Issue 47, December 20, 2021

CDC Science Clips: Volume 13, Issue 47, December 20, 2021

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

  1. 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. Pharmacist Interventions for Medication Adherence: Community Guide Economic Reviews for Cardiovascular Diseaseexternal icon
        Jacob V, Reynolds JA, Chattopadhyay SK, Hopkins DP, Therrien NL, Jones CD, Durthaler JM, Rask KJ, Cuellar AE, Clymer JM, Kottke TE.
        Am J Prev Med. 2021 Dec 4.
        INTRODUCTION: Adherence to medications for cardiovascular disease and its risk factors is less than optimal, although greater adherence to medication has been shown to reduce the risk factors for cardiovascular disease. This paper examines the economics of tailored pharmacy interventions to improve medication adherence for cardiovascular disease prevention and management. METHODS: Literature from inception of databases to May 2019 was searched, yielding 29 studies for cardiovascular disease prevention and 9 studies for cardiovascular disease management. Analyses were done from June 2019 through May 2020. All monetary values are in 2019 U.S. dollars. RESULTS: The median intervention cost per patient per year was $246 for cardiovascular disease prevention and $292 for cardiovascular disease management. The median change in healthcare cost per person per year due to the intervention was -$355 for cardiovascular disease prevention and -$2,430 for cardiovascular disease management. The median total cost per person per year was -$89 for cardiovascular disease prevention, with a median return on investment of 0.01. The median total cost per person per year for cardiovascular disease management was -$1,080, with a median return on investment of 7.52, and 6 of 7 estimates indicating reduced healthcare cost averted exceeded intervention cost. For cardiovascular disease prevention, the median cost per quality-adjusted life year gained was $11,298. There were no cost effectiveness studies for cardiovascular disease management. DISCUSSION: The evidence shows that tailored pharmacy-based interventions to improve medication adherence are cost effective for cardiovascular disease prevention. For cardiovascular disease management, healthcare cost averted exceeds the cost of implementation for a favorable return on investment from a healthcare systems perspective.

      2. Promising Interventions to Prevent Liver Cancer in Idahoexternal icon
        Momin B, Nielsen D, Schaff S, Mezzo JL, Cariou C.
        Health Promot Pract. 2021 Dec 7:15248399211057154.
        INTRODUCTION: The Idaho Comprehensive Cancer Control Program (ICCCP) collaborated with the Idaho Immunization Program (IIP) to plan and implement activities to increase knowledge and awareness of liver cancer prevention through tailored hepatitis B immunization messaging to the Idaho community and health care providers. PURPOSE AND OBJECTIVES: In this article, we report findings from an evaluation of these activities. INTERVENTIONS APPROACH: The two programs implemented liver cancer prevention activities between May 2017 and December 2017; strategies included a social media vaccination awareness campaign and health care provider education. EVALUATION METHODS: Facebook Insights was used to report, and descriptive statistics were used to analyze, data from the social media campaign. Descriptive statistics were used to analyze data collected from a retrospective pre-post survey for the health care provider presentations and paired t-tests were conducted to detect differences between pre- and postexposure. RESULTS: For the social media campaign, ICCCP and IIP posted a total of 32 liver cancer and hepatitis B vaccination posts on their respective Facebook pages, which reached 42,804 unique users. For the health care provider presentations, there was a statistically significant increase in awareness, knowledge, ability, and intention among health care providers. IMPLICATIONS FOR PUBLIC HEALTH: Our evaluation serves as an example of how public health social media can reach consumers and how educating providers can raise awareness on the importance of hepatitis B vaccination as a means of preventing liver cancer.

      3. Trends in leading causes of hospitalisation of adults with diabetes in England from 2003 to 2018: an epidemiological analysis of linked primary care recordsexternal icon
        Pearson-Stuttard J, Cheng YJ, Bennett J, Vamos EP, Zhou B, Valabhji J, Cross AJ, Ezzati M, Gregg EW.
        Lancet Diabetes Endocrinol. 2021 Nov 30.
        BACKGROUND: Diabetes leads to a wide range of established vascular and metabolic complications that has resulted in the implementation of diverse prevention programmes across high-income countries. Diabetes has also been associated with an increased risk of a broader set of conditions including cancers, liver disease, and common infections. We aimed to examine the trends in a broad set of cause-specific hospitalisations in individuals with diabetes in England from 2003 to 2018. METHODS: In this epidemiological analysis, we identified 309 874 individuals 18 years or older with diabetes (type 1 or 2) in England from the Clinical Practice Research Datalink linked to Hospital Episode Statistics inpatient data from 2003 to 2018. We generated a mixed prevalent and incident diabetes study population through serial cross sections and follow-up over time. We used a discretised Poisson regression model to estimate annual cause-specific hospitalisation rates in men and women with diabetes across 17 cause groupings. We generated a 1:1 age-matched and sex-matched population of individuals without diabetes to compare cause-specific hospitalisation rates in those with and without diabetes. FINDINGS: Hospitalisation rates were higher for all causes in persons with diabetes than in those without diabetes throughout the study period. Diabetes itself and ischaemic heart disease were the leading causes of excess (defined as absolute difference in the rate in the populations with and without diabetes) hospitalisation in 2003. By 2018, non-infectious and non-cancerous respiratory conditions, non-diabetes-related cancers, and ischaemic heart disease were the most common causes of excess hospitalisation across men and women. Hospitalisation rates of people with diabetes declined and causes of hospitalisation changed. Almost all traditional diabetes complication groups (vascular diseases, amputations, and diabetes) decreased, while conditions non-specific to diabetes (cancers, infections, non-infectious and non-cancerous respiratory conditions) increased. These differing trends represented a change in the cause of hospitalisation, such that the traditional diabetes complications accounted for more than 50% of hospitalisation in 2003, but only approximately 30% in 2018. In contrast, the proportion of hospitalisations due to respiratory infections between the same time period increased from 3% to 10% in men and from 4% to 12% in women. INTERPRETATIONS: Changes in the composition of excess risk and hospitalisation burden in those with diabetes means that preventative and clinical measures should evolve to reflect the diverse set of causes that are driving persistent excess hospitalisation in those with diabetes. FUNDING: Wellcome Trust.

    • Communicable Diseases
      1. Improving same-day ART in Botswana: effects of a multifaceted national interventionexternal icon
        Montebatsi M, Lavoie MC, Blanco N, Marima R, Sebina K, Mangope J, Ntwayagae O, Whittington A, Letebele M, Lekone P, Hess KL, Thomas V, Ramaabya D, Ramotsababa M, Stafford KA, Ndwapi N.
        Aids. 2021 Dec 6.
        BACKGROUND: In 2019, the Botswana Ministry of Health and Wellness (MOHW) implemented an HIV national Reboot program, which was needed for refocusing and intensifying efforts for achieving epidemic control. The strategies deployed as part of Reboot were reviewed and evaluated for their effect on same-day and within-seven-days (fast-track initiation) antiretroviral therapy (ART) initiation among adults newly identified with HIV. METHODS: We conducted a retrospective cohort analysis of patients aged 18 years or older who were newly diagnosed with HIV from October 2018 to September 2019 across 41 health facilities. We used generalized linear mixed models, adjusting for clustering by facility, to assess the association of the Reboot with same-day or within-seven-days ART initiation (fast-track initiation). RESULTS: From October 2018 to January 2019, 28% (636/2,269) of newly diagnosed HIV patients were initiated the same day of diagnosis, and 56% (1,260/2,269) were initiated within seven days. Following the launch of Reboot (February to September 2019), 59% (2,092/3,553) were initiated the same day of diagnosis, and 77% (2,752/3,553) were initiated within seven days. Clients were 2.08 (aRR 95% CI 1.79-2.43) times more likely to be initiated the same day of diagnosis and 1.39 (aRR 95% CI 1.28-1.52) times more likely to be initiated within seven days than before Reboot after adjusting for sex and age. CONCLUSION: In Botswana, a multifaceted national intervention improved timely ART initiation. Identifying and implementing different client-centered strategies to facilitate ART initiation is critical to preventing AIDS-related complications and prevent ongoing transmission.

      2. Evaluation of Sputum-Culture Results for Tuberculosis Patients in the United States-Affiliated Pacific Islandsexternal icon
        Ghosh S, Felix D, Kammerer JS, Talarico S, Brostrom R, Starks A, Silk B.
        Asia Pac J Public Health. 2021 Dec 7:10105395211060119.
        Sputum-culture confirmation guides tuberculosis (TB) diagnosis and patient management but has previously been reported to be low in the US-Affiliated Pacific Islands (USAPI). We evaluated factors associated with positive sputum-culture results by analyzing TB case surveillance and laboratory data, including sputa quality and quantity for diagnostic specimens from the USAPI. A lower proportion of sputum specimens were reported as culture positive from the USAPI (42%), compared with Hawaii (58%) and the United States (55%). Few (3%) sputa collected from TB patients in the USAPI had both optimal quality and quantity; 40% had optimal quality (mucoid), and 7% had optimal quantity (>5 mL). Suboptimal sputum specimen quality and quantity contributed to fewer sputum-culture positive results in the USAPI. Improving sputum collection and handling might lead to more culture positive results and ultimately improve patient care and TB control in USAPI.

      3. Treatment-adjusted prevalence to assess HIV testing programmesexternal icon
        Tippett Barr BA, Lowrance D, Johnson CC, Baggaley RC, Rogers JH, Balachandra SK, Barker J, Kalua T, Bunga S, Low-Beer D, Payne D, Bulterys MG, Jahn A.
        Bull World Health Organ. 2021 Dec 1;99(12):874-882.
        Scale-up of human immunodeficiency virus (HIV) testing and antiretroviral therapy (ART) for people living with HIV has been increasing in sub-Saharan Africa. As a result, areas with high HIV prevalence are finding a declining proportion of people testing positive in their national testing programmes. In eastern and southern Africa, where there are settings with adult HIV prevalence of 12% and above, the positivity from national HIV testing services has dropped to below 5%. Identifying those in need of ART is therefore becoming more costly for national HIV programmes. Annual target-setting assumes that national testing positivity rates approximate that of population prevalence. This assumption has generated an increased focus on testing approaches which achieve higher rates of HIV positivity. This trend is a departure from the provider-initiated testing and counselling strategy used early in the global HIV response. We discuss a new indicator, treatment-adjusted prevalence, that countries can use as a practical benchmark for estimating the expected adult positivity in a testing programme when accounting for both national HIV prevalence and ART coverage. The indicator is calculated by removing those people receiving ART from the numerator and denominator of HIV prevalence. Treatment-adjusted prevalence can be readily estimated from existing programme data and population estimates, and in 2019, was added to the World Health Organization guidelines for HIV testing and strategic information. Using country examples from Kenya, Malawi, South Sudan and Zimbabwe we illustrate how to apply this indicator and we discuss the potential public health implications of its use from the national to facility level.

      4. Multisystem Inflammatory Syndrome in Children-United States, February 2020-July 2021external icon
        Miller AD, Zambrano LD, Yousaf AR, Abrams JY, Meng L, Wu MJ, Melgar M, Oster ME, Godfred Cato SE, Belay ED, Campbell AP.
        Clin Infect Dis. 2021 Dec 5.
        BACKGROUND: Multisystem inflammatory syndrome in children (MIS-C) is a severe hyperinflammatory condition in persons aged <21 years associated with antecedent SARS-CoV-2 infection. Our objective was to describe MIS-C cases reported to CDC's national surveillance since the COVID-19 pandemic began. METHODS: We included patients meeting the MIS-C case definition with onset date from February 19, 2020 through July 31, 2021, using CDC's MIS-C case report form, which collects information on demographics, clinical presentation, and laboratory results. Trends over time across 3 MIS-C pandemic waves were assessed using Cochran-Armitage test for categorical and Jonckheere-Terpstra test for continuous variables. RESULTS: Of 4,901 reported cases, 4,470 met inclusion criteria. Median patient age increased over time (P<0.001), with a median of 9 years (interquartile range, 5-13 years) during the most recent (third) wave. Male predominance also increased (62% in third wave, P<0.001). A significant (P<0.001) increase in severe hematologic and gastrointestinal involvement was observed across the study period. Frequency of several cardiovascular complications (i.e., cardiac dysfunction, myocarditis, and shock/ vasopressor receipt) and renal failure declined (P<0.001). Provision of critical care including mechanical ventilation (P<0.001) and extracorporeal membrane oxygenation (ECMO; P=0.046) decreased, as did duration of hospitalization and mortality (each P<0.001). CONCLUSIONS: Over the first 3 pandemic waves of MIS-C in the United States, cardiovascular complications and clinical outcomes including length of hospitalization, receipt of ECMO, and death decreased over time. These data serve as a baseline for monitoring future trends associated with SARS-CoV-2 B.1.617.2 (Delta) or other variants and increased COVID-19 vaccination among children.

      5. SARS-CoV-2 Variants, South Sudan, January-March 2021external icon
        Bugembe DL, Phan MV, Abias AG, Ayei J, Deng LL, Lako RL, Rumunu J, Kaleebu P, Wamala JF, Hm JJ, Lodiongo DK, Bunga S, Cotten M.
        Emerg Infect Dis. 2021 Dec;27(12):3133-3136.
        As the coronavirus pandemic continues, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequence data are required to inform vaccine efforts. We provide SARS-CoV-2 sequence data from South Sudan and document the dominance of SARS-CoV-2 lineage B.1.525 (Eta variant) during the country's second wave of infection.

      6. Cluster of SARS-CoV-2 Gamma Variant Infections, Parintins, Brazil, March 2021external icon
        da Silva JF, Esteves RJ, Siza C, Soares EP, Ramos TC, Campelo EC, da Costa CF, de Alencar LC, Cavalcante RP, Florêncio CR, Mattos TP, Bonecini-Almeida MG, Silva-Flannery L, Marston BJ, Morgan J, Plucinski M, Naveca F.
        Emerg Infect Dis. 2021 Dec 2;28(1).
        High case counts after the Gamma (P. 1) variant of severe acute respiratory syndrome coronavirus 2 emerged in Brazil raised concerns that previously infected persons might become reinfected. Investigation of a cluster of coronavirus disease cases in Parintins, in the Brazilian Amazon, suggested household transmission but did not identify high rates of reinfection.

      7. Surface‒Aerosol Stability and Pathogenicity of Diverse Middle East Respiratory Syndrome Coronavirus Strains, 2012‒2018external icon
        van Doremalen N, Letko M, Fischer RJ, Bushmaker T, Schulz J, Yinda CK, Seifert SN, Kim NJ, Hemida MG, Kayali G, Park WB, Perera R, Tamin A, Thornburg NJ, Tong S, Queen K, van Kerkhove MD, Choi YK, Oh MD, Assiri AM, Peiris M, Gerber SI, Munster VJ.
        Emerg Infect Dis. 2021 Dec;27(12):3052-3062.
        Middle East respiratory syndrome coronavirus (MERS-CoV) infects humans and dromedary camels and is responsible for an ongoing outbreak of severe respiratory illness in humans in the Middle East. Although some mutations found in camel-derived MERS-CoV strains have been characterized, most natural variation found across MERS-CoV isolates remains unstudied. We report on the environmental stability, replication kinetics, and pathogenicity of several diverse isolates of MERS-CoV, as well as isolates of severe acute respiratory syndrome coronavirus 2, to serve as a basis of comparison with other stability studies. Although most MERS-CoV isolates had similar stability and pathogenicity in our experiments, the camel-derived isolate C/KSA/13 had reduced surface stability, and another camel isolate, C/BF/15, had reduced pathogenicity in a small animal model. These results suggest that although betacoronaviruses might have similar environmental stability profiles, individual variation can influence this phenotype, underscoring the need for continual global viral surveillance.

