta, Canadaexternal icon
        Zhuo R, Tarr G, Xie J, Freedman SB, Payne DC, Lee BE, McWilliams C, Chui L, Ali S, Pang X.
        J Clin Microbiol. 2021 Aug 18:Jcm0115421.
        Background: While rotavirus vaccine programs effectively protect against severe rotavirus gastroenteritis, rotavirus vaccine strains have been identified in the stool of vaccinated children and their close contacts suffering from acute gastroenteritis. The prevalence of vaccine strains, the emergence of vaccine-derived strains and their role in acute gastroenteritis are not well studied. Methods: We developed a Locked Nucleic Acid Reverse Transcription real-time PCR assay (LNA-RTqPCR) to detect the monovalent rotavirus vaccine (RV1) Rotarix non-structural protein 2 in children with acute gastroenteritis and healthy controls and validated it using sequence confirmed RV1 strains. The association between RV1-derived strains and gastroenteritis was determined using logistic regression. Results: The new assay exhibited 100% (95%CI: 91.7%, 100%) diagnostic sensitivity and 99.4% (95%CI: 96.2%, 100%) diagnostic specificity, with a detection limit of 9.86 copies/reaction and qPCR efficiency of 99.7%. Using this assay, we identified the presence of RV1-derived NSP2 sequences in 7.7% of rotavirus gastroenteritis cases and 98.6% of rotavirus positive healthy children (94.4% had previously received the RV1). Among gastroenteritis cases, those whose stool contained RV1-derived strains had milder gastroenteritis symptoms compared to that of natural rotavirus infections. We observed no significant association between RV1-derived strains and gastroenteritis (OR 0.98; 95% CI 0.60, 1.72). Conclusion: Our study demonstrated that the new assay is suitable for monitoring RV1-derived rotavirus strain circulation and that the RV1-derived strains are not associated with development of gastroenteritis symptoms.

      3. Impact of monovalent rotavirus vaccine on rotavirus hospitalizations among children younger than 5 years of age in the Ouest and Artibonite Departments, Haiti, 2013 to 2019external icon
        Desormeaux AM, Burnett E, Joseph G, Lucien MA, Aliabadi N, Pierre M, Dély P, Pierre K, Fitter D, Leshem E, Tate JE, Bowen MD, Esona M, Gautier J, Siné F, Katz MA, Grant-Greene Y, Parashar UD, Patel R, Boncy J, Juin S.
        Am J Trop Med Hyg. 2021 Aug 16.
        Rotavirus is responsible for 26% of diarrheal deaths in Latin America and the Caribbean. Haiti introduced the monovalent rotavirus vaccine in April 2014. The objective of this analysis is to describe the impact of the rotavirus vaccine on hospitalizations among Haitian children younger than 5 years old during the first 5 years after introduction. This analysis includes all children with diarrhea who were enrolled as part of a sentinel surveillance system at two hospitals from May 2013 to April 2019. We compare the proportion of rotavirus-positive specimens in each post-vaccine introduction year to the pre-vaccine period. To account for the potential dilution of the proportion of rotavirus-positive specimens from a waning cholera outbreak, we also analyzed annual trends in the absolute number of positive stools, fit a two-component finite-mixture model to the negative specimens, and fit a negative binomial time series model to the pre-vaccine rotavirus-positive specimens to predict the number of rotavirus diarrhea hospital admissions in the absence of rotavirus vaccination. The overall percentage of rotavirus-positive specimens declined by 22% the first year after introduction, increased by 17% the second year, and declined by 33% to 50% the subsequent 3 years. All sensitivity analyses confirmed an overall decline. We observed a clear annual rotavirus seasonality before and after vaccine introduction, with the greatest activity in December through April, and a biennial pattern, with high sharp peaks and flatter longer periods of increased rotavirus activity in alternating years, consistent with suboptimal vaccination coverage. Overall, our study shows evidence that the introduction of the rotavirus vaccine reduced the burden of severe rotavirus diarrhea.

