Issue 36, October 5, 2021

CDC Science Clips: Volume 13, Issue 36, October 5, 2021

Science Clips is produced weekly to enhance awareness of emerging scientific knowledge for the public health community. Each article features an Altmetric Attention scoreexternal icon to track social and mainstream media mentions.

  1. Top Articles of the Week
    Selected weekly by a senior CDC scientist from the standard sections listed below.
    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions
      • PURPOSE: Previous reports of gynecologic cancer rates have adjusted for hysterectomy prevalence with data from the Behavioral Risk Factor Surveillance System (BRFSS) or the National Health Interview Survey (NHIS). We sought to determine if BRFSS and NHIS produce similar estimates of hysterectomy prevalence. METHODS: Using data from BRFSS and NHIS, we calculated hysterectomy prevalence for women aged 20-79 years, stratified by 10-year age groups, survey year (2010, 2018), and race/ethnicity (Hispanic, non-Hispanic American Indian or Alaskan Native, non-Hispanic Asian, non-Hispanic Black, non-Hispanic White, non-Hispanic all other race groups). RESULTS: BRFSS and NHIS produced similar increasing trends in hysterectomy prevalence by age and directional differences by race and ethnicity. Fewer than 2% of women aged 20-29 years and more than 4 out of 10 women aged 70-79 years reported having had a hysterectomy. CONCLUSION: Our analyses suggest adjustment for hysterectomy prevalence with data from either survey would likely reduce distortion in cervical and uterine cancer rates. BRFSS, a survey which has a larger sample size than NHIS, may better support analyses of hysterectomy estimates for smaller subpopulations.

    • Communicable Diseases
      • Disease progression and mortality with untreated HIV infection: evidence synthesis of HIV seroconverter cohorts, antiretroviral treatment clinical cohorts and population-based survey dataexternal icon
        Glaubius R, Kothegal N, Birhanu S, Jonnalagadda S, Mahiane SG, Johnson LF, Brown T, Stover J, Mangal TD, Pantazis N, Eaton JW.
        J Int AIDS Soc. 2021 Sep;24 Suppl 5:e25784.
        INTRODUCTION: Model-based estimates of key HIV indicators depend on past epidemic trends that are derived based on assumptions about HIV disease progression and mortality in the absence of antiretroviral treatment (ART). Population-based HIV Impact Assessment (PHIA) household surveys conducted between 2015 and 2018 found substantial numbers of respondents living with untreated HIV infection. CD4 cell counts measured in these individuals provide novel information to estimate HIV disease progression and mortality rates off ART. METHODS: We used Bayesian multi-parameter evidence synthesis to combine data on (1) cross-sectional CD4 cell counts among untreated adults living with HIV from 10 PHIA surveys, (2) survival after HIV seroconversion in East African seroconverter cohorts, (3) post-seroconversion CD4 counts and (4) mortality rates by CD4 count predominantly from European, North American and Australian seroconverter cohorts. We used incremental mixture importance sampling to estimate HIV natural history and ART uptake parameters used in the Spectrum software. We validated modelled trends in CD4 count at ART initiation against ART initiator cohorts in sub-Saharan Africa. RESULTS: Median untreated HIV survival decreased with increasing age at seroconversion, from 12.5 years [95% credible interval (CrI): 12.1-12.7] at ages 15-24 to 7.2 years (95% CrI: 7.1-7.7) at ages 45-54. Older age was associated with lower initial CD4 counts, faster CD4 count decline and higher HIV-related mortality rates. Our estimates suggested a weaker association between ART uptake and HIV-related mortality rates than previously assumed in Spectrum. Modelled CD4 counts in untreated people living with HIV matched recent household survey data well, though some intercountry variation in frequencies of CD4 counts above 500 cells/mm(3) was not explained. Trends in CD4 counts at ART initiation were comparable to data from ART initiator cohorts. An alternate model that stratified progression and mortality rates by sex did not improve model fit appreciably. CONCLUSIONS: Synthesis of multiple data sources results in similar overall survival as previous Spectrum parameter assumptions but implies more rapid progression and longer survival in lower CD4 categories. New natural history parameter values improve consistency of model estimates with recent cross-sectional CD4 data and trends in CD4 counts at ART initiation.

      • Clinical characteristics of multisystem inflammatory syndrome in adults: A systematic reviewexternal icon
        Patel P, DeCuir J, Abrams J, Campbell AP, Godfred-Cato S, Belay ED.
        JAMA Netw Open. 2021 Sep 1;4(9):e2126456.
        IMPORTANCE: Multisystem inflammatory syndrome in adults (MIS-A) has not been well described. Improved diagnosis and treatment of MIS-A might mitigate COVID-19 morbidity and mortality. OBJECTIVE: To summarize the descriptive epidemiology and clinical characteristics of MIS-A. EVIDENCE REVIEW: This systematic review identified patients with MIS-A using 3 strategies: (1) literature review from May 1, 2020, to May 25, 2021, by searching MEDLINE, Embase, Global Health, CAB Abstracts, PsycINFO, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Academic Search Complete, Scopus, World Health Organization Global COVID-19 Literature Database, and Google Scholar; (2) voluntary reports of MIS-A to the Centers for Disease Control and Prevention (CDC); and (3) reports among persons aged 18 to 20 years in the CDC surveillance system for MIS in children. FINDINGS: Of 221 patients with MIS-A, the median age was 21 (interquartile range [IQR], 19-34) years, and 154 of 219 (70%) with data available were men. Sixty of 169 patients (36%) were non-Hispanic Black individuals, and 122 of 209 (58%) had no underlying comorbidity. One hundred two of 149 patients (68%) noted a previous symptomatic COVID-19-like illness (median, 28 [IQR, 20-36] days previously). Most patients with MIS-A presented with fever (197 of 205 [96%]), hypotension (133 of 220 [60%]), cardiac dysfunction (114 of 210 [54%]), shortness of breath (102 of 198 [52%]), and/or diarrhea (102 of 197 [52%]). The median number of organ systems involved was 5 (IQR, 4-6). Median hospital stay was 8 (IQR, 5-12) days; 115 of 201 patients (57%) were admitted to the intensive care unit; 101 of 213 (47%) required respiratory support, and 15 of 220 (7%) died. Most patients (176 of 195 [90%]) had elevated markers of coagulopathy and/or inflammation and a positive SARS-CoV-2 serologic finding (139 of 194 [72%]). Ten patients with MIS-A presented with Kawasaki disease. CONCLUSIONS AND RELEVANCE: These findings suggest that MIS-A is a serious hyperinflammatory condition that presents approximately 4 weeks after onset of acute COVID-19 with extrapulmonary multiorgan dysfunction.

    • Disaster Control and Emergency Services
      • The occupational health effects of responding to a natural gas pipeline explosion among emergency first responders - Lincoln County, Kentucky, 2019external icon
        Bui DP, Kukielka EA, Blau EF, Tompkins LK, Bing KL, Edge C, Hardin R, Miller D, House J, Boehmer T, Winquist A, Orr M, Funk R, Thoroughman D.
        Disaster Med Public Health Prep. 2021 Sep 21:1-8.
        OBJECTIVE: The aim of the study was to assess occupational health effects 1 month after responding to a natural gas pipeline explosion. METHODS: First responders to a pipeline explosion in Kentucky were interviewed about pre- and post-response health symptoms, post-response health care, and physical exertion and personal protective equipment (PPE) use during the response. Logistic regression was used to examine associations between several risk factors and development of post-response symptoms. RESULTS: Among 173 first responders involved, 105 (firefighters [58%], emergency medical services [19%], law enforcement [10%], and others [12%]) were interviewed. Half (53%) reported at least 1 new or worsening symptom, including upper respiratory symptoms (39%), headache (18%), eye irritation (17%), and lower respiratory symptoms (16%). The majority (79%) of symptomatic responders did not seek post-response care. Compared with light-exertion responders, hard-exertion responders (48%) had significantly greater odds of upper respiratory symptoms (aOR: 2.99, 95% CI: 1.25-7.50). Forty-four percent of responders and 77% of non-firefighter responders reported not using any PPE. CONCLUSIONS: Upper respiratory symptoms were common among first responders of a natural gas pipeline explosion and associated with hard-exertion activity. Emergency managers should ensure responders are trained in, equipped with, and properly use PPE during these incidents and encourage responders to seek post-response health care when needed.

    • Environmental Health
    • Health Economics
      • Review of cannabis reimbursement by workers' compensation insurance in the U.S. and Canadaexternal icon
        Howard J, Wurzelbacher S, Osborne J, Wolf J, Ruser J, Chadarevian R.
        Am J Ind Med. 2021 Sep 16.
        Changing public attitudes about cannabis consumption have currently led 36 U.S. states and the District of Columbia to approve laws that make cannabis available to consumers with qualifying medical conditions. This article reviews the 36 states and the District of Columbia with medical cannabis access laws to determine if the state or the District also allows reimbursement of the costs of cannabis for a work-related health condition under that state's or District's workers' compensation insurance (WCI) laws and administrative regulations. The legal basis for a state allowing or not allowing WCI reimbursement is described. The review found that only six of the 36 states expressly allow cannabis WCI reimbursement, six expressly prohibit it, 14 states do not require reimbursement, and 10 states, and the District of Columbia, are silent on the issue. The article describes the role of the insurer, treating physician, and worker in obtaining WCI reimbursement in the six states that expressly allow cannabis WCI reimbursement. Comparisons are made to how selected Canadian provinces and territories administer cannabis reimbursement under Canada's new national cannabis legalization law. The article discusses the future role of cannabis legalization in the United States and the evolving role of cannabis from an international perspective.

    • Immunity and Immunization
      • Effectiveness of mRNA covid-19 vaccine among U.S. health care personnelexternal icon
        Pilishvili T, Gierke R, Fleming-Dutra KE, Farrar JL, Mohr NM, Talan DA, Krishnadasan A, Harland KK, Smithline HA, Hou PC, Lee LC, Lim SC, Moran GJ, Krebs E, Steele MT, Beiser DG, Faine B, Haran JP, Nandi U, Schrading WA, Chinnock B, Henning DJ, Lovecchio F, Lee J, Barter D, Brackney M, Fridkin SK, Marceaux-Galli K, Lim S, Phipps EC, Dumyati G, Pierce R, Markus TM, Anderson DJ, Debes AK, Lin MY, Mayer J, Kwon JH, Safdar N, Fischer M, Singleton R, Chea N, Magill SS, Verani JR, Schrag SJ.
        N Engl J Med. 2021 Sep 22.
        BACKGROUND: The prioritization of U.S. health care personnel for early receipt of messenger RNA (mRNA) vaccines against severe acute respiratory disease coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (Covid-19), allowed for the evaluation of the effectiveness of these new vaccines in a real-world setting. METHODS: We conducted a test-negative case-control study involving health care personnel across 25 U.S. states. Cases were defined on the basis of a positive polymerase-chain-reaction (PCR) or antigen-based test for SARS-CoV-2 and at least one Covid-19-like symptom. Controls were defined on the basis of a negative PCR test for SARS-CoV-2, regardless of symptoms, and were matched to cases according to the week of the test date and site. Using conditional logistic regression with adjustment for age, race and ethnic group, underlying conditions, and exposures to persons with Covid-19, we estimated vaccine effectiveness for partial vaccination (assessed 14 days after receipt of the first dose through 6 days after receipt of the second dose) and complete vaccination (assessed ≥7 days after receipt of the second dose). RESULTS: The study included 1482 case participants and 3449 control participants. Vaccine effectiveness for partial vaccination was 77.6% (95% confidence interval [CI], 70.9 to 82.7) with the BNT162b2 vaccine (Pfizer-BioNTech) and 88.9% (95% CI, 78.7 to 94.2) with the mRNA-1273 vaccine (Moderna); for complete vaccination, vaccine effectiveness was 88.8% (95% CI, 84.6 to 91.8) and 96.3% (95% CI, 91.3 to 98.4), respectively. Vaccine effectiveness was similar in subgroups defined according to age (<50 years or ≥50 years), race and ethnic group, presence of underlying conditions, and level of patient contact. Estimates of vaccine effectiveness were lower during weeks 9 through 14 than during weeks 3 through 8 after receipt of the second dose, but confidence intervals overlapped widely. CONCLUSIONS: The BNT162b2 and mRNA-1273 vaccines were highly effective under real-world conditions in preventing symptomatic Covid-19 in health care personnel, including those at risk for severe Covid-19 and those in racial and ethnic groups that have been disproportionately affected by the pandemic. (Funded by the Centers for Disease Control and Prevention.).

    • Injury and Violence
      • Association of online risk factors with subsequent youth suicide-related behaviors in the USexternal icon
        Sumner SA, Ferguson B, Bason B, Dink J, Yard E, Hertz M, Hilkert B, Holland K, Mercado-Crespo M, Tang S, Jones CM.
        JAMA Netw Open. 2021 Sep 1;4(9):e2125860.
        IMPORTANCE: The association between online activities and youth suicide is an important issue for parents, clinicians, and policy makers. However, most information exploring potential associations is drawn from survey data and mainly focuses on risk related to overall screen time. OBJECTIVE: To evaluate the association between a variety of online risk factors and youth suicide-related behavior using real-world online activity data. DESIGN, SETTING, AND PARTICIPANTS: A matched case-control study was conducted from July 27, 2019, to May 26, 2020, with the sample drawn from more than 2600 US schools participating in an online safety monitoring program via the Bark online safety tool. For 227 youths having a severe suicide/self-harm alert requiring notification of school administrators, cases were matched 1:5 to 1135 controls on location, the amount of follow-up time, and general volume of online activity. EXPOSURES: Eight potential online risk factors (cyberbullying, violence, drug-related, hate speech, profanity, sexual content, depression, and low-severity self-harm) through assessment of text, image, and video data. MAIN OUTCOMES AND MEASURES: Severe suicide/self-harm alert requiring notification of school administrators; severe suicide alerts are statements by youths indicating imminent or recent suicide attempts and/or self-harm. RESULTS: The 1362 participants had a mean (SD) age of 13.3 (2.41) years; 699 (51.3%) were male. All 8 online risk factors studied exhibited differences between case and control populations and were significantly associated with subsequent severe suicide/self-harm alerts when examining total direct and indirect pathways. These associations ranged from an adjusted odds ratio (aOR) of 1.17 (95% CI, 1.09-1.26) for drug-related content to an aOR of 1.82 (95% CI, 1.63-2.03) for depression-related content. When considering the total number of different types of online risk factors among the 8 measured, there was an exponentially larger risk of severe suicide/self-harm alerts; youths with 5 or more of the 8 risk factors present in their online activity had a more than 70-fold increased odds of subsequently having a severe suicide/self-harm alert (aOR, 78.64; 95% CI, 34.39-179.84). CONCLUSIONS AND RELEVANCE: The findings of this study suggest that many discrete types of risk factors are identifiable from online data and associated with subsequent youth suicide-related behavior. Although each risk factor carries a specific association with suicide-related behavior, the greatest risk is evident for youths demonstrating multiple types of online risk factors.

    • Laboratory Sciences
      • Teaching a new mouse old tricks: Humanized mice as an infection model for Variola virusexternal icon
        Hutson CL, Kondas AV, Ritter JM, Reed Z, Ostergaard SD, Morgan CN, Gallardo-Romero N, Tansey C, Mauldin MR, Salzer JS, Hughes CM, Goldsmith CS, Carroll D, Olson VA.
        PLoS Pathog. 2021 Sep;17(9):e1009633.
        Smallpox, caused by the solely human pathogen Variola virus (VARV), was declared eradicated in 1980. While known VARV stocks are secure, smallpox remains a bioterrorist threat agent. Recent U.S. Food and Drug Administration approval of the first smallpox anti-viral (tecovirimat) therapeutic was a successful step forward in smallpox preparedness; however, orthopoxviruses can become resistant to treatment, suggesting a multi-therapeutic approach is necessary. Animal models are required for testing medical countermeasures (MCMs) and ideally MCMs are tested directly against the pathogen of interest. Since VARV only infects humans, a representative animal model for testing therapeutics directly against VARV remains a challenge. Here we show that three different humanized mice strains are highly susceptible to VARV infection, establishing the first small animal model using VARV. In comparison, the non-humanized, immunosuppressed background mouse was not susceptible to systemic VARV infection. Following an intranasal VARV challenge that mimics the natural route for human smallpox transmission, the virus spread systemically within the humanized mouse before mortality (~ 13 days post infection), similar to the time from exposure to symptom onset for ordinary human smallpox. Our identification of a permissive/representative VARV animal model can facilitate testing of MCMs in a manner consistent with their intended use.

    • Maternal and Child Health
      • Epidemiology of intussusception in sub-Saharan Africaexternal icon
        Mwenda JM, Tate JE, Parashar UD.
        Pan Afr Med J. 2021 ;39(Suppl 1):1.
        This supplement contains the findings from intussusception surveillance conducted in 9 countries. These articles provide information on the age distribution of intussusception in the first year of life with cases peaking at 4-6 months of age, highlight the high proportion of cases in most, but not all, countries that undergo surgery and often require bowel resection for the treatment of intussusception, and show the variability of treatment outcomes in different countries. These data will be important for improving diagnosis and treatment of intussusception in young children in sub-Saharan Africa.

    • Occupational Safety and Health
      • Perceptions of work-related health and cancer risks among women firefighters: A qualitative studyexternal icon
        Solle NS, Santiago KM, Feliciano PL, Calkins MM, Fent K, Jahnke S, Parks N, Buren H, Grant C, Burgess JL, Caban-Martinez AJ.
        J Occup Environ Med. 2021 Sep 17.
        OBJECTIVES: We use a qualitative method to gain further insight into women firefighters' experiences, perceptions of cancer, health and safety risks in the fire service. METHODS: We conducted six focus groups with U.S. women firefighters. Participants engaged in a 60-75-minute, semi-structured discussion and completed a sociodemographic questionnaire. A qualitative descriptive approach was used to inductively create themes. Data collection concluded when saturation was met. RESULTS: Forty-nine women firefighters participated. Qualitative results indicated the main health concerns include: Occupational cancer risks including, risks related to hazardous exposures, sleep disruption and stress; and Women's health concerns including, cancer, pregnancy and breastfeeding and lack of resources. CONCLUSIONS: Women firefighters are concerned about their risk for cancer due to their occupation and identify a lack of resources specific to health and safety needs of women firefighters.

