Issue 32, September 8, 2021

CDC Science Clips: Volume 13, Issue 32, September 8, 2021

This week, Science Clips is pleased to feature a selection of articles from the Preventing Chronic Disease collection: Advancing Health Equity, Eliminating Health Disparities, and Improving Population Health.

In an accompanying editorial, editor-in-chief Leonard Jack writes:

"Over the past decade, there has been a range of community-based, technically innovative, and clinically driven prevention strategies in public health to prevent and reduce the burden of chronic conditions among diverse populations worldwide. Articles in this collection describe innovative and successful work to address factors contributing to advancing health equity, eliminating health disparities, and improving population health. They provide the latest information on ways to better understand contextual factors responsible for influencing health outcomes (both negatively and positively) and effective approaches to improve population health among diverse populations in various settings.

At the center of this collection of articles is a shared commitment to the goal of eliminating health disparities, particularly those that continue to persist despite aggressive efforts to ameliorate them. The collection describes a range of diverse and timely examples of efforts to eliminate health disparities and advance health equity among racial and ethnic groups in the US. Articles appearing here represent various types of PCD articles that encompass multiple perspectives, from original research and systematic reviews to implementation evaluation to expert commentaries to tools that can be used in public health practice. As a discipline, we have important work to do, not only to better understand how social determinants of health and other contextual factors impact health but also to design, implement, and evaluate effective multilevel systems approaches that create optimal conditions to promote health for all."

The articles highlighted below address topics related to COVID.

Please visit the collection homepage for articles on additional topics.
  1. Key Scientific Articles in Featured Topic Areas
    Subject matter experts decide what topic to feature, and articles are selected from the last 3 to 6 months of published literature. Key topic coincides monthly with other CDC products (e.g. Vital Signs).
    • Preventing Chronic Disease Collection: Advancing Health Equity, Eliminating Health Disparities, and Improving Population Health
      1. Culture matters in communicating the global response to COVID-19
        Airhihenbuwa CO, Iwelunmor J, Munodawafa D, Ford CL, Oni T, Agyemang C, Mota C, Ikuomola OB, Simbayi L, Fallah MP, Qian Z, Makinwa B, Niang C, Okosun I.
        Prev Chronic Dis. 2020 Jul 9;17:E60.
        Current communication messages in the COVID-19 pandemic tend to focus more on individual risks than community risks resulting from existing inequities. Culture is central to an effective community-engaged public health communication to reduce collective risks. In this commentary, we discuss the importance of culture in unpacking messages that may be the same globally (physical/social distancing) yet different across cultures and communities (individualist versus collectivist). Structural inequity continues to fuel the disproportionate impact of COVID-19 on black and brown communities nationally and globally. PEN-3 offers a cultural framework for a community-engaged global communication response to COVID-19.

      2. Reaching the Hispanic community about COVID-19 through existing chronic disease prevention programs
        Calo WA, Murray A, Francis E, Bermudez M, Kraschnewski J.
        Prev Chronic Dis. 2020 Jun 25;17:E49.
        Publicly available data on racial and ethnic disparities related to coronavirus disease 2019 (COVID-19) are now surfacing, and these data suggest that the novel virus has disproportionately sickened Hispanic communities in the United States. We discuss why Hispanic communities are highly vulnerable to COVID-19 and how adaptations were made to existing infrastructure for Penn State Project ECHO (Extension for Community Healthcare Outcomes) and Better Together REACH (a community-academic coalition using grant funds from Racial and Ethnic Approaches to Community Health) to address these needs. We also describe programming to support COVID-19 efforts for Hispanic communities by using chronic disease prevention programs and opportunities for replication across the country.

      3. A framework for mobilizing health care to respond to the community within the COVID-19 pandemic
        Epps F, Wiley Z, Teunis LJ, Johnson TM, Patzer RE, Ofotokun I, Franks N.
        Prev Chronic Dis. 2021 Apr 1;18:E30.
        Cultural mistrust of government with regard to health issues has pressed the need to engage trusted community leaders with influence and reach in disproportionately affected communities to ensure that essential public health activities related to COVID-19 occur among populations experiencing disproportionate impact from the pandemic. In April of 2020, a Georgia-based integrated academic health care system created a Community Outreach and Health Disparities Collaborative to unite trusted community leaders from faith-based, civic, and health-sector organizations to work with the health system and Emory University to develop tailored approaches and mobilize support within the context of the communities' cultural and individual needs to reduce the burden of COVID-19. We describe the framework used to join health care and academic collaborators with community partners to mobilize efforts to address the disproportionate impact of COVID-19 on racial, ethnic, and socioeconomic minority groups. The framework outlines a series of steps taken that led to a community-driven collaboration designed to engage local influential community leaders as partners in improving access to care for disproportionately affected communities, collaborations that could be replicated by other large health care systems. This framework can also be applied to other chronic diseases or future public health emergencies to improve communication, education, and health care access for communities experiencing disproportionate impact.

      4. COVID-19 and chronic disease: The impact now and in the future
        Hacker KA, Briss PA, Richardson L, Wright J, Petersen R.
        Prev Chronic Dis. 2021 Jun 17;18:E62.

      5. Community engagement of African Americans in the era of COVID-19: Considerations, challenges, implications, and recommendations for public health
        Henry Akintobi T, Jacobs T, Sabbs D, Holden K, Braithwaite R, Johnson LN, Dawes D, Hoffman L.
        Prev Chronic Dis. 2020 Aug 13;17:E83.
        African Americans, compared with all other racial/ethnic groups, are more likely to contract coronavirus disease 2019 (COVID-19), be hospitalized for it, and die of the disease. Psychosocial, sociocultural, and environmental vulnerabilities, compounded by preexisting health conditions, exacerbate this health disparity. Interconnected historical, policy, clinical, and community factors explain and underpin community-based participatory research approaches to advance the art and science of community engagement among African Americans in the COVID-19 era. In this commentary, we detail the pandemic response strategies of the Morehouse School of Medicine Prevention Research Center. We discuss the implications of these complex factors and propose recommendations for addressing them that, adopted together, will result in community and data-informed mitigation strategies. These approaches will proactively prepare for the next pandemic and advance community leadership toward health equity.

      6. Engaging with communities - lessons (re)learned from COVID-19
        Michener L, Aguilar-Gaxiola S, Alberti PM, Castaneda MJ, Castrucci BC, Harrison LM, Hughes LS, Richmond A, Wallerstein N.
        Prev Chronic Dis. 2020 Jul 16;17:E65.
        Coronavirus disease 2019 (COVID-19) has underscored longstanding societal differences in the drivers of health and demonstrated the value of applying a health equity lens to engage at-risk communities, communicate with them effectively, share data, and partner with them for program implementation, dissemination, and evaluation. Examples of engagement - across diverse communities and with community organizations; tribes; state and local health departments; hospitals; and universities - highlight the opportunity to apply lessons from COVID-19 for sustained changes in how public health and its partners work collectively to prevent disease and promote health, especially with our most vulnerable communities.

      7. INTRODUCTION: The disproportionate impact of the COVID-19 pandemic on Latino communities has resulted in greater reports of depression, anxiety, and stress. We present a community-led intervention in Latino communities that integrated social services in mental health service delivery for an equity-based response. METHODS: We used tracking sheets to identify 1,436 unique participants (aged 5-86) enrolled in Latino Health Access's Emotional Wellness program, of whom 346 enrolled in the pre-COVID-19 period (March 2019-February 2020) and 1,090 in the COVID-19 period (March-June 2020). Demographic characteristics and types of services were aggregated to assess monthly trends using Pearson χ(2) tests. Regression models were developed to compare factors associated with referrals in the pre-COVID-19 and COVID-19 periods. RESULTS: During the pandemic, service volume (P < .001) and participant volume (P < .001) increased significantly compared with the prepandemic period. Participant characteristics were similar during both periods, the only differences being age distribution, expanded geographic range, and increased male participation during the pandemic. Nonreferred services, such as peer support, increased during the pandemic period. Type of referrals significantly changed from primarily mental health services and disease management in the prepandemic period to affordable housing support, food assistance, and supplemental income. CONCLUSION: An effective mental health program in response to the pandemic must incorporate direct mental health services and address social needs that exacerbate mental health risk for Latino communities. This study presents a model of how to integrate both factors by leveraging promotor-led programs.

      8. Addressing racial and ethnic disparities in COVID-19 among school-aged children: Are we doing enough?
        White A, Liburd LC, Coronado F.
        Prev Chronic Dis. 2021 Jun 3;18:E55.
        The disproportionate impact of COVID-19 and associated disparities among Hispanic, non-Hispanic Black, and non-Hispanic American Indian/Alaska Native children and teenagers has been documented. Reducing these disparities along with overcoming unintended negative consequences of the pandemic, such as the disruption of in-person schooling, calls for broad community-based collaborations and nuanced approaches. Based on national survey data, children from some racial and ethnic minority groups have a higher prevalence of obesity, asthma, type 2 diabetes, and hypertension; were diagnosed more frequently with COVID-19; and had more severe outcomes compared with their non-Hispanic White (NHW) counterparts. Furthermore, a higher proportion of children from some racial and ethnic minority groups lived in families with incomes less than 200% of the federal poverty level or in households lacking secure employment compared with NHW children. Children from some racial and ethnic minority groups were also more likely to attend school via online learning compared with NHW counterparts. Because the root causes of these disparities are complex and multifactorial, an organized community-based approach is needed to achieve greater proactive and sustained collaborations between local health departments, local school systems, and other public and private organizations to pursue health equity. This article provides a summary of potential community-based health promotion strategies to address racial and ethnic disparities in COVID-19 outcomes and educational inequities among children and teens, specifically in the implementation of strategic partnerships, including initial collective work, outcomes-based activities, and communication. These collaborations can facilitate policy, systems, and environmental changes in school systems that support emergency preparedness, recovery, and resilience when faced with public health crises.

  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. Trends in prevalence of type 1 and type 2 diabetes in children and adolescents in the US, 2001-2017external icon
        Lawrence JM, Divers J, Isom S, Saydah S, Imperatore G, Pihoker C, Marcovina SM, Mayer-Davis EJ, Hamman RF, Dolan L, Dabelea D, Pettitt DJ, Liese AD.
        Jama. 2021 Aug 24;326(8):717-727.
        IMPORTANCE: Changes in the prevalence of youth-onset diabetes have previously been observed. OBJECTIVE: To estimate changes in prevalence of type 1 and type 2 diabetes in youths in the US from 2001 to 2017. DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional observational study, individuals younger than 20 years with physician-diagnosed diabetes were enumerated from 6 areas in the US (4 geographic areas, 1 health plan, and select American Indian reservations) for 2001, 2009, and 2017. EXPOSURES: Calendar year. MAIN OUTCOMES AND MEASURES: Estimated prevalence of physician-diagnosed type 1 and type 2 diabetes overall and by race and ethnicity, age, and sex. RESULTS: Among youths 19 years or younger, 4958 of 3.35 million had type 1 diabetes in 2001, 6672 of 3.46 million had type 1 diabetes in 2009, and 7759 of 3.61 million had type 1 diabetes in 2017; among those aged 10 to 19 years, 588 of 1.73 million had type 2 diabetes in 2001, 814 of 1.85 million had type 2 diabetes in 2009, and 1230 of 1.85 million had type 2 diabetes in 2017. The estimated type 1 diabetes prevalence per 1000 youths for those 19 years or younger increased significantly from 1.48 (95% CI, 1.44-1.52) in 2001 to 1.93 (95% CI, 1.88-1.98) in 2009 to 2.15 (95% CI, 2.10-2.20) in 2017, an absolute increase of 0.67 per 1000 youths (95%, CI, 0.64-0.70) and a 45.1% (95% CI, 40.0%-50.4%) relative increase over 16 years. The greatest absolute increases were observed among non-Hispanic White (0.93 per 1000 youths [95% CI, 0.88-0.98]) and non-Hispanic Black (0.89 per 1000 youths [95% CI, 0.88-0.98]) youths. The estimated type 2 diabetes prevalence per 1000 youths aged 10 to 19 years increased significantly from 0.34 (95% CI, 0.31-0.37) in 2001 to 0.46 (95% CI, 0.43-0.49) in 2009 to 0.67 (95% CI, 0.63-0.70) in 2017, an absolute increase of 0.32 per 1000 youths (95% CI, 0.30-0.35) and a 95.3% (95% CI, 77.0%-115.4%) relative increase over 16 years. The greatest absolute increases were observed among non-Hispanic Black (0.85 per 1000 youths [95% CI, 0.74-0.97]) and Hispanic (0.57 per 1000 youths [95% CI, 0.51-0.64]) youths. CONCLUSIONS AND RELEVANCE: In 6 areas of the US from 2001 to 2017, the estimated prevalence of diabetes among children and adolescents increased for both type 1 and type 2 diabetes.