      4. Improving routine immunization data quality using daily short message system reporting platform: An experience from Nasarawa state, Nigeriaexternal icon
        Akerele A, Uba B, Aduloju M, Etamesor S, Umar JA, Adeoye OB, Enyojo A, Josiah F, Ayandipo E, Olaoye I, Adegoke OJ, Sidney S, Bagana M, Bassey O, Ghiselli ME, Ndadilnasiya W, Bolu O, Shuaib F.
        PLoS One. 2021 ;16(8):e0255563.
        Routine immunization (RI) delivery was declared a public health concern in Nigeria in 2017 because of persistently low immunization coverage rates reported in independent surveys. However, administrative coverage rates remain high, suggesting serious data quality issues. We posit that a shorter timespan between service provision and data reporting can improve the monitoring of RI data, and developed a short message system (SMS) text reporting strategy to generate daily RI data points from health facilities (HFs). The goal was to assess whether daily data collection produces complete, reliable and internally consistent data points. The SMS reporting platform was piloted between December 2017 and April 2018 in two Local Government Areas (LGAs, equivalent to districts) of Nasarawa state, Nigeria. The 145 healthcare workers from 55 HFs received one mobile phone and pre-configured SIM card, and were trained to send data through predefined codes. Healthcare workers compiled the data after each vaccination session and transmitted them via SMS. We analyzed completeness, number of weekly sessions, and supportive supervision conducted. During the pilot phase, we received data from 85% (n = 47) of the 55 HFs. We expected 66 fixed-post sessions and 30 outreach sessions per week, but received data for 33 fixed-post and 8 outreach weekly session on average. More HFs reported on Tuesdays compared to other days of the week. When assessing internal consistency, we observed that the reported number of children vaccinated was sometimes higher than the number of doses available from opening a given number of vaccine vials. When found, this discrepancy was noted for all antigens during fixed-post and outreach vaccination sessions. Despite these initial discrepancies, transmitting RI data sessions via texting is feasible and can provide real-time updates to the performance of the RI services at the HF level.

      5. Measles infection in persons with secondary vaccine failure, New York City, 2018-19external icon
        Iwamoto M, Hickman CJ, Colley H, Arciuolo RJ, Mahle CE, Deocharan B, Siemetzki-Kapoor U, Zucker JR, Rosen JB.
        Vaccine. 2021 Aug 12.
        A large measles outbreak in New York City, which included cases among vaccinated persons and adults presumed to be immune, provided the opportunity to better understand vaccine failure and the potential impact on measles transmission. Immunoglobulin G (IgG) avidity can distinguish primary (low avidity IgG, indicating no evidence of prior immunity) versus secondary vaccine failure (high avidity IgG, indicating prior immune response and waning antibody). Measles IgG avidity was measured on samples from 62 persons: avidity was high in 53 (16 vaccinated and 37 with unknown vaccination history) and low in 9 (1 recently vaccinated and 8 with unknown vaccination history). Secondary transmission from 2 persons with high-avidity IgG results occurred. These findings illustrate that in settings of sustained measles elimination, measles infection and transmission can occur in persons with secondary vaccine failure, underscoring the need to maintain a high index of suspicion for measles during an outbreak despite prior or presumed prior vaccination.