    • Reproductive Health
      • Parents' sources of adolescent sexual health information and their interest in resources from primary careexternal icon
        Mehus CJ, Aldrin S, Steiner RJ, Brar P, Gewirtz O'Brien JR, Gorzkowski J, Grilo S, Klein JD, McRee AL, Ross C, Santelli J, Sieving RE.
        Acad Pediatr. 2021 Sep 18.
        OBJECTIVE: To examine sources of information used by parents to facilitate parent-adolescent communication about sexual and reproductive health (SRH), parents' preferences for receiving SRH information through primary care, and factors associated with parents' interest in primary-care-based SRH information (i.e., resources recommended or offered in the primary care setting). METHODS: In this cross-sectional study, a nationally representative sample of 11-17-year-old adolescents and their parents (n=1,005 dyads) was surveyed online; 993 were retained for these analyses. Parents were asked about their use of 11 resources to help them talk with their adolescents about SRH and rated the likelihood of using specific primary-care-based resources. We used multivariable logistic regression to examine characteristics associated with parent interest in primary-care-based SRH resources. RESULTS: Only 25.8% of parents reported receiving at least a moderate amount of SRH information from primary care; half (53.3%) reported receiving no SRH information from their adolescent's provider. Parents received the most information from personal connections (e.g. spouse/partner, friends). Most parents (59.1%) reported being likely to utilize a primary-care-based resource for SRH information. Parents who previously received SRH information from primary care sources had greater odds of reporting they would be likely to utilize a primary-care-based resources (AOR = 4.06, 95% CI: 2.55-6.46). CONCLUSIONS: This study provides insights into parents' sources of information for communicating with their adolescents about SRH and ways primary care practices might increase support for parents in having SRH conversations with their adolescents. Future studies are needed to establish clinical best practices for promoting parent-adolescent communication about SRH.

  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. Hypertension at delivery hospitalization - United States, 2016-2017external icon
        DeSisto CL, Robbins CL, Ritchey MD, Ewing AC, Ko JY, Kuklina EV.
        Pregnancy Hypertens. 2021 Sep 14;26:65-68.
        In this study, hospital discharge data from the 2016-2017 Healthcare Cost and Utilization Project were analyzed to describe national and, where data were available, state-specific prevalences of chronic hypertension and pregnancy-associated hypertension at delivery hospitalization. In 2016-2017, the prevalence of chronic hypertension was 216 per 10,000 delivery hospitalizations nationwide, ranging from 125 to 400 per 10,000 delivery hospitalizations in individual states. The prevalence of pregnancy-associated hypertension was 1021 per 10,000 delivery hospitalizations nationwide, ranging from 693 to 1382 per 10,000 delivery hospitalizations in individual states. The burden of hypertensive disorders in pregnancy remains high and varies considerably by jurisdiction.

    • Communicable Diseases
      1. Expanding access to HIV services during the COVID-19 pandemic-Nigeria, 2020external icon
        Boyd AT, Jahun I, Dirlikov E, Greby S, Odafe S, Abdulkadir A, Odeyemi O, Dalhatu I, Ogbanufe O, Abutu A, Asaolu O, Bamidele M, Onyenuobi C, Efuntoye T, Fagbamigbe JO, Ene U, Fagbemi A, Tingir N, Meribe C, Ayo A, Bassey O, Nnadozie O, Boyd MA, Onotu D, Gwamna J, Okoye M, Abrams W, Alagi M, Oladipo A, Williams-Sherlock M, Bachanas P, Chun H, Carpenter D, Miller DA, Ijeoma U, Nwaohiri A, Dakum P, Mensah CO, Aliyu A, Oyeledun B, Okonkwo P, Oko JO, Ikpeazu A, Aliyu G, Ellerbrock T, Swaminathan M.
        AIDS Res Ther. 2021 Sep 19;18(1):62.
        BACKGROUND: To accelerate progress toward the UNAIDS 90-90-90 targets, US Centers for Disease Control and Prevention Nigeria country office (CDC Nigeria) initiated an Antiretroviral Treatment (ART) Surge in 2019 to identify and link 340,000 people living with HIV/AIDS (PLHIV) to ART. Coronavirus disease 2019 (COVID-19) threatened to interrupt ART Surge progress following the detection of the first case in Nigeria in February 2020. To overcome this disruption, CDC Nigeria designed and implemented adapted ART Surge strategies during February-September 2020. METHODS: Adapted ART Surge strategies focused on continuing expansion of HIV services while mitigating COVID-19 transmission. Key strategies included an intensified focus on community-based, rather than facility-based, HIV case-finding; immediate initiation of newly-diagnosed PLHIV on 3-month ART starter packs (first ART dispense of 3 months of ART); expansion of ART distribution through community refill sites; and broadened access to multi-month dispensing (MMD) (3-6 months ART) among PLHIV established in care. State-level weekly data reporting through an Excel-based dashboard and individual PLHIV-level data from the Nigeria National Data Repository facilitated program monitoring. RESULTS: During February-September 2020, the reported number of PLHIV initiating ART per month increased from 11,407 to 25,560, with the proportion found in the community increasing from 59 to 75%. The percentage of newly-identified PLHIV initiating ART with a 3-month ART starter pack increased from 60 to 98%. The percentage of on-time ART refill pick-ups increased from 89 to 100%. The percentage of PLHIV established in care receiving at least 3-month MMD increased from 77 to 93%. Among PLHIV initiating ART, 6-month retention increased from 74 to 92%. CONCLUSIONS: A rapid and flexible HIV program response, focused on reducing facility-based interactions while ensuring delivery of lifesaving ART, was critical in overcoming COVID-19-related service disruptions to expand access to HIV services in Nigeria during the first eight months of the pandemic. High retention on ART among PLHIV initiating treatment indicates immediate MMD in this population may be a sustainable practice. HIV program infrastructure can be leveraged and adapted to respond to the COVID-19 pandemic.

      2. Overseas gonorrhea screening among newly arrived refugees during 2018external icon
        Butler KR, Lee D, Hollberg M, Posey DL.
        J Immigr Minor Health. 2021 Sep 17.
        We assessed the overseas gonorrhea results reported in the CDC's Electronic Disease Notification (EDN) system among refugees ≥ 15 years old who arrived in the United States during 2018. Of 18,720 refugees, 57 (0.4%) tested positive. Among those with a positive test, 31 (54.5%) were born in the Democratic Republic of the Congo, followed by 12 (21.1%) from Afghanistan. Thirty-three (57.9%) cases were female. Fifty-one cases (89.4%) were between 15 and 44 years of age; 25 (43.9%) were ages 15-24 and 26 (45.6%) were ages 25-44. Among the cases, 56 (98.2%) were treated overseas with the recommended therapy of ceftriaxone and azithromycin. Our findings suggest that the risk of gonorrhea in refugees is similar to that in the U.S. Given recent worldwide increases in gonorrhea, additional monitoring among refugees are necessary to assess the appropriateness of the gonorrhea screening requirement in the overseas medical examination.

      3. Naomi: a new modelling tool for estimating HIV epidemic indicators at the district level in sub-Saharan Africaexternal icon
        Eaton JW, Dwyer-Lindgren L, Gutreuter S, O'Driscoll M, Stevens O, Bajaj S, Ashton R, Hill A, Russell E, Esra R, Dolan N, Anifowoshe YO, Woodbridge M, Fellows I, Glaubius R, Haeuser E, Okonek T, Stover J, Thomas ML, Wakefield J, Wolock TM, Berry J, Sabala T, Heard N, Delgado S, Jahn A, Kalua T, Chimpandule T, Auld A, Kim E, Payne D, Johnson LF, FitzJohn RG, Wanyeki I, Mahy MI, Shiraishi RW.
        J Int AIDS Soc. 2021 Sep;24 Suppl 5:e25788.
        INTRODUCTION: HIV planning requires granular estimates for the number of people living with HIV (PLHIV), antiretroviral treatment (ART) coverage and unmet need, and new HIV infections by district, or equivalent subnational administrative level. We developed a Bayesian small-area estimation model, called Naomi, to estimate these quantities stratified by subnational administrative units, sex, and five-year age groups. METHODS: Small-area regressions for HIV prevalence, ART coverage and HIV incidence were jointly calibrated using subnational household survey data on all three indicators, routine antenatal service delivery data on HIV prevalence and ART coverage among pregnant women, and service delivery data on the number of PLHIV receiving ART. Incidence was modelled by district-level HIV prevalence and ART coverage. Model outputs of counts and rates for each indicator were aggregated to multiple geographic and demographic stratifications of interest. The model was estimated in an empirical Bayes framework, furnishing probabilistic uncertainty ranges for all output indicators. Example results were presented using data from Malawi during 2016-2018. RESULTS: Adult HIV prevalence in September 2018 ranged from 3.2% to 17.1% across Malawi's districts and was higher in southern districts and in metropolitan areas. ART coverage was more homogenous, ranging from 75% to 82%. The largest number of PLHIV was among ages 35 to 39 for both women and men, while the most untreated PLHIV were among ages 25 to 29 for women and 30 to 34 for men. Relative uncertainty was larger for the untreated PLHIV than the number on ART or total PLHIV. Among clients receiving ART at facilities in Lilongwe city, an estimated 71% (95% CI, 61% to 79%) resided in Lilongwe city, 20% (14% to 27%) in Lilongwe district outside the metropolis, and 9% (6% to 12%) in neighbouring Dowa district. Thirty-eight percent (26% to 50%) of Lilongwe rural residents and 39% (27% to 50%) of Dowa residents received treatment at facilities in Lilongwe city. CONCLUSIONS: The Naomi model synthesizes multiple subnational data sources to furnish estimates of key indicators for HIV programme planning, resource allocation, and target setting. Further model development to meet evolving HIV policy priorities and programme need should be accompanied by continued strengthening and understanding of routine health system data.

      4. Diagnosis of fungal opportunistic infections in people living with HIV from Guatemala and El Salvadorexternal icon
        Forno D, Samayoa B, Medina N, Arathoon E, Mejia CR, Gordillo R, Cedillos R, Rodas J, Ahlquist Cleveland A, Chiller T, Caceres DH.
        Mycoses. 2021 Sep 18.
        OBJECTIVES: Histoplasmosis and cryptococcosis are important public health problems in people living with HIV (PLHIV) in Central America. Conventional laboratory tests, such as culture and microscopy are not optimal, however, antigen tests are rapid, highly sensitive, and specific for diagnosis of fungal opportunistic infections (OI). The aim of this study was to describe the results of a laboratory-based surveillance system for histoplasmosis and cryptococcosis. METHODS: An observational cross-sectional study based on laboratory surveillance, was carried out in two hospitals in Guatemala and one hospital in El Salvador, between July 2012 to and December 2014. Diagnosis of histoplasmosis and cryptococcosis in PLHIV were performed by culture and antigen test. RESULTS: A total of 160 PLHIV were diagnosed with fungal OI, of which, 96 (60%) were diagnosed with histoplasmosis, 62 (39%) were with cryptococcosis, and two patients (1%) were diagnosed with both fungal diseases. Of the 160 patients analyzed in this study, 94 (59%) were diagnosed using only an antigen assay. CD4 cell count data was available for 136 (85%) patients; 127 (93%) patients had a CD4 count <200 and 90 (66%) had counts <50 CD4 cells per µL. Antiretroviral therapy utilization at diagnosis was low (33%). Seventy-one out of 160 (44%) were co-infected with tuberculosis or other OIs. CONCLUSION: More than half of the patients in this study were diagnosed only by rapid laboratory antigen tests. A high percent of the patients had advanced HIV disease.

      5. Outbreak of SARS-CoV-2 B.1.617.2 (Delta) variant infections among incarcerated persons in a federal prison - Texas, July-August 2021external icon
        Hagan LM, McCormick DW, Lee C, Sleweon S, Nicolae L, Dixon T, Banta R, Ogle I, Young C, Dusseau C, Salmonson S, Ogden C, Godwin E, Ballom T, Ross T, Browne H, Harcourt JL, Tamin A, Thornburg NJ, Kirking HL, Salvatore PP, Tate JE.
        MMWR Morb Mortal Wkly Rep. 2021 Sep 24;70(38):1349-1354.
        Incarcerated populations have experienced disproportionately higher rates of COVID-19-related illness and death compared with the general U.S. population, due in part to congregate living environments that can facilitate rapid transmission of SARS-CoV-2, the virus that causes COVID-19, and the high prevalence of underlying medical conditions associated with severe COVID-19 (1,2). The SARS-CoV-2 B.1.617.2 (Delta) variant has caused outbreaks among vaccinated and unvaccinated persons in congregate settings and large public gatherings (3,4). During July 2021, a COVID-19 outbreak involving the Delta variant was identified in a federal prison in Texas, infecting 172 of 233 (74%) incarcerated persons in two housing units. The Federal Bureau of Prisons (BOP) partnered with CDC to investigate. CDC analyzed data on infection status, symptom onset date, hospitalizations, and deaths among incarcerated persons. The attack rate was higher among unvaccinated versus fully vaccinated persons (39 of 42, 93% versus 129 of 185, 70%; p = 0.002).(†) Four persons were hospitalized, three of whom were unvaccinated, and one person died, who was unvaccinated. Among a subset of 70 persons consenting to an embedded serial swabbing protocol, the median interval between symptom onset and last positive reverse transcription-polymerase chain reaction (RT-PCR) test result in fully vaccinated versus unvaccinated persons was similar (9 versus 11 days, p = 0.37). One or more specimens were culture-positive from five of 12 (42%) unvaccinated and 14 of 37 (38%) fully vaccinated persons for whom viral culture was attempted. In settings where physical distancing is challenging, including correctional and detention facilities, vaccination and implementation of multicomponent prevention strategies (e.g., testing, medical isolation, quarantine, and masking) are critical to limiting SARS-CoV-2 transmission (5).

      6. Increasing access to HIV testing through direct-to-consumer HIV self-test distribution - United States, March 31, 2020-March 30, 2021external icon
        Hecht J, Sanchez T, Sullivan PS, DiNenno EA, Cramer N, Delaney KP.
        MMWR Morb Mortal Wkly Rep. 2021 Sep 24;70(38):1322-1325.
        During 2019, approximately 34,800 new HIV infections occurred in the United States (1), and it is estimated that approximately 80% of HIV transmission occurs from persons who either do not know they have HIV infection or are not receiving regular care (2). Since 2006, CDC has recommended that persons who are disproportionately affected by HIV (including men who have sex with men [MSM]) should test for HIV at least annually (3,4). However, data from multiple sources indicate that these recommendations are not being fully implemented (5,6). TakeMeHome, a novel public-private partnership to deliver HIV self-testing kits to persons seeking HIV testing in the United States, was launched during March 2020 as home care options for testing became increasingly important during the COVID-19 pandemic. The initiation of the program coincided with the national COVID-19 Public Health Emergency declaration, issuance of stay-at-home orders, and other restrictions that led to disruption of traditional HIV testing services. During March 31, 2020-March 30, 2021, 17 state and local health departments participating in the program allowed residents of their jurisdictions to order test kits. Marketing for TakeMeHome focused on reaching gay, bisexual, and MSM through messages and embedded links in gay dating applications. Most participants in the program reported that they had either never tested for HIV (36%) or that they had last tested >1 year before receiving their self-test kit (56%). After receiving the self-test kit, >10% of respondents reported accessing additional prevention services. Health departments can increase options for HIV testing by distributing publicly funded self-test kits to persons without proximate access to clinic-based testing or who prefer to test at home. Increased and regular HIV testing among MSM will help meet annual testing goals.

      7. Optimizing community linkage to care and antiretroviral therapy Initiation: Lessons from the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) and their adaptation in Nigeria ART Surgeexternal icon
        Jahun I, Said I, El-Imam I, Ehoche A, Dalhatu I, Yakubu A, Greby S, Bronson M, Brown K, Bamidele M, Boyd AT, Bachanas P, Dirlikov E, Agbakwuru C, Abutu A, Williams-Sherlock M, Onotu D, Odafe S, Williams DB, Bassey O, Ogbanufe O, Onyenuobi C, Adeola A, Meribe C, Efuntoye T, Fagbamigbe OJ, Fagbemi A, Ene U, Nguhemen T, Mgbakor I, Alagi M, Asaolu O, Oladipo A, Amafah J, Nzelu C, Dakum P, Mensah C, Aliyu A, Okonkwo P, Oyeledun B, Oko J, Ikpeazu A, Gambo A, Charurat M, Ellerbrock T, Aliyu S, Swaminathan M.
        PLoS One. 2021 ;16(9):e0257476.
        BACKGROUND: Ineffective linkage to care (LTC) is a known challenge for community HIV testing. To overcome this challenge, a robust linkage to care strategy was adopted by the 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS). The NAIIS linkage to care strategy was further adapted to improve Nigeria's programmatic efforts to achieve the 1st 90 as part of the Nigeria Antiretroviral Therapy (ART) Surge initiative, which also included targeted community testing. In this paper we provide an overview of the NAIIS LTC strategy and describe the impact of this strategy on both the NAIIS and the Surge initiatives. METHODS: The NAIIS collaborated with community-based organizations (CBOs) and deployed mobile health (mHealth) technology with real-time dashboards to manage and optimize community LTC for people living with HIV (PLHIV) diagnosed during the survey. In NAIIS, CBOs' role was to facilitate linkage of identified PLHIV in community to facility of their choice. For the ART Surge, we modified the NAIIS LTC strategy by empowering both CBOs and mobile community teams as responsible for not only active LTC but also for community testing, ART initiation, and retention in care. RESULTS: Of the 2,739 PLHIV 15 years and above identified in NAIIS, 1,975 (72.1%) were either unaware of their HIV-positive status (N = 1890) or were aware of their HIV-positive status but not receiving treatment (N = 85). Of these, 1,342 (67.9%) were linked to care, of which 952 (70.9%) were initiated on ART. Among 1,890 newly diagnosed PLHIV, 1,278 (67.6%) were linked to care, 33.7% self-linked and 66.3% were linked by CBOs. Among 85 known PLHIV not on treatment, 64 (75.3%) were linked; 32.8% self-linked and 67.2% were linked by a CBO. In the ART Surge, LTC and treatment initiation rates were 98% and 100%, respectively. Three-month retention for monthly treatment initiation cohorts improved from 76% to 90% over 6 months. CONCLUSIONS: Active LTC strategies by local CBOs and mobile community teams improved LTC and ART initiation in the ART Surge initiative. The use of mHealth technology resulted in timely and accurate documentation of results in NAIIS. By deploying mHealth in addition to active LTC, CBOs and mobile community teams could effectively scale up ART with real-time documentation of client-level outcomes.