      2. Prevalence of amyotrophic lateral sclerosis (ALS), United States, 2016external icon
        Mehta P, Raymond J, Punjani R, Larson T, Bove F, Kaye W, Nelson LM, Topol B, Han M, Muravov O, Genson C, Davis B, Hicks T, Horton K.
        Amyotroph Lateral Scler Frontotemporal Degener. 2021 Aug 23:1-6.
        Objective: To estimate the prevalence of amyotrophic lateral sclerosis (ALS) in the United States for 2016 using data from the National ALS Registry (Registry). Established in 2009, the Registry collects data on ALS patients in the U.S. to better describe the epidemiology of ALS, examine risk factors such as environmental and occupational exposures, and characterize the demographics of those living with the disease. Methods: To identify adult prevalent cases of ALS, the Registry compiles data from three national administrative databases (maintained by the Centers for Medicare and Medicaid Services, the Veterans Health Administration, and the Veterans Benefits Administration). To ascertain cases not necessarily included in these databases and to better understand risk-factors associated with ALS and disease progression, the Registry also includes data collected from patients who voluntarily enroll via a web portal to complete online surveys. Results: In 2016, the Registry conservatively identified 16,424 adult persons who met the Registry definition of ALS for an age-adjusted prevalence rate of 5.2 per 100,000 U.S. population. The pattern of patient characteristics (e.g., age, sex, and race/ethnicity) has not changed from previous Registry reports. Overall, ALS was more common among whites, males, and persons aged 60-69 years. The age groups with the lowest number of ALS cases were persons aged 18-39 years. Males had a higher prevalence rate of ALS than females overall and across all data sources. Conclusions: Data collected by the National ALS Registry are being used to better describe the epidemiology and demographics of ALS in the U.S.

      3. Clinical follow-up practices after cervical cancer screening by co-testing: A population-based study of adherence to U.S. guideline recommendationsexternal icon
        Perkins RB, Adcock R, Benard V, Cuzick J, Waxman A, Howe J, Melkonian S, Gonzales J, Wiggins C, Wheeler CM.
        Prev Med. 2021 Aug 17:106770.
        Failure to follow-up women after abnormal cervical screening could lead to cervical cancers, yet little is known about adherence to recommended follow-up after abnormal co-testing [cytology and high-risk human papillomavirus (hrHPV) testing]. We documented clinical management following cervical screening by co-testing in a diverse population-based setting. A statewide surveillance program for cervical screening, diagnosis, and treatment was used to investigate all cytology, hrHPV and biopsy reports in the state of New Mexico from January 2015 through August 2019. Guideline-adherent follow-up after co-testing required 1) biopsy within 6 months for low-grade cytology if positive for hrHPV, for high-grade cytology irrespective of hrHPV, and for HPV 16/18 positive results irrespective of cytology and; 2) repeat co-testing within 18 months if cytology was negative and hrHPV test was positive (excluding types 16/18). Screening co-tests (2015-2017) for 164,522 women were analyzed using descriptive statistics, Kaplan Meier curves, and pairwise comparisons between groups. Guideline adherence was highest when both cytology and hrHPV tests were abnormal, ranging from 61.7% to 80.3%. Guideline-adherent follow-up was lower for discordant results. Women with high-grade cytology were less likely to receive a timely biopsy when hrHPV-testing was negative (48.1%) versus positive (83.3%) (p < 0.001). Only 47.9% of women received biopsies following detection of HPV16/18 with normal cytology, and 30.8% received no follow-up within 18-months. Among women with hrHPV-positive normal cytology without evidence of HPV 16/18 infection, 51% received no follow-up within 18 months. Provider education and creation of robust recall systems may help ensure appropriate follow-up of abnormal screening results.

    • Communicable Diseases
      1. Incidence and seasonality of respiratory viruses among medically attended children with acute respiratory infections in an Ecuador birth cohort, 2011-2014external icon
        Azziz-Baumgartner E, Bruno A, Daugherty M, Chico ME, Lopez A, Arriola CS, de Mora D, Ropero AM, Davis WW, McMorrow M, Cooper PJ.
        Influenza Other Respir Viruses. 2021 Aug 25.
        BACKGROUND: Ecuador annually has handwashing and respiratory hygiene campaigns and seasonal influenza vaccination to prevent respiratory virus illnesses but has yet to quantify disease burden and determine epidemic timing. METHODS: To identify respiratory virus burden and assess months with epidemic activity, we followed a birth cohort in northwest Ecuador during 2011-2014. Mothers brought children to the study clinic for routine checkups at ages 1, 2, 3, 5, and 8 years or if children experienced any acute respiratory illness symptoms (e.g., cough, fever, or difficulty breathing); clinical care was provided free of charge. Those with medically attended acute respiratory infections (MAARIs) were tested for common respiratory viruses via real-time reverse-transcription polymerase chain reaction (rRT-PCR). RESULTS: In 2011, 2376 children aged 1-4 years (median 35 months) were enrolled in the respiratory cohort and monitored for 7017.5 child-years (cy). The incidence of respiratory syncytial virus (RSV) was 23.9 (95% CI 17.3-30.5), influenza 10.6 (2.4-18.8), adenoviruses 6.7 (4.6-28.0), parainfluenzas 5.0 (2.3-10.5), and rhinoviruses, bocaviruses, human metapneumoviruses, seasonal coronaviruses, and enteroviruses <3/100 cy among children aged 12-23 months and declined with age. Most (75%) influenza detections occurred April-September. CONCLUSION: Cohort children frequently had MAARIs, and while the incidence decreased rapidly among older children, more than one in five children aged 12-23 months tested positive for RSV, and one in 10 tested positive for influenza. Our findings suggest this substantial burden of influenza occurred more commonly during the winter Southern Hemisphere influenza season.

      2. Revising conventional wisdom about histoplasmosis in the United Statesexternal icon
        Benedict K, Toda M, Jackson BR.
        Open Forum Infect Dis. 2021 ;8(7).
        Studies performed during the 1940s-1960s continue to serve as the foundation of the epidemiology of histoplasmosis given that many knowledge gaps persist regarding its geographic distribution, prevalence, and burden in the United States. We explore 3 long-standing, frequently cited, and somewhat incomplete epidemiologic beliefs about histoplasmosis: (1) histoplasmosis is the most common endemic mycosis in the United States, (2) histoplasmosis is endemic to the Ohio and Mississippi River Valleys, and (3) histoplasmosis is associated with bird or bat droppings. We also summarize recent insights about the clinical spectrum of histoplasmosis and changes in underlying conditions associated with the severe forms. Continuing to identify prevention opportunities will require better epidemiologic data, better diagnostic testing, and greater awareness about this neglected disease among health care providers, public health professionals, and the general public. © 2021 Published by Oxford University Press on behalf of Infectious Diseases Society of America 2021.

      3. Progress toward polio eradication - worldwide, January 2019-June 2021external icon
        Bigouette JP, Wilkinson AL, Tallis G, Burns CC, Wassilak SG, Vertefeuille JF.
        MMWR Morb Mortal Wkly Rep. 2021 Aug 27;70(34):1129-1135.
        In 1988, when the Global Polio Eradication Initiative (GPEI) began, polio paralyzed >350,000 children across 125 countries. Today, only one of three wild poliovirus serotypes, type 1 (WPV1), remains in circulation in only two countries, Afghanistan and Pakistan. This report summarizes progress toward global polio eradication during January 1, 2019-June 30, 2021 and updates previous reports (1,2). In 2020, 140 cases of WPV1 were reported, including 56 in Afghanistan (a 93% increase from 29 cases in 2019) and 84 in Pakistan (a 43% decrease from 147 cases in 2019). As GPEI focuses on the last endemic WPV reservoirs, poliomyelitis outbreaks caused by circulating vaccine-derived poliovirus (cVDPV) have emerged as a result of attenuated oral poliovirus vaccine (OPV) virus regaining neurovirulence after prolonged circulation in underimmunized populations (3). In 2020, 32 countries reported cVDPV outbreaks (four type 1 [cVDPV1], 26 type 2 [cVDPV2] and two with outbreaks of both); 13 of these countries reported new outbreaks. The updated GPEI Polio Eradication Strategy 2022-2026 (4) includes expanded use of the type 2 novel oral poliovirus vaccine (nOPV2) to avoid new emergences of cVDPV2 during outbreak responses (3). The new strategy deploys other tactics, such as increased national accountability, and focused investments for overcoming the remaining barriers to eradication, including program disruptions and setbacks caused by the COVID-19 pandemic.

      4. OBJECTIVES: In this study, we describe changes in LRTI rates from 1998-2014 among hospitalized AI/AN adults residing in Alaska and other Indian Health Service (IHS) regions. METHODS: We calculated age-adjusted hospital discharge rates and rate ratios from the IHS Direct and Contract Health Services Inpatient Dataset, IHS National Patient Information Reporting System for AI/AN adults ≥18 years, hospitalized at an IHS-operated, tribally operated or contract hospital with an LRTI-associated diagnosis during 1998-2014. RESULTS: Overall, there were 13,733 LRTI-associated hospitalizations in Alaska (1998-2014) with an age-adjusted rate of 13.7/1,000 adults. Among non-AK AI/AN, there were a total of 79,170 hospitalizations with a rate of 8.6/1,000 adults. In the pre-PCV7 and pre-PCV13 periods, LRTI rates were higher in AK AI/AN (12.4 and 14.1) compared to non-AK AI/AN (10.1 and 9.1, p<0.0001), respectively. In post-PCV7 and post-PCV13 periods, LRTI rates were also higher in AK (13.5 and 15.0) compared to non-AK (9.2 and 7.3, p<0.0001). CONCLUSIONS: Over the study period, we observed a 26% increase in rates of LRTI among adult AI/AN residing in Alaska compared with a 38% decrease in rates among AI/AN residing in non-AK. This disparity is likely due to a variety of factors such as tobacco use, crowding etc. Strategies to reduce LRTI in AI/AN adults are needed.

      5. Demographic and epidemiological characteristics associated with reduced antimicrobial susceptibility to Neisseria gonorrhoeae in the United States, Strengthening the U.S. Response to Resistant Gonorrhea (SURRG), 2018-2019external icon
        Gieseker K, Learner ER, Mauk K, Barbee LA, McNeil CJ, Hasty GL, Black JM, Johnson K, Quyen Nguyen T, Shrestha D, Pham CD, St Cyr S, Schlanger K, Kirkcaldy RD.
        Sex Transm Dis. 2021 Aug 23.
        BACKGROUND: Jurisdictions participating in Strengthening the United States Response to Resistant Gonorrhea (SURRG) implemented specimen collection for culture and antimicrobial susceptibility testing (AST) from a sample of persons of all genders (at multiple anatomic sites) attending STD clinics and community clinics. We describe the percentage and characteristics of patients whose isolates demonstrated reduced susceptibility (RS) to azithromycin, ceftriaxone, or cefixime. METHODS: We included patients from clinics that participated in SURRG whose isolates underwent AST by Etest. We defined RS as azithromycin minimum inhibitory concentrations (MICs) ≥2 μg/ml (AZM-RS), ceftriaxone MICs ≥0.125 μg/ml (CRO-RS), or cefixime MICs ≥0.25 μg/ml (CFX-RS). Patients with repeated infections appeared >1 time in the data. We calculated the frequency and percentage of patients with an isolate demonstrating RS by epidemiological characteristics. RESULTS: During 2018-2019, 10,013 patients from eight jurisdictions provided 10,735 isolates. Among 10,013 patients, 11.0% (n = 1,099) had ≥1 isolate with AZM-RS (range by jurisdiction 2.5%-18.0%). Approximately 11.3% of 8,771 of patients visiting STD clinics and approximately 8.8% of 1,242 patients visiting community clinics had an AZM-RS isolate. Nearly 6% of 1,013 females had an AZM-RS isolate; among males, the percent of patients with an AZM-RS isolate was 17.7% among 4,177 men who have sex only with men and 6.1% among 3,581 men who have sex only with women. Few (0.4%) patients had isolates with CFX-RS (n = 40) or CRO-RS (n = 43). CONCLUSIONS: Although infections with reduced cephalosporin susceptibility were rare, AZM-RS infections were prevalent in this sample of patients in multiple jurisdictions and across gender and gender of sex partner categories.