    • Informatics
      1. Developing a scalable framework for partnerships between health agencies and the Wikimedia ecosystemexternal icon
        Mietchen D, Rasberry L, Morata T, Sadowski JP, Novakovich J., Heilman JM.
        Researc Ideas and Outcomes. 2021 Jun;7:e68121.
        In this era of information overload and misinformation, it is a challenge to rapidly translate evidence-based health information to the public. Wikipedia is a prominent global source of health information with high traffic, multilingual coverage, and acceptable quality control practices. Viewership data following the Ebola crisis and during the COVID-19 pandemic reveals that a significant number of web users located health guidance through Wikipedia and related projects, including its media repository Wikimedia Commons and structured data complement, Wikidata. The basic idea discussed in this paper is to increase and expedite health institutions' global reach to the general public, by developing a specific strategy to maximize the availability of focused content into Wikimedia's public digital knowledge archives. It was conceptualized from the experiences of leading health organizations such as Cochrane, the World Health Organization (WHO) and other United Nations Organizations, Cancer Research UK, National Network of Libraries of Medicine, and Centers for Disease Control and Prevention (CDC)'s National Institute for Occupational Safety and Health (NIOSH). Each has customized strategies to integrate content in Wikipedia and evaluate responses. We propose the development of an interactive guide on the Wikipedia and Wikidata platforms to support health agencies, health professionals and communicators in quickly distributing key messages during crisis situations. The guide aims to cover basic features of Wikipedia, including adding key health messages to Wikipedia articles, citing expert sources to facilitate fact-checking, staging text for translation into multiple languages; automating metrics reporting; sharing non-text media; anticipating offline reuse of Wikipedia content in apps or virtual assistants; structuring data for querying and reuse through Wikidata, and profiling other flagship projects from major health organizations. In the first phase, we propose the development of a curriculum for the guide using information from prior case studies. In the second phase, the guide would be tested on select health-related topics as new case studies. In its third phase, the guide would be finalized and disseminated.

    • Laboratory Sciences
      1. Background: 2-Hydroxyethyl mercapturic acid (2HEMA, N-acetyl-S-(2-hydroxyethyl)-L-cysteine) is a urinary metabolite of several volatile organic compounds including acrylonitrile and ethylene oxide, which are found in cigarette smoke.Methods: We measured 2HEMA concentrations in urine specimens collected during the National Health and Nutrition Examination Survey (2011-2016) from eligible participants aged >12 years (N = 7,416). We developed two multiple linear regression models to characterize the association between cigarette smoking and 2HEMA concentrations wherein the dependent variable was 2HEMA concentrations among participants who exclusively smoked cigarettes at the time of specimen collection and the independent variables included sex, age, race/ethnicity, creatinine, diet, and either cigarettes smoked per day (CPD) or serum cotinine.Results: We detected 2HEMA in 85% of samples tested among exclusive cigarette smokers, and only 40% of specimens from nonsmokers. When compared to exclusive cigarette smokers who smoked 1-9 CPD, smoking 10-19 CPD was associated with 36% higher 2HEMA (p < 0.0001) and smoking >19 CPD was associated with 61% higher 2HEMA (p < 0.0001). Additionally, 2HEMA was positively associated with serum cotinine.Conclusions: This study demonstrates that cigarette smoking intensity is associated with higher urinary 2HEMA concentrations and is likely a major source of acrylonitrile and/or ethylene oxide exposure.

      2. Innate lymphoid cells (ILC) in SARS-CoV-2 infectionexternal icon
        Kumar A, Cao W, Endrias K, Kuchipudi SV, Mittal SK, Sambhara S.
        Mol Aspects Med. 2021 Aug 13:101008.
        Innate Lymphoid Cells (ILCs) are a class of innate immune cells that form the first line of defense against internal or external abiotic and biotic challenges in the mammalian hosts. As they reside in both the lymphoid and non-lymphoid tissues, they are involved in clearing the pathogens through direct killing or by secretion of cytokines that modulate the adaptive immune responses. There is burgeoning evidence that these cells are important in clearing viral infections; therefore, it is critical to understand their role in the resolution or exacerbation of the disease caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2). In this review, we summarize the recent findings related to ILCs in response to SARS-CoV-2 infections.

      3. We report the results of a laboratory sensitivity and specificity evaluation of the Rapid Analyte Measurement Platform (RAMP®) Dengue Virus (DENV) antigen detection assay, which is designed to detect all serotypes of DENV in mosquito pools. The RAMP DENV assay was able to detect geographically distinct strains of all 4 DENV serotypes in virus-spiked mosquito pools that contained at least 4.3 log10 plaque forming units/ml, although discrete sensitivity limits varied slightly for each serotype. The RAMP DENV assay also detected DENV 1-4 in mosquito pools containing a single infected mosquito and 24 laboratory-reared uninfected mosquitoes. No false positives were detected in negative control mosquito pools or in samples containing high titers of nontarget arboviruses. We found that while the kit-supplied RAMP buffer reduced the infectious titer of DENV, it did not completely inactivate all serotypes. We recommend adding a detergent, Triton X-100, to the buffer to ensure complete inactivation of DENV if the assay is to be conducted at a lower biosafety level than required for DENV handling.