      8. Acute gastroenteritis on cruise ships - Maritime Illness Database and Reporting System, United States, 2006-2019external icon
        Jenkins KA, Vaughan GH, Rodriguez LO, Freeland A.
        MMWR Surveill Summ. 2021 Sep 24;70(6):1-19.
        PROBLEM/CONDITION: Gastrointestinal illness is common worldwide and can be transmitted by an infected person or contaminated food, water, or environmental surfaces. Outbreaks of gastrointestinal illness commonly occur in crowded living accommodations or communities where persons are physically close. Pathogens that cause gastrointestinal illness outbreaks can spread quickly in closed and semienclosed environments, such as cruise ships. CDC's Vessel Sanitation Program (VSP) is responsible for conducting public health inspections and monitoring acute gastroenteritis (AGE) illness on cruise ships entering the United States after visiting a foreign port. PERIOD COVERED: 2006-2019. DESCRIPTION OF SYSTEM: VSP maintains the Maritime Illness Database and Reporting System (MIDRS) for monitoring cases of AGE illness among passengers and crew sailing on cruise ships carrying ≥13 passengers and within 15 days of arrival at U.S. ports from foreign ports of call. Cruise ships under VSP jurisdiction are required to submit a standardized report (24-hour report) of AGE case counts for passengers and crew 24-36 hours before arrival at the first U.S. port after traveling internationally. If the cumulative number of AGE cases increases after submission of the 24-hour report, an updated report must be submitted no less than 4 hours before the ship arrives at the U.S. port. A special report is submitted to MIDRS when vessels are within 15 days of arrival at a U.S. port and cumulative case counts reach 2% of the passenger or crew population during a voyage. VSP declares an outbreak when 3% or more of the passengers or crew on a voyage report AGE symptom to the ship's medical staff. RESULTS: During 2006-2019, a total of 37,276 voyage reports from 252 cruise ships were submitted to MIDRS. Of the 252 cruise ships, 80.6% were extra large in size (60,001-120,000 gross registered tons [GRT]), 37.0% and 32.9% had voyages lasting 3-5 days and 8-10 days, respectively, and 53.2% were traveling to a port in the Southeast region of the United States at the time the final MIDRS report was submitted. During 2006-2019, VSP received 18,040 (48.4%) 24-hour routine reports, 18,606 (49.9%) 4-hour update reports, and 612 (1.6%) special reports (2% and 3% AGE reports). Incidence rates decreased from 32.5 cases per 100,000 travel days to 16.9 for passengers and from 13.5 to 5.2 for crew. Among passengers, AGE incidence rates increased with increasing ship size and voyage length. For crew members, rates were significantly higher on extra-large ships (19.8 per 100,000 travel-days) compared with small and large ships and on voyages lasting 6-7 days. Geographically, passenger incidence rates were highest among ships underway to ports in California, Alaska, Texas, New York, Florida, and Louisiana. Among passengers, AGE incidence rates were significantly higher on ships anchoring in California (32.1 per 100,000 travel-days [95% confidence interval (CI) = 31.7-32.4]); among crew, they were significantly higher in the South region of the United States (25.9 [CI = 25.1-26.7]). INTERPRETATION: This report is the first detailed summary of surveillance data from MIDRS during 2006-2019. AGE incidence rates decreased during this time. Incidence rates among passengers were higher on mega and super-mega ships and voyages lasting >7 days. AGE incidence among crew was higher on extra-large ships and voyages lasting 6-7 days. Ship size and voyage length are associated with AGE incidence rates, and more targeted effort is needed to prevent disproportionate AGE incidence rates among passengers and crew sailing in high-risk situations. PUBLIC HEALTH ACTIONS: Maritime AGE surveillance provides important information about the epidemiology of gastrointestinal illness among cruise ship populations traveling in U.S. jurisdictions. AGE illness is highly contagious and can be transmitted quickly within vessels. State and local public health departments in the United States can use data in this report to better inform the traveling public about the risk for AGE and the importance of their role in minimizing the risk for illness while traveling onboard cruise ships. Key elements for reducing exposure to AGE illness, limiting the spread of illness, and preventing AGE outbreaks are proper hand hygiene practices and prompt isolation of symptomatic persons. Passengers can work in collaboration with cruise lines to promote onboard public health by frequently washing their hands, promptly reporting AGE illness symptoms, and isolating themselves from other persons immediately after illness onset. Access to and proper use of handwashing stations can reduce the risk for illness transmission aboard cruise ships.

      9. Estimates of cases and hospitalizations averted by COVID-19 case investigation and contact tracing in 14 health jurisdictions in the United Statesexternal icon
        Jeon S, Rainisch G, Lash RR, Moonan PK, Oeltmann JE, Greening B, Adhikari BB, Meltzer MI.
        J Public Health Manag Pract. 2021 Sep 15.
        CONTEXT: The implementation of case investigation and contact tracing (CICT) for controlling COVID-19 (caused by SARS-CoV-2 virus) has proven challenging due to varying levels of public acceptance and initially constrained resources, especially enough trained staff. Evaluating the impacts of CICT will aid efforts to improve such programs. OBJECTIVES: Estimate the number of COVID-19 cases and hospitalizations averted by CICT and identify CICT processes that could improve overall effectiveness. DESIGN: We used data on the proportion of cases interviewed, contacts notified or monitored, and days from testing to case and contact notification from 14 jurisdictions to model the impact of CICT on cumulative case counts and hospitalizations over a 60-day period. Using the Centers for Disease Control and Prevention's COVIDTracer Advanced tool, we estimated a range of impacts by assuming either contacts would quarantine only if monitored or would do so upon notification of potential exposure. We also varied the observed program metrics to assess their relative influence. RESULTS: Performance by jurisdictions varied widely. Jurisdictions isolated between 12% and 86% of cases (including contacts that became cases) within 6 to 10 days after infection. We estimated that CICT-related reductions in transmission ranged from 0.4% to 32%. For every 100 remaining cases after other nonpharmaceutical interventions were implemented, CICT averted between 4 and 97 additional cases. Reducing time to case isolation by 1 day increased averted case estimates by up to 15 percentage points. Increasing the proportion of cases interviewed or contacts notified by 20 percentage points each resulted in at most 3 or 6 percentage point improvements in averted cases. CONCLUSIONS: We estimated that CICT reduced the number of COVID-19 cases and hospitalizations among all jurisdictions studied. Reducing time to isolation produced the greatest improvements in impact of CICT.

      10. Estimating the national burden of hospitalizations for influenza-associated severe acute respiratory infection in the Lao People's Democratic Republic, 2016external icon
        Khamphaphongphane B, Chiew M, Mott JA, Khamphanoulath S, Khanthamaly V, Vilivong K, Sisouk T, Bell L, Dueger E, Sullivan S, Iuliano AD, Tsuyuoka R, Keosavanh O.
        Western Pac Surveill Response J. 2021 Apr-Jun;12(2):19-27.
        OBJECTIVE: Estimates of the burden of influenza are needed to inform prevention and control activities for seasonal influenza, including to support the development of appropriate vaccination policies. We used sentinel surveillance data on severe acute respiratory infection (SARI) to estimate the burden of influenza-associated hospitalizations in the Lao People's Democratic Republic. METHODS: Using methods developed by the World Health Organization, we combined data from hospital logbook reviews with epidemiological and virological data from influenza surveillance from 1 January to 31 December 2016 in defined catchment areas for two sentinel sites (Champasack and Luang Prabang provincial hospitals) to derive population-based estimates of influenza-associated SARI hospitalization rates. Hospitalization rates by age group were then applied to national age-specific population estimates using 2015 census data. RESULTS: We estimated the overall influenza-associated SARI hospitalization rate to be 48/100 000 population (95% confidence interval [CI]: 44-51) or 3097 admissions (95% CI: 2881-3313). SARI hospitalization rates were estimated to be as low as 40/100 000 population (95% CI: 37-43) and as high as 92/100 000 population (95% CI: 87-98) after accounting for SARI patient underascertainment in hospital logbooks. Influenza-associated SARI hospitalization rates were highest in children aged < 5 years (219; 95% CI: 198-241) and persons aged (3) 65 years (106; 95% CI: 91-121). DISCUSSION: Our findings have identified age groups at higher risk for influenza-associated SARI hospitalization, which will support policy decisions for influenza prevention and control strategies, including for vaccination. Further work is needed to estimate the burdens of outpatient influenza and influenza in specific high-risk subpopulations.

      11. Reddit on PrEP: Posts about pre-exposure prophylaxis for HIV from Reddit users, 2014-2019external icon
        Loosier PS, Renfro K, Carry M, Williams SP, Hogben M, Aral S.
        AIDS Behav. 2021 Sep 18.
        Social media forums provide a window into how gay, bisexual, and other men who have sex with men talk about pre-exposure prophylaxis for HIV prevention (PrEP) outside of research contexts. To examine information exchange about this important pillar of HIV prevention, discussions around PrEP were collected from the r/askgaybros subreddit of the social media site Reddit (2014-2019). Post titles and asks were qualitatively coded to identify themes describing the primary purpose of the post. In all, 1163 PrEP posts were identified, and a 23.3-fold increase in post volume was seen from 2014 (n = 20) to 2019 (n = 466). The most common post type was a mention of PrEP in a post primarily discussing: an assessment of risk after a sexual encounter (19.2%); a sexual or romantic relationship (6.0%); or other (29.3%). Access challenges (19.1%), information seeking (17.5%), and the cultural effects of PrEP on the gay community (16.3%) were other common themes. Posts regarding the initiation of PrEP (11.8%) and PrEP side-effects (9.4%) were moderately represented. Posts addressing promotion, shade, stigma, and usage were infrequent (≤ 5.5% of posts, respectively). Over time, discussion of PrEP has increased exponentially on r/askgaybros, which may reflect the normalization of PrEP. Qualitative analysis of these posts can be a rich source of data for scientists, practitioners, and healthcare providers interested in increasing uptake of PrEP and decreasing barriers to its use.

      12. Health care providers' views on clinic infrastructure and practice models that may facilitate HIV preexposure prophylaxis (PrEP) prescribing: A qualitative meta-synthesisexternal icon
        Mizuno Y, Gelaude DJ, Crepaz N, Kamitani E, DeLuca JB, Leighton CA, Wichser ME, Smith DK.
        Health Promot Pract. 2021 Sep 22.
        HIV (human immunodeficiency virus) preexposure prophylaxis (PrEP) is an effective biomedical HIV prevention tool. Increasing PrEP use among populations disproportionately affected by HIV is one of the key efforts in the United States' Ending the HIV Epidemic (EHE) initiative and the HIV National Strategic Plan for the United States. Given that PrEP is available only through prescription, it is important to explore structural, organizational, or environmental factors that could facilitate or impede health care provider's PrEP prescribing behavior. The purpose of this systematic review (PROSPERO [CRD: 42019138889]) is to identify qualitative studies that addressed this topic and conduct meta-synthesis using the thematic synthesis method to identify major themes on the characteristics of clinic infrastructure or clinic models that providers consider as facilitators of PrEP prescribing in the United States. Eighteen citations representing 15 studies were included in this review. Five overarching themes were identified: (1) routinized HIV risk assessment; (2) interdisciplinary/coordinated PrEP teams or services; (3) clinic capacity to provide essential PrEP-related services; (4) low out-of-pocket patient costs; and (5) access to the priority populations. Some of these themes are consistent with the recommendations of CDC's PrEP clinical guidelines and the EHE initiative. More recent studies that include perspectives of diverse providers, timely analysis of these studies, and implementation research to assess strategies to address the current practice gaps are needed to further promote PrEP prescribing among providers in the United States.

      13. Infection with the US Neisseria meningitidis urethritis clade does not lower future risk of urethral gonorrheaexternal icon
        Norris Turner A, Carter A, Tzeng YL, Stephens DS, Brown M, Snyder B, Retchless AC, Wang X, Bazan JA.
        Clin Infect Dis. 2021 Sep 20.
        BACKGROUND: Cross-protective immunity between Neisseria meninigitidis (Nm) and Neisseria gonorrhoeae (Ng) may inform gonococcal vaccine development. Meningococcal serogroup B (MenB) outer membrane vesicle (OMV) vaccines confer modest protection against gonorrhea. However, whether urethral Nm infection protects against gonorrhea is unknown. We examined gonorrhea risk among men with US Nm urethritis clade (US_NmUC) infections. METHODS: We conducted a retrospective cohort study of men with urethral US_NmUC (N=128) between January 2015 and April 2018. Using diagnosis date as the baseline visit, we examined Ng status at return visits to compute urethral Ng risk. We compared these data to three referent populations: men with urethral Ng (N=253), urethral chlamydia (Ct) (N=251), and no urethral Ng or Ct (N=255). We conducted sensitivity analyses to assess varied approaches to censoring, missing data, and anatomical site of infection. We also compared sequences of protein antigens in the OMV-based MenB-4C vaccine, US_NmUC, and Ng. RESULTS: Participants were primarily Black (65%) and heterosexual (82%). Over follow-up, 91 men acquired urethral Ng. Men with urethral US_NmUC had similar Ng risk to men with prior urethral Ng (adjusted hazard ratio (AHR): 1∙27, 95% CI: 0∙65-2∙48). Men with urethral US_NmUC had insignificantly increased Ng risk compared to men with urethral Ct (AHR: 1∙51, 95% CI: 0∙79-2∙88), and significantly increased Ng risk compared to men without urethral Ng or Ct (AHR: 3∙55, 95% CI: 1∙27-9∙91). Most of the protein antigens analyzed shared high sequence similarity. CONCLUSIONS: Urethral US_NmUC infection did not protect against gonorrhea despite substantial sequence similarities in shared protein antigens.

      14. Risk factors for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and presence of anti-SARS-CoV-2 antibodies among university student dormitory residents, September-November 2020external icon
        Segaloff HE, Cole D, Rosenblum HG, Lee CC, Morgan CN, Remington P, Pitts C, Kelly P, Baggott J, Bateman A, Somers T, Ruff J, Payne D, Desamu-Thorpe R, Foster MA, Currie DW, Abedi GR, Westergaard R, Hsu CH, Tate JE, Kirking HL.
        Open Forum Infect Dis. 2021 Sep;8(9):ofab405.
        BACKGROUND: Multiple severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks occurred at universities during Fall 2020, but little is known about risk factors for campus-associated infections or immunity provided by anti-SARS-CoV-2 antibodies in young adults. METHODS: We conducted surveys and serology tests among students living in dormitories in September and November to examine infection risk factors and antibody presence. Using campus weekly reverse-transcription polymerase chain reaction (RT-PCR) test results, the relationship between survey responses, SARS-CoV-2 antibodies, and infections was assessed. RESULTS: Of 6136 students, 1197 completed the survey and 572 also completed serologic testing in September compared with 517 and 414 in November, respectively. Participation in fraternity or sorority events (adjusted risk ratio [aRR], 1.9 [95% confidence interval {CI}, 1.4-2.5]) and frequent alcohol consumption (aRR, 1.6 [95% CI, 1.2-2.2]) were associated with SARS-CoV-2 infection. Mask wearing during social events (aRR, 0.6 [95% CI, .6-1.0]) was associated with decreased risk. None of the 20 students with antibodies in September tested positive for SARS-CoV-2 during the semester, while 27.8% of students who tested RT-PCR positive tested negative for antibodies in November. CONCLUSIONS: Frequent drinking and attending social events were associated with SARS-CoV-2 infection. Antibody presence in September appeared to be protective from reinfection, but this finding was not statistically significant.

      15. Surveillance for peri-elimination trachoma recrudescence: Exploratory studies in Ghanaexternal icon
        Senyonjo L, Addy J, Martin DL, Agyemang D, Yeboah-Manu D, Gwyn S, Marfo B, Asante-Poku A, Aboe A, Solomon AW, Bailey RL.
        PLoS Negl Trop Dis. 2021 Sep 20;15(9):e0009744.
        INTRODUCTION: To date, eleven countries have been validated as having eliminated trachoma as a public health problem, including Ghana in 2018. Surveillance for recrudescence is needed both pre- and post-validation but evidence-based guidance on appropriate strategies is lacking. We explored two potential surveillance strategies in Ghana. METHODOLOGY/PRINCIPAL FINDINGS: Amongst randomly-selected communities enrolled in pre-validation on-going surveillance between 2011 and 2015, eight were identified as having had trachomatous-inflammation follicular (TF) prevalence ≥5% in children aged 1-9 years between 2012 and 2014. These eight were re-visited in 2015 and 2016 and neighbouring communities were also added ("TF trigger" investigations). Resident children aged 1-9 years were then examined for trachoma and had a conjunctival swab to test for Chlamydia trachomatis (Ct) and a dried blood spot (DBS) taken to test for anti-Pgp3 antibodies. These investigations identified at least one community with evidence of probable recent Ct ocular transmission. However, the approach likely lacks sufficient spatio-temporal power to be reliable. A post-validation surveillance strategy was also evaluated, this reviewed the ocular Ct infection and anti-Pgp3 seroprevalence data from the TF trigger investigations and from the pre-validation surveillance surveys in 2015 and 2016. Three communities identified as having ocular Ct infection >0% and anti-Pgp3 seroprevalence ≥15.0% were identified, and along with three linked communities, were followed-up as part of the surveillance strategy. An additional three communities with a seroprevalence ≥25.0% but no Ct infection were also followed up ("antibody and infection trigger" investigations). DBS were taken from all residents aged ≥1 year and ocular swabs from all children aged 1-9 years. There was evidence of transmission in the group of communities visited in one district (Zabzugu-Tatale). There was no or little evidence of continued transmission in other districts, suggesting previous infection identified was transient or potentially not true ocular Ct infection. CONCLUSIONS/SIGNIFICANCE: There is evidence of heterogeneity in Ct transmission dynamics in northern Ghana, even 10 years after wide-scale MDA has stopped. There is added value in monitoring Ct infection and anti-Ct antibodies, using these indicators to interrogate past or present surveillance strategies. This can result in a deeper understanding of transmission dynamics and inform new post-validation surveillance strategies. Opportunities should be explored for integrating PCR and serological-based markers into surveys conducted in trachoma elimination settings.