      6. BACKGROUND: Neisseria gonorrhoeae (NG) continues to develop antimicrobial-resistance (AR) and treatment options are limited. ARNG surveillance aids in identifying threats and guiding treatment recommendations but has traditionally been limited to sexually transmitted infection (STI) clinics. Large portions of STI care is delivered outside of STI clinics, such as emergency departments (ED). These facilities might provide additional venues to expand surveillance and outbreak preparedness. METHODS: Through the Strengthening the U.S. Response to Resistant Gonorrhea (SURRG) program, Greensboro, North Carolina, and Indianapolis, Indiana identified four EDs in high-morbidity areas to expand culture collection. Patient demographics, culture recovery rates, and antimicrobial-susceptibility results between EDs and local STI clinics were compared along with lessons learned from reviewing programmatic policies and discussions with key personnel. RESULTS: During 2018-2019, non-Hispanic Black patients were the most represented group at all six sites (73.6%). Age was also similar across sites (median range 23-27). Greensboro isolated 1039 cultures (STI clinic (Women: 141; Men: 612; Transwomen: 3); EDs: 283 (Women: 164, Men: 119)). Indianapolis isolated 1278 cultures (STI clinic: 1265 (Women: 125, Men: 1139, Transwomen: 1); ED: 13 all male). Reduced azithromycin susceptibility was found at the Indianapolis (n = 86) and Greensboro (n = 25) STI clinics, and one Greensboro ED (n = 8).Implementation successes included identifying an on-site "Champion", integrating with electronic medical records, and creating an online training hub. Barriers included cumbersome data collection tools, time constraints, and hesitancy from clinical staff. CONCLUSIONS: Partnering with EDs for ARNG surveillance poses both challenges and opportunities. Program success can be improved by engaging a local "champion" to help lead efforts.

      7. Nurse- and midwife-led HIV services in eastern and southern Africa: Challenges and opportunities for health facilitiesexternal icon
        MacKay RE, Gross JM, Hepburn KW, Spangler SA.
        J Assoc Nurses AIDS Care. 2020 Jul-Aug;31(4):392-404.
        In eastern and southern Africa, much is unknown about implementation of nurse-initiated and managed antiretroviral therapy (NIMART). The purpose of this study was to identify perceived barriers and facilitators of NIMART for the prevention of mother-to-child transmission and pediatric HIV services in high-volume, high HIV-burden health facilities across this region. A total of 211 nurses, midwives, and nurse midwives and 62 supervisors from 30 health facilities in 11 countries participated in this mixed-methods evaluation. The findings show that although nurses, midwives, and nurse midwives clearly had the authority to provide NIMART services, they did not necessarily feel that they were well prepared and supported to do so. Deficits in supportive supervision and clinical mentorship were viewed as substantial challenges to effective provision of NIMART for the prevention of mother-to-child transmission and pediatric HIV services-particularly with respect to pediatric HIV services. Health facilities have important opportunities to advance NIMART practice through strengthening these aspects of in-service support.

      8. HIV and syphilis prevalence among transgender women and men who have sex with men, Silom Community Clinic, Bangkok, Thailand, 2017-2019external icon
        Pattanasin S, Griensven FV, Mock PA, Sukwicha W, Kongpechsatit O, Krasan C, O'Connor S, Hickey AC, Ungsedhapand C, Woodring JV, Connor S, Chitwarakorn A, Dunne EF.
        AIDS Care. 2021 Aug 23:1-9.
        We assessed HIV and syphilis infection among MSM and TGW attending Silom Community Clinic from 2017 to 2019. Walk-in and referral clients completed a registration application including a question on gender identity. We compared the prevalence of HIV, syphilis, and HIV and syphilis coinfection among TGW and MSM. In a total of 1050 clients, 276 (26.3%) were TGW and 774 (74.7%) were MSM. Among TGW clients, HIV prevalence was 29.8%, syphilis prevalence was 38.4%, and coinfection prevalence was 18.5%. Comparing prevalence among TGW to MSM, the adjusted prevalence ratio (aPR) for HIV was 1.8 (95% CI:1.4-2.3), for syphilis was 1.2 (95% CI:1.0-1.4), and for HIV and syphilis coinfection was 2.1 (95% CI:1.4-2.9). The prevalence of syphilis was higher than HIV among TGW, with a PR of 1.3 (95% CI:1.1-1.6), and among MSM, with a PR of 1.4 (95% CI:1.2-1.7). TGW age 15-21 years had an HIV prevalence of 16.9% and syphilis prevalence of 30.8%. After adjusting for age, referral, and sexual behaviors, TGW remain significantly associated with HIV and syphilis prevalence. There is a substantial burden of HIV and HIV/syphilis co-infection among TGW. HIV/STI prevention are needed for TGW, including linkage to HIV care.

      9. 'PrEP'ing Memphis: A qualitative process evaluation of peer navigation supportexternal icon
        Pichon LC, Teti M, Betts JE, Brantley M.
        Eval Program Plann. 2021 Aug 13:101989.
        BACKGROUND: HIV PrEP (pre-exposure prophylaxis) navigation comprises intervention strategies used to improve PrEP uptake via education, linkage, and follow-up/ongoing engagement. During 2016-2019, the Tennessee Department of Health (TDH) implemented a CDC-funded demonstration project ("Project PrIDE") focused on PrEP navigation in Memphis community-based organizations (CBOs) and the Shelby County Health Department (HD). A process evaluation was conducted to determine facilitators and barriers to the implementation of the Memphis-based Project PrIDE PrEP navigation activities. METHODS: A total of fourteen in-depth qualitative interviews were conducted, with nine PrEP navigators in evaluation year 1 (2018) and five of the original navigators in evaluation year 2 (2019), to understand the navigation processes using thematic analysis. RESULTS: Facilitators of PrEP navigation included accessing clients at testing events, accompanying clients to first appointments, rapport building with patient and clinic staff, and maintaining consistent engagement with clients. Factors impeding PrEP navigation included difficulties assessing client readiness, tracking client navigation status, and stigmatizing clinic and social experiences for clients. CONCLUSIONS AND LESSONS LEARNED: Findings have informed the scale-up of PrEP navigation implementation statewide, along with priority setting and resource allocation for the local Ending the HIV Epidemic (EHE) initiative in Memphis.

      10. Test of cure return rate and test positivity, Strengthening the U.S Response to Resistant Gonorrhea (SURRG), United States, 2018-2019external icon
        Schlanger K, Mauk K, Learner ER, Schillinger JA, Nishiyama M, Kohn R, Thibault C, Hermus H, Dewater J, Pabon V, Black J, St Cyr S, Pham CR, Kirkcaldy RD.
        Sex Transm Dis. 2021 Aug 23.
        BACKGROUND: Reduced antibiotic susceptibility (RS) in Neisseria gonorrhoeae (GC) may increase treatment failure. Conducting tests-of-cure (TOC) for patients with RS-GC may facilitate identification of treatment failures. METHODS: We examined 2018-2019 data from eight jurisdictions participating in CDC's Strengthening U.S. Response to Resistant Gonorrhea project. Jurisdictions collected GC isolates and epidemiological data from patients and performed antimicrobial susceptibility testing. Minimum inhibitory concentrations of ceftriaxone ≥0.125 μg/mL, cefixime ≥0.250 μg/mL, or azithromycin ≥2.0 μg/mL were defined as RS. Patients with RS-infections were asked to return for a TOC 8-10 days post-treatment. We calculated a weighted TOC return rate and described time to TOC and suspected reasons for any positive TOC results. RESULTS: Overall, 1,165 patients were diagnosed with RS-infections. Over half returned for TOC (weighted TOC: 61% [95% confidence interval: 50.1%-72.6%], range by jurisdiction: 32%-80%). TOC rates were higher among asymptomatic (68%) than symptomatic patients (53%, p = 0.001), and MSM (62%) compared to MSW (50%; p < 0.001). Median time between treatment and TOC was 12 days (interquartile range: 9-16). Of the 31 (4.5%) TOC patients with positive results, 13 (42%) were suspected due to reinfection and 11 (36%) due to false positive results. There were no treatment failures suspected to be due to RS-GC. CONCLUSIONS: Most patients with a RS-infection returned for a TOC, though return rates varied by jurisdiction and patient characteristics. TOC can identify and facilitate treatment of reinfections, but false positive TOC results may complicate interpretation and clinical management.

      11. Improving sexual health in U.S. rural communities: Reducing the impact of stigmaexternal icon
        Valentine JA, Delgado LF, Haderxhanaj LT, Hogben M.
        AIDS Behav. 2021 Aug 26:1-10.
        Sexually transmitted infections (STI), including HIV, are among the most reported diseases in the U.S. and represent some of America's most significant health disparities. The growing scarcity of health care services in rural settings limits STI prevention and treatment for rural Americans. Local health departments are the primary source for STI care in rural communities; however, these providers experience two main challenges, also known as a double disparity: (1) inadequate capacity and (2) poor health in rural populations. Moreover, in rural communities the interaction of rural status and key determinants of health increase STI disparities. These key determinants can include structural, behavioral, and interpersonal factors, one of which is stigma. Engaging the expertise and involvement of affected community members in decisions regarding the needs, barriers, and opportunities for better sexual health is an asset and offers a gateway to sustainable, successful, and non-stigmatizing STI prevention programs.

      12. Population-based assessment of risks for severe COVID-19 disease outcomesexternal icon
        Zerbo O, Lewis N, Fireman B, Goddard K, Skarbinski J, Sejvar JJ, Azziz-Baumgartner E, Klein NP.
        Influenza Other Respir Viruses. 2021 Aug 25.
        Among approximately 4.6 million members of Kaiser Permanente Northern California, we examined associations of severe COVID-19 with demographic factors and comorbidities. As of July 23, 2021, 16 182 had been hospitalized, 2416 admitted to an ICU, and 1525 died due to COVID-19. Age was strongly associated with hospitalization, ICU admission, and death. Black persons and Hispanic ethnicity had higher risk of death compared with Whites. Among the comorbidities examined, Alzheimer's disease was associated with the highest risk for hospitalization (aHR 3.19, CI: 2.88-3.52) and death (aHR 4.04, CI: 3.32-4.91). Parkinson's disease had the second highest risk of death (aHR = 2.07, CI: 1.50-2.87).

    • Environmental Health

      1. Prenatal exposure to mixtures of persistent endocrine disrupting chemicals and postnatal body size in British girlsexternal icon
        Marks KJ, Howards PP, Smarr MM, Flanders WD, Northstone K, Daniel JH, Sjödin A, Calafat AM, Hartman TJ.
        Early Hum Dev. 2021 Aug 14;161:105450.
        BACKGROUND: Endocrine disrupting chemical (EDC) exposure is ubiquitous. EDC exposure during critical windows of development may interfere with the body's endocrine system, affecting growth. Previous human studies have examined one EDC at a time in relation to infant growth. By studying mixtures, the human experience can be better approximated. AIMS: We investigated the association of prenatal exposure to persistent EDCs (per- and polyfluoroalkyl substances (PFAS), polychlorinated biphenyls (PCBs), and organochlorine pesticides (OCPs)) as mixtures with postnatal body size among female offspring. SUBJECTS: We used a sub-sample of the Avon Longitudinal Study of Parents and Children (N = 425), based in the United Kingdom. STUDY DESIGN: We quantified 52 EDCs in maternal serum collected during pregnancy. We used Bayesian kernel machine regression with a random intercept to examine the association of prenatal concentrations of EDC mixtures with longitudinal postnatal body size measures for each EDC class separately (PFAS, PCBs, and OCPs) and for all three classes combined. OUTCOME MEASURES: Weight and height measures at 0, 2, 9, and 19 months were obtained by health professionals as part of routine child health surveillance. RESULTS: The mixture representing all three classes combined (31 chemicals) (n = 301) was inversely associated with postnatal body size. Holding all EDCs in the 31-chemical mixture at the 75th percentile compared to the 50th percentile was associated with 0.15 lower weight-for-age z-score (95% credible interval -0.26, -0.03). Weak inverse associations were also seen for height-for-age and body mass index-for-age scores. CONCLUSIONS: These results suggest that prenatal exposure to mixtures of persistent EDCs may affect postnatal body size.

      2. Childhood exposure to per- and polyfluoroalkyl substances (PFAS) and neurobehavioral domains in children at age 8 yearsexternal icon
        Vuong AM, Yolton K, Xie C, Dietrich KN, Braun JM, Webster GM, Calafat AM, Lanphear BP, Chen A.
        Neurotoxicol Teratol. 2021 Aug 23:107022.
        BACKGROUND: Toxicological studies have raised concerns regarding the neurotoxic effects of per- and polyfluoroalkyl substances (PFAS). However, observational evidence from human studies investigating the association between childhood PFAS and neurobehavior is limited and remains unclear. OBJECTIVES: To examine whether childhood PFAS concentrations are associated with neurobehavior in children at age 8 years and whether child sex modifies this relationship. METHODS: We used data from 208 mother-child dyads in the Health Outcomes and Measures of the Environment (HOME) Study, a prospective pregnancy and birth cohort (Cincinnati, OH, USA). We quantified PFAS in child serum at 3 and 8 years. We assessed neurobehavioral domains using the Behavior Assessment System for Children-2 at 8 years. We used multiple informant models to estimate score changes per ln-increase in repeated PFAS concentrations. RESULTS: Childhood PFAS were not associated with Externalizing or Internalizing Problems at 8 years. However, we noted effect measure modification by sex, with higher scores in Externalizing Problems among males per ln-unit increase in perfluorononanoate (PFNA) at 3 years (β = 4.3 points, 95% CI: 1.0, 7.7) while females had lower scores (β = -2.8 points, 95% CI: -4.7, -1.0). More Internalizing Problems were observed among males per ln-unit increase in concurrent PFNA concentrations (β = 3.7 points, 95% CI: 0.7, 6.8), but not in females (β = -1.7 points, 95% CI: -4.6, 1.2). Childhood PFNA concentrations were associated with lower scores for attention problems and activity of daily living. CONCLUSION: While findings do not consistently support an association between childhood PFAS serum concentrations and neurobehavior, child sex may play a role in this relationship.