      4. Modeling neuroimmune interactions in human subjects and animal models to predict subtype-specific multidrug treatments for Gulf War illnessexternal icon
        Carrera Arias FJ, Aenlle K, Abreu M, Holschbach MA, Michalovicz LT, Kelly KA, Klimas N, O'Callaghan J P, Craddock TJ.
        Int J Mol Sci. 2021 ;22(16).
        Gulf War Illness (GWI) is a persistent chronic neuroinflammatory illness exacerbated by external stressors and characterized by fatigue, musculoskeletal pain, cognitive, and neurological problems linked to underlying immunological dysfunction for which there is no known treatment. As the immune system and the brain communicate through several signaling pathways, including the hypothalamic-pituitary-adrenal (HPA) axis, it underlies many of the behavioral and physiological responses to stressors via blood-borne mediators, such as cytokines, chemokines, and hormones. Signaling by these molecules is mediated by the semipermeable blood-brain barrier (BBB) made up of a monocellular layer forming an integral part of the neuroimmune axis. BBB permeability can be altered and even diminished by both external factors (e.g., chemical agents) and internal conditions (e.g., acute or chronic stress, or cross-signaling from the hypothalamic-pituitary-gonadal (HPG) axis). Such a complex network of regulatory interactions that possess feed-forward and feedback connections can have multiple response dynamics that may include several stable homeostatic states beyond normal health. Here we compare immune and hormone measures in the blood of human clinical samples and mouse models of Gulf War Illness (GWI) subtyped by exposure to traumatic stress for subtyping this complex illness. We do this via constructing a detailed logic model of HPA-HPG-Immune regulatory behavior that also considers signaling pathways across the BBB to neuronal-glial interactions within the brain. We apply conditional interactions to model the effects of changes in BBB permeability. Several stable states are identified in the system beyond typical health. Following alignment of the human and mouse blood profiles in the context of the model, mouse brain sample measures were used to infer the neuroinflammatory state in human GWI and perform treatment simulations using a genetic algorithm to optimize the Monte Carlo simulations of the putative treatment strategies aimed at returning the ill system back to health. We identify several ideal multi-intervention strategies and potential drug candidates that may be used to treat chronic neuroinflammation in GWI. Copyright © 2021 by the authors. Licensee MDPI, Basel, Switzerland.

      5. The performance of immunoassays to measure antibodies to the Chlamydia trachomatis antigen Pgp3 in different epidemiological settings for trachomaexternal icon
        Gwyn S, Nute AW, Sata E, Tadesse Z, Chernet A, Haile M, Zeru T, Bethea D, Laurent C, Callahan EK, Nash SD, Martin D.
        Am J Trop Med Hyg. 2021 Aug 16.
        Programs to eliminate trachoma as a public health problem use prevalence of the clinical sign trachomatous inflammation-follicular (TF) in 1- to 9-year-olds in endemic districts to make decisions to begin or end mass drug administration with azithromycin. Trachomatous inflammation-follicular is used as a proxy for transmission of ocular Chlamydia trachomatis infection. Long-term monitoring of previously endemic districts for recrudescence of ocular C. trachomatis infection would benefit from a simple blood test that could be integrated with other public health programs. In this study, we evaluated multiple tests to measure antibodies against the C. trachomatis antigen Pgp3-a multiplex bead assay (MBA), an ELISA, and two versions of a lateral flow assay (LFA)-in four districts of the Amhara region of Ethiopia with varying levels of TF. Seroprevalence and seroconversion rate (SCR) results were proportional to TF prevalence by district for most tests, with the notable exception of the LFA using colloidal gold as the developing reagent. Changing the test developing reagent to black latex improved agreement between serological measures and TF prevalence and in inter-rater agreement. Seroconversion rate estimates using data derived from the LFA-gold assay were inconsistent with the shape of the age-seroprevalence curve, which did not increase in older ages. These data revealed potential complications with using SCR that will need further evaluation. Data from MBA, ELISA, and LFA with the black test line showed good agreement with each other and proportionality to TF estimates, providing further data that serology has potential utility for trachoma surveillance.