      16. Estimating male circumcision coverage in 15 priority countries in sub-Saharan Africaexternal icon
        Stegman PM, Yee R, Davis J, Tchuenche M, Linder R, Zembe L, Frescura L, Kripke KE.
        J Int AIDS Soc. 2021 Sep;24 Suppl 5:e25789.
        INTRODUCTION: Given the importance of voluntary medical male circumcision (VMMC) in reducing HIV incidence, access to and use of quality data for programme planning and management are essential. Unfortunately, such data are currently not standardized for reliable and consistent programme use in priority countries. To redress this, the UNAIDS Reference Group (RG) on Estimates, Modelling, and Projection worked with partner Avenir Health to use the Decision Makers Program Planning Toolkit (DMPPT) 2 Online to provide estimates of VMMC coverage and to support countries to set age- and geographic-specific targets. This article describes the methods and tools used for assembling, reviewing and validating VMMC programme data as part of the 2021 Estimates process. DISCUSSION: The approach outlined for integrating VMMC data using the DMPPT2 Online required significant country engagement as well as upgrades to the DMPPT2 Online. The process brought together local-level VMMC stakeholders, for example Ministries of Health, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the US President's Emergency Plan for AIDS Relief, the World Health Organization (WHO), VMMC implementers and so on, to review, amend and agree on historical and more recent VMMC data. The DMPPT2 Online was upgraded to align with the Spectrum and Naomi models used in the Annual HIV Estimates process. In addition, new and revised inputs were incorporated to enhance accuracy of modelled outputs. The process was successful in mobilizing stakeholders behind efforts to integrate VMMC into the annual HIV Estimates process and generating comprehensive, country-owned and validated VMMC data that will enhance programme monitoring and planning. CONCLUSIONS: VMMC programme data from most of the priority countries were successfully reviewed, updated, validated and incorporated into the annual HIV Estimates process in 2020. It is important to ensure that these data continue to be used for programme planning and management. Current and future data issues will need to be addressed, and countries will need ongoing support to do so. The integration of the DMPPT2 Online into the annual HIV Estimates process is a positive step forward in terms of streamlining country-owned planning and analytical practices for the HIV response.

      17. Seroprevalence and risk factors for SARS-CoV-2 Infection in selected urban areas in Ethiopia: a cross-sectional evaluation during July 2020external icon
        Tadesse EB, Endris AA, Solomon H, Alayu M, Kebede A, Eshetu K, Teka G, Seid BE, Ahmed J, Abayneh SA, Moges B, Gerawork H, Sugerman D, Assefa Z, Abayneh A, Abate E, Taddese L.
        Int J Infect Dis. 2021 Aug 16;111:179-185.
        BACKGROUND: Ethiopia reported the first case of COVID-19 on 13(th) March, 2020 with community transmission ensuing by mid-May. A national, population-based serosurvey against anti-SARS-CoV-2 IgG was conducted to measure the prevalence of prior COVID-19 infections and better approximate the burden across major towns in Ethiopia. METHODS: We conducted a cross-sectional, population-based serosurvey from June 24 to July 8, 2020 in 14 major urban areas. Two-stage cluster sampling was used to randomly select enumeration areas and households. All persons aged ≥15 years were enrolled. Serum samples were tested by Abbott™ ARCHITECT™ assay for SARS-CoV-2 IgG antibodies. National COVID-19 surveillance data on the median date of the serosurvey is analyzed for comparison. FINDINGS: Adjusted seroprevalence was 3.5% (95% CI: 3.2%-3.8%) after controlling for age, sex and test kit performance. Males (3.7%) and females (3.3%) were nearly equally infected, while middle-aged adults '40-65 years' had the highest (4.0%) prevalence. Gambella (7.5%), Dire Dawa (6.2%) and Jigjiga (6.1%) were the most affected towns. About 6.7% and 8.0% of seropositives had symptoms and chronic underlying illness, respectively. A surveillance system had identified 4,416 RT-PCR confirmed cases in Addis Ababa. INTERPRETATION: This serosurvey shows that a majority of urban Ethiopians remain uninfected with SARS-CoV-2. Most anti-SARS-CoV-2 IgG positive cases were asymptomatic with no underlying illness, keeping case detection to a minimum.

      18. Human respiratory syncytial virus diversity and epidemiology among patients hospitalized with severe respiratory illness in South Africa, 2012-2015external icon
        Valley-Omar Z, Tempia S, Hellferscee O, Walaza S, Variava E, Dawood H, Kahn K, McMorrow M, Pretorius M, Mtshali S, Mamorobela E, Wolter N, Venter M, von Gottberg A, Cohen C, Treurnicht FK.
        Influenza Other Respir Viruses. 2021 Sep 16.
        BACKGROUND: We aimed to describe the prevalence of human respiratory syncytial virus (HRSV) and evaluate associations between HRSV subgroups and/or genotypes and epidemiologic characteristics and clinical outcomes in patients hospitalized with severe respiratory illness (SRI). METHODS: Between January 2012 and December 2015, we enrolled patients of all ages admitted to two South African hospitals with SRI in prospective hospital-based syndromic surveillance. We collected respiratory specimens and clinical and epidemiological data. Unconditional random effect multivariable logistic regression was used to assess factors associated with HRSV infection. RESULTS: HRSV was detected in 11.2% (772/6908) of enrolled patients of which 47.0% (363/772) were under the age of 6 months. There were no differences in clinical outcomes of HRSV subgroup A-infected patients compared with HRSV subgroup B-infected patients but among patients aged <5 years, children with HRSV subgroup A were more likely be coinfected with Streptococcus pneumoniae (23/208, 11.0% vs. 2/90, 2.0%; adjusted odds ratio 5.7). No significant associations of HRSV A genotypes NA1 and ON1 with specific clinical outcomes were observed. CONCLUSIONS: While HRSV subgroup and genotype dominance shifted between seasons, we showed similar genotype diversity as noted worldwide. We found no association between clinical outcomes and HRSV subgroups or genotypes.

    • Disease Reservoirs and Vectors
      1. Multi-year mass-trapping with autocidal gravid ovitraps has limited influence on insecticide susceptibility in Aedes aegypti (Diptera: Culicidae) from Puerto Ricoexternal icon
        Hemme RR, Smith EA, Felix G, White BJ, Diaz-Garcia MI, Rodriguez D, Ruiz-Valcarcel J, Acevedo V, Amador M, Barrera R.
        J Med Entomol. 2021 Sep 17.
        Mass-trapping has been used to control outbreaks of Aedes aegypti (Linnaeus) (Diptera: Culicidae) in Puerto Rico since 2011. We investigated the effect of multi-year, insecticide-free mass trapping had on the insecticide susceptibility profile of Ae. aegypti. Eggs collected in southern Puerto Rico were used to generate F1 populations that were tested for susceptibility to permethrin, sumethrin, bifenthrin, deltamethrin, and malathion according to CDC bottle bioassays protocols. All populations of Ae. aegypti were resistant to the synthetic pyrethroids and mosquitoes from two locations were partially resistant to malathion. Population genetic analysis, using a double digest restriction sites associated DNA sequencing (ddRADseq) approach, indicated a large amount of migration between study sites effectively homogenizing the mosquito populations. Mass-trapping using noninsecticidal autocidal gravid ovitraps did not restore susceptibility to five active ingredients that are found in commercial insecticides. Migration between communities was high and would have brought outside alleles, including resistant alleles to the treatment communities. Further investigation suggests that household use of commercially available insecticide products may continue to select for resistance in absence of public health space spraying of insecticides.

      2. Host selection pattern and flavivirus screening of mosquitoes in a disturbed Colombian rainforestexternal icon
        Hoyos J, Carrasquilla MC, León C, Montgomery JM, Salyer SJ, Komar N, González C.
        Sci Rep. 2021 Sep 20;11(1):18656.
        Studies on the feeding behavior of hematophagous insects, particularly those of medical importance, are relevant for tracking possible pathogen transmission routes and identifying biases in the choice of vertebrates. We evaluated host selection of blood-feeding mosquitoes in a disturbed forest in the Magdalena Medio valley in Colombia from March 2017 to April 2018, after the introduction of Zika virus to the Americas from the 2015-2016 outbreak. We estimated vertebrate diversity and collected blood-engorged female mosquitoes. Genomic DNA/RNA was extracted from the mosquito's abdomen for vertebrate host identification and pathogen detection. We performed conventional PCR and sequencing, using universal primers targeting vertebrate regions of the eukaryotic mitochondrial genome to determine bloodmeal host. Additionally, we tested for the presence of flaviviruses in all mosquito samples with RT-PCR. Based on the identity and quantity of detected bloodmeals, we performed mosquito-vertebrate interaction network analysis and estimated topology metrics. In total, we collected 292 engorged female mosquitoes representing 20 different species. Bloodmeal analyses identified 26 vertebrate species, the majority of which were mammals (N = 16; 61.5%). No flaviviruses of medical importance were detected from the samples. Although feeding patterns varied, network analyses showed a high degree of specialization by mosquitoes and revealed ecological and phylogenetic relationships among the host community. We conclude that host selection or preference by mosquitoes is species specific.

      3. Temperature plays a significant role in the vector competence, extrinsic incubation period, and intensity of infection of arboviruses within mosquito vectors. Most laboratory infection studies use static incubation temperatures that may not accurately reflect daily temperature ranges (DTR) to which mosquitoes are exposed. This could potentially compromise the application of results to real world scenarios. We evaluated the effect of fluctuating DTR versus static temperature treatments on the infection, dissemination, and transmission rates and viral titers of Culex tarsalis and Culex quinquefasciatus mosquitoes for West Nile virus. Two DTR regimens were tested including an 11 and 15◦C range, both fluctuating around an average temperature of 28◦C. Overall, no significant differences were found between DTR and static treatments for infection, dissemination, or transmission rates for either species. However, significant treatment differences were identified for both Cx. tarsalis and Cx. quinquefasciatus viral titers. These effects were species-specific and most prominent later in the infection. These results indicate that future studies on WNV infections in Culex mosquitoes should consider employing realistic DTRs to reflect interactions most accurately between the virus, vector, and environment. © 2021 by the authors. Licensee MDPI, Basel, Switzerland.

    • Epidemiology and Surveillance
      1. National and subnational size estimation of female sex workers in Ghana 2020: Comparing 3-source capture-recapture with other approachesexternal icon
        Guure C, Dery S, Afagbedzi S, Tun W, Weir SS, Quaye S, Ankomah A, Torpey K.
        PLoS One. 2021 ;16(9):e0256949.
        BACKGROUND: Key Population size estimation (PSE) is instrumental for HIV/STI preventive, treatment and care services planning, implementation and delivery. The objective was to estimate the overall population of female sex workers (FSW) in all the 16 regions of Ghana using different PSE methods. METHOD: Mapping of venues and complete enumeration of seaters was conducted at the formative stage prior to the bio-behavioral survey (BBS). Three PSE methods were used to derive the size estimates of FSW in the 16 regions. These include: Capture-recapture (CRC), service multiplier and three-source capture recapture (3SCRC) methods. The final choice of the estimation method used to estimate the roamer population was 3SCRC. This method was chosen because of its perfect record-linkage-hierarchic combination of three names that minimizes overmatching as well as the addition of an interaction term in the model which corrects for the dependencies in CRC. RESULTS: The total population size estimate of the female sex workers in the country obtained for roamers using capture re-capture was 41,746 (95% CI: 41,488-41,932). Using the service multiplier, the total population for both the roamers and seaters was 41,153 (95% CI: 37,242-45,984). The 3-source capture re-capture yielded 55,686 roamers FSW (95% CI: 47,686-63,686). The seater population was 4,363 FSW based on census/complete enumeration. The total population size estimate of FSW (seaters and roamers) in Ghana was 60,049 when 3SCRC and census were added. This represents about 0.76% of all estimated adult females aged 15-49yrs in Ghana. CONCLUSION: We report population size estimates (PSE) for FSW in Ghana. These estimates are the results of 3SCRC. These findings provide a valid and reliable source of information that should be referenced by government officials and policymakers to plan, implement and provide HIV/STI preventive, treatment, and care services for FSW in Ghana.

    • Food Safety
      1. Decreased incidence of infections caused by pathogens transmitted commonly through food during the COVID-19 pandemic - Foodborne Diseases Active Surveillance Network, 10 U.S. Sites, 2017-2020external icon
        Ray LC, Collins JP, Griffin PM, Shah HJ, Boyle MM, Cieslak PR, Dunn J, Lathrop S, McGuire S, Rissman T, Scallan Walter EJ, Smith K, Tobin-D'Angelo M, Wymore K, Kufel JZ, Wolpert BJ, Tauxe R, Payne DC.
        MMWR Morb Mortal Wkly Rep. 2021 Sep 24;70(38):1332-1336.
        Foodborne illnesses are a substantial and largely preventable public health problem; before 2020 the incidence of most infections transmitted commonly through food had not declined for many years. To evaluate progress toward prevention of foodborne illnesses in the United States, the Foodborne Diseases Active Surveillance Network (FoodNet) of CDC's Emerging Infections Program monitors the incidence of laboratory-diagnosed infections caused by eight pathogens transmitted commonly through food reported by 10 U.S. sites.* FoodNet is a collaboration among CDC, 10 state health departments, the U.S. Department of Agriculture's Food Safety and Inspection Service (USDA-FSIS), and the Food and Drug Administration. This report summarizes preliminary 2020 data and describes changes in incidence with those during 2017-2019. During 2020, observed incidences of infections caused by enteric pathogens decreased 26% compared with 2017-2019; infections associated with international travel decreased markedly. The extent to which these reductions reflect actual decreases in illness or decreases in case detection is unknown. On March 13, 2020, the United States declared a national emergency in response to the COVID-19 pandemic. After the declaration, state and local officials implemented stay-at-home orders, restaurant closures, school and child care center closures, and other public health interventions to slow the spread of SARS-CoV-2, the virus that causes COVID-19 (1). Federal travel restrictions were declared (1). These widespread interventions as well as other changes to daily life and hygiene behaviors, including increased handwashing, have likely changed exposures to foodborne pathogens. Other factors, such as changes in health care delivery, health care-seeking behaviors, and laboratory testing practices, might have decreased the detection of enteric infections. As the pandemic continues, surveillance of illness combined with data from other sources might help to elucidate the factors that led to the large changes in 2020; this understanding could lead to improved strategies to prevent illness. To reduce the incidence of these infections concerted efforts are needed, from farm to processing plant to restaurants and homes. Consumers can reduce their risk of foodborne illness by following safe food-handling and preparation recommendations.

    • Global Health
      1. A logic model framework for planning an international refugee health research, evaluation, and ethics committeeexternal icon
        Payton C, Kumar GS, Kimball S, Clarke SK, AlMasri I, Karaki FM.
        Health Promot Pract. 2021 Sep 19.
        Collaborative approaches to supporting the health of refugees and other newcomer populations in their resettlement country are needed to address the complex medical and social challenges they may experience after arrival. Refugee health professionals within the Society of Refugee Healthcare Providers (SRHP)-the largest medical society dedicated to refugee health in North America-have expressed interest in greater research collaborations across SRHP membership and a need for guidance in conducting ethical research on refugee health. This article describes a logic model framework for planning the SRHP Research, Evaluation, and Ethics Committee. A logic model was developed to outline the priorities, inputs, outputs, outcomes, assumptions, external factors, and evaluation plan for the committee. The short-term outcomes include (1) establish professional standards in refugee health research, (2) support evaluation of existing refugee health structures and programs, and (3) establish and disseminate an ethical framework for refugee health research. The SRHP Research, Evaluation, and Ethics Committee found the logic model to be an effective planning tool. The model presented here could support the planning of other research committees aimed at helping to achieve health equity for resettled refugee populations.

    • Health Behavior and Risk
      1. Minority stress, coping, and transgender youth in schools-results from the Resilience and Transgender Youth Studyexternal icon
        Johns MM, Zamantakis A, Andrzejewski J, Boyce L, Rasberry CN, Jayne PE.
        J Sch Health. 2021 Sep 17.
        BACKGROUND: Transgender youth report high rates of negative experiences in schools. Using a lens of minority stress, this study sought to examine in-school experiences of transgender youth to understand youth coping and to identify key opportunities for improving school environments for transgender youth. METHODS: Participants included 41 youth across 33 in-depth interviews (M(age)  = 21.7) and two focus groups (N = 8; M(age)  = 17.3). Thematic analysis was used to analyze data. Themes related to stress, coping, and facilitators/barriers to stress/coping were derived and coded. RESULTS: Distal stressors, such as structural discrimination and prejudice events, were found to contribute to the exclusion of transgender youth from school life, while proximal stressors, such as concealment and expectations of rejection, reinforced transgender youth's feelings of personal isolation. Participants expressed coping with both challenges by advocating for inclusion through direct action with teachers and administrators and seeking/finding connection with trusted staff and peers. CONCLUSIONS: Findings suggest that creating safe and supportive environments at school for transgender youth is an attainable goal, as all identified barriers to inclusivity and connection were modifiable. By considering the needs of transgender youth in policies and programming, schools may improve climate for and wellbeing of transgender students.