      8. INTRODUCTION: We assessed reproductive intentions and associated characteristics among men enrolled in the Sustainable Health Center Implementation pre-exposure prophylaxis (PrEP) Pilot (SHIPP) Study. METHODS: We analyzed baseline data from 1275 men who self-identified as gay or bisexual and participated in the SHIPP study. SHIPP was a cohort study of PrEP implementation in five community health centers in Chicago, Jackson, Philadelphia, and Washington, D.C. conducted from 2014 to 2016. Participants completed audio computer-assisted self-interviews querying intentions to have a child in the future. We estimated the association between participants' reproductive intentions and their characteristics using Poisson regression models. RESULTS: Approximately 47% of participants indicated their intentions to have a child. Black/non-Hispanic (aPR = 1.40; 95% CI: 1.10-1.78) and other/non-Hispanic participants (aPR = 1.40; 95% CI: 1.01-1.93) were more likely to report intentions to have a child than white/non-Hispanic participants. Participants were less likely to report intentions to have children as age increased (18-29 years, reference group; 30-39 years, aPR = 0.80, 95% CI: 0.64-0.99; 40-49 years, aPR = 0.49, 95% CI: 0.33-0.72; 50+ years, aPR = 0.07, 95% CI: 0.02-0.21). CONCLUSIONS: Clinicians offering PrEP to black and other/non-Hispanic gay and bisexual men should assess their reproductive intentions as family-planning counseling may be an opportunity to introduce PrEP to HIV-negative gay and bisexual men.

      9. Prevalence and genetic characterization of noroviruses in children with acute gastroenteritis in Senegal, 2007-2010external icon
        Kebe O, Fernandez-Garcia MD, Zinsou BE, Diop A, Fall A, Ndiaye N, Vinjé J, Ndiaye K.
        J Med Virol. 2021 Dec 2.
        Norovirus is the leading cause of sporadic and epidemic acute gastroenteritis (AGE) in children and adults around the world. We investigated the molecular diversity of noroviruses in a paediatric population in Senegal between 2007-2010 prior to rotavirus vaccine implementation. Stool samples were collected from 599 children under 5 years of age consulting for AGE in a hospital in Dakar. Specimens were screened for noroviruses using the Allplex™ GI-Virus Assay. Positive samples were genotyped after sequencing of conventional RT-PCR products. Noroviruses were detected in 79 (13.2%) of the children, with GII.4 (64%) and GII.6 (10%) as the most frequently identified genotypes. Our study describes the distribution of genotypes between 2007 and 2010 and should be a baseline for comparison with more contemporary studies. This could help decision makers on possible choices of norovirus vaccines in the event of future introduction. This article is protected by copyright. All rights reserved.

      10. Genetic and Antigenic Characterization of an Influenza A(H3N2) Outbreak in Cambodia and the Greater Mekong Subregion during the COVID-19 Pandemic, 2020external icon
        Siegers JY, Dhanasekaran V, Xie R, Deng YM, Patel S, Ieng V, Moselen J, Peck H, Aziz A, Sarr B, Chin S, Heng S, Khalakdina A, Kinzer M, Chau D, Raftery P, Duong V, Sovann L, Barr IG, Karlsson EA.
        J Virol. 2021 Nov 23;95(24):e0126721.
        Introduction of non-pharmaceutical interventions to control COVID-19 in early 2020 coincided with a global decrease in active influenza circulation. However, between July and November 2020, an influenza A(H3N2) epidemic occurred in Cambodia and in other neighboring countries in the Greater Mekong Subregion in Southeast Asia. We characterized the genetic and antigenic evolution of A(H3N2) in Cambodia and found that the 2020 epidemic comprised genetically and antigenically similar viruses of Clade3C2a1b/131K/94N, but they were distinct from the WHO recommended influenza A(H3N2) vaccine virus components for 2020-2021 Northern Hemisphere season. Phylogenetic analysis revealed multiple virus migration events between Cambodia and bordering countries, with Laos PDR and Vietnam also reporting similar A(H3N2) epidemics immediately following the Cambodia outbreak: however, there was limited circulation of these viruses elsewhere globally. In February 2021, a virus from the Cambodian outbreak was recommended by WHO as the prototype virus for inclusion in the 2021-2022 Northern Hemisphere influenza vaccine. IMPORTANCE The 2019 coronavirus disease (COVID-19) pandemic has significantly altered the circulation patterns of respiratory diseases worldwide and disrupted continued surveillance in many countries. Introduction of control measures in early 2020 against Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection has resulted in a remarkable reduction in the circulation of many respiratory diseases. Influenza activity has remained at historically low levels globally since March 2020, even when increased influenza testing was performed in some countries. Maintenance of the influenza surveillance system in Cambodia in 2020 allowed for the detection and response to an influenza A(H3N2) outbreak in late 2020, resulting in the inclusion of this virus in the 2021-2022 Northern Hemisphere influenza vaccine.

      11. Immune-mediated attenuation of influenza illness after infection: opportunities and challengesexternal icon
        Patel MM, York IA, Monto AS, Thompson MG, Fry AM.
        Lancet Microbe. 2021 ;2(12):e715-e725.

      12. Vital Signs: HIV Infection, Diagnosis, Treatment, and Prevention Among Gay, Bisexual, and Other Men Who Have Sex with Men - United States, 2010-2019external icon
        Pitasi MA, Beer L, Cha S, Lyons SJ, Hernandez AL, Prejean J, Valleroy LA, Crim SM, Trujillo L, Hardman D, Painter EM, Petty J, Mermin JH, Daskalakis DC, Hall HI.
        MMWR Morb Mortal Wkly Rep. 2021 Dec 3;70(48):1669-1675.
        BACKGROUND: Men who have sex with men (MSM) accounted for two thirds of new HIV infections in the United States in 2019 despite representing approximately 2% of the adult population. METHODS: CDC analyzed surveillance data to determine trends in estimated new HIV infections and to assess measures of undiagnosed infection and HIV prevention and treatment services including HIV testing, preexposure prophylaxis (PrEP) use, antiretroviral therapy (ART) adherence, and viral suppression, as well as HIV-related stigma. RESULTS: The estimated number of new HIV infections among MSM was 25,100 in 2010 and 23,100 in 2019. New infections decreased significantly among White MSM but did not decrease among Black or African American (Black) MSM and Hispanic/Latino MSM. New infections increased among MSM aged 25-34 years. During 2019, approximately 83% of Black MSM and 80% of Hispanic/Latino MSM compared with 90% of White MSM with HIV had received an HIV diagnosis. The lowest percentage of diagnosed infection was among MSM aged 13-24 years (55%). Among MSM with a likely PrEP indication, discussions about PrEP with a provider and PrEP use were lower among Black MSM (47% and 27%, respectively) and Hispanic/Latino MSM (45% and 31%) than among White MSM (59% and 42%). Among MSM with an HIV diagnosis, adherence to ART and viral suppression were lower among Black MSM (48% and 62%, respectively) and Hispanic/Latino MSM (59% and 67%) compared with White MSM (64% and 74%). Experiences of HIV-related stigma among those with an HIV diagnosis were higher among Black MSM (median = 33; scale = 0-100) and Hispanic/Latino MSM (32) compared with White MSM (26). MSM aged 18-24 years had the lowest adherence to ART (45%) and the highest median stigma score (39). CONCLUSION: Improving access to and use of HIV services for MSM, especially Black MSM, Hispanic/Latino MSM, and younger MSM, and addressing social determinants of health, such as HIV-related stigma, that contribute to unequal outcomes will be essential to end the HIV epidemic in the United States.

      13. Coronavirus Disease 2019-Associated Invasive Fungal Infectionexternal icon
        Baddley JW, Thompson GR, Chen SC, White PL, Johnson MD, Nguyen MH, Schwartz IS, Spec A, Ostrosky-Zeichner L, Jackson BR, Patterson TF, Pappas PG.
        Open Forum Infect Dis. 2021 Dec;8(12):ofab510.
        Coronavirus disease 2019 (COVID-19) can become complicated by secondary invasive fungal infections (IFIs), stemming primarily from severe lung damage and immunologic deficits associated with the virus or immunomodulatory therapy. Other risk factors include poorly controlled diabetes, structural lung disease and/or other comorbidities, and fungal colonization. Opportunistic IFI following severe respiratory viral illness has been increasingly recognized, most notably with severe influenza. There have been many reports of fungal infections associated with COVID-19, initially predominated by pulmonary aspergillosis, but with recent emergence of mucormycosis, candidiasis, and endemic mycoses. These infections can be challenging to diagnose and are associated with poor outcomes. The reported incidence of IFI has varied, often related to heterogeneity in patient populations, surveillance protocols, and definitions used for classification of fungal infections. Herein, we review IFI complicating COVID-19 and address knowledge gaps related to epidemiology, diagnosis, and management of COVID-19-associated fungal infections.

      14. Improving uptake of prevention of mother-to-child HIV transmission services in Benue State, Nigeria through a faith-based congregational strategyexternal icon
        Montandon M, Efuntoye T, Itanyi IU, Onoka CA, Onwuchekwa C, Gwamna J, Schwitters A, Onyenuobi C, Ogidi AG, Swaminathan M, Oko JO, Ijaodola G, Odoh D, Ezeanolue EE.
        PLoS One. 2021 ;16(12):e0260694.
        BACKGROUND: Nigeria has low antiretroviral therapy (ART) coverage among HIV-positive pregnant women. In a previous cluster-randomized trial in Nigeria, Baby Shower events resulted in higher HIV testing coverage and linkage of pregnant women to ART; here, we assess outcomes of Baby Shower events in a non-research setting. METHODS: Baby Shower events, including a prayer ceremony, group education, music, gifting of a "mama pack" with safe delivery supplies, and HIV testing with ART linkage support for HIV-positive pregnant women, were conducted in eighty sites in Benue State, Nigeria. Client questionnaires (including demographics, ANC attendance, and HIV testing history), HIV test results, and reported linkage to ART were analyzed. Descriptive data on HIV testing and ART linkage data for facility-based care at ANC clinics in Benue State were also analyzed for comparison. RESULTS: Between July 2016 and October 2017, 10,056 pregnant women and 6,187 male partners participated in Baby Shower events; 61.5% of women attended with a male partner. Nearly half of female participants (n = 4515, 44.9%) were not enrolled in ANC for the current pregnancy, and 22.3% (n = 2,241) of female and 24.8% (n = 1,532) of male participants reported they had never been tested for HIV. Over 99% (n = 16,240) of participants had their HIV status ascertained, with 7.2% of females (n = 724) and 4.0% of males (n = 249) testing HIV-positive, and 2.9% of females (n = 274) and 2.3% of males (n = 138) receiving new HIV-positive diagnoses. The majority of HIV-positive pregnant women (93.0%, 673/724) were linked to ART. By comparison, at health facilities in Benue State during a similar time period, 99.7% of pregnant women had HIV status ascertained, 8.4% had a HIV-positive status, 2.1% were newly diagnosed HIV-positive, and 100% were linked to ART. CONCLUSION: Community-based programs such as the faith-based Baby Shower intervention complement facility-based approaches and can reach individuals who would not otherwise access facility-based care. Future Baby Showers implementation should incorporate enhanced support for ART linkage and retention to maximize the impact of this intervention on vertical HIV transmission.

      15. HIV incidence, viremia, and the national response in Eswatini: Two sequential population-based surveysexternal icon
        Nkambule R, Philip NM, Reid G, Mnisi Z, Nuwagaba-Biribonwoha H, Ao TT, Ginindza C, Duong YT, Patel H, Saito S, Solmo C, Brown K, Moore CS, Voetsch AC, Bicego G, Bock N, Mhlanga F, Dlamini T, Mabuza K, Zwane A, Sahabo R, Dobbs T, Parekh BS, El-Sadr W, Ryan C, Justman J.
        PLoS One. 2021 ;16(12):e0260892.
        With the highest HIV incidence and prevalence globally, the government of Eswatini started a substantial scale-up of HIV treatment and prevention services in 2011. Two sequential large population-based surveys were conducted before and after service expansion to assess the impact of the national response. Cross-sectional, household-based, nationally representative samples of adults, ages 18 to 49 years, were sampled in 2011 and 2016. We measured HIV prevalence, incidence (recent infection based on limiting antigen ≤1.5 optical density units and HIV RNA ≥1000 copies/mL), viral load suppression (HIV RNA <1000 copies/mL among all seropositive adults) and unsuppressed viremia (HIV RNA ≥1000 copies/mL among all, regardless of HIV status) and assessed for temporal changes by conducting a trend analysis of the log ratio of proportions, using a Z statistic distribution. HIV prevalence remained stable from 2011 to 2016 [32% versus 30%, p = 0.10]. HIV incidence significantly declined 48% [2.48% versus 1.30%, p = 0.01]. Incidence remained higher among women than men [2011: 3.16% versus 1.83%; 2016: 1.76% versus 0.86%], with a smaller but significant relative reduction among women [44%; p = 0.04] than men [53%; p = 0.09]. The proportion of seropositive adults with viral load suppression significantly increased from 35% to 71% [p < .001]. The proportion of the total adult population with unsuppressed viremia decreased from 21% to 9% [p < .001]. National HIV incidence in Eswatini decreased by nearly half and viral load suppression doubled over a five-year period. Unsuppressed viremia in the total population decreased 58%. These population-based findings demonstrate the national impact of expanded HIV services in a hyperendemic country.

      16. Uninterrupted HIV treatment for women: Policies and practices for care transitions during pregnancy and breastfeeding in Côte d'Ivoire, Lesotho and Malawiexternal icon
        Phillips TK, Olsen H, Teasdale CA, Geller A, Ts'oeu M, Buono N, Kayira D, Ngeno B, Modi S, Abrams EJ.
        PLoS One. 2021 ;16(12):e0260530.
        Transitions between services for continued antiretroviral treatment (ART) during and after pregnancy are a commonly overlooked aspect of the HIV care cascade, but ineffective transitions can lead to poor health outcomes for women and their children. In this qualitative study, we conducted interviews with 15 key stakeholders from Ministries of Health along with PEPFAR-supported and other in-country non-governmental organizations actively engaged in national programming for adult HIV care and prevention of mother-to-child-transmission of HIV (PMTCT) services in Côte d'Ivoire, Lesotho and Malawi. We aimed to understand perspectives regarding transitions into and out of PMTCT services for continued ART. Thematic analysis revealed that, although transitions of care are necessary and a potential point of loss from ART care in all three countries, there is a lack of clear guidance on transition approach and no formal way of monitoring transition between services. Several opportunities were identified to monitor and strengthen transitions of care for continued ART along the PMTCT cascade.