      6. Use of guanidine thiocyanate-based nucleic acid extraction buffers to inactivate poliovirus in potentially infectious materialsexternal icon
        Honeywood MJ, Jeffries-Miles S, Wong K, Harrington C, Burns CC, Oberste MS, Bowen MD, Vega E.
        J Virol Methods. 2021 Aug 9:114262.
        The efforts of the Global Poliovirus Eradication Initiative (GPEI) have brought about the near elimination of poliovirus worldwide. The World Health Organization has issued guidelines for the safe handling and containment of infectious materials (IM) and potentially infectious materials (PIM) following poliovirus eradication. Inactivation of poliovirus in IM and PIM is needed to prevent inadvertent re-introduction of polioviruses post-eradication. In this study, we investigated the use of guanidine thiocyanate-based nucleic acid extraction buffers from commercially available nucleic acid extraction kits to inactivate poliovirus in cell culture isolates and stool suspensions, two common types of poliovirus IM and PIM, respectively. Incubation with selected nucleic acid extraction buffers or extraction buffers supplemented with ethanol reduced the infectivity of high-titer wild poliovirus type 1 (WPV1), wild poliovirus type 3 (WPV3), Sabin 1 (SL1), and Sabin 3 (SL3) cell culture isolates below the limit of detection in CCID(50) assays. Stool suspensions containing WPV1, WPV3, SL1, SL2, or SL3 were also inactivated by the extraction buffers tested. Blind passage of WPV1-spiked stool suspensions confirmed complete inactivation of WPV1 after incubation with extraction buffers. Moreover, treatment with a buffer consisting of 4 M guanidine thiocyanate with 30% ethanol inactivated a high-titer WPV1 culture isolate and a WPV1-spiked stool suspension. Taken together, these results show that guanidine thiocyanate-based nucleic acid extraction buffers are an effective means of inactivating poliovirus IM and PIM, and thus will be instrumental in ensuring containment compliance and preventing potential re-emergence of contained polioviruses.

    • Occupational Safety and Health
      1. Comfortable SCBA weights from biomechanical models for firefighting tasksexternal icon
        Xu S, Hu M, Powell J, Zhuang Z.
        AHFE International Conference on Human Factors and Simulation and the AHFE International Conference on Digital Human Modeling and Applied Optimization, 2021. 2021 ;264:231-238.
        Firefighters are required to use a self-contained breathing apparatus (SCBA) for respiratory protection when engaged in a variety of firefighting duties. While the SCBA provides crucial respiratory support and protection, it is also cumbersome and heavy. Questions have arisen to address the current weight limitation listed in 42 CFR Part 84, which mandates the maximum weight of 16 kg (35.2 lbs) for an SCBA system. The objective of the overarching study is to inform a maximum comfortable SCBA weight by developing static and dynamic biomechanical models and collecting physiological burden and postural stability data to evaluate stressors for firefighting tasks. This paper presents data from the static models. Eight representative firefighting tasks (stair climb, hose carry, weighted carry, rope pull, dummy drag, hammer slam, overhaul, and hose advance) were used in the biomechanical models. Maximum comfortable SCBA weights were calculated based on three biomechanical models (abdominal extension/tension, lateral extension/tension, and abdominal rotation). This study found that the maximum comfortable weight for an SCBA was 39 lbs for the static postures of interest. Further studies with human subjects to investigate the SCBA weight limit by using physiological burden and dynamic models are underway and will provide crucial data to inform updates to the current weight limits for SCBAs allowing more features and extended durations of these devices without compromising user safety, performance, or comfort. © 2021, The Author(s), under exclusive license to Springer Nature Switzerland AG.