      2. PURPOSE: The purpose of the study is to assess associations between exposure to a multilevel, socio-ecological health program administered by local education agencies and changes in health behaviors among high school students. METHODS: This analysis used a multilevel difference-in-differences approach to compare student health experiences and outcomes between schools selected by local education agencies nationwide to implement the program (exposed schools) and schools that were not (unexposed schools). We measured repeated cross-sectional outcomes using the 2015 and 2017 Youth Risk Behaviors Surveys. The final analytic sample comprised 638 schools in total (N = 64,838 students), with 237 exposed schools (n = 30,336 students) and 401 unexposed schools (n = 34,502 students). RESULTS: Students in exposed schools demonstrated significant reduction in odds compared with those in unexposed schools in ever having sex (adjusted odds ratio [aOR] = .88, 95% confidence interval [CI]: .81-.96), having four or more lifetime sexual partners (aOR = .84, 95% CI: .72-.97), being currently sexually active (aOR = .78, 95% CI: .78-.96), and using effective hormonal birth control (aOR = .7, 95% CI: .56-.88). Exposure to the program was associated with significant reduction in odds of not going to school because of safety concerns (aOR = .87, 95% CI: .78-.97), having experienced forced sex (aOR = .76, 95% CI: .68-.86), ever used marijuana (aOR = .89, 95% CI: .81-.98), and currently using marijuana (aOR = .77, 95% CI: .64-.93). CONCLUSIONS: Exposure to the program was associated with significant decreases in sexual risk behaviors, experience of violence, and substance use.

      3. Infants, children, and adolescents who do not get sufficient sleep are at increased risk for injuries, obesity, type 2 diabetes, poor mental health, attention and behavior problems, and poor cognitive development (1). The American Academy of Sleep Medicine (AASM) provides age-specific sleep duration recommendations to promote optimal health (1). CDC analyzed data from the 2016-2018 National Survey of Children's Health (NSCH) to assess the prevalence of short sleep duration among persons in the United States aged 4 months-17 years. Overall, on the basis of parent report, 34.9% of persons aged 4 months-17 years slept less than recommended for their age. The prevalence of short sleep duration was higher in southeastern states and among racial and ethnic minority groups, persons with low socioeconomic status, and those with special health care needs. The prevalence of short sleep duration ranged from 31.2% among adolescents aged 13-17 years to 40.3% among infants aged 4-11 months. Persons aged 4 months-17 years with a regular bedtime were more likely to get enough sleep. Public health practitioners, educators, and clinicians might advise parents on the importance of meeting recommended sleep duration and implementing a consistent bedtime for healthy development.

    • Health Disparities
      1. Racial and ethnic disparities in HIV diagnoses among heterosexually active persons in the United States nationally and by state, 2018external icon
        Martin EG, Ansari B, Hart-Malloy R, Smith DK, Delaney KP, Gift TL, Berruti AA, Trigg M, Rosenberg ES.
        PLoS One. 2021 ;16(9):e0257583.
        BACKGROUND: Despite declining HIV infection rates, persistent racial and ethnic disparities remain. Appropriate calculations of diagnosis rates by HIV transmission category, race and ethnicity, and geography are needed to monitor progress towards reducing systematic disparities in health outcomes. We estimated the number of heterosexually active adults (HAAs) by sex and state to calculate appropriate HIV diagnosis rates and disparity measures within subnational regions. METHODS: The analysis included all HIV diagnoses attributed to heterosexual transmission in 2018 in the United States, in 50 states and the District of Columbia. Logistic regression models estimated the probability of past-year heterosexual activity among adults in three national health surveys, by sex, age group, race and ethnicity, education category, and marital status. Model-based probabilities were applied to estimated counts of HAAs by state, which were synthesized through meta-analysis. HIV diagnoses were overlaid to calculate racial- and ethnic-specific rates, rate differences (RDs), and rate ratios (RRs) among HAAs by sex and state. RESULTS: Nationally, HAA women have a two-fold higher HIV diagnosis rate than HAA men (rate per 100,000 HAAs, women: 6.57; men: 3.09). Compared to White non-Hispanic HAAs, Black HAAs have a 20-fold higher HIV diagnosis rate (RR, men: 21.28, women: 19.55; RD, men: 15.40, women: 31.78) and Hispanic HAAs have a 4-fold higher HIV diagnosis rate (RR, men: 4.68, RD, women: 4.15; RD, men: 2.79, RD, women: 5.39). Disparities were ubiquitous across regions, with >75% of states in each region having Black-to-White RR ≥10. CONCLUSION: The racial and ethnic disparities across regions suggests a system-wide failure particularly with respect to preventing HIV among Black and Hispanic women. Pervasive disparities emphasize the role for coordinated federal responses such as the current Ending the HIV Epidemic (EHE) initiative.

    • Health Economics
      1. The prevalence of diagnosis of major eye diseases and their associated payments in the Medicare fee-for-service programexternal icon
        Wittenborn JS, Gu Q, Erdem E, Ahmed F, Zhang P, Saaddine J, Lundeen EA, Rein DB.
        Ophthalmic Epidemiol. 2021 Sep 16:1-13.
        PURPOSE: To estimate the prevalence of diagnosis of major eye disorders and their associated payments, in total and per-person diagnosed, among Medicare fee-for-service (FFS) beneficiaries in 2018. METHODS: We analyzed 100% Medicare Part B FFS claims and Part D Events among beneficiaries continuously enrolled for 12 months in 2018 to calculate the proportion of beneficiaries with ≥1 claim indicating age-related macular degeneration (AMD), cataract, diabetic retinopathy (DR), or glaucoma, and their associated payments, including Medicare and patient out-of-pocket. Eye disease and eye care services were identified using case definitions from the Centers for Disease Control and Prevention's (CDC) Vision & Eye Health Surveillance System (VEHSS). Outcomes are reported by disease overall and by age group (0-39, 40-64, 65-84, 85+ years), sex, race/ethnicity, and U.S. state. RESULTS: Among nearly 30 million Medicare Part B FFS beneficiaries in 2018, over 41% (12.4 million) had a claim containing a diagnosis of at least one of the four eye disorders; 33.7% with cataract, 13.3% with glaucoma, 9.2% with AMD and 3.2% with DR. Payments for eye care services and drugs associated with these four conditions were $10.1billion; $3.6 billion for cataract, $3.5 billion for AMD, $2.2 billion for glaucoma and $0.8 billion for DR. The average cost per beneficiary diagnosed was $816: $1,290 for AMD, $781 for DR, $543 for glaucoma, and $360 for cataract. CONCLUSIONS: Major eye disorders are common among Medicare FFS beneficiaries and account for approximately 4.3% of Medicare Part B and 1% of Medicare Part D spending.

    • Healthcare Associated Infections
      1. Impact of implementation of the core elements of outpatient antibiotic stewardship within Veterans Health Administration emergency departments and primary care clinics on antibiotic prescribing and patient outcomesexternal icon
        Madaras-Kelly K, Hostler C, Townsend M, Potter EM, Spivak ES, Hall SK, Goetz MB, Nevers M, Ying J, Haaland B, Rovelsky SA, Pontefract B, Fleming-Dutra K, Hicks LA, Samore MH.
        Clin Infect Dis. 2021 Sep 7;73(5):e1126-e1134.
        BACKGROUND: The Core Elements of Outpatient Antibiotic Stewardship provide a framework to improve antibiotic use. We report the impact of core elements implementation within Veterans Health Administration sites. METHODS: In this quasiexperimental controlled study, effects of an intervention targeting antibiotic prescription for uncomplicated acute respiratory tract infections (ARIs) were assessed. Outcomes included per-visit antibiotic prescribing, treatment appropriateness, ARI revisits, hospitalization, and ARI diagnostic changes over a 3-year pre-implementation period and 1-year post-implementation period. Logistic regression adjusted for covariates (odds ratio [OR], 95% confidence interval [CI]) and a difference-in-differences analysis compared outcomes between intervention and control sites. RESULTS: From 2014-2019, there were 16 712 and 51 275 patient visits within 10 intervention and 40 control sites, respectively. Antibiotic prescribing rates pre- and post-implementation within intervention sites were 59.7% and 41.5%, compared to 73.5% and 67.2% within control sites, respectively (difference-in-differences, P < .001). Intervention site pre- and post-implementation OR to receive appropriate therapy increased (OR, 1.67; 95% CI, 1.31-2.14), which remained unchanged within control sites (OR,1.04; 95% CI, .91-1.19). ARI-related return visits post-implementation (-1.3% vs -2.0%; difference-in-differences P = .76) were not different, but all-cause hospitalization was lower within intervention sites (-0.5% vs -0.2%; difference-in-differences P = .02). The OR to diagnose non-specific ARI compared with non-ARI diagnoses increased post-implementation forintervention (OR, 1.27; 95% CI, 1.21 -1.34) but not control (OR, 0.97; 95% CI, .94-1.01) sites. CONCLUSIONS: Implementation of the core elements was associated with reduced antibiotic prescribing for RIs and a reduction in hospitalizations. Diagnostic coding changes were observed.

    • Immunity and Immunization

      1. Rural adolescent immunization: Delivery practices and barriers to uptakeexternal icon
        Cataldi JR, Brewer SE, Perreira C, Furniss A, Nederveld A, Suresh K, Williams C, O'Leary ST, Dempsey AF.
        J Am Board Fam Med. 2021 Sep-Oct;34(5):937-949.
        BACKGROUND: Rural adolescent vaccination rates lag behind urban. We sought to assess rural-urban differences in barriers to adolescent vaccination, perceived parental vaccine attitudes, and immunization delivery practices among public health nursing (PHN), pediatric (Peds), and family medicine (FM) clinicians. METHODS: Internet and mail survey of Colorado PHN, Peds, and FM clinicians from June-August 2019. Study population was recruited from local health plans and the American Medical Association Physician Masterfile. Rural and urban responses were compared using Cochran Armitage trend, Fisher's exact, and chi-square tests. RESULTS: Response rate was 38% (163/433; 91 rural, 72 urban). Rural respondents were less likely than urban to agree most patients have insurance that covers vaccination (86% vs 97%; P = .02). Rural respondents were less likely than urban to indicate most parents in their practice would agree with statements about vaccine benefits (P = .02) and trust in medical providers (P = .05). Rural respondents were more likely than urban to report adolescents were somewhat/very likely to receive vaccines at public health departments (65% vs 28%; P < .0001) and less likely to report adolescents were somewhat/very likely to receive vaccines at pharmacies (26% vs 45%; P = .02). Fewer providers strongly recommended HPV vaccine (81% for females, 80% for males 11 to 12 years) than other adolescent immunizations (Tdap: 97%, MenACWY at 11 to 12 years: 87%; influenza at 11 to 17 years: 87%; each P < .005, rural-urban responses did not differ). CONCLUSIONS: Rural barriers to adolescent vaccination include logistic issues and parental vaccine attitudes. Efforts to improve rural adolescent vaccination should include public health departments and address vaccine confidence and access barriers.

      2. Estimation of oral poliovirus vaccine effectiveness in Afghanistan, 2010-2020external icon
        Chard AN, Martinez M, Matanock A, Kassem AM.
        Vaccine. 2021 Sep 16.
        BACKGROUND: Afghanistan is one of two countries with endemic wild poliovirus type 1 (WPV1). The oral poliovirus vaccine (OPV) is the predominant vaccine used for polio eradication. Although OPV has been administered in routine childhood immunization and during frequent supplementary immunization activities, WPV1 continues to circulate in Afghanistan and case incidence has been increasing since 2017. We estimated the effectiveness of OPV in Afghanistan during 2010-2020. METHODS: We conducted a matched case-control analysis using acute flaccid paralysis (AFP) surveillance data from 29,370 children < 15 years with AFP onset between January 1, 2010 and December 31, 2020. We matched children with confirmed WPV1 (cases) with children with non-polio AFP (controls) by age at onset of paralysis (+/- 3 months), date of onset of paralysis (+/- 3 months), and province of residence, and compared their reported OPV vaccination history to estimate the effectiveness of OPV in preventing paralysis by WPV1 using conditional logistic regression. To account for changes in OPV formulations provided over the analysis period, we stratified the analysis based on dates of the global switch from trivalent OPV (tOPV) to bivalent OPV (bOPV) in April 2016. RESULTS: Between January 1, 2010 and December 31, 2020, there were 329 WPV1 cases in Afghanistan. The per-dose estimated effectiveness of OPV against WPV1 was 19% (95% CI: 15%-22%) and of ≥ 7 doses was 94% (95% CI: 90%-97%). Before the global switch from tOPV to bOPV, the per-dose estimated effectiveness of OPV was 14% (95% CI: 11%-18%) and of ≥ 7 doses was 92% (95% CI: 85%-96%). After the switch, the per-dose estimated effectiveness of OPV against WPV1 was 32% (24%-39%) and of ≥ 7 doses was 96% (95% CI: 90%-99%). DISCUSSION: OPV is highly effective in preventing paralysis by WPV1; these results indicate that continued WPV1 transmission in Afghanistan is due to failure to vaccinate, not failure of the vaccine. Although difficult to implement in parts of country, improving the administration of OPV in routine immunization and supplementary immunization activities will be critical for achieving polio eradication in Afghanistan.

      3. Use of Pfizer-BioNTech COVID-19 vaccine in persons aged ≥16 years: Recommendations of the Advisory Committee on Immunization Practices - United States, September 2021external icon
        Dooling K, Gargano JW, Moulia D, Wallace M, Rosenblum HG, Blain AE, Hadler SC, Plumb ID, Moline H, Gerstein J, Collins JP, Godfrey M, Campos-Outcalt D, Morgan RL, Brooks O, Talbot HK, Lee GM, Daley MF, Oliver SE.
        MMWR Morb Mortal Wkly Rep. 2021 Sep 24;70(38):1344-1348.
        The Pfizer-BioNTech COVID-19 vaccine (BNT162b2) is a lipid nanoparticle-formulated, nucleoside mRNA vaccine encoding the prefusion spike glycoprotein of SARS-CoV-2, the virus that causes COVID-19. Vaccination with the Pfizer-BioNTech COVID-19 vaccine consists of 2 intramuscular doses (30 μg, 0.3 mL each) administered 3 weeks apart. In December 2020, the vaccine was granted Emergency Use Authorization (EUA) by the Food and Drug Administration (FDA) as well as an interim recommendation for use among persons aged ≥16 years by the Advisory Committee on Immunization Practices (ACIP) (1). In May 2021, the EUA and interim ACIP recommendations for Pfizer-BioNTech COVID-19 vaccine were extended to adolescents aged 12-15 years (2). During December 14, 2020-September 1, 2021, approximately 211 million doses of Pfizer-BioNTech COVID-19 vaccine were administered in the United States.* On August 23, 2021, FDA approved a Biologics License Application for use of the Pfizer-BioNTech COVID-19 vaccine, Comirnaty (Pfizer, Inc.), in persons aged ≥16 years (3). The ACIP COVID-19 Vaccines Work Group's conclusions regarding the evidence for the Pfizer-BioNTech COVID-19 vaccine were presented to ACIP at a public meeting on August 30, 2021. To guide its deliberations regarding the Pfizer-BioNTech COVID-19 vaccine, ACIP used the Evidence to Recommendation (EtR) Framework,(†) and incorporated a Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.(§) In addition to initial clinical trial data, ACIP considered new information gathered in the 8 months since issuance of the interim recommendation for Pfizer-BioNTech COVID-19 vaccine, including additional follow-up time in the clinical trial, real-world vaccine effectiveness studies, and postauthorization vaccine safety monitoring. The additional information increased certainty that benefits from prevention of asymptomatic infection, COVID-19, and associated hospitalization and death outweighs vaccine-associated risks. On August 30, 2021, ACIP issued a recommendation(¶) for use of the Pfizer-BioNTech COVID-19 vaccine in persons aged ≥16 years for the prevention of COVID-19.

      4. Influence of pre-season antibodies against influenza virus on risk of influenza infection among health care personnelexternal icon
        Gorse GJ, Rattigan SM, Kirpich A, Simberkoff MS, Bessesen MT, Gibert C, Nyquist AC, Price CS, Gaydos CA, Radonovich LJ, Perl TM, Rodriguez-Barradas MC, Cummings DA.
        J Infect Dis. 2021 Sep 17.
        BACKGROUND: The association of hemagglutination inhibition (HAI) antibodies with protection from influenza among healthcare personnel (HCP) with occupational exposure to influenza viruses has not been well-described. METHODS: The Respiratory Protection Effectiveness Clinical Trial was a cluster-randomized, multi-site study that compared medical masks to N95 respirators in preventing viral respiratory infections among HCP in outpatient healthcare settings for 5,180 participant-seasons. Serum HAI antibody titers before each influenza season and influenza virus infection confirmed by polymerase chain reaction were studied over four study years. RESULTS: In univariate models, the risk of influenza A(H3N2) and B virus infections was associated with HAI titers to each virus, study year, and site. HAI titers were strongly associated with vaccination. Within multivariate models, each log base 2 increase in titer was associated with 15%, 26% and 33-35% reductions in the hazard of influenza A(H3N2), A(H1N1) and B infections, respectively. Best models included pre-season antibody titers and study year, but not other variables. CONCLUSIONS: HAI titers were associated with protection from influenza among HCP with routine exposure to patients with respiratory illness and influenza season contributed to risk. HCP can be reassured about receiving influenza vaccination to stimulate immunity.

      5. Significant declines in juvenile-onset recurrent respiratory papillomatosis following human papillomavirus (HPV) vaccine introduction in the United Statesexternal icon
        Meites E, Stone L, Amiling R, Singh V, Unger ER, Derkay CS, Markowitz LE.
        Clin Infect Dis. 2021 Sep 7;73(5):885-890.
        BACKGROUND: Juvenile-onset recurrent respiratory papillomatosis (JORRP) is a rare and serious disease caused by human papillomavirus (HPV) presumably acquired during vaginal delivery. HPV vaccination of females through age 26 years, recommended in the United States since 2006, can prevent HPV transmission. We assessed trends in JORRP cases before and after HPV vaccine introduction in the United States. METHODS: Case-patients were identified from 26 pediatric otolaryngology centers in 23 U.S. states. Demographics and clinical history were abstracted from medical records. Case-patients were grouped by year of birth, and birth-cohort incidences were calculated using number of births from either national or state-level natality data from the 23 states. We calculated incidence rate ratios (IRR) and 95% confidence intervals (CI) in 2-year intervals. RESULTS: We identified 576 U.S. JORRP case-patients born in 2004-2013. Median age at diagnosis was 3.4 years (interquartile range: 1.9, 5.5). Number of identified JORRP case-patients declined from a baseline of 165 born in 2004-2005 to 36 born in 2012-2013. Incidence of JORRP per 100 000 births using national data declined from 2.0 cases in 2004-2005 to 0.5 cases in 2012-2013 (IRR = 0.2, 95% CI = .1-.4); incidence using state-level data declined from 2.9 cases in 2004-2005 to 0.7 cases in 2012-2013 (IRR = 0.2, 95% CI = .1-.4). CONCLUSIONS: Over a decade, numbers of JORRP case-patients and incidences declined significantly. Incidences calculated using national denominator data are likely underestimates; those calculated using state-level denominator data could be overestimates. These declines are most likely due to HPV vaccination. Increasing vaccination uptake could lead to elimination of this HPV-related disease.