      17. Characteristics and clinical outcomes of patients hospitalized with laboratory-confirmed COVID-19-Puerto Rico, March-August 2020external icon
        Volkman HR, Pérez-Padilla J, Wong JM, Sánchez-González L, Acevedo-Molina L, Lugo-Menéndez M, Oliveras García CA, Adams LE, Frasqueri-Quintana VM, Rodriguez-Gonzalez R, González-Cosme JA, Calvo Díaz AE, Alvarado LI, Rivera-Amill V, Brown J, Wong KK, Bertrán-Pasarell J, Paz-Bailey G.
        PLoS One. 2021 ;16(12):e0260599.
        Hispanics are the majority ethnic population in Puerto Rico where we reviewed charts of 109 hospitalized COVID-19 patients to better understand demographic and clinical characteristics of COVID-19 and determine risk factors for poor outcomes. Eligible medical records of hospitalized patients with confirmed COVID-19 illnesses were reviewed at four participating hospitals in population centers across Puerto Rico and data were abstracted that described the clinical course, interventions, and outcomes. We found hospitalized patients had a median of 3 underlying conditions with obesity and diabetes as the most frequently reported conditions. Intensive care unit (ICU) admission occurred among 28% of patients and 18% of patients died during the hospitalization. Patients 65 or older or with immune deficiencies had a higher risk for death. Common symptoms included cough, dyspnea, and fatigue; less than half of patients in the study reported fever which was less frequent than reported elsewhere in the literature. It is important for interventions within Hispanic communities to protect high-risk groups.

      18. Best Practices Implementation: Congenital Syphilis Prevention Efforts in Monroe County, New York 2018external icon
        Drame F, Urban MA, Inscho RR, Mendoza MD, Hiltunen K, Owens J, Stone C, Hart-Malloy R.
        Sex Transm Dis. 2021 Dec 6.

    • Disaster Preparedness and Emergency Services
      1. Global Health Security Preparedness and Response: An Analysis of the Relationship between Joint External Evaluation Scores and COVID-19 Response Performanceexternal icon
        Nguyen L, Brown MS, Couture A, Krishnan S, Shamout M, Hernandez L, Beaver J, Gomez Lopez A, Whitson C, Dick L, Greiner AL.
        BMJ Open. 2021 Dec 2;11(12):e050052.
        OBJECTIVES: The COVID-19 pandemic has highlighted the importance and complexity of a country's ability to effectively respond. The Joint External Evaluation (JEE) assessment was launched in 2016 to assess a country's ability to prevent, detect and respond to public health emergencies. We examined whether JEE indicators could be used to predict a country's COVID-19 response performance to tailor a country's support more effectively. DESIGN: From April to August 2020, we conducted interviews with Centers for Disease Control and Prevention country offices that requested COVID-19 support and previously completed the JEE (version 1.0). We used an assessment tool, the 'Emergency Response Capacity Tool' (ERCT), to assess COVID-19 response performance. We analysed 28 ERCT indicators aligned with eight JEE indicators to assess concordance and discordance using strict agreement and weighted kappa statistics. Generalised estimating equation (GEE) models were used to generate predicted probabilities for ERCT scores using JEE scores as the independent model variable. RESULTS: Twenty-three countries met inclusion criteria. Of the 163 indicators analysed, 42.3% of JEE and ERCT scores were in agreement (p value=0.02). The JEE indicator with the highest agreement (62%) was 'Emergency Operations Center (EOC) operating procedures and plans', while the lowest (16%) was 'capacity to activate emergency operations'. Findings were consistent with weighted kappa statistics. In the GEE model, EOC operating procedures and plans had the highest predicted probability (0.86), while indicators concerning response strategy and coordination had the lowest (≤0.5). CONCLUSIONS: Overall, there was low agreement between JEE scores and COVID-19 response performance, with JEE scores often trending higher. JEE indicators concerning coordination and operations were least predictive of COVID-19 response performance, underscoring the importance of not inferring country response readiness from JEE scores alone. More in-depth country-specific investigations are likely needed to accurately estimate response capacity and tailor countries' global health security activities.

    • Disease Reservoirs and Vectors
      1. Assessment of community support for Wolbachia-mediated population suppression as a control method for Aedes aegypti mosquitoes in a community cohort in Puerto Ricoexternal icon
        Sánchez-González L, Adams LE, Saavedra R, Little EM, Medina NA, Major CG, Bruck M, Miranda J, Rosado-Santiago C, Ryff K, Ortiz M, Brown G, Barrera R, Pérez-Guerra CL, Rivera-Amill V, Paz-Bailey G.
        PLoS Negl Trop Dis. 2021 Dec 6;15(12):e0009966.
        Arboviral diseases transmitted by Aedes species mosquitoes pose an increasing public health challenge in tropical regions. Wolbachia-mediated population suppression (Wolbachia suppression) is a vector control method used to reduce Aedes mosquito populations by introducing male mosquitoes infected with Wolbachia, a naturally occurring endosymbiotic bacterium. When Wolbachia-infected male mosquitoes mate with female wild mosquitoes, the resulting eggs will not hatch. Public support is vital to the successful implementation and sustainability of vector control interventions. Communities Organized to Prevent Arboviruses (COPA) is a cohort study to determine the incidence of arboviral disease in Ponce, Puerto Rico and evaluate vector control methods. Focus groups were conducted with residents of COPA communities to gather their opinion on vector control methods; during 2018-2019, adult COPA participants were interviewed regarding their views on Wolbachia suppression; and a follow-up questionnaire was conducted among a subset of participants and non-participants residing in COPA communities. We analyzed factors associated with support for this method. Among 1,528 participants in the baseline survey, median age was 37 years and 63% were female. A total of 1,032 (68%) respondents supported Wolbachia suppression. Respondents with an income of $40,000 or more were 1.34 times as likely [95% CI: 1.03, 1.37] to support Wolbachia suppression than those who earned less than $40,000 annually. Respondents who reported repellant use were 1.19 times as likely to support Wolbachia suppression [95% CI: 1.03, 1.37]. A follow-up survey in 2020 showed that most COPA participants (86%) and non-participants living in COPA communities (84%) supported Wolbachia suppression during and after an educational campaign. The most frequent questions regarding this method were related to its impact on human and animal health, and the environment. Continuous community engagement and education efforts before and during the implementation of novel vector control interventions are necessary to increase and maintain community support.

    • Environmental Health
      1. Human Melioidosis Caused by Novel Transmission of Burkholderia pseudomallei from Freshwater Home Aquarium, United Statesexternal icon
        Dawson P, Duwell MM, Elrod MG, Thompson RJ, Crum DA, Jacobs RM, Gee JE, Kolton CB, Liu L, Blaney DD, Thomas LG, Sockwell D, Weiner Z, Bower WA, Hoffmaster AR, Salzer JS.
        Emerg Infect Dis. 2021 Dec;27(12):3030-3035.
        Nearly all cases of melioidosis in the continental United States are related to international travel to areas to which Burkholderia pseudomallei, the bacterium that causes melioidosis, is endemic. We report the diagnosis and clinical course of melioidosis in a patient from the United States who had no international travel history and the public health investigation to determine the source of exposure. We tested environmental samples collected from the patient's home for B. pseudomallei by PCR and culture. Whole-genome sequencing was conducted on PCR-positive environmental samples, and results were compared with sequences from the patient's clinical specimen. Three PCR-positive environmental samples, all collected from a freshwater home aquarium that had contained imported tropical fish, were a genetic match to the clinical isolate from the patient. This finding suggests a novel route of exposure and a potential for importation of B. pseudomallei, a select agent, into the United States from disease-endemic areas.

      2. Climate Change and Human Health ECHO: Global Telementoring for Health Professionalsexternal icon
        Katzman JG, Herring D, Schramm P, Tomedi L, Maury JM, Kalishman S, Kazhe-Dominguez B, Liu J, Martin C, Arora S.
        J Med Educ Curric Dev. 2021 Jan-Dec;8:23821205211061019.
        OBJECTIVE: To increase the knowledge and communication skills of health professionals related to climate change and human health (CCHH). METHODS: From February to April 2021, Project ECHO (Extension for Community Healthcare Outcomes) created an 8-week, synchronous and virtual, CCHH ECHO telementoring series for health professionals. Didactics, simulated cases, and climate change tools were used to educate the interprofessional group of participants. RESULTS: During this CCHH ECHO pilot series, 625 unique participants represented 45 US states and 25 countries. The participants reported that they increased their knowledge, skills, and communication techniques regarding climate change and health. CONCLUSIONS: The human health effects of climate change is an emerging field, and increasing knowledge and communication skills among health practitioners is of critical importance. The CCHH ECHO is one potential platform that may reach a diverse community of health professionals globally due to the diffusion and demonopolization of knowledge.

      3. Demographic differences in use of household tap water in a representative sample of US adults, FallStyles 2019external icon
        Vanden Esschert K, Barrett CE, Collier SA, Garcia-Williams AG, Hannapel E, Yoder JS, Benedict KM.
        J Water Health. 2021 Dec;19(6):1014-1020.
        Tap water that is safe to consume may cause respiratory illness (e.g., Legionnaires' disease) when water conditions allow for proliferation and aerosolization of biofilm-associated pathogens. This study assessed household tap water consumption, exposure to aerosolized tap water, and associated demographics. A nationally representative FallStyles survey administered by Porter Novelli Public Services was sent to 4,677 US adult panelists in October 2019. There were 3,624 adults who completed the survey (77.5% response rate). Respondents were asked about self-reported use of household tap water for consumption (i.e., drinking, rinsing produce, or making ice) and use through water-aerosolizing devices (e.g., showerheads, humidifiers). Demographics included gender, age, race/ethnicity, education, income, region, and health status. Weighted analyses using complex sample survey procedures were used to assess tap water exposure by route and demographics. Most US adults are exposed to aerosolized tap water through showering (80.6%), and one in five are exposed through other water-aerosolizing devices (20.3%). Consumption and showering were greatest among older, White, higher educated, and higher-income adults. Aerosolized tap water can transmit waterborne pathogens and cause respiratory illness, especially among older age groups and people with weakened immune systems. These results will help target health messages for using water-aerosolizing devices safely.

      4. An evaluation of water, sanitation, and hygiene status and household assets and their associations with soil-transmitted helminthiasis and reported diarrhea in Nueva Santa Rosa, Guatemalaexternal icon
        Rao G, Blackstock AJ, Derado G, Cuéllar VM, Juliao P, Alvarez M, López B, Muñoz F, Thornton A, Patel JC, Lopez G, Rivera JG, Reyes L, Arvelo W, Lindblade KA, Roy SL.
        Journal of Water Sanitation and Hygiene for Development. 2021 ;11(3):362-373.
        Soil-transmitted helminth (STH) infections and diarrheal illness affect billions of people yearly. We conducted a cross-sectional survey in Nueva Santa Rosa, Guatemala to identify factors associated with STH infections and diarrhea using univariable and multivariable logistic regression models. On multivariable analyses, we found associations between STH infections and two factors: school-aged children (odds ratio (OR) vs. adults: 2.35, 95% CI 1.10–4.99) and household drinking water supply classified as ‘other improved’ (OR vs. ‘improved’: 7.00, CI 1.22–40.14). Finished floors in the household vs. natural floors were highly protective (OR 0.16, CI 0.05–0.50) for STH infection. In crowded households (>2.5 people/bedroom), observing water present at handwashing stations was also protective (OR 0.32, CI 0.11–0.98). When adjusted for drying hands, diarrhea was associated with preschool-age children (OR vs. adults: 3.33, CI 1.83–6.04), spending >10 min per round trip collecting water (OR 1.90, CI 1.02–3.56), and having a handwashing station ≤10 m near a sanitation facility (OR 3.69, CI 1.33–10.21). Our study indicates that familiar WASH interventions, such as increasing drinking water quantity and water at handwashing stations in crowded homes, coupled with a hygiene intervention like finished flooring may hold promise for STH and diarrhea control programs. © 2021 The Authors.

      5. Collateral consequences of agricultural fungicides on pathogenic yeasts: A One Health perspective to tackle azole resistanceexternal icon
        Castelo-Branco D, Lockhart SR, Chen YC, Santos DA, Hagen F, Hawkins NJ, Lavergne RA, Meis J, Le Pape P, Rocha MF, Sidrim JJ, Arendrup M, Morio F.
        Mycoses. 2021 Nov 25.
        Candida and Cryptococcus affect millions of people yearly, being responsible for a wide array of clinical presentations, including life-threatening diseases. Interestingly, most human pathogenic yeasts are not restricted to the clinical setting, as they are also ubiquitous in the environment. Recent studies raise concern regarding the potential impact of agricultural use of azoles on resistance to medical antifungals in yeasts, as previously outlined with Aspergillus fumigatus. Thus, we undertook a narrative review of the literature and provide lines of evidence suggesting that an alternative, environmental route of azole resistance, may develop in pathogenic yeasts, in addition to patient route. However, it warrants sound evidence to support that pathogenic yeasts cross border between plants, animals and humans and that environmental reservoirs may contribute to azole resistance in Candida or other yeasts for humans. As these possibilities could concern public health, we propose a road map for future studies under the One Health perspective.

      6. Modeling complex effects of exposure to particulate matter and extreme heat during pregnancy on congenital heart defects: A U.S. population-based case-control study in the National Birth Defects Prevention Studyexternal icon
        Simmons W, Lin S, Luben TJ, Sheridan SC, Langlois PH, Shaw GM, Reefhuis J, Romitti PA, Feldkamp ML, Nembhard WN, Desrosiers TA, Browne ML, Stingone JA.
        Sci Total Environ. 2021 Dec 2:152150.
        BACKGROUND/OBJECTIVE: Research suggests gestational exposure to particulate matter ≤2.5 μm (PM(2.5)) and extreme heat may independently increase risk of birth defects. We investigated whether duration of gestational extreme heat exposure modifies associations between PM(2.5) exposure and specific congenital heart defects (CHDs). We also explored nonlinear exposure-outcome relationships. METHODS: We identified CHD case children (n = 2824) and non-malformed live-birth control children (n = 4033) from pregnancies ending between 1999 and 2007 in the National Birth Defects Prevention Study, a U.S. population-based multicenter case-control study. We assigned mothers 6-week averages of PM(2.5) exposure during the cardiac critical period (postconceptional weeks 3-8) using the closest monitor within 50 km of maternal residence. We assigned a count of extreme heat days (EHDs, days above the 90th percentile of daily maximum temperature for year, season, and weather station) during this period using the closest weather station. Using generalized additive models, we explored logit-nonlinear exposure-outcome relationships, concluding logistic models were reasonable. We estimated joint effects of PM(2.5) and EHDs on six CHDs using logistic regression models adjusted for mean dewpoint and maternal age, education, and race/ethnicity. We assessed multiplicative and additive effect modification. RESULTS: Conditional on the highest observed EHD count (15) and at least one critical period day during spring/summer, each 5 μg/m(3) increase in average PM(2.5) exposure was significantly associated with perimembranous ventricular septal defects (VSDpm; OR: 1.54 [95% CI: 1.01, 2.41]). High EHD counts (8+) in the same population were positively, but non-significantly, associated with both overall septal defects and VSDpm. Null or inverse associations were observed for lower EHD counts. Multiplicative and additive effect modification estimates were consistently positive in all septal models. CONCLUSIONS: Results provide limited evidence that duration of extreme heat exposure modifies the PM(2.5)-septal defects relationship. Future research with enhanced exposure assessment and modeling techniques could clarify these relationships.