    • Epidemiology and Surveillance
      1. How to improve outbreak response: a case study of integrated outbreak analytics from Ebola in Eastern Democratic Republic of the Congoexternal icon
        Carter SE, Ahuka-Mundeke S, Pfaffmann Zambruni J, Navarro Colorado C, van Kleef E, Lissouba P, Meakin S, le Polain de Waroux O, Jombart T, Mossoko M, Bulemfu Nkakirande D, Esmail M, Earle-Richardson G, Degail MA, Umutoni C, Anoko JN, Gobat N.
        BMJ Glob Health. 2021 Aug;6(8).
        The emerging field of outbreak analytics calls attention to the need for data from multiple sources to inform evidence-based decision making in managing infectious diseases outbreaks. To date, these approaches have not systematically integrated evidence from social and behavioural sciences. During the 2018-2020 Ebola outbreak in Eastern Democratic Republic of the Congo, an innovative solution to systematic and timely generation of integrated and actionable social science evidence emerged in the form of the Cellulle d'Analyse en Sciences Sociales (Social Sciences Analytics Cell) (CASS), a social science analytical cell. CASS worked closely with data scientists and epidemiologists operating under the Epidemiological Cell to produce integrated outbreak analytics (IOA), where quantitative epidemiological analyses were complemented by behavioural field studies and social science analyses to help better explain and understand drivers and barriers to outbreak dynamics. The primary activity of the CASS was to conduct operational social science analyses that were useful to decision makers. This included ensuring that research questions were relevant, driven by epidemiological data from the field, that research could be conducted rapidly (ie, often within days), that findings were regularly and systematically presented to partners and that recommendations were co-developed with response actors. The implementation of the recommendations based on CASS analytics was also monitored over time, to measure their impact on response operations. This practice paper presents the CASS logic model, developed through a field-based externally led consultation, and documents key factors contributing to the usefulness and adaption of CASS and IOA to guide replication for future outbreaks.

    • Genetics and Genomics
      1. BACKGROUND: Streptococcus agalactiae (Group B Streptococcus, GBS) is one of the major bacterial pathogens responsible for neonatal sepsis. Whole genome sequencing has, in recent years, emerged as a reliable tool for capsular typing and antimicrobial resistance prediction. This study characterized vaginal and rectal isolates of Group B Streptococcus obtained from pregnant women in Port Harcourt, Nigeria using a whole-genome sequence-based approach. RESULTS: Capsular types Ia, Ib, II, III, IV and V were detected among the 43 isolates sequenced. Twelve sequence types (STs) were identified, with ST19 (n = 9, 27.3 %) and ST486 (n = 5, 15.2 %) the most frequent among non-duplicated isolates. Of the alpha-like proteins (alp) identified, Alp1 was the most prevalent in 11 (33.3 %) isolates. Macrolide and lincosamide resistance determinants were present in 15 (45.5 %) isolates; ermB was detected in 1 (3 %), ermTR in 7 (21.2 %) isolates, lnu gene was detected in 6 (18.2 %) and mef was identified in 3 (9.1 %) isolates. Resistance of GBS to erythromycin and clindamycin (predicted from presence of erm or mef genes) was found to be 30.3 % and 24.2 %, respectively. All isolates were predicted resistant to tetracycline with only the tetM gene identified. Fluoroquinolone-resistance conferring substitutions in gyrA + parC were detected in 9 (27.3 %) isolates and chloramphenicol resistance was predicted from presence of aac6'-aph2 gene in 11 (33.3 %). CONCLUSIONS: The data available from the whole genome sequencing of these isolates offers a small but insightful description of common serotypes and resistance features within colonizing GBS in Nigeria.

      2. MOTIVATION: Tools used to identify genes in microbial sequences using a reference database generally report matches as a percent identity, which can be difficult to interpret in cases with <100%sequence identity, as changes to specific amino acids can have dramatic effects on protein function, such as when they occur in substrate binding regions or enzyme active sites, which in turn can have dramatic effects on phenotypes like antimicrobial resistance or virulence. RESULTS: Here we present GAMMA, an open-source tool for Gene Allele Mutation Microbial Assessment, which uses protein coding-level identity to make gene calls from any gene database and generates a classification (e.g., mutant, truncation) and translated annotation (e.g., Y190S mutation, truncation at residue 110) for these calls. GAMMA accurately called antimicrobial resistance genes from a large set of genomes faster than three other tools. It can also be used with any gene database, as we demonstrated by identifying virulence genes in the same genome set. Because of its speed and flexibility, GAMMA can be used to rapidly find and annotate any gene matches of interest in microbial sequencing data. AVAILABILITY: GAMMA is freely available as a Bioconda package ( and as a command line script ( SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online.

    • Health Behavior and Risk
      1. Mental health and substance use among adults with disabilities during the COVID-19 pandemic - United States, February-March 2021external icon
        Czeisler M, Board A, Thierry JM, Czeisler CA, Rajaratnam SM, Howard ME, Clarke KE.
        MMWR Morb Mortal Wkly Rep. 2021 Aug 27;70(34):1142-1149.
        Adults with disabilities, a group including >25% of U.S. adults (1), experience higher levels of mental health and substance use conditions and lower treatment rates than do adults without disabilities* (2,3). Survey data collected during April-September 2020 revealed elevated adverse mental health symptoms among adults with disabilities (4) compared with the general adult population (5). Despite disproportionate risk for infection with SARS-CoV-2, the virus that causes COVID-19, and COVID-19-associated hospitalization and mortality among some adults with disabilities (6), information about mental health and substance use in this population during the pandemic is limited. To identify factors associated with adverse mental health symptoms and substance use among adults with disabilities, the COVID-19 Outbreak Public Evaluation (COPE) Initiative(†) administered nonprobability-based Internet surveys to 5,256 U.S. adults during February-March 2021 (response rate = 62.1%). Among 5,119 respondents who completed a two-item disability screener, nearly one third (1,648; 32.2%) screened as adults with disabilities. These adults more frequently experienced symptoms of anxiety or depression (56.6% versus 28.7%, respectively), new or increased substance use (38.8% versus 17.5%), and suicidal ideation (30.6% versus 8.3%) than did adults without disabilities. Among all adults who had received a diagnosis of mental health or substance use conditions, adults with disabilities more frequently (42.6% versus 35.3%; p <0.001) reported that the pandemic made it harder for them to access related care or medication. Enhanced mental health and substance use screening among adults with disabilities and improved access to medical services are critical during public health emergencies such as the COVID-19 pandemic.

    • Health Disparities
      1. Rates of influenza-associated hospitalization, intensive care unit admission, and in-hospital death by race and ethnicity in the United States from 2009 to 2019external icon
        O'Halloran AC, Holstein R, Cummings C, Daily Kirley P, Alden NB, Yousey-Hindes K, Anderson EJ, Ryan P, Kim S, Lynfield R, McMullen C, Bennett NM, Spina N, Billing LM, Sutton M, Schaffner W, Talbot HK, Price A, Fry AM, Reed C, Garg S.
        JAMA Netw Open. 2021 Aug 2;4(8):e2121880.
        IMPORTANCE: Racial and ethnic minority groups, such as Black, Hispanic, American Indian or Alaska Native, and Asian or Pacific Islander persons, often experience higher rates of severe influenza disease. OBJECTIVE: To describe rates of influenza-associated hospitalization, intensive care unit (ICU) admission, and in-hospital death by race and ethnicity over 10 influenza seasons. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data from the Influenza-Associated Hospitalization Surveillance Network (FluSurv-NET), which conducts population-based surveillance for laboratory-confirmed influenza-associated hospitalizations in selected counties, representing approximately 9% of the US population. Influenza hospitalizations from the 2009 to 2010 season to the 2018 to 2019 season were analyzed. Data were analyzed from October 2020 to July 2021. MAIN OUTCOMES AND MEASURES: The main outcomes were age-adjusted and age-stratified rates of influenza-associated hospitalization, ICU admission, and in-hospital death by race and ethnicity overall and by influenza season. RESULTS: Among 113 352 persons with an influenza-associated hospitalization (34 436 persons [32.0%] aged ≥75 years; 61 009 [53.8%] women), 70 225 persons (62.3%) were non-Hispanic White (White), 24 850 persons (21.6%) were non-Hispanic Black (Black), 11 903 persons (10.3%) were Hispanic, 5517 persons (5.1%) were non-Hispanic Asian or Pacific Islander, and 857 persons (0.7%) were non-Hispanic American Indian or Alaska Native. Among persons aged younger than 75 years and compared with White persons of the same ages, Black persons were more likely to be hospitalized (eg, age 50-64 years: rate ratio [RR], 2.50 95% CI, 2.43-2.57) and to be admitted to an ICU (eg, age 50-64 years: RR, 2.09; 95% CI, 1.96-2.23). Among persons aged younger than 50 years and compared with White persons of the same ages, American Indian or Alaska Native persons were more likely to be hospitalized (eg, age 18-49 years: RR, 1.72; 95% CI, 1.51-1.96) and to be admitted to an ICU (eg, age 18-49 years: RR, 1.84; 95% CI, 1.40-2.42). Among children aged 4 years or younger and compared with White children, hospitalization rates were higher in Black children (RR, 2.21; 95% CI, 2.10-2.33), Hispanic children (RR, 1.87; 95% CI, 1.77-1.97), American Indian or Alaska Native children (RR, 3.00; 95% CI, 2.55-3.53), and Asian or Pacific Islander children (RR, 1.26; 95% CI, 1.16-1.38), as were rates of ICU admission (Black children: RR, 2.74; 95% CI, 2.43-3.09; Hispanic children: RR, 1.96; 95% CI, 1.73-2.23; American Indian and Alaska Native children: RR, 3.51; 95% CI, 2.45-5.05). In this age group and compared with White children, in-hospital death rates were higher among Hispanic children (RR, 2.98; 95% CI, 1.23-7.19), Black children (RR, 3.39; 95% CI, 1.40-8.18), and Asian or Pacific Islander children (RR, 4.35; 95% CI, 1.55-12.22). Few differences were observed in rates of severe influenza-associated outcomes by race and ethnicity among adults aged 75 years or older. For example, in this age group, compared with White adults, hospitalization rates were slightly higher only among Black adults (RR, 1.05; 95% CI 1.02-1.09). Overall, Black persons had the highest age-adjusted hospitalization rate (68.8 [95% CI, 68.0-69.7] hospitalizations per 100 000 population) and ICU admission rate (11.6 [95% CI, 11.2-11.9] admissions per 100 000 population). CONCLUSIONS AND RELEVANCE: This cross-sectional study found racial and ethnic disparities in rates of severe influenza-associated disease. These data identified subgroups for whom improvements in influenza prevention efforts could be targeted.

      2. Estimates of HIV prevalence, and how it changes over time, are needed to inform action (e.g., resource allocation) to improve HIV-related public health. However, creating adequate estimates of (diagnosed and undiagnosed) HIV prevalence is challenging due to biases in samples receiving HIV testing and due to difficulties enumerating key risk populations. To our knowledge, estimates of HIV prevalence among high risk heterosexuals in the United States produced for geographic areas smaller than the entire nation have to date been only for single years and/or for single cities (or other single geographic locations). The present study addresses these gaps by using multilevel modeling on multiple data series, in combination with previous estimates of HIV prevalence among heterosexuals from the extant literature, to produce annual estimates of HIV prevalence among high risk heterosexuals for each of 89 metropolitan statistical areas, from 1992-2013. It also produces estimates for these MSAs and years by racial/ethnic subgroup to allow for an examination of change over time in racial/ethnic disparities in HIV prevalence among high risk heterosexuals. The resulting estimates suggest that HIV prevalence among high risk heterosexuals has decreased steadily, on average, from 1992-2013. Examination of these estimates by racial/ethnic subgroup suggests that this trend is primarily due to decreases among Black and Hispanic/Latino high risk heterosexuals. HIV prevalence among white high risk heterosexuals remained steady over time at around 1 percent during the study period. Although HIV prevalence among Black and Hispanic/Latino high risk heterosexuals was much higher (approximately 3.5% and 3.3%, respectively) than that among whites in 1992, over time these differences decreased as HIV prevalence decreased over time among these subgroups. By 2013, HIV prevalence among Hispanic/Latino high risk heterosexuals was estimated to be very similar to that among white high risk heterosexuals (approximately 1 percent), with prevalence among Black high risk heterosexuals still estimated to be almost twice as high. It is likely that as HIV incidence has decreased among heterosexuals from 1992-2013, mortality due to all causes has remained disparately high among racial/ethnic minorities, thereby outpacing new HIV cases. Future research should aim to empirically examine this by comparing changes over time in estimated HIV incidence among heterosexuals to changes over time in mortality and causes of death among HIV-positive heterosexuals, by racial/ethnic subgroup.