      6. Influenza vaccination rates and hospitalizations among Medicaid enrollees with and without sickle cell disease, 2009-2015external icon
        Payne AB, Adamkiewicz TV, Grosse SD, Steffens A, Shay DK, Reed C, Schieve LA.
        Pediatr Blood Cancer. 2021 Sep 20:e29351.
        BACKGROUND: Personswith sickle cell disease (SCD) face increased risks for pulmonary and infection-related complications. This study examines influenza vaccination coverage and estimates influenza-related morbidity among Medicaid enrollees with and without SCD. PROCEDURE: Influenza vaccination coverage and hospitalizations related to influenza and pneumonia/acute chest syndrome (ACS) during each influenza season from 2009-2010 to 2014-2015 were assessed among enrollees in the IBM MarketScan® Multi-State Medicaid Database. Enrollees with SCD were identified as enrollees with greater than or equal to three claims listing SCD within a 5-year period during 2003-2017. Vaccinations were identified in outpatient claims. Hospitalizations associated with influenza or pneumonia/ACS were identified using inpatient claims. This study includes a series of cross-sectional assessments by season. RESULTS: From 2009-2010 through 2014-2015 seasons, the SCD sample ranged from 5044 to 8651 enrollees; the non-SCD sample ranged from 1,841,756 to 3,796,337 enrollees. Influenza vaccination coverage was higher among enrollees with SCD compared with enrollees without SCD for all seasons (24.5%-33.6% and 18.2%-22.0%, respectively). Age-standardized rates of influenza-related hospitalizations were 20-42 times higher among SCD enrollees compared with non-SCD enrollees, and ACS/pneumonia hospitalizations were 18-29 times higher. Among enrollees with SCD, influenza-related hospitalization rates were highest among children aged 0-9 years. Among enrollees without SCD, influenza-related hospitalization rates were highest among adults aged 40-64 years. CONCLUSIONS: Although vaccine coverage was higher in persons with versus without SCD, efforts to increase influenza coverage further are warranted for this high-risk group, who experienced markedly higher rates of influenza and ACS/pneumonia hospitalizations during each season.

      7. Comparative effectiveness of Moderna, Pfizer-BioNTech, and Janssen (Johnson & Johnson) vaccines in preventing COVID-19 hospitalizations among adults without immunocompromising conditions - United States, March-August 2021external icon
        Self WH, Tenforde MW, Rhoads JP, Gaglani M, Ginde AA, Douin DJ, Olson SM, Talbot HK, Casey JD, Mohr NM, Zepeski A, McNeal T, Ghamande S, Gibbs KW, Files DC, Hager DN, Shehu A, Prekker ME, Erickson HL, Gong MN, Mohamed A, Henning DJ, Steingrub JS, Peltan ID, Brown SM, Martin ET, Monto AS, Khan A, Hough CL, Busse LW, Ten Lohuis CC, Duggal A, Wilson JG, Gordon AJ, Qadir N, Chang SY, Mallow C, Rivas C, Babcock HM, Kwon JH, Exline MC, Halasa N, Chappell JD, Lauring AS, Grijalva CG, Rice TW, Jones ID, Stubblefield WB, Baughman A, Womack KN, Lindsell CJ, Hart KW, Zhu Y, Mills L, Lester SN, Stumpf MM, Naioti EA, Kobayashi M, Verani JR, Thornburg NJ, Patel MM.
        MMWR Morb Mortal Wkly Rep. 2021 Sep 24;70(38):1337-1343.
        Three COVID-19 vaccines are authorized or approved for use among adults in the United States (1,2). Two 2-dose mRNA vaccines, mRNA-1273 from Moderna and BNT162b2 from Pfizer-BioNTech, received Emergency Use Authorization (EUA) by the Food and Drug Administration (FDA) in December 2020 for persons aged ≥18 years and aged ≥16 years, respectively. A 1-dose viral vector vaccine (Ad26.COV2 from Janssen [Johnson & Johnson]) received EUA in February 2021 for persons aged ≥18 years (3). The Pfizer-BioNTech vaccine received FDA approval for persons aged ≥16 years on August 23, 2021 (4). Current guidelines from FDA and CDC recommend vaccination of eligible persons with one of these three products, without preference for any specific vaccine (4,5). To assess vaccine effectiveness (VE) of these three products in preventing COVID-19 hospitalization, CDC and collaborators conducted a case-control analysis among 3,689 adults aged ≥18 years who were hospitalized at 21 U.S. hospitals across 18 states during March 11-August 15, 2021. An additional analysis compared serum antibody levels (anti-spike immunoglobulin G [IgG] and anti-receptor binding domain [RBD] IgG) to SARS-CoV-2, the virus that causes COVID-19, among 100 healthy volunteers enrolled at three hospitals 2-6 weeks after full vaccination with the Moderna, Pfizer-BioNTech, or Janssen COVID-19 vaccine. Patients with immunocompromising conditions were excluded. VE against COVID-19 hospitalizations was higher for the Moderna vaccine (93%; 95% confidence interval [CI] = 91%-95%) than for the Pfizer-BioNTech vaccine (88%; 95% CI = 85%-91%) (p = 0.011); VE for both mRNA vaccines was higher than that for the Janssen vaccine (71%; 95% CI = 56%-81%) (all p<0.001). Protection for the Pfizer-BioNTech vaccine declined 4 months after vaccination. Postvaccination anti-spike IgG and anti-RBD IgG levels were significantly lower in persons vaccinated with the Janssen vaccine than the Moderna or Pfizer-BioNTech vaccines. Although these real-world data suggest some variation in levels of protection by vaccine, all FDA-approved or authorized COVID-19 vaccines provide substantial protection against COVID-19 hospitalization.

    • Informatics
      1. Use of large scale EHR data to evaluate A1c utilization among sickle cell disease patientsexternal icon
        Sivasankar S, Cheng AL, Lubin IM, Lankachandra K, Hoffman MA.
        BMC Med Inform Decis Mak. 2021 Sep 18;21(1):268.
        BACKGROUND: The glycated hemoglobin (A1c) test is not recommended for sickle cell disease (SCD) patients. We examine ordering patterns of diabetes-related tests for SCD patients to explore misutilization of tests among this underserved population. METHODS: We used de-identified electronic health record (EHR) data in the Cerner Health Facts™ (HF) data warehouse to evaluate the frequency of A1c and fructosamine tests during 2010 to 2016, for 37,151 SCD patients from 393 healthcare facilities across the United States. After excluding facilities with no A1c data, we defined three groups of facilities based on the prevalence of SCD patients with A1c test(s): adherent facilities (no SCD patients with A1c test(s)), minor non-adherent facilities, major non-adherent facilities. RESULTS: We determined that 11% of SCD patients (3927 patients) treated at 393 facilities in the US received orders for at least one A1c test. Of the 3927 SCD patients with an A1c test, only 89 patients (2.3%) received an order for a fructosamine test. At the minor non-adherent facilities, 5% of the SCD patients received an A1c test while 58% of the SCD patients at the least adherent facilities had at least one A1c test. Overall, the percent of A1c tests ordered for SCD patients between 2010 and 2016 remained similar. CONCLUSIONS: Inappropriate A1c test orders among a sickle cell population is a significant quality gap. Interventions to advance adoption of professional recommendations that advocate for alternate tests, such as fructosamine, can guide clinicians in test selection to reduce this quality gap are discussed. The informatics strategy used in this work can inform other largescale analyses of lab test utilization using de-identified EHR data.

    • Injury and Violence
      1. Since 1999, the Office of the United States Surgeon General has identified suicide prevention as a national public health priority. The National Strategy on Suicide Prevention, coordinated by the public-private Action Alliance, was most recently updated in 2012. In early 2021, the Surgeon General's office released a Call to Action to fully implement the national strategy. Six core types of actions to prevent suicide include adopting a broad public health approach, addressing upstream factors including social determinants of health, reducing access to multiple forms of lethal means, adopting evidence-based care for persons at risk, enhancing crisis care and care transitions, and improving the quality and use of suicide-related data. From 1999 through 2018, suicide rates in the U.S. increased by approximately one-third, and suicide had become the tenth leading cause of death. While most recent national data indicate a small reduction in the suicide rate, decreases were not seen across all demographic groups. Population groups which may require special emphasis or outreach efforts include adolescents, working age adults, military veterans, and American Indians/Alaskan Natives. Increases in social isolation, mental distress, and economic hardship during the COVID-19 pandemic indicate clear needs to address the full spectrum of suicidal behavior. This will require a multisector and whole of government approach, using contemporary evidence-informed approaches and best practices as well as innovative methods including those based on predictive analytics.

      2. Nonheterosexual (sexual minority) women report experiencing more sexual violence than heterosexual (sexual majority) women (1,2). Sexual minority women are often categorized as a collective whole, which fails to capture the nuances in sexual violence among subgroups of sexual minority women, such as bisexual and lesbian women (3). To estimate the prevalence of lifetime forced vaginal intercourse (forced sex) and of nonvoluntary first vaginal intercourse among women aged 18-44 years in the United States, CDC analyzed data from female respondents who were interviewed during 2011-2017 for the National Survey of Family Growth (NSFG); respondents were stratified by self-reported sexual identity, attraction, and behavior. Log-binomial regressions and analyses of variance (ANOVAs) were performed to compare experiences across each dimension of sexual orientation, controlling for demographic characteristics. Compared with sexual majority women,* prevalence of any male-perpetrated nonvoluntary first vaginal intercourse or forced sex (nonvoluntary or forced sex) was higher among women who identified as bisexual (36.1% versus 17.5%), reported attraction to the opposite and same sex (30.3% versus 15.8%), and reported sexual behavior with the opposite and same sex (35.7% versus 15.9%). These sexual minority women reported that their earliest experience of nonvoluntary or forced sex occurred at younger ages than did that of sexual majority women. Among women who were unsure of their sexual attraction, the prevalence of nonvoluntary first vaginal intercourse was also higher than among sexual majority women. These findings underscore the need for comprehensive prevention approaches tailored for sexual minority women and prevention of child sexual abuse, given the average ages at earliest nonvoluntary or forced sex experience among sexual minority women (range = 12.5-16.3 years). Additional research is needed into the circumstances of and norms or attitudes that influence perpetration of nonvoluntary or forced sex and broader sexual violence against sexual minority women. Prevention of nonvoluntary or forced sex victimization among sexual minority women will require comprehensive approaches to prevent sexual violence and child sexual abuse. Engaging sexual minority women in the development of sexual violence prevention efforts and research would help ensure that the experiences of sexual minority women across the spectrum are represented.

    • Laboratory Sciences
      1. Anthrax is endemic in Ethiopia with sporadic outbreaks despite the regular vaccination of domestic livestock. This has raised concerns on the effectiveness of the vaccination strategy which may be associated with breaches in the vaccine cold chain maintenance. This study was aimed at demonstrating the tolerance of anthrax vaccine to cold chain breaches through evaluation of viable spore counts expressed as colony forming units per mL (CFU/mL) of freeze-dried and suspension anthrax vaccines stored at 5 °C, 20 °C and 37 °C for up to 6 months. Both vaccine formulations maintained above the recommended minimum required titre (2 × 10(6) culturable spores per dose for cattle, buffaloes and horses, and not <1 × 10(6) for sheep and goats) for up to 6 months at 5 °C storage. In storage at 20 °C, the viability of freeze-dried anthrax vaccine maintained the minimum required titre up to 6 months while up to 90 days in case of the suspension formulation. Both types of vaccine formulations maintained the minimum titre per dose for up to 30 days at 37 °C storage. Generally, both vaccine formulations showed similar trends in titre fall in all of the three storage temperatures (5 °C, 20 °C and 37 °C) as observed in the almost linearly overlapping 95% confidence intervals (CI) up to day 90 at 5 °C and 20 °C storages while up to day 30 at 37 °C storage. However, a significant (P < 0.05) drop in titre was observed after day 90 for storages at 5 °C and 20 °C, and after day 30 for 37 °C storage as observed in the non overlapping 95% CI from the average titres of previous time points. This study showed that if temperature excursion occurs above the recommended temperature range (4-8 °C) during storage or transport, the vaccine should remain effective and can still be used in vaccination programs.

      2. Epidemiologic characteristics associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antigen-based test results, real-time reverse transcription polymerase chain reaction (rRT-PCR) cycle threshold values, subgenomic RNA, and viral culture results from university testingexternal icon
        Ford L, Lee C, Pray IW, Cole D, Bigouette JP, Abedi GR, Bushman D, Delahoy MJ, Currie DW, Cherney B, Kirby MK, Fajardo GC, Caudill M, Langolf K, Kahrs J, Zochert T, Kelly P, Pitts C, Lim A, Aulik N, Tamin A, Harcourt JL, Queen K, Zhang J, Whitaker B, Browne H, Medrzycki M, Shewmaker PL, Bonenfant G, Zhou B, Folster JM, Bankamp B, Bowen MD, Thornburg NJ, Goffard K, Limbago B, Bateman A, Tate JE, Gieryn D, Kirking HL, Westergaard RP, Killerby ME.
        Clin Infect Dis. 2021 Sep 15;73(6):e1348-e1355.
        BACKGROUND: Real-time reverse transcription polymerase chain reaction (rRT-PCR) and antigen tests are important diagnostics for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Sensitivity of antigen tests has been shown to be lower than that of rRT-PCR; however, data to evaluate epidemiologic characteristics that affect test performance are limited. METHODS: Paired mid-turbinate nasal swabs were collected from university students and staff and tested for SARS-CoV-2 using both Quidel Sofia SARS Antigen Fluorescent Immunoassay (FIA) and rRT-PCR assay. Specimens positive by either rRT-PCR or antigen FIA were placed in viral culture and tested for subgenomic RNA (sgRNA). Logistic regression models were used to evaluate characteristics associated with antigen results, rRT-PCR cycle threshold (Ct) values, sgRNA, and viral culture. RESULTS: Antigen FIA sensitivity was 78.9% and 43.8% among symptomatic and asymptomatic participants, respectively. Among rRT-PCR positive participants, negative antigen results were more likely among asymptomatic participants (odds ratio [OR] 4.6, 95% confidence interval [CI]: 1.3-15.4) and less likely among participants reporting nasal congestion (OR 0.1, 95% CI: .03-.8). rRT-PCR-positive specimens with higher Ct values (OR 0.5, 95% CI: .4-.8) were less likely, and specimens positive for sgRNA (OR 10.2, 95% CI: 1.6-65.0) more likely, to yield positive virus isolation. Antigen testing was >90% positive in specimens with Ct values < 29. Positive predictive value of antigen test for positive viral culture (57.7%) was similar to that of rRT-PCR (59.3%). CONCLUSIONS: SARS-CoV-2 antigen test advantages include low cost, wide availability and rapid turnaround time, making them important screening tests. The performance of antigen tests may vary with patient characteristics, so performance characteristics should be accounted for when designing testing strategies and interpreting results.

      3. Streptococcus pneumoniae serotypes that frequently colonise the human nasopharynx are common recipients of penicillin-binding protein gene fragments from Streptococcus mitisexternal icon
        Kalizang'oma A, Chaguza C, Gori A, Davison C, Beleza S, Antonio M, Beall B, Goldblatt D, Kwambana-Adams B, Bentley SD, Heyderman RS.
        Microb Genom. 2021 Sep;7(9).
        Streptococcus pneumoniae is an important global pathogen that causes bacterial pneumonia, sepsis and meningitis. Beta-lactam antibiotics are the first-line treatment for pneumococcal disease, however, their effectiveness is hampered by beta-lactam resistance facilitated by horizontal genetic transfer (HGT) with closely related species. Although interspecies HGT is known to occur among the species of the genus Streptococcus, the rates and effects of HGT between Streptococcus pneumoniae and its close relatives involving the penicillin binding protein (pbp) genes remain poorly understood. Here we applied the fastGEAR tool to investigate interspecies HGT in pbp genes using a global collection of whole-genome sequences of Streptococcus mitis, Streptococcus oralis and S. pneumoniae. With these data, we established that pneumococcal serotypes 6A, 13, 14, 16F, 19A, 19F, 23F and 35B were the highest-ranking serotypes with acquired pbp fragments. S. mitis was a more frequent pneumococcal donor of pbp fragments and a source of higher pbp nucleotide diversity when compared with S. oralis. Pneumococci that acquired pbp fragments were associated with a higher minimum inhibitory concentration (MIC) for penicillin compared with pneumococci without acquired fragments. Together these data indicate that S. mitis contributes to reduced β-lactam susceptibility among commonly carried pneumococcal serotypes that are associated with long carriage duration and high recombination frequencies. As pneumococcal vaccine programmes mature, placing increasing pressure on the pneumococcal population structure, it will be important to monitor the influence of antimicrobial resistance HGT from commensal streptococci such as S. mitis.

      4. Virus destabilization and inactivation are critical considerations in providing safe drinking water. We demonstrate that iron electrocoagulation simultaneously removed (via sweep flocculation) and inactivated a non-enveloped virus surrogate (MS2 bacteriophage) under slightly acidic conditions, resulting in highly effective virus control (e.g., 5-logs at 20 mg Fe/L and pH 6.4 in 30 min). Electrocoagulation simultaneously generated H(2)O(2) and Fe(II) that can potentially trigger electro-Fenton reactions to produce reactive oxygen species such as (•)OH and high valent oxoiron(IV) that are capable of inactivating viruses. To date, viral attenuation during water treatment has been largely probed by evaluating infective virions (as plaque forming units) or genomic damage (via the quantitative polymerase chain reaction). In addition to these existing means of assessing virus attenuation, a novel technique of correlating transmission electron micrographs of electrocoagulated MS2 with their computationally altered three-dimensional electron density maps was developed to provide direct visual evidence of capsid morphological damages during electrocoagulation. The majority of coliphages lost at least 10-60% of the capsid protein missing a minimum of one of the 5-fold and two of 3- and 2-fold regions upon electrocoagulation, revealing substantial localized capsid deformation. Attenuated total reflectance-Fourier transform infrared spectroscopy revealed potential oxidation of viral coat proteins and modification of their secondary structures that were attributed to reactive oxygen species. Iron electrocoagulation simultaneously disinfects and coagulates non-enveloped viruses (unlike conventional coagulation), adding to the robustness of multiple barriers necessary for public health protection and appears to be a promising technology for small-scale distributed water treatment.