    • Epidemiology and Surveillance
      1. Advancements in the National Vital Statistics System to Meet the Real-Time Data Needs of a Pandemicexternal icon
        Ahmad FB, Anderson RN, Knight K, Rossen LM, Sutton PD.
        Am J Public Health. 2021 Dec;111(12):2133-2140.
        The National Center for Health Statistics' (NCHS's) National Vital Statistics System (NVSS) collects, processes, codes, and reviews death certificate data and disseminates the data in annual data files and reports. With the global rise of COVID-19 in early 2020, the NCHS mobilized to rapidly respond to the growing need for reliable, accurate, and complete real-time data on COVID-19 deaths. Within weeks of the first reported US cases, NCHS developed certification guidance, adjusted internal data processing systems, and stood up a surveillance system to release daily updates of COVID-19 deaths to track the impact of the COVID-19 pandemic on US mortality. This report describes the processes that NCHS took to produce timely mortality data in response to the COVID-19 pandemic. (Am J Public Health. 2021;111(12):2133-2140.

      2. High-quality data are accurate, relevant, and timely. Large national health surveys have always balanced the implementation of these quality dimensions to meet the needs of diverse users. The COVID-19 pandemic shifted these balances, with both disrupted survey operations and a critical need for relevant and timely health data for decision-making. The National Health Interview Survey (NHIS) responded to these challenges with several operational changes to continue production in 2020. However, data files from the 2020 NHIS were not expected to be publicly available until fall 2021. To fill the gap, the National Center for Health Statistics (NCHS) turned to 2 online data collection platforms-the Census Bureau's Household Pulse Survey (HPS) and the NCHS Research and Development Survey (RANDS)-to collect COVID-19‒related data more quickly. This article describes the adaptations of NHIS and the use of HPS and RANDS during the pandemic in the context of the recently released Framework for Data Quality from the Federal Committee on Statistical Methodology. (Am J Public Health. 2021;111(12):2167-2175.

      3. The National Health and Nutrition Examination Survey (NHANES), 2021-2022: Adapting Data Collection in a COVID-19 Environmentexternal icon
        Paulose-Ram R, Graber JE, Woodwell D, Ahluwalia N.
        Am J Public Health. 2021 Dec;111(12):2149-2156.
        The National Health and Nutrition Examination Survey (NHANES) is a unique source of national data on the health and nutritional status of the US population, collecting data through interviews, standard exams, and biospecimen collection. Because of the COVID-19 pandemic, NHANES data collection was suspended, with more than a year gap in data collection. NHANES resumed operations in 2021 with the NHANES 2021-2022 survey, which will monitor the health and nutritional status of the nation while adding to the knowledge of COVID-19 in the US population. This article describes the reshaping of the NHANES program and, specifically, the planning of NHANES 2021-2022 for data collection during the COVID-19 pandemic. Details are provided on how NHANES transformed its participant recruitment and data collection plans at home and at the mobile examination center to safely collect data in a COVID-19 environment. The potential implications for data users are also discussed. (Am J Public Health. 2021;111(12):2149-2156.

      4. Adapting Survey Data Collection to Respond to the COVID-19 Pandemic: Experiences From a Local Health Departmentexternal icon
        Seligson AL, Alroy KA, Sanderson M, Maleki AN, Fernandez S, Aviles A, Dumas SE, Perlman SE, Peebles K, Norman CC, Gwynn RC, Gould LH.
        Am J Public Health. 2021 Dec;111(12):2176-2185.
        The New York City (NYC) Department of Health and Mental Hygiene ("Health Department") conducts routine surveys to describe the health of NYC residents. During the COVID-19 pandemic, the Health Department adjusted existing surveys and developed new ones to improve our understanding of the impact of the pandemic on physical health, mental health, and social determinants of health and to incorporate more explicit measures of racial inequities. The longstanding Community Health Survey was adapted in 2020 to ask questions about COVID-19 and recruit respondents for a population-based severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serosurvey. A new survey panel, Healthy NYC, was launched in June 2020 and is being used to collect data on COVID-19, mental health, and social determinants of health. In addition, 7 Health Opinion Polls were conducted from March 2020 through March 2021 to learn about COVID-19-related knowledge, attitudes, and opinions, including vaccine intentions. We describe the contributions that survey data have made to the emergency response in NYC in ways that address COVID-19 and the profound inequities of the pandemic. (Am J Public Health. 2021;111(12):2176-2185.

      5. COVID-19 Pandemic Impact on the National Health Care Surveysexternal icon
        Ward BW, Sengupta M, DeFrances CJ, Lau DT.
        Am J Public Health. 2021 Dec;111(12):2141-2148.
        While underscoring the need for timely, nationally representative data in ambulatory, hospital, and long-term-care settings, the COVID-19 pandemic posed many challenges to traditional methods and mechanisms of data collection. To continue generating data from health care and long-term-care providers and establishments in the midst of the COVID-19 pandemic, the National Center for Health Statistics had to modify survey operations for several of its provider-based National Health Care Surveys, including quickly adding survey questions that captured the experiences of providing care during the pandemic. With the aim of providing information that may be useful to other health care data collection systems, this article presents some key challenges that affected data collection activities for these national provider surveys, as well as the measures taken to minimize the disruption in data collection and to optimize the likelihood of disseminating quality data in a timely manner. (Am J Public Health. 2021;111(12):2141-2148.

      6. Detection of SARS-CoV-2 in Wastewater at Residential College, Maine, USA, August-November 2020external icon
        Brooks YM, Gryskwicz B, Sheehan S, Piers S, Mahale P, McNeil S, Chase J, Webber D, Borys D, Hilton M, Robinson D, Sears S, Smith E, Lesher EK, Wilson R, Goodwin M, Pardales M.
        Emerg Infect Dis. 2021 ;27(12):3111-3114.
        We used wastewater surveillance to identify 2 coronavirus disease outbreaks at a college in Maine, USA. Cumulative increases of >1 log(10) severe acute respiratory syndrome coronavirus 2 RNA in consecutive 24-hour composite samples preceded the outbreaks. For 76% of cases, RNA was identified in grab samples from residence halls <7 days before case discovery.

      7. Recruitment of Patients With Amyotrophic Lateral Sclerosis for Clinical Trials and Epidemiological Studies: Descriptive Study of the National ALS Registry's Research Notification Mechanismexternal icon
        Mehta P, Raymond J, Han MK, Larson T, Berry JD, Paganoni S, Mitsumoto H, Bedlack RS, Horton DK.
        J Med Internet Res. 2021 Dec 7;23(12):e28021.
        BACKGROUND: Researchers face challenges in patient recruitment, especially for rare, fatal diseases such as amyotrophic lateral sclerosis (ALS). These challenges include obtaining sufficient statistical power as well as meeting eligibility requirements such as age, sex, and study proximity. Similarly, persons with ALS (PALS) face difficulty finding and enrolling in research studies for which they are eligible. OBJECTIVE: The aim of this study was to describe how the federal Agency for Toxic Substances and Disease Registry's (ATSDR) National ALS Registry is linking PALS to scientists who are conducting research, clinical trials, and epidemiological studies. METHODS: Through the Registry's online research notification mechanism (RNM), PALS can elect to be notified about new research opportunities. This mechanism allows researchers to upload a standardized application outlining their study design and objectives, and proof of Institutional Review Board approval. If the application is approved, ATSDR queries the Registry for PALS meeting the study's specific eligibility criteria, and then distributes the researcher's study material and contact information to PALS via email. PALS then need to contact the researcher directly to take part in any research. Such an approach allows ATSDR to protect the confidentiality of Registry enrollees. RESULTS: From 2013 to 2019, a total of 46 institutions around the United States and abroad have leveraged this tool and over 600,000 emails have been sent, resulting in over 2000 patients conservatively recruited for clinical trials and epidemiological studies. Patients between the ages of 60 and 69 had the highest level of participation, whereas those between the ages of 18 and 39 and aged over 80 had the lowest. More males participated (4170/7030, 59.32%) than females (2860/7030, 40.68%). CONCLUSIONS: The National ALS Registry's RNM benefits PALS by connecting them to appropriate ALS research. Simultaneously, the system benefits researchers by expediting recruitment, increasing sample size, and efficiently identifying PALS meeting specific eligibility requirements. As more researchers learn about and use this mechanism, both PALS and researchers can hasten research and expand trial options for PALS.

    • Food Safety
      1. Agritourism and Kidding Season: A Large Outbreak of Human Shiga Toxin-Producing Escherichia coli O157 (STEC O157) Infections Linked to a Goat Dairy Farm-Connecticut, 2016external icon
        Nichols MC, Gacek P, Phan Q, Gambino-Shirley KJ, Gollarza LM, Schroeder MN, Mercante A, Mullins J, Blackstock A, Laughlin ME, Olson SM, Pizzo E, Nguyen TN, Mank L, Holmes-Talbot K, McNutt A, Noel D, Muyombwe A, Razeq JH, Lis MJ, Sherman B, Kasacek W, Whitlock L, Strockbine N, Martin H, Vidyaprakash E, McCormack P, Cartter M.
        Front Vet Sci. 2021 ;8:744055.
        The objective of this study was to determine sources of Shiga toxin-producing Escherichia coli O157 (STEC O157) infection among visitors to Farm X and develop public health recommendations. A case-control study was conducted. Case-patients were defined as the first ill child (aged <18 years) in the household with laboratory-confirmed STEC O157, or physician-diagnosed hemolytic uremic syndrome with laboratory confirmation by serology, who visited Farm X in the 10 days prior to illness. Controls were selected from Farm X visitors aged <18 years, without symptoms during the same time period as case-patients. Environment and animal fecal samples collected from Farm X were cultured; isolates from Farm X were compared with patient isolates using whole genome sequencing (WGS). Case-patients were more likely than controls to have sat on hay bales at the doe barn (adjusted odds ratio: 4.55; 95% confidence interval: 1.41-16.13). No handwashing stations were available; limited hand sanitizer was provided. Overall, 37% (29 of 78) of animal and environmental samples collected were positive for STEC; of these, 62% (18 of 29) yielded STEC O157 highly related by WGS to patient isolates. STEC O157 environmental contamination and fecal shedding by goats at Farm X was extensive. Farms should provide handwashing stations with soap, running water, and disposable towels. Access to animal areas, including animal pens and enclosures, should be limited for young children who are at risk for severe outcomes from STEC O157 infection. National recommendations should be adopted to reduce disease transmission.

    • Genetics and Genomics
      1. Background. Whole genome sequencing (WGS) has gained increasing importance in responses to enteric bacterial outbreaks. Common analysis procedures for WGS, single nucleotide polymorphisms (SNPs) and genome assembly, are highly dependent upon WGS data quality. Methods. Raw, unprocessed WGS reads from Escherichia coli, Salmonella enterica, and Shigella sonnei outbreak clusters were characterized for four quality metrics: PHRED score, read length, library insert size, and ambiguous nucleotide composition. PHRED scores were strongly correlated with improved SNPs analysis results in E. coli and S. enterica clusters. Results. Assembly quality showed only moderate correlations with PHRED scores and library insert size, and then only for Salmonella. To improve SNP analyses and assemblies, we compared seven read-healing pipelines to improve these four quality metrics and to see how well they improved SNP analysis and genome assembly. The most effective read healing pipelines for SNPs analysis incorporated quality-based trimming, fixed-width trimming, or both. The Lyve-SET SNPs pipeline showed a more marked improvement than the CFSAN SNP Pipeline, but the latter performed better on raw, unhealed reads. For genome assembly, SPAdes enabled significant improvements in healed E. coli reads only, while Skesa yielded no significant improvements on healed reads. Conclusions. PHRED scores will continue to be a crucial quality metric albeit not of equal impact across all types of analyses for all enteric bacteria. While trimming-based read healing performed well for SNPs analyses, different read healing approaches are likely needed for genome assembly or other, emerging WGS analysis methodologies. © 2021 PeerJ Inc.. All rights reserved.

    • Global Health
      1. Subclinical Burkholderia pseudomallei Infection Associated with Travel to the British Virgin Islandsexternal icon
        Dewart CM, Almeida FA, Koval C, Nowicki S, Gee JE, Elrod MG, Gulvik CA, Salzer JS, de Fijter S, Liu L.
        Emerg Infect Dis. 2021 Dec;27(12):3182-3184.
        Phylogenetic analysis of a clinical isolate associated with subclinical Burkholderia pseudomallei infection revealed probable exposure in the British Virgin Islands, where reported infections are limited. Clinicians should consider this geographic distribution when evaluating possible infection among persons with compatible travel history.

      2. Evaluation of Candida auris acquisition in U.S. international travelers using a culture-based screening protocolexternal icon
        Turbett SE, Becker M, Belford B, Kelly M, Desrosiers L, Oliver E, Branda JA, Walters M, Walker AT, LaRocque R, Ryan ET.
        J Travel Med. 2021 Dec 7.
        We establish the feasibility of evaluating U.S. international travelers for Candida auris acquisition using a culture-based screening protocol. Corynebacterium auris was not identified in any of the travelers in this small cohort; further study is needed to determine the overall risk and risk factors for travel-associated acquisition.

    • Health Disparities
      1. INTRODUCTION: Health disparities among racial and ethnic and socioeconomic groups are pervasive, and the COVID-19 pandemic has not been an exception. This study explores the key demographic and socioeconomic factors related to racial and ethnic disparities in COVID-19 vaccination coverage. METHODS: Using recent (January 2021-March 2021) data on adults from the U.S. Census Bureau Household Pulse Survey, a regression-based decomposition method was used to estimate how much of the observed racial and ethnic disparities in vaccination coverage could be explained by particular socioeconomic and demographic factors (i.e., age, number of children and adults in household). RESULTS: Demographics, socioeconomic factors, and experiencing economic hardship during the pandemic each explained a statistically significant portion of vaccination coverage disparities between non-Hispanic White and racial/ethnic minority individuals. The largest disparity was observed among people who identified as Hispanic or Latino, whose vaccination coverage was 8.0 (95% CI=7.1, 8.9) percentage points lower than that of their non-Hispanic White counterparts. Socioeconomic factors explained 4.8 (95% CI=4.3, 5.2) percentage points of this disparity, and economic hardship explained an additional 1.4 (95% CI=1.2, 1.6) percentage points. CONCLUSIONS: This paper identified the key factors related to racial and ethnic disparities in adult vaccination coverage. The variables that explained the largest portions of the disparities were age, education, employment, and income. The study findings can help to inform efforts to increase equitable vaccine access and engage various segments of the population to prevent the further exacerbation of COVID-19 health disparities.