        Lecture Notes in Networks and Systems

      2. Gaseous and particulate content of laser tattoo removal plumeexternal icon
        Levin YS, Grant MP, Glassford E, Green BJ, Lemons AR, Avram MM.
        Dermatol Surg. 2021 Aug 1;47(8):1071-1078.
        BACKGROUND: There is increasing awareness of the potential hazards of surgical plumes. The plume associated with laser tattoo removal remains uncharacterized. OBJECTIVE: To determine the gaseous, particulate, and microbiological content of the laser tattoo removal plume. MATERIALS AND METHODS: Air sampling was performed during laser tattoo removal from pig skin and from patients. Measurement of metals, volatile organic compounds (VOCs), carbon monoxide (CO), hydrogen sulfide (HS), and ultrafine particulates (UPs) as well as bacterial 16S ribosomal DNA sequencing were performed. RESULTS: Metals were identified in the plume from both pig and human skin. Volatile organic compounds were found at similar levels within and outside the treatment room. Several bacterial phyla were detected in the treatment room, but not outside. High levels of UPs were measured throughout the treatment room during tattoo removal from pig skin. Ultrafine particulates were detected at low levels in the room periphery during tattoo removal from human skin, but at higher levels in the immediate treatment zone. HS and CO were not detected. CONCLUSION: Metals, VOCs, HS, and CO were found at levels below applicable occupational exposure limits. The presence of bacteria is of uncertain significance, but may be hazardous. High levels of UPs require further investigation.

      3. Leveraging strategic foresight to advance worker safety, health and well-beingexternal icon
        Streit JM, Felknor SA, Edwards NT, Howard J.
        Int J Environ Res Public Health. 2021 ;18(16).
        Attending to the ever-expanding list of factors impacting work, the workplace, and the workforce will require innovative methods and approaches for occupational safety and health (OSH) research and practice. This paper explores strategic foresight as a tool that can enhance OSH capacity to anticipate, and even shape, the future as it pertains to work. Equal parts science and art, strategic foresight includes the development and analysis of plausible alternative futures as inputs to strategic plans and actions. Here, we review several published foresight approaches and exam-ples of work-related futures scenarios. We also present a working foresight framework tailored for OSH and offer recommendations for next steps to incorporate strategic foresight into research and practice in order to advance worker safety, health, and well-being. © 2021 by the authors. Licensee MDPI, Basel, Switzerland.

      4. Occupational safety and health and illicit opioids: State of the research on protecting against the threat of occupational exposureexternal icon
        Basham C, Cerles A, Rush M, Alexander-Scott M, Greenawald L, Chiu S, Broadwater K, Hirst D, Snawder J, Roberts J, Weber A, Knuth M, Casagrande R.
        New Solut. 2021 Aug 18.
        The nationwide opioid crisis continues to affect not only people who use opioids but also communities at large by increasing the risk of accidental occupational exposure to illicit opioids. In addition, the emergence of highly potent synthetic opioids such as fentanyl and carfentanil increases the need to protect workers who may encounter unknown drug substances during job activities. To support the National Institute for Occupational Safety and Health Opioids Research Gaps Working Group, we examined the state of the literature concerning methods to protect workers against accidental occupational exposure to illicit opioids, and have identified unmet research needs concerning personal protective equipment, decontamination methods, and engineering controls. Additional studies are needed to overcome gaps in technical knowledge about personal protective equipment, decontamination, and control methods, and gaps in understanding how these measures are utilized by workers. Increasing our knowledge of how to protect against exposure to illicit opioids has the potential to improve occupational health across communities.

      5. Sailors and the risk of asbestos-related cancerexternal icon
        Lemen RA, Landrigan PJ.
        Int J Environ Res Public Health. 2021 ;18(16).
        Sailors have long been known to experience high rates of injury, disease, and premature death. Many studies have shown asbestos-related diseases among shipyard workers, but few have examined the epidemiology of asbestos-related disease and death among asbestos-exposed sailors serving on ships at sea. Chrysotile and amphibole asbestos were used extensively in ship construction for insulation, joiner bulkhead systems, pipe coverings, boilers, machinery parts, bulkhead pan-els, and many other uses, and asbestos-containing ships are still in service. Sailors are at high risk of exposure to shipboard asbestos, because unlike shipyard workers and other occupationally exposed groups, sailors both work and live at their worksite, making asbestos standards and permissible exposure limits (PELs). based on an 8-hour workday inadequate to protect their health elevated risks of mesothelioma and other asbestos-related cancers have been observed among sailors through epidemiologic studies. We review these studies here. © 2021 by the authors. Licensee MDPI, Basel, Switzerland.