    • Health Economics
      1. Vaccine preventable diseases surveillance in Nepal: How much does it cost?external icon
        Huang XX, Bose AS, Gupta BP, Rai P, Joshi S, Gautam JS, Tinkari BS, Vandelaer J, Cohen AL, Patel MK.
        Vaccine. 2021 Aug 18.
        Assessing the cost of vaccine preventable diseases (VPD) surveillance is becoming more important in the context of the Global Polio Eradication Initiative (GPEI) funding transition, since GPEI support to polio surveillance helped the incremental building of VPD surveillance systems in many countries, including low income countries such as Nepal. However, there is limited knowledge on the cost of conducting VPD surveillance, especially the national cost for surveillance of multiple vaccine-preventable diseases. The current study sought to calculate the economic and financial costs of Nepal's comprehensive VPD surveillance systems from July 2016 to July 2017. At thecentral level, all surveillance units were included in the sample. At sub-national level, a purposive sampling strategy was used to select a representative sample from locations involved in conducting surveillance. The sub-national sample costs were extrapolated to the nationwide VPD surveillance system. Nepal's total annual economic cost of VPD surveillance was USD 4.81 million or USD 0.18 per capita, while the total financial cost was USD 4.38 million or USD 0.16 per capita. Government expenditures accounted for 56% of the total economic cost, and World Health Organization accounting for 44%. The biggest cost driver was personnel accounting for 51% of the total economic cost. WHO supported trained surveillance personnel through donor funding, mainly from Global Polio Eradication Initiative. As a polio transition priority country, Nepal will need to make strategic choices to fully self-finance or seek full donor support or a mixed-financing model as polio program funding diminishes.

      2. OBJECTIVE: To assess national trends in out-of-pocket (OOP) costs among adults aged 18-64 years with diabetes in the U.S. RESEARCH DESIGN AND METHODS: Using data from the 2001-2017 Medical Expenditure Panel Survey, we estimated total per person annual OOP costs (insurance premiums, prescription drug costs, inpatient and outpatient deductibles, copays, and other payments not covered by insurance) and high OOP cost rate, defined as the percentage of people with OOP spending >10% of their family's pretax income. We examined trends overall, by subgroup (insurance type, income level, insulin use, size of patient's employer, and whether the patient was enrolled in a high deductible health plan), and by type of service. Changes in trends were identified using joinpoint analysis; costs were adjusted to 2017 U.S. dollars. RESULTS: From 2001 to 2017, OOP costs decreased 4.3%, from $4,328 to $4,139, and the high OOP cost rate fell 32%, from 28 to 19% (P < 0.001). Changes in the high OOP cost rate varied by subgroup, declining among those with public or no insurance and those with an income <200% of the federal poverty level (P < 0.001) but remaining stable among those with private insurance and higher income. Drug prescription OOP costs decreased among all subgroups (P < 0.001). Decreases in total (-$58 vs. -$37, P < 0.001) and prescription (-$79 vs. -$68, P < 0.001) OOP costs were higher among insulin users than noninsulin users. CONCLUSIONS: OOP costs among U.S. nonelderly adults with diabetes declined, especially among those least able to afford them. Future studies may explore factors contributing to the decline in OOP costs and the impact on the quality of diabetes care and complication rates.

    • Healthcare Associated Infections
      1. Enhancing U.S. local, state, and federal preparedness through simulated interactive tabletop exercises of a mock antibiotic-resistant gonorrhea outbreak, 2018-2019external icon
        Schlanger K, Black JM, Smith M, Ridpath A, Crause C, Holderman JL, Henderson K, Hardrick H, Pham CD, Howard G, Kirkcaldy RD.
        Sex Transm Dis. 2021 Aug 23.
        BACKGROUND: Responding effectively to outbreaks of antibiotic-resistant gonorrhea (ARGC) in the future will likely prove challenging. Tabletop exercises (TTXs) may assist local, state, and federal public health officials evaluate existing ARGC outbreak response plans, strengthen preparedness and response effectiveness, and identify critical gaps to address prior to an outbreak. METHODS: In 2018-2019, CDC collaborated with state partners to develop and implement TTXs to simulate a public health emergency involving an ARGC outbreak. Prior to the TTXs, two state-local health department pairs developed ARGC outbreak response plans. During each one-day exercise (in Indiana and Illinois), participants discussed roles, clinical management, public health response, and communication based on pre-developed response plans. Observers identified outbreak response strengths and gaps, and participants completed feedback forms. RESULTS: Forty-one (Illinois) and 48 people (Indiana) participated in each TTX, including: STD clinical staff, laboratorians, public health infectious disease program staff, and CDC observers. Strengths and gaps varied by jurisdiction, but identified gaps included: (1) local access to gonorrhea culture and timely antimicrobial susceptibility testing (AST), (2) protocols for clinical management of suspected treatment failures, (3) communication plans, and (4) clarity regarding state and local responsibilities. CDC observers identified opportunities to provide national-level technical assistance, foster local AST, and develop further response guidance. TTX summary reports were used to guide modifications to local response plans to address gaps. CONCLUSIONS: The TTXs allowed participants to practice responding to a simulated public health emergency and may have enhanced local response capacity. CDC made TTX implementation materials publicly available.

    • Immunity and Immunization
      1. Human papillomavirus (HPV) vaccine introduction in Sikkim state: Best practices from the first statewide multiple-age cohort HPV vaccine introduction in India-2018-2019external icon
        Ahmed D, VanderEnde K, Harvey P, Bhatnagar P, Kaur N, Roy S, Singh N, Denzongpa P, Haldar P, Loharikar A.
        Vaccine. 2021 Aug 21.
        BACKGROUND: Cervical cancer is a leading cause of cancer-associated mortality among women in India, with 96,922 new cases and 60,078 deaths each year, almost one-fifth of the global burden. In 2018, Sikkim state in India introduced human papillomavirus (HPV) vaccine for 9-13-year-old girls, primarily through school-based vaccination, targeting approximately 25,000 girls. We documented the program's decision-making and implementation processes. METHODS: We conducted a post-introduction evaluation in 2019, concurrent with the second dose campaign, by interviewing key stakeholders (state, district, and local level), reviewing planning documents, and observing cold chain sites in two purposefully-sampled community areas in each of the four districts of Sikkim. Using standard questionnaires, we interviewed health and education officials, school personnel, health workers, community leaders, and age-eligible girls on program decision-making, planning, training, vaccine delivery, logistics, and communication. RESULTS: We conducted 279 interviews and 29 observations in eight community areas across four districts of Sikkim. Based on reported administrative data, Sikkim achieved >95% HPV vaccination coverage among targeted girls for both doses via two campaigns; no severe adverse events were reported. HPV vaccination was well accepted by all stakeholders; minimal refusal was reported. Factors identified for successful vaccine introduction included strong political commitment, statewide mandatory school enrollment, collaboration between health and education departments at all levels, and robust social mobilization strategies. CONCLUSIONS: Sikkim successfully introduced the HPV vaccine to multiple-age cohorts of girls via school-based vaccination, demonstrating a model that could be replicated in other regions in India or similar low- and middle-income country settings.

      2. During December 14, 2020-April 10, 2021, data from the HEROES-RECOVER Cohorts,* a network of prospective cohorts among frontline workers, showed that the Pfizer-BioNTech and Moderna mRNA COVID-19 vaccines were approximately 90% effective in preventing symptomatic and asymptomatic infection with SARS-CoV-2, the virus that causes COVID-19, in real-world conditions (1,2). This report updates vaccine effectiveness (VE) estimates including all COVID-19 vaccines available through August 14, 2021, and examines whether VE differs for adults with increasing time since completion of all recommended vaccine doses. VE before and during SARS-CoV-2 B.1.617.2 (Delta) variant predominance, which coincided with an increase in reported COVID-19 vaccine breakthrough infections, were compared (3,4).

      3. Effectiveness of Pfizer-BioNTech and Moderna vaccines in preventing SARS-CoV-2 infection among nursing home residents before and during widespread circulation of the SARS-CoV-2 B.1.617.2 (Delta) Variant - National Healthcare Safety Network, March 1-August 1, 2021external icon
        Nanduri S, Pilishvili T, Derado G, Soe MM, Dollard P, Wu H, Li Q, Bagchi S, Dubendris H, Link-Gelles R, Jernigan JA, Budnitz D, Bell J, Benin A, Shang N, Edwards JR, Verani JR, Schrag SJ.
        MMWR Morb Mortal Wkly Rep. 2021 Aug 27;70(34):1163-1166.
        Nursing home and long-term care facility residents live in congregate settings and are often elderly and frail, putting them at high risk for infection with SARS-CoV-2, the virus that causes COVID-19, and severe COVID-19-associated outcomes; therefore, this population was prioritized for early vaccination in the United States (1). Following rapid distribution and administration of the mRNA COVID-19 vaccines (Pfizer-BioNTech and Moderna) under an Emergency Use Authorization by the Food and Drug Administration (2), observational studies among nursing home residents demonstrated vaccine effectiveness (VE) ranging from 53% to 92% against SARS-CoV-2 infection (3-6). However, concerns about the potential for waning vaccine-induced immunity and the recent emergence of the highly transmissible SARS-CoV-2 B.1.617.2 (Delta) variant(†) highlight the need to continue to monitor VE (7). Weekly data reported by the Centers for Medicaid & Medicare (CMS)-certified skilled nursing facilities or nursing homes to CDC's National Healthcare Safety Network (NHSN)(§) were analyzed to evaluate effectiveness of full vaccination (2 doses received ≥14 days earlier) with any of the two currently authorized mRNA COVID-19 vaccines during the period soon after vaccine introduction and before the Delta variant was circulating (pre-Delta [March 1-May 9, 2021]), and when the Delta variant predominated(¶) (Delta [June 21-August 1, 2021]). Using 17,407 weekly reports from 3,862 facilities from the pre-Delta period, adjusted effectiveness against infection for any mRNA vaccine was 74.7% (95% confidence interval [CI] = 70.0%-78.8%). Analysis using 33,160 weekly reports from 11,581 facilities during an intermediate period (May 10-June 20) found that the adjusted effectiveness was 67.5% (95% CI = 60.1%-73.5%). Analysis using 85,593 weekly reports from 14,917 facilities during the Delta period found that the adjusted effectiveness was 53.1% (95% CI = 49.1%-56.7%). Effectiveness estimates were similar for Pfizer-BioNTech and Moderna vaccines. These findings indicate that mRNA vaccines provide protection against SARS-CoV-2 infection among nursing home residents; however, VE was lower after the Delta variant became the predominant circulating strain in the United States. This analysis assessed VE against any infection, without being able to distinguish between asymptomatic and symptomatic presentations. Additional evaluations are needed to understand protection against severe disease in nursing home residents over time. Because nursing home residents might remain at some risk for SARS-CoV-2 infection despite vaccination, multiple COVID-19 prevention strategies, including infection control, testing, and vaccination of nursing home staff members, residents, and visitors, are critical. An additional dose of COVID-19 vaccine might be considered for nursing home and long-term care facility residents to optimize a protective immune response.

    • Injury and Violence
      1. For public health agencies, the pragmatic need to bring together science and practice to affect public health outcomes manifests in the implementation of prevention strategies with the best available evidence. Knowledge translation makes scientific findings understandable to the knowledge user, often through synthesis of the best available evidence. Implementation science promotes the adoption and integration of evidence through prevention strategies implemented within various contexts. Working together, knowledge translation and implementation science can promote the uptake and advancement of scientific and practice-based evidence for strategies that will have the greatest impact across a variety of contexts. Violence Prevention in Practice (VPP) is an online resource designed to help practitioners select, adapt, implement, and evaluate multiple prevention strategies included in five technical packages developed by Centers for Disease Control's Division of Violence Prevention. A technical package translates the best available evidence into a core set of prevention strategies intended to be broadly implemented. VPP supports communities in using the technical package strategies in combination, drawing on key implementation science principles. In this article, we explain the process for developing VPP and provide a framework that can be used to develop similar guidance in other health promotion areas. The framework explains how both general components, such as selection and adaptation, come together with strategy-specific implementation guidance. Distinct from typical planning models, VPP is not designed as a linear stepwise process, and it allows practitioners to use one or more components alone, as well as helps practitioners link across components as needed.