      2. Walking distance for vulnerable populations to public health emergency response points of dispensing in New York Cityexternal icon
        Whittemore K, Ali M, Schroeder A, Vora NM, Starr D, Daskalakis D, Lucero DE.
        J Emerg Manag. 2021 Nov-Dec;19(6):519-529.
        During certain public health emergencies, points of dispensing (PODs) may be used to rapidly distribute medical countermeasures such as antibiotics to the general public to prevent disease. Jurisdictions across the country have identified sites for PODs in preparation for such an emergency; in New York City (NYC), the sites are identified based largely on population density. Vulnerable populations, defined for this analysis as persons with income below the federal poverty level, persons with less than a high school diploma, foreign-born persons, persons of color, persons aged ≥65 years, physically disabled persons, and unemployed persons, often experience a wide range of health inequities. In NYC, these populations are often concentrated in certain geographic areas and rely heavily on public transportation. Because public transportation will almost certainly be affected during large-scale public health emergencies that would require the rapid mass dispensing of medical countermeasures, we evaluated walking distances to PODs. We used an ordinary least squares (OLS) model and a geographically weighted regression (GWR) model to determine if certain characteristics that increase health inequities in the population are associated with longer distances to the nearest POD relative to the general NYC population. Our OLS model identified shorter walking distances to PODs in neighborhoods with a higher percentage of persons with income below the federal poverty level, higher percentage of foreign-born persons, or higher percentage of persons of color, and identified longer walking distances to PODs in neighborhoods with a higher percentage of persons with less than a high school diploma. Our GWR model confirmed the findings from the OLS model and further illustrated these patterns by certain neighborhoods. Our analysis shows that currently identified locations for PODs in NYC are generally serving vulnerable populations equitably-particularly those defined by race or income status-at least in terms of walking distance.

      3. Sociodemographic Characteristics, Comorbidities, and Mortality Among Persons Diagnosed With Tuberculosis and COVID-19 in Close Succession in California, 2020external icon
        Nabity SA, Han E, Lowenthal P, Henry H, Okoye N, Chakrabarty M, Chitnis AS, Kadakia A, Villarino E, Low J, Higashi J, Barry PM, Jain S, Flood J.
        JAMA Netw Open. 2021 Dec 1;4(12):e2136853.
        IMPORTANCE: Tuberculosis (TB) and COVID-19 are respiratory diseases that disproportionately occur among medically underserved populations; little is known about their epidemiologic intersection. OBJECTIVE: To characterize persons diagnosed with TB and COVID-19 in California. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional analysis of population-based public health surveillance data assessed the sociodemographic, clinical, and epidemiologic characteristics of California residents who were diagnosed with TB (including cases diagnosed and reported between September 3, 2019, and December 31, 2020) and COVID-19 (including confirmed cases based on positive results on polymerase chain reaction tests and probable cases based on positive results on antigen assays reported through February 2, 2021) in close succession compared with those who were diagnosed with TB before the COVID-19 pandemic (between January 1, 2017, and December 31, 2019) or diagnosed with COVID-19 alone (through February 2, 2021). This analysis included 3 402 713 California residents with COVID-19 alone, 6280 with TB before the pandemic, and 91 with confirmed or probable COVID-19 diagnosed within 120 days of a TB diagnosis (ie, TB/COVID-19). EXPOSURES: Sociodemographic characteristics, medical risk factors, factors associated with TB severity, and health equity index. MAIN OUTCOMES AND MEASURES: Frequency of reported successive TB and COVID-19 (TB/COVID-19) diagnoses within 120 days, frequency of deaths, and age-adjusted mortality rates. RESULTS: Among the 91 persons with TB/COVID-19, the median age was 58.0 years (range, 3.0-95.0 years; IQR, 41.0-73.0 years); 52 persons (57.1%) were male; 81 (89.0%) were born outside the US; and 28 (30.8%) were Asian or Pacific Islander, 4 (4.4%) were Black, 55 (60.4%) were Hispanic or Latino, 4 (4.4%) were White. The frequency of reported COVID-19 among those who received a TB diagnosis between September 3, 2019, and December 31, 2020, was 225 of 2210 persons (10.2%), which was similar to that of the general population (3 402 804 of 39 538 223 persons [8.6%]). Compared with persons with TB before the pandemic, those with TB/COVID-19 were more likely to be Hispanic or Latino (2285 of 6279 persons [36.4%; 95% CI, 35.2%-37.6%] vs 55 of 91 persons [60.4%; 95% CI, 49.6%-70.5%], respectively; P < .001), reside in low health equity census tracts (1984 of 6027 persons [32.9%; 95% CI, 31.7%-34.1%] vs 40 of 89 persons [44.9%; 95% CI, 34.4%-55.9%]; P = .003), live in the US longer before receiving a TB diagnosis (median, 19.7 years [IQR, 7.2-32.3 years] vs 23.1 years [IQR, 15.2-31.5 years]; P = .03), and have diabetes (1734 of 6280 persons [27.6%; 95% CI, 26.5%-28.7%] vs 42 of 91 persons [46.2%; 95% CI, 35.6%-56.9%]; P < .001). The frequency of deaths among those with TB/COVID-19 successively diagnosed within 30 days (8 of 34 persons [23.5%; 95% CI, 10.8%-41.2%]) was more than twice that of persons with TB before the pandemic (631 of 5545 persons [11.4%; 95% CI, 10.6%-12.2%]; P = .05) and 20 times that of persons with COVID-19 alone (42 171 of 3 402 713 persons [1.2%; 95% CI, 1.2%-1.3%]; P < .001). Persons with TB/COVID-19 who died were older (median, 81.0 years; IQR, 75.0-85.0 years) than those who survived (median, 54.0 years; IQR, 37.5-68.5 years; P < .001). The age-adjusted mortality rate remained higher among persons with TB/COVID-19 (74.2 deaths per 1000 persons; 95% CI, 26.2-122.1 deaths per 1000 persons) compared with either disease alone (TB before the pandemic: 56.3 deaths per 1000 persons [95% CI, 51.2-61.4 deaths per 1000 persons]; COVID-19 only: 17.1 deaths per 1000 persons [95% CI, 16.9-17.2 deaths per 1000 persons]). CONCLUSIONS AND RELEVANCE: In this cross-sectional analysis, TB/COVID-19 was disproportionately diagnosed among California residents who were Hispanic or Latino, had diabetes, or were living in low health equity census tracts. These results suggest that tuberculosis and COVID-19 occurring together may be associated with increases in mortality compared with either disease alone, especially among older adults. Addressing health inequities and integrating prevention efforts could avert the occurrence of concurrent COVID-19 and TB and potentially reduce deaths.

      4. The Alaska Native/American Indian experience of hepatitis C treatment with sofosbuvir-based direct-acting antiviralsexternal icon
        Townshend-Bulson L, Roik E, Barbour Y, Bruden DJ, Homan CE, Espera HG, Stevenson TJ, Hewitt AM, Rhodes W, Gove JE, Plotnik JN, Snowball MM, McGilvray J, Simons BC, Johnston JM, McMahon BJ.
        PLoS One. 2021 ;16(12):e0260970.
        BACKGROUND: Direct-acting antiviral (DAA) drugs have been effective in the treatment of chronic hepatitis C virus (HCV) infection. Limited data are available on safety, tolerability, and efficacy in American Indian or Alaska Native people. We aim to evaluate the treatment outcomes of sofosbuvir- based regimens for treatment of HCV in a real life setting in Alaska Native/American Indian (AN/AI) people. METHODS: AN/AI patients within the Alaska Tribal Health System with confirmed positive anti-HCV and HCV RNA, who were 18 years of age and older were included in the study. Pretreatment baseline patient characteristics, treatment efficacy based on sustained virologic response (SVR) 12 weeks after treatment completion, and adverse effects were assessed. The following treatments were given according to the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) HCV Guidance: ledipasvir/sofosbuvir, sofosbuvir plus weight-based ribavirin, and sofosbuvir/velpatasvir. RESULTS: We included 501 patients with a mean age of 54.3 (range 21.3-78.3) in the study. Overall SVR was achieved in 95.2% of patients who received one of the three DAA regimens. For those with cirrhosis, overall SVR was 92.8% and for those with genotype 3 91.1% achieved SVR. The most common symptom experienced during treatment was headache. Joint pain was found to decrease during treatment. One person discontinued sofosbuvir plus ribavirin due to myocardial infarction and one discontinued sofosbuvir/velpatasvir due to urticaria. CONCLUSIONS: In the real-world setting, sofosbuvir-based treatment is safe, effective, and well tolerated in AN/AI patients. Sustained virologic response was high regardless of HCV genotype or cirrhosis status.

      5. Trends in COVID-19 vaccination intent and factors associated with deliberation and reluctance among adult homeless shelter residents and staff, 1 November 2020 to 28 February 2021 - King County, Washingtonexternal icon
        Rogers JH, Cox SN, Hughes JP, Link AC, Chow EJ, Fosse I, Lukoff M, Shim MM, Uyeki TM, Ogokeh C, Jackson ML, Boeckh M, Englund JA, Mosites E, Rolfes MA, Chu HY.
        Vaccine. 2021 Nov 15.
        INTRODUCTION: Little is known about COVID-19 vaccination intent among people experiencing homelessness. This study assesses surveyed COVID-19 vaccination intent among adult homeless shelter residents and staff and identifies factors associated with vaccine deliberation (responded "undecided") and reluctance (responded "no"), including time trends. METHODS: From 11/1/2020-2/28/21, we conducted repeated cross-sectional surveys at nine shelters in King County, WA as part of ongoing community-based SARS-CoV-2 surveillance. We used a multinomial model to identify characteristics associated with vaccine deliberation and reluctance. RESULTS: A total of 969 unique staff (n = 297) and residents (n = 672) participated and provided 3966 survey responses. Among residents, 53.7% (n = 361) were vaccine accepting, 28.1% reluctant, 17.6% deliberative, and 0.6% already vaccinated, whereas among staff 56.2% were vaccine accepting, 14.1% were reluctant, 16.5% were deliberative, and 13.1% already vaccinated at their last survey. We observed higher odds of vaccine deliberation or reluctance among Black/African American individuals, those who did not receive a seasonal influenza vaccine, and those with lower educational attainment. There was no significant trend towards vaccine acceptance. CONCLUSIONS: Strong disparities in vaccine intent based on race, education, and prior vaccine history were observed. Increased vaccine intent over the study period was not detected. An intersectional, person-centered approach to addressing health inequities by public health authorities planning vaccination campaigns in shelters is recommended. Clinical Trial Registry Number: NCT04141917.

    • Health Economics
      1. OBJECTIVE: To evaluate whether reported prevalence of unemployment, subsistence needs, and symptoms of depression and anxiety among adults with diagnosed HIV during the COVID-19 pandemic were higher than expected. DESIGN: The Medical Monitoring Project (MMP) is a complex sample survey of adults with diagnosed HIV in the United States. METHODS: We analyzed 2015-2019 MMP data using linear regression models to calculate expected prevalence, along with corresponding prediction intervals (PI), for unemployment, subsistence needs, depression, and anxiety for June-November 2020. We then assessed whether observed estimates fell within the expected prediction interval for each characteristic, overall and among specific groups. RESULTS: Overall, the observed estimate for unemployment was higher than expected (17% vs 12%) and exceeded the upper limit of the PI. Those living in households with incomes > = 400% of FPL were the only group where the observed prevalence of depression and anxiety during the COVID-19 period was higher than the PIs; in this group, the prevalence of depression was 9% compared with a predicted value of 5% (75% higher) and the prevalence of anxiety was 11% compared with a predicted value 5% (137% higher). We did not see elevated levels of subsistence needs, although needs were higher among Black and Hispanic compared with White persons. CONCLUSIONS: Efforts to deliver enhanced employment assistance to persons with HIV and provide screening and access to mental health services among higher income persons may be needed to mitigate the negative effects of the US COVID-19 pandemic.

      2. Coronavirus Disease Contact Tracing Outcomes and Cost, Salt Lake County, Utah, USA, March-May 2020external icon
        Fields VL, Kracalik IT, Carthel C, Lopez A, Schwartz A, Lewis NM, Bray M, Claflin C, Jorgensen K, Khong H, Richards W, Risk I, Smithee M, Clawson M, Booth LC, Scribellito T, Lowry J, Huynh J, Davis L, Birch H, Tran T, Walker J, Fry A, Hall A, Baker J, Pevzner E, Dunn AC, Tate JE, Kirking HL, Kiphibane T, Tran CH.
        Emerg Infect Dis. 2021 Dec;27(12):2999-3008.
        Outcomes and costs of coronavirus disease (COVID-19) contact tracing are limited. During March-May 2020, we constructed transmission chains from 184 index cases and 1,499 contacts in Salt Lake County, Utah, USA, to assess outcomes and estimate staff time and salaries. We estimated 1,102 staff hours and $29,234 spent investigating index cases and contacts. Among contacts, 374 (25%) had COVID-19; secondary case detection rate was ≈31% among first-generation contacts, ≈16% among second- and third-generation contacts, and ≈12% among fourth-, fifth-, and sixth-generation contacts. At initial interview, 51% (187/370) of contacts were COVID-19-positive; 35% (98/277) became positive during 14-day quarantine. Median time from symptom onset to investigation was 7 days for index cases and 4 days for first-generation contacts. Contact tracing reduced the number of cases between contact generations and time between symptom onset and investigation but required substantial resources. Our findings can help jurisdictions allocate resources for contact tracing.

      3. State-Level Economic Costs of Fatal Injuries - United States, 2019external icon
        Peterson C, Luo F, Florence C.
        MMWR Morb Mortal Wkly Rep. 2021 Dec 3;70(48):1660-1663.
        Unintentional and violence-related injury fatalities, including suicide, homicide, overdoses, motor vehicle crashes, and falls, were among the 10 leading causes of death for all age groups in the United States in 2019.* There were 246,041 injury deaths in 2019 (unintentional injury was the most frequent cause of death after heart disease and cancer) with an economic cost of $2.2 trillion (1). Extending a national analysis (1), CDC examined state-level economic costs of fatal injuries based on medical care costs and the value of statistical life assigned to 2019 injury records from the CDC's Web-based Injury Statistics Query and Reporting System (WISQARS).(†) West Virginia had the highest per capita cost ($11,274) from fatal injury, more than twice that of New York, the state with the lowest cost ($4,538). The five areas with the highest per capita total fatal injury costs were West Virginia, New Mexico, Alaska, District of Columbia (DC), and Louisiana; costs were lowest in New York, California, Minnesota, Nebraska, and Texas. All U.S. states face substantial avoidable costs from injury deaths. Individual persons, families, organizations, communities, and policymakers can use targeted proven strategies to prevent injuries and violence. Resources for best practices for preventing injuries and violence are available online from the CDC's National Center for Injury Prevention and Control.(§).