    • Parasitic Diseases
      1. Death from primary amebic meningoencephalitis after recreational water exposure during recent travel to India-Santa Clara County, California, 2020external icon
        Harris GR, Karmarkar EN, Quenelle R, Chaille L, Madhok J, Tien V, Gupta J, Jain S, Liu M, Roy S, Narasimhan S, Kimura A, Cope JR, Ali IK.
        Open Forum Infect Dis. 2021 Aug;8(8):ofab322.
        BACKGROUND: In February 2020, a man returned to the United States after an 11-day trip to India and died of primary amebic meningoencephalitis (PAM), caused by nasal exposure to the free-living ameba Naegleria fowleri found in warm water. We identified potential exposures, confirmed etiology, and described the molecular epidemiology of the infection. METHODS: We reviewed medical records to describe his clinical course and interviewed his family to determine water exposures. Genotyping was performed on the N. fowleri strain and compared with North American strains through repetitive nonpolymorphic nuclear loci analysis to identify differences. We reviewed N. fowleri strains in the National Center for Biotechnology Information database (GenBank) to determine genotypes present in India. RESULTS: The patient became acutely encephalopathic 3 days after returning; the only known nasal water exposure was at an indoor swimming pool in India 5 days earlier. Cerebrospinal fluid (CSF) testing demonstrated neutrophil-predominant pleocytosis and low glucose, but negative gram stain and culture. CSF microscopy revealed trophozoites; N. fowleri was detected by real-time polymerase chain reaction. Classical genotyping confirmed genotype I, common in the United States and among Indian strains in GenBank. The North American N. fowleri strains and the patient's strain varied at 5 nonpolymorphic loci. CONCLUSIONS: A man died from PAM after likely exposure at a vacation rental pool in India. We recommend including PAM in the differential diagnosis when CSF studies suggest bacterial meningitis but gram stain is negative. Genotyping can advance our understanding of N. fowleri molecular epidemiology and support future investigations.

      2. Parasitic disease surveillance, Mississippi, USAexternal icon
        Bradbury RS, Lane M, Arguello I, Handali S, Cooley G, Pilotte N, Williams JM, Jameson S, Montgomery SP, Hellmann K, Tharp M, Haynie L, Galloway R, Brackin B, Kirmse B, Stempak L, Byers P, Williams S, Faruque F, Hobbs CV.
        Emerg Infect Dis. 2021 Aug;27(8):2201-2204.
        Surveillance for soil-transmitted helminths, strongyloidiasis, cryptosporidiosis, and giardiasis was conducted in Mississippi, USA. PCR performed on 224 fecal samples for all soil-transmitted helminths and on 370 samples for only Necator americanus and Strongyloides stercoralis identified 1 S. stercoralis infection. Seroprevalences were 8.8% for Toxocara, 27.4% for Cryptosporidium, 5.7% for Giardia, and 0.2% for Strongyloides parasites.