      2. This study examined the population-based incidence of firearm homicide in the United States to identify geographic concentrations and to determine whether such concentrations have changed over time. It further examined the simultaneous associations of urbanization, poverty, and ethnicity/race with firearm homicide incidence. Using county-level data from the National Vital Statistics System and the U.S. Census Bureau for the years 2004-2018, the findings show geographic patterns not commonly recognized, including several lengthy and continuous corridors with a high incidence of firearm homicide, traversing both metro and non-metro areas. While the data clearly show a strongly disproportionate concentration of firearm homicide incidence in a subset of the population defined by geography, they do not suggest increasing concentration over time. The study findings also generally indicate increasing firearm homicide incidence with increasing levels of surrounding poverty, a phenomenon observed for both metro and non-metro areas.

      3. OBJECTIVE: The purpose of this research is to identify how data science is applied in suicide prevention literature, describe the current landscape of this literature and highlight areas where data science may be useful for future injury prevention research. DESIGN: We conducted a literature review of injury prevention and data science in April 2020 and January 2021 in three databases. METHODS: For the included 99 articles, we extracted the following: (1) author(s) and year; (2) title; (3) study approach (4) reason for applying data science method; (5) data science method type; (6) study description; (7) data source and (8) focus on a disproportionately affected population. RESULTS: Results showed the literature on data science and suicide more than doubled from 2019 to 2020, with articles with individual-level approaches more prevalent than population-level approaches. Most population-level articles applied data science methods to describe (n=10) outcomes, while most individual-level articles identified risk factors (n=27). Machine learning was the most common data science method applied in the studies (n=48). A wide array of data sources was used for suicide research, with most articles (n=45) using social media and web-based behaviour data. Eleven studies demonstrated the value of applying data science to suicide prevention literature for disproportionately affected groups. CONCLUSION: Data science techniques proved to be effective tools in describing suicidal thoughts or behaviour, identifying individual risk factors and predicting outcomes. Future research should focus on identifying how data science can be applied in other injury-related topics.

    • Laboratory Sciences
      1. Protozoan-viral-bacterial co-infections alter galectin levels and associated immunity mediators in the female genital tractexternal icon
        Fichorova RN, DeLong AK, Cu-Uvin S, King CC, Jamieson DJ, Klein RS, Sobel JD, Vlahov D, Yamamoto HS, Mayer KH.
        Front Cell Infect Microbiol. 2021 ;11:649940.
        Co-infections with sexually transmittable pathogens are common and more likely in women with disturbed vaginal bacteriome. Among those pathogens, the protozoan parasite Trichomonas vaginalis (TV) is most common after accounting for the highly persistent DNA viruses human papillomavirus (HPV) and genital herpes. The parasitic infection often concurs with the dysbiotic syndrome diagnosed as bacterial vaginosis (BV) and both are associated with risks of superimposed viral infections. Yet, the mechanisms of microbial synergisms in evading host immunity remain elusive. We present clinical and experimental evidence for a new role of galectins, glycan-sensing family of proteins, in mixed infections. We assessed participants of the HIV Epidemiology Research Study (HERS) at each of their incident TV visits (223 case visits) matched to controls who remained TV-negative throughout the study. Matching criteria included age, race, BV (by Nugent score), HIV status, hysterectomy, and contraceptive use. Non-matched variables included BV status at 6 months before the matched visit, and variables examined at baseline, within 6 months of and/or at the matched visit e.g. HSV-2, HPV, and relevant laboratory and socio-demographic parameters. Conditional logistic regression models using generalized estimating equations calculated odds ratios (OR) for incident TV occurrence with each log(10) unit higher cervicovaginal concentration of galectins and cytokines. Incident TV was associated with higher levels of galectin-1, galectin-9, IL-1β and chemokines (ORs 1.53 to 2.91, p <0.001). Galectin-9, IL-1β and chemokines were up and galectin-3 down in TV cases with BV or intermediate Nugent versus normal Nugent scores (p <0.001). Galectin-9, IL-1β and chemokines were up in TV-HIV and down in TV-HPV co-infections. In-vitro, TV synergized with its endosymbiont Trichomonasvirus (TVV) and BV bacteria to upregulate galectin-1, galectin-9, and inflammatory cytokines. The BV-bacterium Prevotella bivia alone and together with TV downregulated galectin-3 and synergistically upregulated galectin-1, galectin-9 and IL-1β, mirroring the clinical findings of mixed TV-BV infections. P. bivia also downregulated TVV+TV-induced anti-viral response e.g. IP-10 and RANTES, providing a mechanism for conducing viral persistence in TV-BV co-infections. Collectively, the experimental and clinical data suggest that galectin-mediated immunity may be dysregulated and exploited by viral-protozoan-bacterial synergisms exacerbating inflammatory complications from dysbiosis and sexually transmitted infections.

      2. Since 2013, group A rotavirus strains characterized as novel DS-1-like inter-genogroup reassortant 'equine-like G3' strains have emerged and spread across five continents among human populations in at least 14 countries. Here we report a novel one-step TaqMan quantitative real-time reverse transcription-PCR assay developed to genotype and quantify the viral load for samples containing rotavirus equine-like G3 strains. Using a universal G forward primer and a newly designed reverse primer and TaqMan probe, we developed and validated an assay with a linear dynamic range of 2.3 × 10(9) - 227 copies per reaction and a limit of detection of 227 copies. The percent positive agreement, percent negative agreement, and precision of our assay were 100.00%, 99.63%, and 100.00%, respectively. This assay can simultaneously detect and quantify the viral load for samples containing DS-1-like inter-genogroup reassortant equine-like G3 strains with high sensitivity and specificity, faster turnaround time, and decreased cost and will be valuable for high-throughput screening of stool samples collected to monitor equine-like G3 strain prevalence and circulation among human populations throughout the world.

      3. Oxidant-induced epithelial alarmin pathway mediates lung inflammation and functional decline following ultrafine carbon and ozone inhalation co-exposureexternal icon
        Majumder N, Goldsmith WT, Kodali VK, Velayutham M, Friend SA, Khramtsov VV, Nurkiewicz TR, Erdely A, Zeidler-Erdely PC, Castranova V, Harkema JR, Kelley EE, Hussain S.
        Redox Biol. 2021 Aug 5;46:102092.
        Environmental inhalation exposures are inherently mixed (gases and particles), yet regulations are still based on single toxicant exposures. While the impacts of individual components of environmental pollution have received substantial attention, the impact of inhalation co-exposures is poorly understood. Here, we mechanistically investigated pulmonary inflammation and lung function decline after inhalation co-exposure and individual exposures to ozone (O(3)) and ultrafine carbon black (CB). Environmentally/occupationally relevant lung deposition levels in mice were achieved after inhalation of stable aerosols with similar aerodynamic and mass median distributions. X-ray photoemission spectroscopy detected increased surface oxygen contents on particles in co-exposure aerosols. Compared with individual exposures, co-exposure aerosols produced greater acellular and cellular oxidants detected by electron paramagnetic resonance (EPR) spectroscopy, and in vivo immune-spin trapping (IST), as well as synergistically increased lavage neutrophils, lavage proteins and inflammation related gene/protein expression. Co-exposure induced a significantly greater respiratory function decline compared to individual exposure. A synthetic catalase-superoxide dismutase mimetic (EUK-134) significantly blunted lung inflammation and respiratory function decline confirming the role of oxidant imbalance. We identified a significant induction of epithelial alarmin (thymic stromal lymphopoietin-TSLP)-dependent interleukin-13 pathway after co-exposure, associated with increased mucin and interferon gene expression. We provided evidence of interactive outcomes after air pollution constituent co-exposure and identified a key mechanistic pathway that can potentially explain epidemiological observation of lung function decline after an acute peak of air pollution. Developing and studying the co-exposure scenario in a standardized and controlled fashion will enable a better mechanistic understanding of how environmental exposures result in adverse outcomes.

      4. Repeated antigen testing among SARS-CoV-2-positive nursing home residentsexternal icon
        Moritz ED, McKay SL, Tobolowsky FA, LaVoie SP, Waltenburg MA, Lecy KD, Thornburg NJ, Harcourt JL, Tamin A, Folster JM, Negley J, Brown AC, McDonald LC, Kutty PK.
        Infect Control Hosp Epidemiol. 2021 Aug 20:1-10.
        Repeated antigen testing of 12 SARS-CoV-2-positive nursing home residents using Abbott BinaxNOW™ identified 9/9 (100%) culture-positive specimens up to 6 days after initial positive test. Antigen positivity lasted 2-24 days. Antigen positivity might last beyond the infectious period, but was reliable in residents with evidence of early infection.

      5. Impact of anatomic site, specimen collection timing, and patient symptom status on Neisseria gonorrhoeae culture recoveryexternal icon
        Nash EE, Pham CD, Raphael B, Learner ER, Mauk K, Weiner J, Mettenbrink C, Thibault CS, Fukuda A, Dobre-Buonya O, Black JM, Johnson K, Sellers K, Schlanger K.
        Sex Transm Dis. 2021 Aug 23.
        BACKGROUND: Neisseria gonorrhoeae culture is required for antimicrobial susceptibility testing (AST), but recovering isolates from clinical specimens is challenging. While many variables influence culture recovery, studies evaluating the impact of culture specimen collection timing and patient symptom status are limited. This study analyzed urogenital and extragenital culture recovery data from CDC's Strengthening US Response to Resistant Gonorrhea (SURRG) program, a multi-site project, which enhances local N. gonorrhoeae culture and AST capacity. METHODS: Eight SURRG jurisdictions collected gonococcal cultures from patients with N. gonorrhoeae-positive nucleic acid amplification tests (NAATs) attending STD and community clinics. Matched NAAT and culture specimens from the same anatomic site were collected, and culture recovery was assessed. Time between NAAT and culture specimen collection was categorized as, same day, 1-7 days, 8-14 days, or ≥ 15 days and patient symptoms were matched to the anatomic site where culture specimens were collected. RESULTS: From 2018-2019, among persons with N. gonorrhoeae-positive NAAT, urethral infections resulted in the highest culture recovery (5927/6515 = 91.0%), followed by endocervical, (222/363 = 61.2%), vaginal (63/133 = 47.4%) rectal (1117/2805 = 39.8%), and pharyngeal (1019/3678 = 27.7%) infections. Culture recovery was highest when specimens were collected on the same day as NAAT specimens and significantly decreased after 7 days. Symptoms were significantly associated with culture recovery at urethral (p = <0.0001) and rectal (p = <0.0001) sites of infection but not endocervical, vaginal, or pharyngeal sites. CONCLUSIONS: Culture specimen collection timing and patient symptomatic status can impact culture recovery. These findings can guide decisions about culture collection protocols to maximize culture recovery and strengthen detection of antimicrobial resistant infections.

      6. Pharmacokinetics of vaginally applied integrase inhibitors in macaquesexternal icon
        Nishiura K, Sharma S, Sterling M, Makarova N, Martin A, Dinh C, Mitchell J, García-Lerma JG, Heneine W, Dobard C.
        J Antimicrob Chemother. 2021 Aug 23.
        OBJECTIVES: We conducted a detailed pharmacokinetic assessment in macaques treated with vaginal gels formulated with HIV integrase strand transfer inhibitors (INSTIs) to better understand drug distribution and identify INSTI concentrations associated with previously demonstrated in vivo protection against vaginal simian HIV challenge. METHODS: Six macaques received vaginal gel containing 1% raltegravir (30 mg) once-weekly over 6 weeks. Following a washout period, five macaques received once-weekly gel containing 0.23% L-870,812 (7 mg). Drug concentrations were measured in plasma, mucosal fluids and vaginal tissues at baseline and 2, 5 and 24 h post-dosing. RESULTS: The median maximum concentration (Cmax) for raltegravir and L-870,812 in plasma was below the limit of quantification and 41.1 ng/mL, respectively. The Cmax in vaginal fluids (1441 and 1250 μg/mL) and tissues (266.7 and 368.4 μg/g) was achieved 2-5 h after dosing, respectively. A similar half-life was observed for raltegravir and L-870,812 in vaginal fluids (8-10 h) and remained 3-4 orders of magnitude above the protein-adjusted IC95 (0.016 and 0.106 μg/mL, respectively) at 24 h. Drug concentrations in vaginal fluids correlated well with those in vaginal tissues (Pearson r ≥ 0.788). Both drugs were consistently detected in rectal fluids 2 h after vaginal dosing, albeit at much lower levels (31-92-fold) than those in vaginal fluids. CONCLUSIONS: To the best of our knowledge, this study provides the first data on INSTI levels in vaginal tissues associated with in vivo protection and demonstrates rectal drug distribution of INSTIs after vaginal dosing. These findings may inform dose selection for topical products with INSTIs for HIV prevention.