      4. Economic Cost of Injury - United States, 2019external icon
        Peterson C, Miller GF, Barnett SB, Florence C.
        MMWR Morb Mortal Wkly Rep. 2021 Dec 3;70(48):1655-1659.
        Unintentional and violence-related injuries, including suicide, homicide, overdoses, motor vehicle crashes, and falls, were among the top 10 causes of death for all age groups in the United States and caused nearly 27 million nonfatal emergency department (ED) visits in 2019.*(,)(†) CDC estimated the economic cost of injuries that occurred in 2019 by assigning costs for medical care, work loss, value of statistical life, and quality of life losses to injury records from the CDC's Web-based Injury Statistics Query and Reporting System (WISQARS).(§) In 2019, the economic cost of injury was $4.2 trillion, including $327 billion in medical care, $69 billion in work loss, and $3.8 trillion in value of statistical life and quality of life losses. More than one half of this cost ($2.4 trillion) was among working-aged adults (aged 25-64 years). Individual persons, families, organizations, communities, and policymakers can use targeted proven strategies to prevent injuries and violence. Resources for best practices for preventing injuries and violence are available online from CDC's National Center for Injury Prevention and Control.(¶).

    • Healthcare Associated Infections
      1. Comparative genomic analysis of clinical Candida glabrata isolates identifies multiple polymorphic loci that can improve existing multilocus sequence typing strategyexternal icon
        Arastehfar A, Marcet-Houben M, Daneshnia F, Taj-Aldeen SJ, Batra D, Lockhart SR, Shor E, Gabaldón T, Perlin DS.
        Studies in Mycology. 2021 ;100.
        Candida glabrata is the second leading cause of candidemia in many countries and is one of the most concerning yeast species of nosocomial importance due to its increasing rate of antifungal drug resistance and emerging multidrug-resistant isolates. Application of multilocus sequence typing (MLST) to clinical C. glabrata isolates revealed an association of certain sequence types (STs) with drug resistance and mortality. The current C. glabrata MLST scheme is based on single nucleotide polymorphisms (SNPs) at six loci and is therefore relatively laborious and costly. Furthermore, only a few high-quality C. glabrata reference genomes are available, limiting rapid analysis of clinical isolates by whole genome sequencing. In this study we provide long-read based assemblies for seven additional clinical strains belonging to three different STs and use this information to simplify the C. glabrata MLST scheme. Specifically, a comparison of these genomes identified highly polymorphic loci (HPL) defined by frequent insertions and deletions (indels), two of which proved to be highly resolutive for ST. When challenged with 53 additional isolates, a combination of TRP1 (a component of the current MLST scheme) with either of the two HPL fully recapitulated ST identification. Therefore, our comparative genomic analysis identified a new typing approach combining SNPs and indels and based on only two loci, thus significantly simplifying ST identification in C. glabrata. Because typing tools are instrumental in addressing numerous clinical and biological questions, our new MLST scheme can be used for high throughput typing of C. glabrata in clinical and research settings. © 2021 The Authors

    • Immunity and Immunization
      1. Interpretation of Relative Efficacy and Effectiveness for Influenza Vaccinesexternal icon
        Lewis NM, Chung JR, Uyeki TM, Grohskopf L, Ferdinands JM, Patel MM.
        Clin Infect Dis. 2021 Dec 7.
        Relative vaccine effectiveness (rVE) are metrics commonly reported to compare absolute VE (aVE) of two vaccine products. Estimates of rVE for enhanced influenza vaccines (eIV) vs. standard inactivated influenza vaccine (IIV) have been assessed across different seasons, influenza-specific endpoints, and nonspecific endpoints (e.g., all-cause cardiovascular hospitalizations). To illustrate the challenges of comparability across studies, we conducted a scenario analysis to evaluate the effects of varying absolute VE (aVE) of IIV (i.e., as compared with placebo) on the interpretation of rVE of eIV vs IIV. We show that estimates of rVE might not be comparable across studies because additional benefits commensurate with a given estimate of rVE are dependent on the aVE for the comparator vaccine, which can depend on factors such as host response to vaccine, virus type, and clinical endpoint evaluated. These findings have implications for interpretation of rVE across studies and for sample size considerations in future trials.

      2. Risk of Guillain-Barré syndrome following herpes zoster, United States, 2010-2018external icon
        Anderson TC, Leung JW, Harpaz R, Dooling KL.
        Hum Vaccin Immunother. 2021 Dec 2:1-7.
        Epidemiologic data regarding the risk of Guillain-Barré syndrome (GBS) following herpes zoster (HZ) are limited. We conducted a self-controlled case series analysis using two large national data sources to evaluate the risk of GBS following HZ among U.S. adults. We analyzed medical claims from the IBM® MarketScan® Commercial Claims and Encounters (persons 18-64 years during 2010-2018) and Centers for Medicare and Medicaid Services Medicare (persons ≥65 years during 2014-2018) databases. HZ cases were defined as persons with an outpatient claim with a primary or secondary ICD-9 or ICD-10 diagnostic code for HZ. GBS cases were defined as persons with an inpatient claim with a principle diagnostic code for GBS and an associated procedural code. We compared the rates of GBS following HZ in the 1-42-day risk window versus primary (100-365-day) or secondary (43-99-day) control windows. We identified 489,516 persons 18-64 years of age and 650,229 persons ≥65 years of age with HZ, among whom 11 and 41, respectively, developed GBS 1-365 days following HZ. The risk of GBS following HZ was increased during the risk window as compared to the primary control window for both groups, with a rate ratio of 6.3 (95% CI, 1.8-21.9) for those 18-64 years and 4.1 (95% CI, 1.9-8.7) for those ≥65 years. This study provides new and methodologically rigorous epidemiologic support for an association between HZ and GBS, and useful context regarding the benefits versus potential risks of zoster vaccination.

      3. Impact of diabetes status on immunogenicity of trivalent inactivated influenza vaccine in older adultsexternal icon
        Spencer S, Chung JR, Belongia EA, Sundaram M, Meece J, Coleman LA, Zimmerman RK, Nowalk MP, Moehling Geffel K, Ross T, Carter CE, Shay D, Levine M, Liepkalns J, Kim JH, Sambhara S, Thompson MG, Flannery B.
        Influenza Other Respir Viruses. 2021 Dec 3.
        Individuals with type 2 diabetes mellitus experience high rates of influenza virus infection and complications. We compared the magnitude and duration of serologic response to trivalent influenza vaccine in adults aged 50-80 with and without type 2 diabetes mellitus. Serologic response to influenza vaccination was similar in both groups: greater fold-increases in antibody titer occurred among participants with lower pre-vaccination antibody titers. Waning of antibody titers was not influenced by diabetes status.

      4. Notes from the Field: COVID-19 Vaccination Coverage Among Persons Experiencing Homelessness - Six U.S. Jurisdictions, December 2020-August 2021external icon
        Montgomery MP, Meehan AA, Cooper A, Toews KA, Ghinai I, Schroeter MK, Gibbs R, Rehman N, Stylianou KS, Yeh D, Thomas-Campbell N, Washington NC, Brosnan HK, Chang AH, Gomih A, Ngo C, Vickery KD, Harrison B, Winkelman TN, Gerstenfeld A, Zeilinger L, Mosites E.
        MMWR Morb Mortal Wkly Rep. 2021 Dec 3;70(48):1676-1678.

    • Injury and Violence
      1. Incidence of Nonfatal Traumatic Brain Injury-Related Hospitalizations - United States, 2018external icon
        Peterson AB, Thomas KE.
        MMWR Morb Mortal Wkly Rep. 2021 Dec 3;70(48):1664-1668.
        Traumatic brain injury (TBI), which can disrupt normal brain function and result in short- and long-term adverse clinical outcomes, including disability and death, is preventable. To describe the 2018 incidence of nonfatal TBI-related hospitalizations in the United States by sociodemographic characteristics, injury intent, and mechanism of injury, CDC analyzed data from the Healthcare Cost and Utilization Project (HCUP) National (Nationwide) Inpatient Sample. During 2018, there were 223,050 nonfatal TBI-related hospitalizations; rates among persons aged ≥75 years were approximately three times higher than those among persons aged 65-74 years, and the age-adjusted rate among males was approximately double that among females. Unintentional falls were the most common mechanism of injury leading to nonfatal TBI-related hospitalization, followed by motor vehicle crashes. Proper and consistent use of recommended restraints (i.e., seatbelts, car seats, and booster seats) and, particularly for persons aged ≥75 years, learning about individual fall risk from health care providers are two steps the public can take to prevent the most common injuries leading to nonfatal TBIs. The findings in this report could be used by public health officials and clinicians to identify priority areas for prevention programs.

    • Laboratory Sciences
      1. U.S. Federal Agency interests and key considerations for new approach methodologies for nanomaterialsexternal icon
        Petersen EJ, Ceger P, Allen DG, Coyle J, Derk R, Garcia-Reyero N, Gordon J, Kleinstreuer N, Matheson J, McShan D, Nelson BC, Patri AK, Rice P, Rojanasakul L, Sasidharan A, Scarano L, Chang X.
        Altex. 2021 Dec 3.
        Engineered nanomaterials (ENMs) come in a wide array of shapes, sizes, surface coatings, and compositions, and often possess novel or enhanced properties compared to larger‑sized particles of the same elemental composition. To ensure the safe commercialization of products containing ENMs, it is important to thoroughly understand their potential risks. Given that ENMs can be created in an almost infinite number of variations, it is not feasible to conduct in vivo testing on each type of ENM. Instead, new approach methodologies (NAMs) such as in vitro or in chemico test methods may be needed, given their capacity for higher throughput testing, lower cost, and ability to provide information on toxicological mechanisms. However, the different behaviors of ENMs compared to dissolved chemicals may challenge safety testing of ENMs using NAMs. In this study, member agencies within the Interagency Coordinating Committee on the Validation of Alternative Methods were queried about what types of ENMs are of agency interest and whether there is agency-specific guidance for ENMs toxicity testing. To support the ability of NAMs to provide robust results in ENM testing, two key issues in the usage of NAMs, namely dosimetry and interference/bias controls, are thoroughly discussed.

      2. Rapid establishment of a frontline field laboratory in response to an imported outbreak of Ebola virus disease in western Uganda, June 2019external icon
        Schuh AJ, Kyondo J, Graziano J, Balinandi S, Kainulainen MH, Tumusiime A, Nyakarahuka L, Mulei S, Baluku J, Lonergan W, Mayer O, Masereka R, Masereka F, Businge E, Gatare A, Kabyanga L, Muhindo S, Mugabe R, Makumbi I, Kayiwa J, Wetaka MM, Brown V, Ojwang J, Nelson L, Millard M, Nichol ST, Montgomery JM, Taboy CH, Lutwama JJ, Klena JD.
        PLoS Negl Trop Dis. 2021 Dec 3;15(12):e0009967.
        The Democratic Republic of the Congo (DRC) declared an Ebola virus disease (EVD) outbreak in North Kivu in August 2018. By June 2019, the outbreak had spread to 26 health zones in northeastern DRC, causing >2,000 reported cases and >1,000 deaths. On June 10, 2019, three members of a Congolese family with EVD-like symptoms traveled to western Uganda's Kasese District to seek medical care. Shortly thereafter, the Viral Hemorrhagic Fever Surveillance and Laboratory Program (VHF program) at the Uganda Virus Research Institute (UVRI) confirmed that all three patients had EVD. The Ugandan Ministry of Health declared an outbreak of EVD in Uganda's Kasese District, notified the World Health Organization, and initiated a rapid response to contain the outbreak. As part of this response, UVRI and the United States Centers for Disease Control and Prevention, with the support of Uganda's Public Health Emergency Operations Center, the Kasese District Health Team, the Superintendent of Bwera General Hospital, the United States Department of Defense's Makerere University Walter Reed Project, and the United States Mission to Kampala's Global Health Security Technical Working Group, jointly established an Ebola Field Laboratory in Kasese District at Bwera General Hospital, proximal to an Ebola Treatment Unit (ETU). The laboratory consisted of a rapid containment kit for viral inactivation of patient specimens and a GeneXpert Instrument for performing Xpert Ebola assays. Laboratory staff tested 76 specimens from alert and suspect cases of EVD; the majority were admitted to the ETU (89.3%) and reported recent travel to the DRC (58.9%). Although no EVD cases were detected by the field laboratory, it played an important role in patient management and epidemiological surveillance by providing diagnostic results in <3 hours. The integration of the field laboratory into Uganda's National VHF Program also enabled patient specimens to be referred to Entebbe for confirmatory EBOV testing and testing for other hemorrhagic fever viruses that circulate in Uganda.

      3. N-glycosylation profiles of the SARS-CoV-2 spike D614G mutant and its ancestral protein characterized by advanced mass spectrometryexternal icon
        Wang D, Zhou B, Keppel TR, Solano M, Baudys J, Goldstein J, Finn MG, Fan X, Chapman AP, Bundy JL, Woolfitt AR, Osman SH, Pirkle JL, Wentworth DE, Barr JR.
        Sci Rep. 2021 Dec 7;11(1):23561.
        N-glycosylation plays an important role in the structure and function of membrane and secreted proteins. The spike protein on the surface of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, is heavily glycosylated and the major target for developing vaccines, therapeutic drugs and diagnostic tests. The first major SARS-CoV-2 variant carries a D614G substitution in the spike (S-D614G) that has been associated with altered conformation, enhanced ACE2 binding, and increased infectivity and transmission. In this report, we used mass spectrometry techniques to characterize and compare the N-glycosylation of the wild type (S-614D) or variant (S-614G) SARS-CoV-2 spike glycoproteins prepared under identical conditions. The data showed that half of the N-glycosylation sequons changed their distribution of glycans in the S-614G variant. The S-614G variant showed a decrease in the relative abundance of complex-type glycans (up to 45%) and an increase in oligomannose glycans (up to 33%) on all altered sequons. These changes led to a reduction in the overall complexity of the total N-glycosylation profile. All the glycosylation sites with altered patterns were in the spike head while the glycosylation of three sites in the stalk remained unchanged between S-614G and S-614D proteins.