    • Physical Activity
      1. Associations between perceptions and measures of weather and walking, United States—2015external icon
        Carlson SA, Whitfield GP, Davis RT, Peterson EL, Fulton JE, Berrigan D.
        Int J Environ Res Public Health. 2021 ;18(16).
        Introduction: Weather can be a barrier to walking. Understanding how perceptions of weather as a barrier and measured temperature are associated with walking can inform monitor-ing and promotion strategies. The objective of this study is to examine the association between perceptions of weather as a barrier to walking and measured weather with the volume of leisure and transportation walking. Methods: The 2015 National Health Interview Survey (NHIS) assessed participation in and volume of walking (transportation, leisure) in the past week and frequency of reporting weather as a barrier to walking. Data were collected over the entire year. In 2019, we merged month-specific temperature data from the PRISM climate group with individual NHIS records. We examined associations using logistic (participation) and linear regression models (volume). Re-sults: Participation in walking increased as frequency of reporting weather as a barrier to walking decreased, from ‘almost always’ (transportation: 23%, leisure: 42%) to ‘a little of the time’ (transporta-tion: 40%, leisure: 67%). Among adults reporting walking, walking volume increased as frequency of reporting weather as a barrier decreased from ‘almost always’ (transportation: 51 min/week, leisure: 64 min/week) to ‘never’ (transportation: 69 min/week, leisure: 98 min/week). Month-specific temperature was significantly associated with leisure walking with lower participation at the lowest and highest temperature quintiles, although the strength of the association differed by frequency of reporting weather as a barrier. Conclusions: In general, prevalence and volume of leisure and transportation walking decreased as the perception of weather as a barrier increased. Low and high temperature conditions were also associated with leisure walking participation, particularly among adults with increased perceptions of weather as a barrier. Our findings highlight the importance of including strategies to help adults overcome perceived and actual weather-related barriers in walking promotion efforts. © 2021 by the authors. Licensee MDPI, Basel, Switzerland.

    • Reproductive Health
      1. Enhancing reviews and surveillance to eliminate maternal mortalityexternal icon
        Callahan T, Zaharatos J, St Pierre A, Merkt PT, Goodman D.
        J Womens Health (Larchmt). 2021 Aug;30(8):1068-1073.
        Multisectoral investments over the past decade have accelerated the growth of Maternal Mortality Review Committee (MMRC) programs across the United States. The U.S. Centers for Disease Control and Prevention (CDC) launched the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) Initiative in 2019. Under ERASE MM, CDC directly funds 24 U.S. jurisdictions supporting MMRCs in 25 states. With increased investment in programs nationally, the CDC has designed a performance management framework to identify areas for improvement or sustained achievement and standardize measurement of key process benchmarks across programs. This article presents a report on the baseline measures collected through this performance management approach and suggests key partnerships required to continue to accelerate progress toward the elimination of preventable maternal mortality in the United States.

    • Substance Use and Abuse
      1. Trends in secondhand smoke exposure, 2011−2018: Impact and implications of expanding serum cotinine rangeexternal icon
        Tsai J, Homa DM, Neff LJ, Sosnoff CS, Wang L, Blount BC, Melstrom PC, King BA.
        Am J Prev Med. 2021 ;61(3):e109-e117.
        Introduction: The impact of defining secondhand smoke exposure among nonsmokers using an expanded serum cotinine range is currently unknown. Methods: This study assessed the trends in secondhand smoke exposure prevalence among a nationally representative sample of 23,753 U.S. nonsmokers aged ≥3 years. Serum cotinine ranges of 0.05–10 ng/mL (established) and of 0.015–10 ng/mL (expanded) were analyzed in 2021 using data from the 2011–2018 National Health and Nutrition Examination Survey. Results: During 2011–2018, the percentage of people with a serum cotinine range of 0.05–10 ng/mL remained stable (25.3% to 24.6%) across most sociodemographic subgroups but declined significantly among adult Mexican Americans aged ≥20 years (23.9% to 14.1%). However, the percentage of people with serum cotinine range of 0.015–10 ng/mL significantly declined (58.3% to 52.3%) among male individuals (60.9% to 55.0%), among female individuals (56.2% to 50.0%), among adults aged ≥20 years (55.8% to 49.2%), among Mexican Americans (60.9% to 41.2%), among people with a college degree or higher (44.4% to 36.0%), among those who rented their housing (71.7% to 62.5%), among people not living with someone who smoked inside the home (56.1% to 50.0%), and among Mexican Americans aged ≥20 years (60.9% to 39.1%) (all p<0.05 for linear trend test). Conclusions: Expanding the serum cotinine range to 0.015–10 ng/mL more than doubles the estimated proportion of U.S. nonsmokers exposed to secondhand smoke. In contrast to a serum cotinine range of 0.05–10 ng/mL, it suggests that progress has been made in reducing population-level secondhand smoke exposure during 2011–2018, especially among nonsmokers experiencing lower exposure levels. © 2021

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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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