      7. Horizontal gene transfer is the main driver of antimicrobial resistance in broiler chicks infected with Salmonella enterica serovar Heidelbergexternal icon
        Oladeinde A, Abdo Z, Press MO, Cook K, Cox NA, Zwirzitz B, Woyda R, Lakin SM, Thomas JC, Looft T, Cosby DE, Hinton A, Guard J, Line E, Rothrock MJ, Berrang ME, Herrington K, Zock G, Plumblee Lawrence J, Cudnik D, House S, Ingram K, Lariscy L, Wagner M, Aggrey SE, Chai L, Ritz C.
        mSystems. 2021 Aug 24:e0072921.
        The overuse and misuse of antibiotics in clinical settings and in food production have been linked to the increased prevalence and spread of antimicrobial resistance (AR). Consequently, public health and consumer concerns have resulted in a remarkable reduction in antibiotics used for food animal production. However, there are no data on the effectiveness of antibiotic removal in reducing AR shared through horizontal gene transfer (HGT). In this study, we used neonatal broiler chicks and Salmonella enterica serovar Heidelberg, a model food pathogen, to test if chicks raised antibiotic free harbor transferable AR. We challenged chicks with an antibiotic-susceptible S. Heidelberg strain using various routes of inoculation and determined if S. Heidelberg isolates recovered carried plasmids conferring AR. We used antimicrobial susceptibility testing and whole-genome sequencing (WGS) to show that chicks grown without antibiotics harbored an antimicrobial resistant S. Heidelberg population at 14 days after challenge and chicks challenged orally acquired AR at a higher rate than chicks inoculated via the cloaca. Using 16S rRNA gene sequencing, we found that S. Heidelberg infection perturbed the microbiota of broiler chicks, and we used metagenomics and WGS to confirm that a commensal Escherichia coli population was the main reservoir of an IncI1 plasmid acquired by S. Heidelberg. The carriage of this IncI1 plasmid posed no fitness cost to S. Heidelberg but increased its fitness when exposed to acidic pH in vitro. These results suggest that HGT of plasmids carrying AR shaped the evolution of S. Heidelberg and that antibiotic use reduction alone is insufficient to limit antibiotic resistance transfer from commensal bacteria to Salmonella enterica. IMPORTANCE The reported increase in antibiotic-resistant bacteria in humans has resulted in a major shift away from antibiotic use in food animal production. This shift has been driven by the assumption that removing antibiotics will select for antibiotic susceptible bacterial taxa, which in turn will allow the currently available antibiotic arsenal to be more effective. This change in practice has highlighted new questions that need to be answered to assess the effectiveness of antibiotic removal in reducing the spread of antibiotic resistance bacteria. This research demonstrates that antibiotic-susceptible Salmonella enterica serovar Heidelberg strains can acquire multidrug resistance from commensal bacteria present in the gut of neonatal broiler chicks, even in the absence of antibiotic selection. We demonstrate that exposure to acidic pH drove the horizontal transfer of antimicrobial resistance plasmids and suggest that simply removing antibiotics from food animal production might not be sufficient to limit the spread of antimicrobial resistance.

      8. The long-term health effects of using e-cigarette, or vaping, products (EVPs; also known as e-cigarettes, electronic nicotine delivery systems, and vape pens) remain largely unknown. The inhalation of excipients, such as propylene glycol (PG) and glycerin (GLY), may have long-term health effects. In addition to the direct health effects of PG and GLY, glycerin-containing products can be contaminated with toxic ethylene glycol (EG) and diethylene glycol (DEG). To assess this issue, we developed a simple, versatile, high-throughput isotope dilution gas chromatography-tandem mass spectrometry method for quantifying these common excipients and contaminants. The method is applicable to both the liquid contents and machine-generated aerosols of EVPs. Our rigorous method validation demonstrates that the new method is specific, precise, accurate, and rugged/robust. The calibration range is linear from 0.1-7 mg for the excipients and 2.5-1,000 µg for the contaminants. These ranges encompass expected excipients levels in EVP e-liquids and their machine-generated aerosols and the relevant maximum residue safety limit of 1 mg/g, or 0.1% (w/w), for the contaminants. The calculated limits of detection for PG, GLY, EG, and DEG were determined as 0.0109 mg, 0.0132 mg, 0.250 µg, and 0.100 µg, respectively. The method was applied to the aerosol emissions analysis of 141 EVPs associated with the 2019 lung injury outbreak, and found typical levels of PG (120.28-689.35 mg/g of aerosol) and GLY (116.83-845.96 mg/g of aerosol) in all nicotine-containing products; PG (81.58-491.92 mg/g of aerosol) and GLY (303.86-823.47 mg/g of aerosol) in 13% of cannabidiol (CBD) products; PG (74.02-220.18 mg/g of aerosol) and GLY (596.43-859.81 mg/g of aerosol) in products with neither nicotine nor CBD; and none detected in tetrahydrocannabinol (THC) products. No products contained glycol contaminants above the recommended maximum residue safety limit.

      9. E-cigarette, or vaping, product (EVP) use has increased dramatically in the United States over the last 4 years, particularly in youth and young adults. Little information is available on the chemical contents of these products. Typically, EVPs contain an active ingredient such as nicotine, CBD, or THC dissolved in a suitable solvent that facilitates aerosol generation. One EVP solvent, vitamin E acetate (VEA), has been measured in EVP liquids associated with lung injury. However, no validated analytical methods for measuring VEA in the aerosol from these devices was previously available. Therefore, we developed a high throughput isotope dilution LC-MS/MS method to simultaneously measure VEA and three other related tocopherols in aerosolized EVP samples. The assay was precise, with VEA repeatability ranging from 4.0 to 8.3% and intermediate precision ranging from 2.5 to 6.7%. Similar precision was obtained for the three other tocopherols measured. The LODs for the four analytes ranged from 8.85 × 10(-6) to 2.28 × 10(-5) μg analyte per mL of aerosol puff volume, and calibration curves were linear (R (2) > 0.99). This method was used to analyze aerosol emissions of 147 EVPs associated with EVALI case patients. We detected VEA in 46% of the case-associated EVPs with a range of 1.87 × 10(-4)-74.1 µg per mL of aerosol puff volume and mean of 25.1 µg per mL of aerosol puff volume. Macro-levels of VEA (>0.1% w/w total aerosol particulate matter) were not detected in nicotine or cannabidiol (CBD) products; conversely 71% of the EVALI associated tetrahydrocannabinol (THC) products contained macro-levels of VEA. Trace levels of other tocopherol isoforms were detected at lower rates and concentrations (α-tocopherol: 41% detected, mean 0.095 µg analyte per mL of aerosol puff volume; γ-tocopherol: 5% detected, mean 0.0193 µg analyte per mL of aerosol puff volume; δ-tocopherol: not detected). Our results indicate that VEA can be efficiently transferred to aerosol by EVALI-associated EVPs vaped using a standardized protocol.

      10. Implementation and evaluation of gradient strip antimicrobial susceptibility testing in US public health laboratories to respond to resistant gonorrheaexternal icon
        Raphael BH, Pham CD, Sharpe S, Mauk K, Harvey A, Khubbar M, Triplett L, Soge OO, Denny M, Palavecino EL, Finney R, Olsen A, Carlson J, St Cyr SB, Schlanger K, Kersh EN.
        Sex Transm Dis. 2021 Aug 23.
        BACKGROUND: Gradient strip antimicrobial susceptibility testing (AST) using Etest® is conducted by local public health jurisdictions participating in the Strengthening the U.S. Response to Resistant Gonorrhea (SURRG) program to inform public health responses to resistant gonorrhea. Proficiency testing results across the participating laboratories were analyzed and a comparison of Etest® with the agar dilution method was conducted. METHODS: Laboratories participating in SURRG performed Etest® for azithromycin (AZM), cefixime (CFX), and ceftriaxone (CRO). Concurrence between minimum inhibitory concentrations (MICs) obtained with Etest® versus the agar dilution method using corresponding isolates was defined as +/- 1 double dilution. Specific levels of reduced susceptibility were termed "alerts" and included isolates with the following MICs: ≥ 2.0 μg/ml (AZM), ≥ 0.25 μg/ml (CFX), and ≥ 0.125 μg/ml (CRO). Categorical (alert/non-alert) agreement was calculated for MICs determined using Etest® and agar dilution methods. RESULTS: SURRG laboratories had high proficiency testing scores (≥98%) and low levels of inter-laboratory variations in MICs. The overall concurrence of MICs (essential agreement) determined using agar dilution and Etest® was 96% (CRO), 96% (CFX), and 95% (AZM). Depending on the antibiotic tested, between 27-66% of isolates with alert MICs determined by Etest® also had alert MICs using the reference agar dilution methodology, however most of these alert MICs were detected at threshold levels. CONCLUSIONS: This study demonstrates that MICs produced by SURRG laboratories using Etest® have a high level of concurrence with agar dilution. Although confirmation of specific alert MICs varied, Etest® facilities rapid detection and response to emerging resistant gonorrhea.

      11. A deep neural-network classifier for photograph-based estimation of hearing protection attenuation and fitexternal icon
        Smalt CJ, Ciccarelli GA, Rodriguez AR, Murphy WJ.
        J Acoust Soc Am. 2021 ;150(2):1067-1075.
        Occupational and recreational acoustic noise exposure is known to cause permanent hearing damage and reduced quality of life, which indicates the importance of noise controls including hearing protection devices (HPDs) in situations where high noise levels exist. While HPDs can provide adequate protection for many noise exposures, it is often a challenge to properly train HPD users and maintain compliance with usage guidelines. HPD fit-testing systems are commercially available to ensure proper attenuation is achieved, but they often require specific facilities designed for hearing testing (e.g., a quiet room or an audiometric booth) or special equipment (e.g., modified HPDs designed specifically for fit testing). In this study, we explored using visual information from a photograph of an HPD inserted into the ear to estimate hearing protector attenuation. Our dataset consists of 960 unique photographs from four types of hearing protectors across 160 individuals. We achieved 73% classification accuracy in predicting if the fit was greater or less than the median measured attenuation (29 dB at 1 kHz) using a deep neural network. Ultimately, the fit-test technique developed in this research could be used for training as well as for automated compliance monitoring in noisy environments to prevent hearing loss. © 2021 Author(s).

      12. Development of a multiplex bead assay to detect immunoglobulin G antibodies to Babesia duncani in human serumexternal icon
        Wang Y, Aderohunmu T, Bishop H, McAuliffe I, Rivera HN, Smith D, Wilkins PP, Bowden KE, Reed MS, Svoboda P, Stuchlik O, Pohl J, Wiegand RE, Handali S.
        J Clin Microbiol. 2021 Aug 25:Jcm0045821.
        Babesia duncani is the causative agent of babesiosis in the western United States. The indirect fluorescent antibody (IFA) assay is the diagnostic test of choice for detection of B. duncani specific antibodies. However, this test requires parasitized red blood cells harvested from infected hamsters and test results are often difficult to interpret. To simplify serological testing for B. duncani, a proteomics approach was employed to identify candidate immunodiagnostic antigens. Several proteins were identified by electrospray ionization (ESI) mass spectrometric analysis and four recombinant protein constructs were expressed and used in a multiplex bead assay (MBA) to detect B. duncani-specific antibodies. Two antigens, AAY83295.1 and AAY83296.1, performed well with high sensitivities and specificities. AAY83295.1 had a higher sensitivity (100%) but lower specificity (89%) in comparison to AAY83296.1, which had a sensitivity of 90% and a specificity of 96%. Combining these two antigens did not improve the performance of the assay. This MBA could be useful for diagnosis, serosurveillance, and blood donor screening for B. duncani infection.

    • Maternal and Child Health
      1. Evaluation of the feasibility and perceived value of integrating learn the signs. Act early. Developmental monitoring resources in Early Head Startexternal icon
        Abercrombie J, Pann J, Shin F, Taylor E, Brisendine AE, Swanson-Holm R, James C, Viehweg S, Chödrön G.
        Early Child Educ J. 2021 .
        Many children with developmental disabilities are not identified before age 3 years of age, preventing them from being able to fully benefit from early intervention services. Early childhood educators, particularly those in Early Head Start (EHS) programs, are important partners in the early identification of children with developmental delays. Learn the Signs. Act Early. (LTSAE) is a program of the U.S. Centers for Disease Control and Prevention that provides free developmental monitoring resources to increase the early identification of children with developmental delays and disabilities. This paper presents findings from the first evaluation of the use of LTSAE resources in EHS, which was conducted across four states and 11 EHS programs from fall 2018 through spring 2019. Surveys (n = 448) and interviews (n = 39) with EHS management, staff, and parents indicated that LTSAE resources were valued and accepted, and their use in EHS considered feasible. Importantly, families and staff reported the LTSAE materials provided shared language to help them more effectively discuss development. These findings inform EHS and other early education programs that wish to enhance developmental monitoring, screening, and referral. © 2021, This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.