      4. Evaluation of a laboratory-developed multiplex real-time PCR assay for diagnosis of syphilis, herpes and chancroid genital ulcers in four public health laboratories in the USAexternal icon
        Koralur M, Chen CY, Pillay A, White B, Pettus K, Chi KH, Stringer J, Aroh C, Dasu T, Bhattacharyya S, Perkins K, Chen J, Riner D, Soehnlen M, Cao W, Gaynor AM, Kersh EN.
        Sex Transm Infect. 2021 Dec 6.
        OBJECTIVE: To evaluate the field performance of a multiplex PCR (M-PCR) assay for detection of herpes simplex virus (HSV)-1 and HSV-2, Treponema pallidum (T. pallidum) and Haemophilus ducreyi (H. ducreyi) in genital ulcer disease (GUD) specimens. METHODS: GUD M-PCR was performed on 186 remnant specimens, previously collected for HSV testing, by four public health laboratories (PHLs) and the Laboratory Reference and Research Branch (LRRB) at the Centers for Disease Control and Prevention. The results from the PHLs were compared with those of LRRB, which served as the reference testing method, and percentage agreement was calculated. RESULTS: HSV was detected in 31 of 52 (59.6%), 20 of 40 (50%), 43 of 44 (97.7%) and 19 of 50 (38.0%) specimens from PHL1, PHL2, PHL3 and PHL4, respectively. There were seven discrepant results for HSV, and the overall percent agreement between the PHLs and the LRRB was 94%-100%, with a kappa value of 0.922, which demonstrates high agreement. T. pallidum was identified in 7 of 51 (13.7%) specimens from PHL1 with 94.1% agreement and in 2 of 40 (5.0%) specimens from PHL2 with 100% agreement. The LRRB identified three additional T. pallidum-positive specimens from PHL1. The kappa value (0.849) for T. pallidum testing suggests good agreement. Consistent with the LRRB results, no T. pallidum was detected in specimens from PHL3 and PHL4, and H. ducreyi was not detected at any of the study sites. CONCLUSIONS: The GUD M-PCR assay performed well in four independent PHLs and 12 suspected syphilis cases were identified in this study. The M-PCR assay could provide improved diagnostic options for GUD infections in state and local PHLs.

      5. West Nile virus vaccination protects against usutu virus disease in miceexternal icon
        Salgado R, Hawks SA, Frere F, Vázquez A, Huang CY, Duggal NK.
        Viruses. 2021 ;13(12).
        West Nile virus (WNV) and Usutu virus (USUV) are mosquito‐borne flaviviruses that can cause neuroinvasive disease in humans. WNV and USUV circulate in both Africa and Europe and are closely related. Due to antigenic similarity, WNV‐specific antibodies and USUV‐specific antibodies have the potential to bind heterologous viruses; however, it is unclear whether this interaction may offer protection against infection. To investigate how prior WNV exposure would influ-ence USUV infection, we used an attenuated WNV vaccine that contains the surface proteins of WNV in the backbone of a dengue virus 2 vaccine strain and protects against WNV disease. We hypothesized that vaccination with this attenuated WNV vaccine would protect against USUV in-fection. Neutralizing responses against WNV and USUV were measured in vitro using sera following vaccination. Sera from vaccinated CD‐1 and Ifnar1−/− mice cross‐neutralized with WNV and USUV. All mice were then subsequently challenged with an African or European USUV strain. In CD‐1 mice, there was no difference in USUV titers between vaccinated and mock‐vaccinated mice. However, in the Ifnar1−/− model, vaccinated mice had significantly higher survival rates and significantly lower USUV viremia compared to mock‐vaccinated mice. Our results indicate that exposure to an attenuated form of WNV protects against severe USUV disease in mice and elicits a neutralizing response to both WNV and USUV. Future studies will investigate the immune mechanisms responsible for the protection against USUV infection induced by WNV vaccination, providing critical insight that will be essential for USUV and WNV vaccine development. © 2021 by the authors. Licensee MDPI, Basel, Switzerland.

    • Maternal and Child Health
      1. OBJECTIVE: Describe sources of discrepancy between self-assessed LoMC (level of maternal care) and CDC LOCATe(®)-assessed (Levels of Care Assessment Tool) LoMC. STUDY DESIGN: CDC LOCATe(®) was implemented at 480 facilities in 13 jurisdictions, including states, territories, perinatal regions, and hospital systems, in the U.S. Cross-sectional analyses were conducted to compare facilities' self-reported LoMC and LOCATe(®)-assessed LoMC. RESULT: Among 418 facilities that self-reported an LoMC, 41.4% self-reported a higher LoMC than their LOCATe(®)-assessed LoMC. Among facilities with discrepancies, the most common elements lacking to meet self-reported LoMC included availability of maternal-fetal medicine (27.7%), obstetric-specializing anesthesiologist (16.2%), and obstetric ultrasound services (12.1%). CONCLUSION: Two in five facilities self-report a LoMC higher than their LOCATe(®)-assessed LoMC, indicating discrepancies between perceived maternal care capabilities and those recommended in current LoMC guidelines. Results highlight an opportunity for states to engage with facilities, health systems, and other stakeholders about LoMC and collaborate to strengthen systems for improving maternal care delivery.

      2. Prevalence and Characteristics of Autism Spectrum Disorder Among Children Aged 8 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2018external icon
        Maenner MJ, Shaw KA, Bakian AV, Bilder DA, Durkin MS, Esler A, Furnier SM, Hallas L, Hall-Lande J, Hudson A, Hughes MM, Patrick M, Pierce K, Poynter JN, Salinas A, Shenouda J, Vehorn A, Warren Z, Constantino JN, DiRienzo M, Fitzgerald RT, Grzybowski A, Spivey MH, Pettygrove S, Zahorodny W, Ali A, Andrews JG, Baroud T, Gutierrez J, Hewitt A, Lee LC, Lopez M, Mancilla KC, McArthur D, Schwenk YD, Washington A, Williams S, Cogswell ME.
        MMWR Surveill Summ. 2021 Dec 3;70(11):1-16.
        PROBLEM/CONDITION: Autism spectrum disorder (ASD). PERIOD COVERED: 2018. DESCRIPTION OF SYSTEM: The Autism and Developmental Disabilities Monitoring (ADDM) Network conducts active surveillance of ASD. This report focuses on the prevalence and characteristics of ASD among children aged 8 years in 2018 whose parents or guardians lived in 11 ADDM Network sites in the United States (Arizona, Arkansas, California, Georgia, Maryland, Minnesota, Missouri, New Jersey, Tennessee, Utah, and Wisconsin). To ascertain ASD among children aged 8 years, ADDM Network staff review and abstract developmental evaluations and records from community medical and educational service providers. In 2018, children met the case definition if their records documented 1) an ASD diagnostic statement in an evaluation (diagnosis), 2) a special education classification of ASD (eligibility), or 3) an ASD International Classification of Diseases (ICD) code. RESULTS: For 2018, across all 11 ADDM sites, ASD prevalence per 1,000 children aged 8 years ranged from 16.5 in Missouri to 38.9 in California. The overall ASD prevalence was 23.0 per 1,000 (one in 44) children aged 8 years, and ASD was 4.2 times as prevalent among boys as among girls. Overall ASD prevalence was similar across racial and ethnic groups, except American Indian/Alaska Native children had higher ASD prevalence than non-Hispanic White (White) children (29.0 versus 21.2 per 1,000 children aged 8 years). At multiple sites, Hispanic children had lower ASD prevalence than White children (Arizona, Arkansas, Georgia, and Utah), and non-Hispanic Black (Black) children (Georgia and Minnesota). The associations between ASD prevalence and neighborhood-level median household income varied by site. Among the 5,058 children who met the ASD case definition, 75.8% had a diagnostic statement of ASD in an evaluation, 18.8% had an ASD special education classification or eligibility and no ASD diagnostic statement, and 5.4% had an ASD ICD code only. ASD prevalence per 1,000 children aged 8 years that was based exclusively on documented ASD diagnostic statements was 17.4 overall (range: 11.2 in Maryland to 29.9 in California). The median age of earliest known ASD diagnosis ranged from 36 months in California to 63 months in Minnesota. Among the 3,007 children with ASD and data on cognitive ability, 35.2% were classified as having an intelligence quotient (IQ) score ≤70. The percentages of children with ASD with IQ scores ≤70 were 49.8%, 33.1%, and 29.7% among Black, Hispanic, and White children, respectively. Overall, children with ASD and IQ scores ≤70 had earlier median ages of ASD diagnosis than children with ASD and IQ scores >70 (44 versus 53 months). INTERPRETATION: In 2018, one in 44 children aged 8 years was estimated to have ASD, and prevalence and median age of identification varied widely across sites. Whereas overall ASD prevalence was similar by race and ethnicity, at certain sites Hispanic children were less likely to be identified as having ASD than White or Black children. The higher proportion of Black children compared with White and Hispanic children classified as having intellectual disability was consistent with previous findings. PUBLIC HEALTH ACTION: The variability in ASD prevalence and community ASD identification practices among children with different racial, ethnic, and geographical characteristics highlights the importance of research into the causes of that variability and strategies to provide equitable access to developmental evaluations and services. These findings also underscore the need for enhanced infrastructure for diagnostic, treatment, and support services to meet the needs of all children.

      3. Early Identification of Autism Spectrum Disorder Among Children Aged 4 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2018external icon
        Shaw KA, Maenner MJ, Bakian AV, Bilder DA, Durkin MS, Furnier SM, Hughes MM, Patrick M, Pierce K, Salinas A, Shenouda J, Vehorn A, Warren Z, Zahorodny W, Constantino JN, DiRienzo M, Esler A, Fitzgerald RT, Grzybowski A, Hudson A, Spivey MH, Ali A, Andrews JG, Baroud T, Gutierrez J, Hallas L, Hall-Lande J, Hewitt A, Lee LC, Lopez M, Mancilla KC, McArthur D, Pettygrove S, Poynter JN, Schwenk YD, Washington A, Williams S, Cogswell ME.
        MMWR Surveill Summ. 2021 Dec 3;70(10):1-14.
        PROBLEM/CONDITION: Autism spectrum disorder (ASD). PERIOD COVERED: 2018. DESCRIPTION OF SYSTEM: The Autism and Developmental Disabilities Monitoring Network is an active surveillance program that estimates ASD prevalence and monitors timing of ASD identification among children aged 4 and 8 years. This report focuses on children aged 4 years in 2018, who were born in 2014 and had a parent or guardian who lived in the surveillance area in one of 11 sites (Arizona, Arkansas, California, Georgia, Maryland, Minnesota, Missouri, New Jersey, Tennessee, Utah, and Wisconsin) at any time during 2018. Children were classified as having ASD if they ever received 1) an ASD diagnostic statement (diagnosis) in an evaluation, 2) a special education classification of ASD (eligibility), or 3) an ASD International Classification of Diseases (ICD) code. Suspected ASD also was tracked among children aged 4 years. Children who did not meet the case definition for ASD were classified as having suspected ASD if their records contained a qualified professional's statement indicating a suspicion of ASD. RESULTS: For 2018, the overall ASD prevalence was 17.0 per 1,000 (one in 59) children aged 4 years. Prevalence varied from 9.1 per 1,000 in Utah to 41.6 per 1,000 in California. At every site, prevalence was higher among boys than girls, with an overall male-to-female prevalence ratio of 3.4. Prevalence of ASD among children aged 4 years was lower among non-Hispanic White (White) children (12.9 per 1,000) than among non-Hispanic Black (Black) children (16.6 per 1,000), Hispanic children (21.1 per 1,000), and Asian/Pacific Islander (A/PI) children (22.7 per 1,000). Among children aged 4 years with ASD and information on intellectual ability, 52% met the surveillance case definition of co-occurring intellectual disability (intelligence quotient ≤70 or an examiner's statement of intellectual disability documented in an evaluation). Of children aged 4 years with ASD, 72% had a first evaluation at age ≤36 months. Stratified by census-tract-level median household income (MHI) tertile, a lower percentage of children with ASD and intellectual disability was evaluated by age 36 months in the low MHI tertile (72%) than in the high MHI tertile (84%). Cumulative incidence of ASD diagnosis or eligibility received by age 48 months was 1.5 times as high among children aged 4 years (13.6 per 1,000 children born in 2014) as among those aged 8 years (8.9 per 1,000 children born in 2010). Across MHI tertiles, higher cumulative incidence of ASD diagnosis or eligibility received by age 48 months was associated with lower MHI. Suspected ASD prevalence was 2.6 per 1,000 children aged 4 years, meaning for every six children with ASD, one child had suspected ASD. The combined prevalence of ASD and suspected ASD (19.7 per 1,000 children aged 4 years) was lower than ASD prevalence among children aged 8 years (23.0 per 1,000 children aged 8 years). INTERPRETATION: Groups with historically lower prevalence of ASD (non-White and lower MHI) had higher prevalence and cumulative incidence of ASD among children aged 4 years in 2018, suggesting progress in identification among these groups. However, a lower percentage of children with ASD and intellectual disability in the low MHI tertile were evaluated by age 36 months than in the high MHI group, indicating disparity in timely evaluation. Children aged 4 years had a higher cumulative incidence of diagnosis or eligibility by age 48 months compared with children aged 8 years, indicating improvement in early identification of ASD. The overall prevalence for children aged 4 years was less than children aged 8 years, even when prevalence of children suspected of having ASD by age 4 years is included. This finding suggests that many children identified after age 4 years do not have suspected ASD documented by age 48 months. PUBLIC HEALTH ACTION: Children born in 2014 were more likely to be identified with ASD by age 48 months than children born in 2010, indicating increased early identification. However, ASD identification among children aged 4 years varied by site, suggesting opportunities to examine developmental screening and diagnostic practices that promote earlier identification. Children aged 4 years also were more likely to have co-occurring intellectual disability than children aged 8 years, suggesting that improvement in the early identification and evaluation of developmental concerns outside of cognitive impairments is still needed. Improving early identification of ASD could lead to earlier receipt of evidence-based interventions and potentially improve developmental outcomes.

    • Nutritional Sciences
      1. Approaches for Implementing Healthy Food Interventions in Settings With Limited Resources: A Case Study of Sodium Reduction Interventions in Emergency Food Programs Addressing Food Insecurityexternal icon
        Strazza K, Jordan J, Ferriola-Bruckenstein K, Kane H, Whitehill J, Teachout E, Yarnoff B.
        Am J Health Promot. 2021 Dec 3:8901171211056121.
        PURPOSE: This study describes how recipients of the Centers for Disease Control and Prevention funded Sodium Reduction in Communities Program (SRCP) worked with emergency food programs to improve access to healthy food to address chronic conditions. DESIGN: SRCP recipients partnered with emergency food programs to implement sodium reduction strategies including nutrition standards, procurement practices, environmental strategies, and behavioral economics approaches. SETTING: SRCP recipients and emergency food programs in Washington County and Benton County, Arkansas and King County, Washington. SUBJECTS: SRCP recipient staff, emergency food program staff, and key stakeholders. MEASURES: We conducted semi-structured interviews with key stakeholders and systematic review of program documents. ANALYSIS: Data were analyzed using effects matrices for each recipient. Matrices were organized using select implementation science constructs and compared in a cross-case analysis. RESULTS: Despite limited resources, emergency food programs can implement sodium reduction interventions which may provide greater access to healthy foods and lead to reductions in health disparities. Emergency food programs successfully implemented sodium reduction interventions by building on the external and internal settings; selecting strategies that align with existing processes; implementing change incrementally and engaging staff, volunteers, and clients; and sustaining changes. CONCLUSION: Findings contribute to understanding the ways in which emergency food programs and other organizations with limited resources have implemented public health nutrition interventions addressing food insecurity and improving access to healthy foods. These strategies may be transferable to other settings with limited resources.