      5. An open-label pharmacokinetic and pharmacodynamic assessment of tenofovir gel and oral emtricitabine / tenofovir disoproxil fumarateexternal icon
        McGowan IM, Kunjara Na Ayudhya RP, Brand RM, Marzinke MA, Hendrix CW, Johnson S, Piper J, Holtz TH, Curlin ME, Chitwarakorn A, Raengsakulrach B, Doncel G, Schwartz Icloud Com J, Rooney JF, Cranston RD.
        AIDS Res Hum Retroviruses. 2021 Sep 20.
        The MTN-017 study was undertaken to characterize the safety, acceptability, pharmacokinetic, and pharmacodynamic profile of the reduced-glycerin (RG) 1% tenofovir (RG-TFV) gel compared to oral emtricitabine / tenofovir disoproxil fumarate (FTC/TDF). The study was a Phase 2, three-period, randomized sequence, open-label, expanded safety and acceptability crossover study. In each 8-week study period, HIV-1 uninfected participants were randomized to RG-TFV rectal gel daily; or RG-TFV rectal gel before and after receptive anal intercourse (RAI) (or at least twice weekly in the event of no RAI); or daily oral FTC/TDF. A mucosal substudy was conducted at sites in the USA and Thailand. Samples were collected to evaluate PK and ex vivo biopsy challenge with HIV-1. A total of 195 MSM and transgender women (TW) were enrolled in the parent study and 37 in the mucosal substudy. As previously reported, both products were found to be safe and acceptable. Systemic TFV concentrations were significantly higher following oral exposure and daily rectal administration compared to RAI-associated product use (p<0.001). All three routes of PrEP administration resulted in inhibition of explant infection (p<0.05) and there was a significant inverse correlation between explant HIV-1 p24 and tissue concentrations of TFV and FTC (p<0.0001). Despite significant differences in systemic and mucosal drug concentrations, all three PrEP regimens were able to protect rectal explants from ex vivo HIV infection. These data suggest that there is a rationale for co-development of oral and topical antiretroviral PrEP for HIV prevention.

      6. Sustained replication of synthetic canine distemper virus defective genomes in vitro and in vivoexternal icon
        Tilston-Lunel NL, Welch SR, Nambulli S, de Vries RD, Ho GW, Wentworth DE, Shabman R, Nichol ST, Spiropoulou CF, de Swart RL, Rennick LJ, Duprex WP.
        mSphere. 2021 Sep 22:e0053721.
        Defective interfering (DI) genomes restrict viral replication and induce type I interferon. Since DI genomes have been proposed as vaccine adjuvants or therapeutic antiviral agents, it is important to understand their generation, delineate their mechanism of action, develop robust production capacities, assess their safety and in vivo longevity, and determine their long-term effects. To address this, we generated a recombinant canine distemper virus (rCDV) from an entirely synthetic molecular clone designed using the genomic sequence from a clinical isolate obtained from a free-ranging raccoon with distemper. rCDV was serially passaged in vitro to identify DI genomes that naturally arise during rCDV replication. Defective genomes were identified by Sanger and next-generation sequencing techniques, and predominant genomes were synthetically generated and cloned into T7-driven plasmids. Fully encapsidated DI particles (DIPs) were then generated using a rationally attenuated rCDV as a producer virus to drive DI genome replication. We demonstrate that these DIPs interfere with rCDV replication in a dose-dependent manner in vitro. Finally, we show sustained replication of a fluorescent DIP in experimentally infected ferrets over a period of 14 days. Most importantly, DIPs were isolated from the lymphoid tissues, which are a major site of CDV replication. Our established pipeline for detection, generation, and assaying DIPs is transferable to highly pathogenic paramyxoviruses and will allow qualitative and quantitative assessment of the therapeutic effects of DIP administration on disease outcome. IMPORTANCE Defective interfering (DI) genomes have long been considered inconvenient artifacts that suppressed viral replication in vitro. However, advances in sequencing technologies have led to DI genomes being identified in clinical samples, implicating them in disease progression and outcome. It has been suggested that DI genomes might be harnessed therapeutically. Negative-strand RNA virus research has provided a rich pool of natural DI genomes over many years, and they are probably the best understood in vitro. Here, we demonstrate the identification, synthesis, production, and experimental inoculation of novel CDV DI genomes in highly susceptible ferrets. These results provide important evidence that rationally designed and packaged DI genomes can survive the course of a wild-type virus infection.

    • Maternal and Child Health
      1. Epidemiology of intussusception in infants less than one year of age in Ghana, 2012-2016external icon
        Glover-Addy H, Ansong D, Enweronu-Laryea C, Tate JE, Amponsa-Achiano K, Sarkodie B, Mwenda JM, Diamenu S, Owusu SK, Nimako B, Mensah NK, Armachie J, Narh C, Pringle K, Grytdal SP, Binka F, Lopman B, Parashar UD, Armah G.
        Pan Afr Med J. 2021 ;39(Suppl 1):8.
        INTRODUCTION: we examined the epidemiology, clinical and demographic characteristics of intussusception in Ghanaian infants. METHODS: active sentinel surveillance for pediatric intussusception was conducted at Komfo Anokye Teaching Hospital in Kumasi and Korle Bu Teaching Hospital in Accra. From March 2012 to December 2016, infants < 1 year of age who met the Brighton Collaboration level 1 diagnostic criteria for intussusception were enrolled. Data were collected through parental interviews and medical records abstraction. RESULTS: a total of 378 children < 1 year of age were enrolled. Median age at onset of intussusception was 27 weeks; only 12 cases (1%) occurred in infants < 12 weeks while most occurred in infants aged 22-34 weeks. Median time from symptom onset until referral to a tertiary hospital was 2 days (IQR: 1-4 days). Overall, 35% of infants were treated by enema, 33% had surgical reduction and 32% required surgical reduction and bowel resection. Median length of hospital stay was 5 days (IQR: 3-8 days) with most patients (95%) discharged home. Eleven (3%) infants died. Infants undergoing enema reduction were more likely than those treated surgically to present for treatment sooner after symptom onset (median 1 vs 3 days; p < 0.0001) and have shorter hospital stays (median 3 vs 7 days; p < 0.001). CONCLUSION: Ghanaian infants had a relatively low case fatality rate due to intussusception, with a substantial proportion of cases treated non-surgically. Early presentation for treatment, possibly enhanced by community-based health education programs and health information from various media platforms during the study period might contribute to both the low fatality rate and high number of successful non-surgical treatments in this population.

      2. Delays in presentation of intussusception and development of gangrene in Zimbabweexternal icon
        Mazingi D, Burnett E, Mujuru HA, Nathoo K, Tate J, Mwenda J, Weldegebriel G, Manangazira P, Mukaratirwa A, Parashar U, Zimunhu T, Mbuwayesango BA.
        Pan Afr Med J. 2021 ;39(Suppl 1):3.
        INTRODUCTION: prompt diagnosis and treatment are considered key to successful management of intussusception. We examined pre-treatment delay among intussusception cases in Zimbabwe and conducted an exploratory analysis of factors associated with intraoperative finding of gangrene. METHODS: data were prospectively collected as part of the African Intussusception Network using a questionnaire administered on consecutive patients with intussusception managed at Harare Children´s Hospital. Delays were classified using the Three-Delays-Model: care-seeking delay (time from onset of symptoms to first presentation for health care), health-system delay (referral time from presentation to first facility to treatment facility) and treatment delay (time from presentation at treatment facility to treatment). RESULTS: ninety-two patients were enrolled from August 2014 to December 2016. The mean care-seeking interval was 1.9 days, the mean health-system interval was 1.5 days, and the mean treatment interval was 1.1 days. Mean total time from symptom onset to treatment was 4.4 days. Being transferred from another institution added 1.4 days to the patient journey. Gangrene was found in 2 (25%) of children who received treatment within 1 day, 13 (41%) of children who received treatment 2-3 days, and 26 (50%) of children who received treatment more than 3 days after symptom onset (p = 0.34). CONCLUSION: significant care-seeking and health-system delays are encountered by intussusception patients in Zimbabwe. Our findings highlight the need to explore approaches to improve the early diagnosis of intussusception and prompt referral of patients for treatment.

      3. Intussusception among infants in Tanzania: findings from prospective hospital-based surveillance, 2013-2016external icon
        Mbaga M, Msuya D, Mboma L, Jani B, Michael F, Kamugisha C, Said SA, Saleh A, Mwenda J, Cortese M.
        Pan Afr Med J. 2021 ;39(Suppl 1):4.
        INTRODUCTION: intussusception surveillance was initiated in Tanzania in 2013 after monovalent rotavirus vaccine was introduced, as part of the 7-country African evaluation to assess whether the vaccine was associated with an increased risk of intussusception. An increased risk from vaccine was not identified. Published data on intussusception in Tanzanian infants are limited. METHODS: prospective intussusception surveillance was conducted at 7 referral hospitals during 2013-2016 to identify all infants with intussusception meeting Brighton Level 1 criteria. Demographic, household and clinical data were collected by hospital clinicians and analyzed. RESULTS: a total of 207 intussusception cases were identified. The median age of cases was 5.8 months and nearly three-quarters were aged 4-7 months. Median number of days from symptom onset to admission at treatment hospital was 3 (IQR 2-5). Seventy-eight percent (152/195) of cases had been admitted at another hospital before transfer to the treating hospital. Enema reduction was not available; all infants were treated surgically and 55% (114/207) had intestinal resection. The overall case-fatality rate was 30% (62/206). Compared with infants who survived, those who died had longer duration of symptoms before admission to treatment hospital (median 4 vs 3 days; p < 0.01), higher rate of intestinal resection (81% [60/82] vs 44% [64/144], p < 0.001), and from families with lower incomes (i.e., less likely to own a television [p < 0.01] and refrigerator [p < 0.05). CONCLUSION: Tanzanian infants who develop intussusception have a high case-fatality rate. Raising the index of suspicion among healthcare providers, allocating resources to allow wider availability of abdominal ultrasound for earlier diagnosis, and training teams in ultrasound-guided enema reduction techniques used in other African countries could reduce the fatality rate.

      4. Age distribution and mortality associated with intussusception in children under two years of age in nine sentinel surveillance hospitals in Zambia, 2007-2018external icon
        Mpabalwani EM, Bvulani B, Simwaka J, Chitambala P, Matapo B, Tate J, Parashar U, Mwenda J.
        Pan Afr Med J. 2021 ;39(Suppl 1):6.
        INTRODUCTION: recipients of monovalent rotavirus vaccine have a low risk of developing intussusception (IS) in high- to medium-high-income countries. In sub-Saharan Africa, Zambia included, this risk of IS has not been assessed. Two-dose monovalent rotavirus vaccine, introduced in Zambia in 2012 in the capital of Lusaka, and rolled out countrywide in 2013, is administered at 6 and 10 weeks of age with no catch-up dose. Active IS surveillance monitoring in children < 2 years has been ongoing in Zambia since July 2009 and additional retrospective review was conducted from 2007- June 2009. METHODS: retrospective review (January 2007-June 2009) and prospective (July 2009-December 2018) IS surveillance was conducted at nine hospitals and four large paediatric hospital departments in Zambia, respectively. Demographic and clinical data were collected from medical folder abstraction and supplemented by parental interview during prospective surveillance. RESULTS: a total of 248 children < 2 years with IS were identified; 57.3% were male. Most cases with IS were infants (85.5%). IS admissions remained stable during the surveillance period with no seasonality pattern although an increase in cases occurred between August and October, hot dry season. The median time from symptom onset to presentation for treatment was 2 days and 63.6% (154/242) of IS diagnoses were made during surgery. The bowel resection rate was 46.6%. A high CFR of 23.3% was observed. CONCLUSION: the number of intussusception cases in Zambia was relatively small and remained stable over the 12-year study period. However, a high CFR was observed among cases.

      5. Half century since SIDS: A reappraisal of terminologyexternal icon
        Shapiro-Mendoza CK, Palusci VJ, Hoffman B, Batra E, Yester M, Corey TS, Sens MA.
        Pediatrics. 2021 Sep 20.
        After a sudden infant death, parents and caregivers need accurate and open communication about why their infant died. Communicating tragic news about a child's death to families and caregivers is difficult. Shared and consistent terminology is essential for pediatricians, other physicians, and nonphysician clinicians to improve communication with families and among themselves. When families do not have complete information about why their child died, pediatricians will not be able to support them through the process and make appropriate referrals for pediatric specialty and mental health care. Families can only speculate about the cause and may blame themselves or others for the infant's death. The terminology used to describe infant deaths that occur suddenly and unexpectedly includes an assortment of terms that vary across and among pediatrician, other physician, or nonphysician clinician disciplines. Having consistent terminology is critical to improve the understanding of the etiology, pathophysiology, and epidemiology of these deaths and communicate with families. A lack of consistent terminology also makes it difficult to reliably monitor trends in mortality and hampers the ability to develop effective interventions. This report describes the history of sudden infant death terminology and summarizes the debate over the terminology and the resulting diagnostic shift of these deaths. This information is to assist pediatricians, other physicians, and nonphysician clinicians in caring for families during this difficult time. The importance of consistent terminology is outlined, followed by a summary of progress toward consensus. Recommendations for pediatricians, other physicians, and nonphysician clinicians are proposed.

      6. Epidemiology of intussusception among infants in Ethiopia, 2013-2016external icon
        Tadesse A, Teshager F, Weldegebriel G, Ademe A, Wassie E, Gosaye A, Pringle K, Mwenda JM, Parashar UD, Tate JE.
        Pan Afr Med J. 2021 ;39(Suppl 1):2.
        INTRODUCTION: intussusception is a condition in which one segment of the bowel prolapses into another causing obstruction. Information on the epidemiology of intussusception in sub-Saharan Africa is limited. We describe the sociodemographic and clinical characteristics of children with intussusception in Ethiopia. METHODS: active surveillance for children < 12 months of age with intussusception was conducted at six sentinel hospitals in Ethiopia. Limited socio-economic and clinical data were collected from enrolled children. Characteristics among children who died and children who survived were compared using the Wilcoxon rank sum test for continuous variables and Chi-square tests for categorical variables. RESULTS: total of 164 children < 12 months of age with intussusception were enrolled; 62% were male. The median age at symptom onset was 6 months with only 12 (7%) of cases occurring in the first 3 months of life. Intussusception was reduced by surgery in 90% of cases and 10% were reduced by enema; 13% of cases died. Compared to survivors, children who died had a significantly longer time to presentation to the first health care facility and to the treating health care facility (median 3 days versus 2 days, p = 0.02, respectively). CONCLUSION: the high mortality rate, late presentation of intussusception cases, and lack of modalities for non-surgical management at some facilities highlight the need for better management of intussusception cases in Ethiopia.

      7. Acute intestinal intussusception among children under five years of age admitted in an Ouagadougou hospital, Burkina Faso, 2008-2013: epidemiological, clinical and therapeutic aspectsexternal icon
        Toussaint TW, Wandaogo A, Yaméogo WI, Ouédraogo I, Ouédraogo SM, Zampou O, Béré B, Aliabadi N, Leshem E, Nikièma M, Ouattara M, Mwenda JM, Bonkoungou I, Bandré E, Parashar UD, Tate JE.
        Pan Afr Med J. 2021 ;39(Suppl 1):5.
        INTRODUCTION: acute intestinal intussusception is a life-threatening surgical condition. In some settings, rotavirus vaccines have been associated with a low-level increased risk of intussusception. We describe the epidemiology, clinical manifestations and management of intussusception in a tertiary referral hospital in Burkina Faso prior to the introduction of rotavirus vaccine in October 2013. METHODS: we retrospectively reviewed medical records of all children under 5 years of age treated at the Charles de Gaulle Pediatric Hospital for intussusception meeting the Brighton level 1 diagnostic criteria, from October 31st, 2008 to October 30th, 2013. We report the incidence of intussusception as well as descriptive characteristics of these cases. RESULTS: a total of 107 Brighton level 1 intussusception cases were identified, representing a hospital incidence of 21.4 cases / year. There were 69 males and 38 females (sex ratio of 1.8), with a median age of 8 months (range 2 months to 4 years). Sixty-two percent of intussusception cases occurred among infants (n = 67 cases). The average time from symptom onset to seeking medical consultation was 3.8 days +/- 2.7 (range 0 to 14 days). Treatment was mainly surgical (105 patients, 98.1%) with 35 patients (32.7%) undergoing intestinal resection. Thirty-seven patients (35.5%) experienced post-operative complications. The mortality rate was 9.3%. Intestinal resection was a risk factor for death from intussusception. CONCLUSION: in this review of intussusception hospitalizations prior to rotavirus vaccine introduction in Burkina Faso, delays in seeking care were common and were associated with mortality.