    • Medicine

    • Occupational Safety and Health
      1. A review of hand-arm vibration studies conducted by US NIOSH since 2000external icon
        Dong RG, Wu JZ, Xu XS, Welcome DE, Krajnak K.
        Vibration. 2021 Jun 15;4(2):482-528.
        Studies on hand-transmitted vibration exposure, biodynamic responses, and biological effects were conducted by researchers at the Health Effects Laboratory Division (HELD) of the National Institute for Occupational Safety and Health (NIOSH) during the last 20 years. These studies are systematically reviewed in this report, along with the identification of areas where additional research is needed. The majority of the studies cover the following aspects: (i) the methods and techniques for measuring hand-transmitted vibration exposure; (ii) vibration biodynamics of the hand-arm system and the quantification of vibration exposure; (iii) biological effects of hand-transmitted vibration exposure; (iv) measurements of vibration-induced health effects; (iv) quantification of influencing biomechanical effects; and (v) intervention methods and technologies for controlling hand-transmitted vibration exposure. The major findings of the studies are summarized and discussed.

      2. Exploring the dynamics of workplace typologies for sex workers in Eastern Ukraineexternal icon
        Herpai N, Lazarus L, Forget E, Balakireva O, Pavlova D, McClarty L, Lorway R, Pickles M, Isac S, Sandstrom P, Aral S, Mishra S, Ma H, Blanchard J, Becker M.
        Glob Public Health. 2021 Aug 17:1-20.
        We examine the typologies of workplaces for sex workers in Dnipro, Ukraine as part of the larger Dynamics Study, which explores the influence of conflict on sex work. We conducted a cross-sectional survey with 560 women from September 2017 to October 2018. The results of our study demonstrate a diverse sex work environment with heterogeneity across workplace typologies in terms of remuneration, workload, and safety. Women working in higher prestige typologies earned a higher hourly wage, however client volume also varied which resulted in comparable monthly earnings from sex work across almost all workplace types. While sex workers in Dnipro earn a higher monthly wage than the city mean, they also report experiencing high rates of violence and a lack of personal safety at work. Sex workers in all workplaces, with the exception of those working in art clubs, experienced physical and sexual violence perpetrated by law enforcement officers and sex partners. By understanding more about sex work workplaces, programmes may be better tailored to meet the needs of sex workers and respond to changing work environments due to ongoing conflict and COVID-19 pandemic.

      3. BACKGROUND: Isolation gowns are recommended to protect healthcare personnel (HCP), patients, and visitors from transfer of microorganisms and body fluids in patient isolation situations. Standards provide limited information about barrier performance of isolation gowns for possible exposure scenarios. One of the most vulnerable areas of the personal protective equipment (PPE) ensemble is considered the glove-gown interface. However, current classification standards do not consider the interface regions of the PPE system while assessing the level of protection. The purpose of this study was to quantitatively evaluate the fluid leakage through the glove-gown interface by simulating exposures and HCP arm movements in patient care. METHODS: We tested fluid leakage of two examination gloves with different cuff lengths and seven isolation gown models designed with varying levels of barrier resistance and multiple cuff types. RESULTS: Our results demonstrated that leakage through the glove-gown interface depends on multiple factors, including glove cuff length and gown cuff design. Gowns with the thumb loop design provided better protection than the elastic cuff design, and the elastic cuff design provided better protection compared to the knit cuff design for a given AAMI PB70 level. More importantly, a substantial penetration through gown fabrics was observed. CONCLUSION: This research identifies a need to develop a standardized method to evaluate leakage at the glove-gown interface to improve worker protection.

      4. NIOSH responds to the U.S. drug overdose epidemicexternal icon
        Osborne JC, Chosewood LC.
        New Solut. 2021 Aug 25.
        The United States is experiencing an evolving and worsening drug overdose epidemic. Although the rate of drug use among workers has remained relatively stable, the risk of overdose and death among drug users has not, as illicit drugs have increased in potency and lethality. The cumulative impacts of COVID-19 and the opioid crisis increase the likelihood of illness and death among workers with opioid use disorder. Workplaces represent a critical point of contact for people living in the United States who are struggling with or recovering from a substance use disorder, and employment is a vital source of recovery "capital." The benefits of addressing substance use in the workplace, supporting treatment, and employing workers in recovery are evident. The National Institute for Occupational Safety and Health has published research to inform policy and practice toward prevention efforts and has developed accessible resources and toolkits to support workers, employers, and workplaces in combatting the opioid overdose crisis and creating safer, healthier communities.

    • Reproductive Health
      1. A methodological approach for evaluating the Enterprise Community Healthy Start Program in Rural Georgia: An analysis using linked PRAMS, birth records and program dataexternal icon
        Vladutiu CJ, Mobley SC, Ji X, Thomas S, Kandasamy V, Sutherland D, Inglett S, Li R, Cox S.
        Matern Child Health J. 2021 Aug 20.
        INTRODUCTION: Community Healthy Start program evaluations are often limited by a lack of robust data and rigorous study designs. This study describes an enhanced methodological approach using local program data linked with existing population-level datasets for external comparison to evaluate the Enterprise Community Healthy Start (ECHS) program in two rural Georgia counties and presents results from the evaluation. METHODS: ECHS program data were linked to birth records and the Pregnancy Risk Assessment Monitoring System (PRAMS) for 869 women who delivered a live birth in Burke and McDuffie counties from 2010 to 2011. Multivariate logistic regressions with and without propensity score methods modeled the association between ECHS participation and maternal health indicators and pregnancy outcomes. RESULTS: 107 ECHS participants and 726 non-participants responded to PRAMS and met eligibility criteria. Compared with non-participants, ECHS participants were younger, completed fewer years of education, and were more likely to be non-Hispanic Black, unmarried, insured with Medicaid, participating in WIC, and having an unintended pregnancy. Models with and without propensity score weighting derived similar results: there was a positive association between ECHS participation and receiving adequate or adequate plus prenatal care (p < 0.05); no statistically significant associations were observed between ECHS participation and any other health behaviors, health care access and utilization measures or pregnancy outcomes. DISCUSSION: Rigorous evaluation of a local Healthy Start program using linked PRAMS and birth records with a population-based external comparison group and propensity score methods is an enhanced and feasible approach that can be applied in other local and state jurisdictions.

    • Substance Use and Abuse
      1. Notes from the field: Illicit benzodiazepines detected in patients evaluated in emergency departments for suspected opioid overdose - four states, October 6, 2020-March 9, 2021external icon
        Aldy K, Mustaquim D, Campleman S, Meyn A, Abston S, Krotulski A, Logan B, Gladden MR, Hughes A, Amaducci A, Shulman J, Schwarz E, Wax P, Brent J, Manini A.
        MMWR Morb Mortal Wkly Rep. 2021 Aug 27;70(34):1177-1179.

      2. Vaping, lung injury, and mental health Minnesota 2018-2019external icon
        Cole C, Wiens T, Taylor J, Danila R, D'Heilly P, Margetta J, Bye M, Mumm E, Schwerzler L, Makhtal R, Holzbauer S, Lynfield R.
        Minn Med. 2021 Jan 5;104(3):41-43.
        This report describes and contextualizes the high prevalence of mental health conditions (MHC) among Minnesota 2019 EVALI patients by examining the prevalence of MHC and associations between MHC and e-cigarette or vaping product (EVP) use in Minnesota population surveys. Investigators reviewed medical records for 140 EVALI patients to determine history of MHC. History of MHC and EVP use in the general population was estimated using self-reported measures and screening tools from two population-based surveys, the 2019 Minnesota Student Survey (MSS) and the 2018 Minnesota Behavioral Risk Factor Surveillance Survey (MN-BRFSS). Some 64.3% of EVALI patients had an MHC. In both Minnesota population surveys, MHCs were common among people who used EVP. The odds of MHC among youth aged <18 were higher among those who reported current EVP use compared with those did not report EVP use. Similarly, the odds of depression were higher among adults who reported current EVP use compared with those who did not. Clinicians treating patients with EVALI should consider evaluating the need for, and providing indicated referrals to, post-discharge mental health services for their patients.

      3. Trends in nonfatal and fatal overdoses involving benzodiazepines - 38 states and the District of Columbia, 2019-2020external icon
        Liu S, O'Donnell J, Gladden RM, McGlone L, Chowdhury F.
        MMWR Morb Mortal Wkly Rep. 2021 Aug 27;70(34):1136-1141.
        Nonfatal and fatal drug overdoses increased overall from 2019 to 2020 (1).* Illicit benzodiazepines (e.g., etizolam, flualprazolam, and flubromazolam)(†) were increasingly detected among postmortem and clinical samples in 2020, often with opioids,(§) and might have contributed to overall increases in drug overdoses. Availability of recent multistate trend data on nonfatal benzodiazepine-involved overdoses and involvement of illicit benzodiazepines in overdoses is limited. This data gap was addressed by analyzing annual and quarterly trends in suspected benzodiazepine-involved nonfatal overdoses(¶) treated in emergency departments (EDs) (benzodiazepine overdose ED visits) during January 2019-December 2020 (32 states and the District of Columbia [DC]) and benzodiazepine-involved overdose deaths (benzodiazepine deaths), which include both illicit and prescription benzodiazepines, during January 2019-June 2020 (23 states) from CDC's Overdose Data to Action (OD2A) program. From 2019 to 2020, benzodiazepine overdose ED visits per 100,000 ED visits increased (23.7%), both with opioid involvement (34.4%) and without (21.0%). From April-June 2019 to April-June 2020, overall benzodiazepine deaths increased 42.9% (from 1,004 to 1,435), prescription benzodiazepine deaths increased 21.8% (from 921 to 1,122), and illicit benzodiazepine deaths increased 519.6% (from 51 to 316). During January-June 2020, most (92.7%) benzodiazepine deaths also involved opioids, mainly illicitly manufactured fentanyls (IMFs) (66.7%). Improving naloxone availability and enhancing treatment access for persons using benzodiazepines and opioids and calling emergency services for overdoses involving benzodiazepines and opioids, coupled with primary prevention of drug use and misuse, could reduce morbidity and mortality.

    • Zoonotic and Vectorborne Diseases
      1. Cutaneous anthrax associated with handling carcasses of animals that died suddenly of unknown cause: Arua District, Uganda, January 2015-August 2017external icon
        Aceng FL, Ario AR, Alitubeera PH, Neckyon MM, Kadobera D, Sekamatte M, Okethwangu D, Bulage L, Harris JR, Nguma W, Ndumu DB, Buule J, Nyakarahuka L, Zhu BP.
        PLoS Negl Trop Dis. 2021 Aug;15(8):e0009645.
        BACKGROUND: Anthrax is a zoonotic disease that can be transmitted to humans from infected animals. During May-June 2017, three persons with probable cutaneous anthrax were reported in Arua District, Uganda; one died. All had recently handled carcasses of livestock that died suddenly and a skin lesion from a deceased person tested positive by PCR for Bacillus anthracis. During July, a bull in the same community died suddenly and the blood sample tested positive by PCR for Bacillus anthracis. The aim of this investigation was to establish the scope of the problem, identify exposures associated with illness, and recommend evidence-based control measures. METHODS: A probable case was defined as acute onset of a papulo-vesicular skin lesion subsequently forming an eschar in a resident of Arua District during January 2015-August 2017. A confirmed case was a probable case with a skin sample testing positive by polymerase chain reaction (PCR) for B. anthracis. Cases were identified by medical record review and active community search. In a case-control study, exposures between case-patients and frequency- and village-matched asymptomatic controls were compared. Key animal health staff were interviewed to learn about livestock deaths. RESULTS: There were 68 case-patients (67 probable, 1 confirmed), and 2 deaths identified. Cases occurred throughout the three-year period, peaking during dry seasons. All cases occurred following sudden livestock deaths in the villages. Case-patients came from two neighboring sub-counties: Rigbo (attack rate (AR) = 21.9/10,000 population) and Rhino Camp (AR = 1.9/10,000). Males (AR = 24.9/10,000) were more affected than females (AR = 0.7/10,000). Persons aged 30-39 years (AR = 40.1/10,000 population) were most affected. Among all cases and 136 controls, skinning (ORM-H = 5.0, 95%CI: 2.3-11), butchering (ORM-H = 22, 95%CI: 5.5-89), and carrying the carcass of livestock that died suddenly (ORM-H = 6.9, 95%CI: 3.0-16) were associated with illness. CONCLUSIONS: Exposure to carcasses of animals that died suddenly was a likely risk factor for cutaneous anthrax in Arua District during 2015-2017. The recommendations are investigation of anthrax burden in livestock, prevention of animal infections through vaccinations, safe disposal of the carcasses, public education on risk factors for infection and prompt treatment of illness following exposure to animals that died suddenly.

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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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