    • Obituary
      1. Remembering Dr Li-Ching Lee, a pioneer of global autism researchexternal icon
        Rubenstein E, Rice C, Hollingue C, Tsai PC, Stewart L, Daniele Fallin M.
        Autism. 2021 Dec 5:13623613211059641.
        The field of global autism research lost a pioneer, champion, and innovator with the passing of Dr Li-Ching Lee in May 2021. Dr Lee served as the editor for a special issue in Autism on global autism research (2017, Volume 21, Issue 5) and her substantial impact on autism research and autistic individuals and their families in low- and middle-income countries warrants a place in this special issue. While a giant in the professional arena, her large impact on science is minor compared to the compassion, kindness, and love she brought to her family, friends, and her professional communities at Johns Hopkins, across institutions, her native Taiwan, and the areas in which she conducted her research. Dr Lee was immensely humble and intensely focused on harnessing epidemiology to positively impact the lives of people with autism and developmental disabilities. Her humility and professional dedication was coupled with a desire to keep her own challenges and triumphs private including her courageous efforts to stave off cancer while accomplishing so much in support of others.

    • Occupational Safety and Health
      1. Objectives. To determine the prevalence and predictors of US home health care workers' (HHWs') self-reported general, physical, and mental health. Methods. Using the 2014-2018 Behavioral Risk Factor Surveillance System, we analyzed the characteristics and health of 2987 HHWs (weighted n = 659 000) compared with 2 similar low-wage worker groups (health care aides and health care support workers, not working in the home). We conducted multivariable logistic regression to determine which characteristics predicted HHWs' health. Results. Overall, 26.6% of HHWs had fair or poor general health, 14.1% had poor physical health, and 20.9% had poor mental health; the prevalence of each outcome was significantly higher than that of the comparison groups. Among HHWs, certain factors, such as low household income, an inability to see a doctor because of cost, and a history of depression, were associated with all 3 aspects of suboptimal health. Conclusions. HHWs had worse general, physical, and mental health compared with low-wage workers not in home health. Public Health Implications. Increased attention to the health of HHWs by public health experts and policymakers is warranted. In addition, targeted interventions appropriate to their specific health needs may be required. (Am J Public Health. 2021;111(12):2239-2250.

      2. Coffee production is a global industry with roasteries throughout the world. Workers in this industry are exposed to complex mixtures of gases, dusts, and vapors including carbon monoxide, carbon dioxide, coffee dust, allergens, alpha-diketones, and other volatile organic compounds (VOCs). Adverse respiratory health outcomes such as respiratory symptoms, reduced pulmonary function, asthma, and obliterative bronchiolitis can occur among exposed workers. In response to health hazard evaluations requests received from 17 small- to medium-sized coffee facilities across the United States, the National Institute for Occupational Safety and Health conducted investigations during 2016-2017 to understand the burden of respiratory abnormalities, exposure characteristics, relationships between exposures and respiratory effects, and opportunities for exposure mitigation. Full-shift, task-based, and instantaneous personal and area air samples for diacetyl, 2,3-pentanedione and other VOCs were collected, and engineering controls were evaluated. Medical evaluations included questionnaire, spirometry, impulse oscillometry, and fractional exhaled nitric oxide. Exposure and health assessments were conducted using standardized tools and approaches, which enabled pooling data for aggregate analysis. The pooled data provided a larger population to better address the requestors' concern of the effect of exposure to alpha-diketones on the respiratory heath of coffee workers. This paper describes the rationale for the exposure and health assessment strategy, the approach used to achieve the study objectives, and its advantages and limitations.

    • Occupational Safety and Health - Mining
      1. An Overview of Existing EMI Standards Applicable to Miningexternal icon
        Girman M, Reyes M, Zhou C.
        Mining, Metallurgy and Exploration. 2021 .
        Electromagnetic energy emitted from electronic devices has been known to interfere with other electronic systems, hindering their ability to function properly. Mines have many electronic devices critical to the health and safety of mine workers that could be negatively affected by electromagnetic interference (EMI). To ensure that devices are electromagnetically compatible, tests must first be conducted to measure emissions and check for immunity. There are many standards available across multiple industries that prescribe emission limits and test methods for electronic devices. Due to the unique environment of an underground mine, it may not be enough to simply adopt a standard from another industry to mining. A literature review has been conducted, and an overview of EMI standards in other industries will be provided in this paper. Also, an example of how a standard can be applied to mining equipment is presented. Finally, recommendations on standards which could potentially be applied to mining will also be included. This work will inform the mining industry of EMI standards in other industries so that mine workers and technology manufacturers have guidance of the steps that can be taken to investigate and reduce the impact of electromagnetic interference and potentially work toward electromagnetic compatibility. The findings and research involved in this effort can also be used to explore the need to develop mining-specific EMI recommendations and standards. © 2021, This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.

    • Parasitic Diseases
      1. Determinants of malaria testing at health facilities: the case of Ugandaexternal icon
        Kigozi RN, Bwanika J, Goodwin E, Thomas P, Bukoma P, Nabyonga P, Isabirye F, Oboth P, Kyozira C, Niang M, Belay K, Sebikaari G, Tibenderana JK, Gudoi SS.
        Malar J. 2021 Dec 4;20(1):456.
        BACKGROUND: The World Health Organization (WHO) recommends prompt malaria diagnosis with either microscopy or malaria rapid diagnostic tests (RDTs) and treatment with an effective anti-malarial, as key interventions to control malaria. However, in sub-Saharan Africa, malaria diagnosis is still often influenced by clinical symptoms, with patients and care providers often interpreting all fevers as malaria. The Ministry of Health in Uganda defines suspected malaria cases as those with a fever. A target of conducting testing for at least 75% of those suspected to have malaria was established by the National Malaria Reduction Strategic Plan 2014-2020. METHODS: This study investigated factors that affect malaria testing at health facilities in Uganda using data collected in March/April 2017 in a cross-sectional survey of health facilities from the 52 districts that are supported by the US President's Malaria Initiative (PMI). The study assessed health facility capacity to provide quality malaria care and treatment. Data were collected from all 1085 public and private health facilities in the 52 districts. Factors assessed included supportive supervision, availability of malaria management guidelines, laboratory infrastructure, and training health workers in the use of malaria rapid diagnostic test (RDT). Survey data were matched with routinely collected health facility malaria data obtained from the district health information system Version-2 (DHIS2). Associations between testing at least 75% of suspect malaria cases with several factors were examined using multivariate logistic regression. RESULTS: Key malaria commodities were widely available; 92% and 85% of the health facilities reported availability of RDTs and artemether-lumefantrine, respectively. Overall, 933 (86%) of the facilities tested over 75% of patients suspected to have malaria. Predictors of meeting the testing target were: supervision in the last 6 months (OR: 1.72, 95% CI 1.04-2.85) and a health facility having at least one health worker trained in the use of RDTs (OR: 1.62, 95% CI 1.04-2.55). CONCLUSION: The study findings underscore the need for malaria control programmes to provide regular supportive supervision to health facilities and train health workers in the use of RDTs.

      2. Guiding placement of health facilities using multiple malaria criteria and an interactive toolexternal icon
        Toh KB, Millar J, Psychas P, Abuaku B, Ahorlu C, Oppong S, Koram K, Valle D.
        Malar J. 2021 Dec 3;20(1):455.
        BACKGROUND: Access to healthcare is important in controlling malaria burden and, as a result, distance or travel time to health facilities is often a significant predictor in modelling malaria prevalence. Adding new health facilities may reduce overall travel time to health facilities and may decrease malaria transmission. To help guide local decision-makers as they scale up community-based accessibility, the influence of the spatial allocation of new health facilities on malaria prevalence is evaluated in Bunkpurugu-Yunyoo district in northern Ghana. A location-allocation analysis is performed to find optimal locations of new health facilities by separately minimizing three district-wide objectives: malaria prevalence, malaria incidence, and average travel time to health facilities. METHODS: Generalized additive models was used to estimate the relationship between malaria prevalence and travel time to the nearest health facility and other geospatial covariates. The model predictions are then used to calculate the optimisation criteria for the location-allocation analysis. This analysis was performed for two scenarios: adding new health facilities to the existing ones, and a hypothetical scenario in which the community-based healthcare facilities would be allocated anew. An interactive web application was created to facilitate efficient presentation of this analysis and allow users to experiment with their choice of health facility location and optimisation criteria. RESULTS: Using malaria prevalence and travel time as optimisation criteria, two locations that would benefit from new health facilities were identified, regardless of scenarios. Due to the non-linear relationship between malaria incidence and prevalence, the optimal locations chosen based on the incidence criterion tended to be inequitable and was different from those based on the other optimisation criteria. CONCLUSIONS: This study findings underscore the importance of using multiple optimisation criteria in the decision-making process. This analysis and the interactive application can be repurposed for other regions and criteria, bridging the gap between science, models and decisions.

    • Reproductive Health
      1. Factors Associated with Unplanned Pregnancy Among Cancer Survivorsexternal icon
        Shandley LM, Kipling LM, Spencer JB, Morof D, Mertens AC, Howards PP.
        J Womens Health (Larchmt). 2021 Dec 2.
        Background: Approximately half of all pregnancies in the United States are unintended. However, women who are diagnosed with cancer in their reproductive years may be a unique population. This study examines the prevalence of and identifies factors associated with unplanned pregnancy among cancer survivors. Methods: Female cancer survivors aged 22-45 years, diagnosed between ages 20-35 years and at least 2 years postdiagnosis, and women with no history of cancer were interviewed about their reproductive histories, including pregnancy intention. Using a random matching process, comparison women were assigned an artificial age at cancer diagnosis equal to that of her cancer survivor match. An adjusted Cox model was fit examining time to unintended pregnancy after cancer for each of 1,000 matches. Cox proportional hazards models were also fit to assess associations between participant characteristics and unplanned pregnancy after cancer among survivors. Results: Cancer survivors (n = 1,282) and comparison women (n = 1,073) reported a similar likelihood of having an unplanned pregnancy in models adjusted for race, income, history of sexually-transmitted infection, and history of unplanned pregnancy before diagnosis (adjusted hazard ratio [aHR] 1.06, 95% simulation interval 0.85-1.36). After adjusting for confounders, unplanned pregnancy among survivors was associated with age <30 years at diagnosis (hazard ratio [HR]: 1.79, 95% confidence interval [CI]: 1.32-2.44), black race (HR: 1.55, 95% CI: 1.13-2.12; referent: white), receiving fertility counseling (aHR: 1.41, 95% CI: 1.04-1.92), and having at least one child before diagnosis (aHR: 1.44, 95% CI: 1.05-1.97). Conclusion: Cancer survivors and comparison women had similar likelihood of unplanned pregnancy. Rates of unplanned pregnancy after cancer were not higher for cancer survivors compared with comparison women, but 46.4% of survivors with a postcancer pregnancy reported an unplanned pregnancy. Cancer patients may benefit from patient-centered guidelines and counseling before cancer treatment that covers both risks of infertility and risks of unplanned pregnancy.

    • Substance Use and Abuse
      1. The most alarming aspect of the Sudanese toombak smokeless tobacco is that it contains high levels of highly toxic Tobacco-Specific Nitrosamines (TSNAs). Understanding the microbiology of toombak is of relevance because TSNAs are an indirect result of microbial-mediated nitrate reductions. We conducted shotgun metagenomic sequencing on a toombak product for which relevant features are presented here. The microbiota was composed of over 99% Bacteria. The most abundant taxa included Actinobacteria, specifically genera Enteractinococcus and Corynebacterium, while Firmicutes were represented by Family Bacillaceae and the genus Staphylococcus. Selected gene targets were nitrate reduction and transport, antimicrobial resistance, and other genetic transference mechanisms. Canonical nitrate reduction and transport genes (i.e., nar) were found for Enteractinococcus and Corynebacterium while various species of Staphylococcus exhibited a notable number of antimicrobial resistance and genetic transference genes. The nitrate reduction activity of the microbiota in toombak is suspected to be a contributing factor to its high levels of TSNAs. Additionally, the presence of antimicrobial resistance and transference genes could contribute to deleterious effects on oral and gastrointestinal health of the end user. Overall, the high toxicity and increased incidences of cancer and oral disease of toombak users warrants further investigation into the microbiology of toombak.

      2. A gas chromatography-mass spectrometry method for quantifying squalane and squalene in aerosol emissions of electronic cigarette, or vaping, productsexternal icon
        Cowan EA, Tran H, Gray N, Perez JJ, Watson C, Blount BC, Valentín-Blasini L.
        Talanta. 2022 Feb 1;238(Pt 1):122985.
        Numerous chemicals of unknown inhalational toxicity have been measured in electronic cigarette, or vaping, products (EVPs). In addition, little is known about the liquid-to-aerosol transmission and deliveries of these chemicals, including oil-like terpenes such as squalene (SQE) and squalane (SQA). To provide information on the aerosol deliveries of these compounds from EVPs, we developed and validated a quantitative method to measure squalene and squalane in EVP aerosol emissions. Validation parameters include measurement repeatability (SQA and SQE %RSD <6%), intermediate precision (SQA: %RSD 11%, SQE: %RSD 17%), accuracy (SQA: 86-107%, SQE: 104-113%), matrix effects, method robustness, and analyte stability. Limits of detection were 6.06 ng/mL puffed air volume for both squalene and squalane. The method was used to measure squalene and squalane in aerosol emissions of 153 EVPs associated with case patients from a recent outbreak of e-cigarette, or vaping, product use associated lung injury (EVALI). The EVPs analyzed were organized into nicotine, cannabidiol, and tetrahydrocannabinol products by the percentage of nicotine, cannabidiol, and tetrahydrocannabinol in total particulate matter after vaping. In case-associated tetrahydrocannabinol products the detection rates and mean concentrations were 82.4% and 33.0 ng/mL puffed air for squalene and 4.41% and 7.80 ng/mL puffed air for squalane.

    • Zoonotic and Vectorborne Diseases
      1. Novel Assay to Measure Seroprevalence of Zika Virus in the Philippinesexternal icon
        Adams C, Jadi R, Segovia-Chumbez B, Daag J, Ylade M, Medina FA, Sharp TM, Munoz-Jordan JL, Yoon IK, Deen J, Lopez AL, de Silva AM, Premkumar L.
        Emerg Infect Dis. 2021 Dec;27(12):3073-3081.
        Zika virus (ZIKV) is a member of the Flaviviridae family, which includes other clinically notable viruses such as the 4 dengue virus serotypes (DENV-1-4). Distinguishing DENVs from ZIKV using the established serologic assays widely used for monitoring DENV transmission is difficult because of antibody cross-reactivity between these closely related flaviviruses. We describe a modified and improved recombinant envelope domain III-based serologic assay for detecting ZIKV type-specific antibodies in regions with endemic DENV transmission. When the assay was used to measure ZIKV seroprevalence in 2017 among children 9-14 years of age living in a region of the Philippines with endemic DENV transmission, we observed a ZIKV seroprevalence of 18%. Investigators should consider using the ZIKV envelope domain III-based assay, which is simple and readily adaptable for use in standard clinical and public health laboratories, to assess ZIKV seroprevalence in areas with endemic DENV transmission.

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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