      8. Epidemiology of intussusception among infants in Togo, 2015-2018external icon
        Tsolenyanu E, Akakpo-Numado K, Akolly DE, Mwenda J, Tate J, Boko A, Landoh D, Gnassingne K, Atakouma Y, Parashar U.
        Pan Afr Med J. 2021 ;39(Suppl 1):7.
        INTRODUCTION: intussusception is the leading cause of bowel obstruction in infants and young children. We describe the epidemiology and diagnostic and treatment characteristics of intussusception among Togolese infants over a 4-year period. METHODS: we implemented active surveillance among infants younger than 1 year of age admitted with intussusception from 2015 to 2018 at Sylvanus Olympio Teaching Hospital and in 2018 at Campus Teaching Hospital. Brighton Collaboration Level 1 case definition criteria were used to confirm the diagnosis of intussusception. RESULTS: during four years, 41 cases of intussusception, with an annual range of 8 to 14 cases (median: 10) were reported; and the highest number of cases (89%) was enrolled at Sylvanus Olympio teaching hospital. Intussusception was uncommon in the first 2 months of life, peaked from 5 to 7 months old (63%), with male predominance (63%), and showed no significant seasonality. One third of cases (34%) were transferred to the sentinel surveillance site from another health facility; and the median delay in seeking care was 4 days (range: 0-11) with ≥ 48-hour delay in 59% of cases. Clinical symptoms, ultrasound and surgery were combined to diagnose intussusception in all the cases (100%). The treatment was exclusively surgical, and intestinal resection was common (28/41, 68%). A high case fatality rate (23%) was observed and the average length of hospital stay was 10 days (range: 1-23). CONCLUSION: active surveillance for intussusception in Togo has highlighted exclusive use of surgical therapy; often associated to an intestinal resection with a very high case fatality rate.

      9. Reading proficiency trends following newborn hearing screening implementationexternal icon
        Yoshinaga-Itano C, Mason CA, Wiggin M, Grosse SD, Gaffney M, Gilley PM.
        Pediatrics. 2021 Sep 22.
        OBJECTIVES: To investigate trends in population-level school-aged reading scores among students with hearing loss in an urban Colorado school district after implementation of universal newborn hearing screening (UNHS) and Early Hearing Detection and Intervention. METHODS: The final sample included 1422 assessments conducted during the 2000-2001 through 2013-2014 school years for 321 children with hearing loss in grades 3 through 10. Longitudinal hierarchical linear modeling analyses were used to examine reading proficiency (controlling for birth year, grade in school, free and reduced lunch status, additional disability services, and English not spoken in the home). The Colorado Student Assessment Program was administered to students in third through 10th grades throughout the state. The test years chosen included children born before and after implementation of UNHS. RESULTS: After implementation of UNHS, significant longitudinal reading proficiency improvements were observed by birth year and grade overall and for all subgroups. However, gains in reading proficiency were substantially less for children eligible for free and reduced lunch and those with moderate-severe to profound hearing loss. With each succeeding birth cohort and grade, increased numbers of children participated in testing because of improved language skills, with higher proportions identified as proficient or advanced readers. CONCLUSIONS: Notable improvements in reading proficiency after Early Hearing Detection and Intervention implementation were demonstrated, as all groups of children with hearing loss became more likely to achieve proficient and advanced reading levels. On the other hand, some disparities increased, with greater improvements in reading proficiency for children in economically advantaged families.

    • Occupational Safety and Health
      1. HLA-DPB1 E69 genotype and exposure in beryllium sensitisation and diseaseexternal icon
        Crooks J, Mroz MM, VanDyke M, McGrath A, Schuler C, McCanlies EC, Virji MA, Rosenman KD, Rossman M, Rice C, Monos D, Fingerlin TE, Maier LA.
        Occup Environ Med. 2021 Sep 17.
        OBJECTIVES: Human leukocyte antigen-DP beta 1 (HLA-DPB1) with a glutamic acid at the 69th position of the ß chain (E69) genotype and inhalational beryllium exposure individually contribute to risk of chronic beryllium disease (CBD) and beryllium sensitisation (BeS) in exposed individuals. This retrospective nested case-control study assessed the contribution of genetics and exposure in the development of BeS and CBD. METHODS: Workers with BeS (n=444), CBD (n=449) and beryllium-exposed controls (n=890) were enrolled from studies conducted at nuclear weapons and primary beryllium manufacturing facilities. Lifetime-average beryllium exposure estimates were based on workers' job questionnaires and historical and industrial hygienist exposure estimates, blinded to genotype and case status. Genotyping was performed using sequence-specific primer-PCR. Logistic regression models were developed allowing for over-dispersion, adjusting for workforce, race, sex and ethnicity. RESULTS: Having no E69 alleles was associated with lower odds of both CBD and BeS; every additional E69 allele increased odds for CBD and BeS. Increasing exposure was associated with lower odds of BeS. CBD was not associated with exposure as compared to controls, yet the per cent of individuals with CBD versus BeS increased with increasing exposure. No evidence of a gene-by-exposure interaction was found for CBD or BeS. CONCLUSIONS: Risk of CBD increases with E69 allele frequency and increasing exposure, although no gene by environment interaction was found. A decreased risk of BeS with increasing exposure and lack of exposure response in CBD cases may be due to the limitations of reconstructed exposure estimates. Although reducing exposure may not prevent BeS, it may reduce CBD and the associated health effects, especially in those carrying E69 alleles.

    • Occupational Safety and Health - Mining
      1. Laboratory development and pilot-scale deployment of a two-part foamed rock dustexternal icon
        Brown CB, Perera IE, Harris ML, Chasko LL, Addis JD, Klima S.
        J Loss Prev Process Ind. 2022 ;74.
        U.S. Code of Federal Regulations 30 CFR 75.402 and 75.403 require 80% total incombustible content to be maintained within 40 feet of the coal mine face via the liberal application of rock dust. Unfortunately, this application of rock dust limits miners' visibility downwind and can increase the miners' exposures to a respirable nuisance dust. Wet rock dust applied as a slurry is, at times, used to negate these negative effects. Although this aids in meeting the total incombustible limits, the slurry forms a hard cake when dried and no longer effectively disperses as needed to suppress a coal dust explosion. As a result, a dry rock dust must be reapplied to maintain a dispersible layer. Therefore, researchers from the National Institute for Occupational Safety and Health (NIOSH) have been working towards finding and testing a foamed rock dust formulation that can be applied wet on mine surfaces and remain dispersible once dried which minimizes the likelihood of mine disasters, including mine explosions. The initial tests were aimed at discerning dispersion characteristics of three different foamed rock dusts via the NIOSH-developed dispersion chamber and led to identification of a two-part foam with adequate dispersion characteristics. The current study was conducted to assess the robustness of the two-part foamed rock dust. Through a series of laboratory-scale experiments using the dispersibility chamber, the effects of testing conditions and product formulations on the foam's dispersibility was determined. Some of the tested variables include: exposing the foam to high humidity, varying the component levels of the foamed rock dust, altering the rock dust size distribution, and varying the rock dust types. Further pilot-scale tests examined the atmospheric concentrations of dust via personal dust monitors downwind of foamed rock dust production and application. Additionally, product consistency was recorded during pilot-scale testing at key points in the formulation and application. The results of these experiments will be discussed in this paper. © 2021

    • Program Evaluation
      1. We applied a three-step process, abstracting and analyzing program budgets to examine how Colorectal Cancer Control Program (CRCCP) awardees are structuring their programs and to assess the fidelity of program design to the CRCCP public health model. We reviewed 23 state, one tribal organization, and six university awardee budgets. We assessed resource allocations, staffing structures, and contracted partners and their activities. Awardees allocated 83% of all funds to contracts and personnel. Program managers were the most budgeted personnel type across three measures: number of people, full-time equivalency, and personnel costs. Awardees not only contracted with health care systems and clinics (39% of all contracts) but also contracted other partner types. Contractors were mainly funded to implement evidence-based interventions (25%) and conduct evaluation (24%). Program design varied among awardees in the number of staff (0-22), number of full-time equivalencies (0-5.4), and the number of contracts (1-11) budgeted. State awardees budgeted more resources to contracts, compared with university awardees (57% vs. 31%), while universities budgeted more for total personnel costs (41% vs. 30%). We learned that awardees designed their programs with fidelity to the CRCCP model. Although implementation approaches varied, overall results suggest implementation requires a combination of internal capacities and contracted partners. Budgets provide opportunities to use already existing program data to evaluate program design, partnerships, and planned activities.

    • Public Health Leadership and Management
      1. An international needs assessment survey of guideline developers demonstrates variability in resources and challenges to collaboration between organizationsexternal icon
        Sultan S, Siedler MR, Morgan RL, Ogunremi T, Dahm P, Fatheree LA, Getchius TS, Ginex PK, Jakhmola P, McFarlane E, Murad MH, Temple Smolkin RL, Amer YS, Alam M, Kang BY, Falck-Ytter Y, Mustafa RA.
        J Gen Intern Med. 2021 Sep 20.
        BACKGROUND: The development of rigorous, high-quality clinical guidelines increases the need for resources and skilled personnel within guideline-producing organizations. While collaboration between organizations provides a unique opportunity to pool resources and save time and effort, the collaboration presents its own unique challenges. OBJECTIVE: To assess the perceived needs and current challenges of guideline producers worldwide related to guideline development and collaboration efforts. DESIGN: Survey questions were developed by the Guidelines International Network and the US GRADE Network, pilot-tested among attendees of a guideline development workshop, and disseminated electronically using convenience and snowball sampling methods. PARTICIPANTS: A total of 171 respondents representing 30 countries and more than 112 unique organizations were included in this analysis. MAIN MEASURES: The survey included free-response, multiple-choice, and seven-point Likert-scale questions. Questions assessed respondents' perceived value of guidelines, resource availability and needs, guideline development processes, and collaboration efforts of their organization. KEY RESULTS: Time required to develop high-quality systematic reviews and guidelines was the most relevant need (median=7; IQR=5.5-7). In-house resources to conduct literature searches (median=4; IQR=3-6) and the resources to develop rigorous guidelines rapidly (median=4; IQR=2-5) were perceived as the least available resources. Difficulties reconciling differences in guideline methodology (median=6; IQR=4-7) and the time required to establish collaborative agreements (median=6; IQR=5-6) were the most relevant barriers to collaboration between organizations. Results also indicated a general need for improvement in conflict of interest (COI) disclosure policies. CONCLUSION: The survey identified organizational challenges in supporting rigorous guideline development, including the time, resources, and personnel required. Connecting guideline developers to existing databases of high-quality systematic reviews and the use of freely available online platforms may facilitate guideline development. Guideline-producing organizations may also consider allocating resources to hiring or training personnel with expertise in systematic review methodologies or utilizing resources more effectively by establishing collaborations with other organizations.

    • Substance Use and Abuse
      1. Methamphetamine use, methamphetamine use disorder, and associated overdose deaths among US adultsexternal icon
        Han B, Compton WM, Jones CM, Einstein EB, Volkow ND.
        JAMA Psychiatry. 2021 Sep 22.
        IMPORTANCE: Mortality associated with methamphetamine use has increased markedly in the US. Understanding patterns of methamphetamine use may help inform related prevention and treatment. OBJECTIVE: To assess the national trends in and correlates of past-year methamphetamine use, methamphetamine use disorder (MUD), injection, frequent use, and associated overdose mortality from 2015 to 2019. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study analyzed methamphetamine use, MUD, injection, and frequent use data from participants in the 2015 to 2019 National Surveys on Drug Use and Health (NSDUH). Mortality data were obtained from the 2015 to 2019 National Vital Statistics System Multiple Cause of Death files. EXPOSURES: Methamphetamine use. MAIN OUTCOMES AND MEASURES: Methamphetamine use, MUD, injection, frequent use, and overdose deaths. RESULTS: Of 195 711 NSDUH respondents aged 18 to 64 years, 104 408 were women (weighted percentage, 50.9%), 35 686 were Hispanic individuals (weighted percentage, 18.0%), 25 389 were non-Hispanic Black (hereafter, Black) individuals (weighted percentage, 12.6%), and 114 248 were non-Hispanic White (hereafter, White) individuals (weighted percentage, 60.6%). From 2015 to 2019, overdose deaths involving psychostimulants other than cocaine (largely methamphetamine) increased 180% (from 5526 to 15 489; P for trend <.001); methamphetamine use increased 43% (from 1.4 million [95% CI, 1.2-1.6 million] to 2.0 million [95% CI, 1.7-2.3 million]; P for trend = .002); frequent methamphetamine use increased 66% (from 615 000 [95% CI, 512 000-717 000] to 1 021 000 [95% CI, 860 000-1 183 000]; P for trend = .002); methamphetamine and cocaine use increased 60% (from 402 000 [95% CI, 306 000-499 000] to 645 000 [95% CI, 477 000-813 000]; P for trend = .001); and MUD without injection increased 105% (from 397 000 [95% CI, 299 000-496 000] to 815 000 [95% CI, 598 000-1 033 000]; P for trend = .006). The prevalence of MUD or injection surpassed the prevalence of methamphetamine use without MUD or injection in each year from 2017 to 2019 (60% to 67% vs 37% to 40%; P for trend ≤.001). Adults with MUD or using injection were more likely to use methamphetamine frequently (52.68%-53.84% vs 32.59%; adjusted risk ratio, 1.62-1.65; 95% CI, 1.35-1.94). From 2015 to 2019, the adjusted prevalence of MUD without injection more than tripled among heterosexual women (from 0.24% to 0.74%; P < .001) and lesbian or bisexual women (from 0.21% to 0.71%; P < .001) and more than doubled among heterosexual men (from 0.29% to 0.79%; P < .001) and homosexual or bisexual men (from 0.29% to 0.80%; P = .007). It increased over 10-fold among Black individuals (from 0.06% to 0.64%; P < .001), nearly tripled among White individuals (from 0.28% to 0.78%; P < .001), and more than doubled among Hispanic individuals (from 0.39% to 0.82%; P < .001). Risk factors for methamphetamine use, MUD, injection, and frequent use included lower educational attainment, lower annual household income, lack of insurance, housing instability, criminal justice involvement, comorbidities (eg, HIV/AIDS, hepatitis B or C virus, depression), suicidal ideation, and polysubstance use. CONCLUSIONS AND RELEVANCE: This cross-sectional study found consistent upward trends in overdose mortality, greater risk patterns of methamphetamine use, and populations at higher risk for MUD diversifying rapidly, particularly those with socioeconomic risk factors and comorbidities. Evidence-based prevention and treatment interventions are needed to address surges in methamphetamine use and MUD.

      2. The "Outcome Reporting in Brief Intervention Trials: Alcohol" (ORBITAL) core outcome set: International consensus on outcomes to measure in efficacy and effectiveness trials of alcohol brief interventionsexternal icon
        Shorter GW, Bray JW, Heather N, Berman AH, Giles EL, Clarke M, Barbosa C, O'Donnell AJ, Holloway A, Riper H, Daeppen JB, Monteiro MG, Saitz R, McNeely J, McKnight-Eily L, Cowell A, Toner P, Newbury-Birch D.
        J Stud Alcohol Drugs. 2021 Sep;82(5):638-646.
        OBJECTIVE: The purpose of this study was to report the "Outcome Reporting in Brief Intervention Trials: Alcohol" (ORBITAL) recommended core outcome set (COS) to improve efficacy and effectiveness trials/evaluations for alcohol brief interventions (ABIs). METHOD: A systematic review identified 2,641 outcomes in 401 ABI articles measured by 1,560 different approaches. These outcomes were classified into outcome categories, and 150 participants from 19 countries participated in a two-round e-Delphi outcome prioritization exercise. This process prioritized 15 of 93 outcome categories for discussion at a consensus meeting of key stakeholders to decide the COS. A psychometric evaluation determined how to measure the outcomes. RESULTS: Ten outcomes were voted into the COS at the consensus meeting: (a) typical frequency, (b) typical quantity, (c) frequency of heavy episodic drinking, (d) combined consumption measure summarizing alcohol use, (e) hazardous or harmful drinking (average consumption), (f) standard drinks consumed in the past week (recent, current consumption), (g) alcohol-related consequences, (h) alcohol-related injury, (i) use of emergency health care services (impact of alcohol use), and (j) quality of life. CONCLUSIONS: The ORBITAL COS is an international consensus standard for future ABI trials and evaluations. It can improve the synthesis of new findings, reduce redundant/selective reporting (i.e., reporting only some, usually significant outcomes), improve between-study comparisons, and enhance the relevance of trial and evaluation findings to decision makers. The COS is the recommended minimum and does not exclude other, additional outcomes.

      3. Understanding behavioral characteristics and health outcomes of people with HIV (PWH) who inject drugs and PWH who use drugs, but do not inject, can help inform public health interventions and improve HIV clinical outcomes. However, recent, nationally representative estimates are lacking. We used 2015-2018 Medical Monitoring Project data to examine health outcome differences among adults with diagnosed HIV who injected drugs or who only used non-injection drugs in the past year. Data were obtained from participant interviews and medical record abstraction. We reported weighted percentages and prevalence ratios with predicted marginal means to assess differences between groups (P < 0.05). PWH who injected drugs were more likely to engage in high-risk sex; experience depression and anxiety symptoms, homelessness, and incarceration; and have lower levels of care retention, antiretroviral therapy adherence, and viral suppression. Tailored, comprehensive interventions are critical for improving outcomes among PWH who use drugs, particularly among those who inject drugs.

    • Veterinary Medicine
      1. OBJECTIVES: Information on knowledge of public health professionals about health aspects of the human-animal interface, referred to as One Health, is limited. The objective of this study was to identify factors associated with animal welfare attitudes, practices, and One Health awareness among US Public Health Service (USPHS) officers to assess preparedness for public health response. METHODS: USPHS officers participated in an online, self-administered survey from February 15 through March 2, 2018. A total of 1133 of 6474 (17.5%) USPHS officers responded. We collected information on officers' demographic characteristics, animal welfare attitudes and practices, volunteer and work exposure to animals, and One Health knowledge. We compared (1) One Health knowledge and animal work exposure (deployment, regular assignment, or none) and (2) animal welfare importance and animal work exposure. To adjust for demographic characteristics associated with One Health knowledge, we used multivariable logistic regression. RESULTS: One-third of nonveterinary officers reported encountering animals during deployment, and 65% reported that animal welfare was very or extremely important. We found no difference in One Health knowledge between nonveterinary officers who participated in deployments involving animals and nonveterinary officers who had no work exposure to animals (adjusted odds ratio [aOR] = 1.11; 95% CI, 0.71-1.75). Nonveterinary officers who participated in animal-related public health activities during regular assignment were more likely to have One Health knowledge than nonveterinary officers who had no work exposure to animals (aOR = 7.88; 95% CI, 5.36-11.59). CONCLUSIONS: One Health knowledge and awareness should be further explored in the current US public health workforce to identify training needs for emergency preparedness and other collaborative opportunities.

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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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