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Issue 48, December 28, 2021

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CDC Science Clips: Volume 13, Issue 48, December 28, 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.

The report consists of these components:

  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. Clinical outcomes among hospitalized US adults with asthma or chronic obstructive pulmonary disease, with or without COVID-19external icon
        Cornwell CR, Hsu J, Tompkins LK, Pennington AF, Flanders WD, Sircar K.
        J Asthma. 2021 Dec 13:1-16.
        Objective: This study assesses the risk of severe clinical outcomes during hospitalizations of adults with asthma and/or COPD plus COVID-19 and compares those risks with those during hospitalizations of adults with asthma and/or COPD without COVID-19.Methods: We used data from 877 U.S. hospitals from the Premier Healthcare Database during March 2020-March 2021. Hospitalizations (n = 311,215) among patients aged ≥18 years with an ICD-10-CM diagnosis involving asthma or COPD were classified into three groups: adults with asthma (but not COPD), adults with COPD (but not asthma), and adults with both asthma and COPD. We used multivariable Poisson regression to assess associations of severe clinical outcomes [intensive care unit (ICU) admission, use of invasive mechanical ventilation (IMV), and death] and COVID-19 status.Results: The percentage of hospitalizations among patients with asthma and COVID-19 resulting in ICU admission, IMV, and death were 46.9%, 14.0%, and 8.0%, respectively. These risks were higher than those among patients with asthma without COVID-19 (adjusted risk ratio [aRR], 1.17 [95% confidence interval (CI), 1.14-1.21], 1.61 [95% CI, 1.50-1.73], and 5.56 [95% CI, 4.89-6.32]), respectively. Risks of ICU admission, IMV, and death were also high among patients with COPD and COVID-19 and exceeded the corresponding risks among patients with COPD without COVID-19.Conclusion: Hospitalizations among patients with asthma and/or COPD with COVID-19 had a more severe clinical course than hospitalizations for asthma and/or COPD exacerbations without COVID-19.

      2. Trends in Asthma-Related School Health Policies and Practices in the US Statesexternal icon
        Qin X, Zahran HS, Leon-Nguyen M, Kilmer G, Collins P, Welch P, Malilay J.
        J Sch Health. 2021 Dec 14.
        BACKGROUND: Asthma is one of the leading causes of school absenteeism. Schools can play an important role in coordinating asthma care. The purpose of this study was to assess the implementation of asthma-related school health policies and practices across states and how they have changed over time. METHODS: Data were analyzed from 36 states that conducted School Health Profiles surveys during 2008 to 2018. Trends in 6 topics were analyzed by logistic regression and JointPoint trend test. RESULTS: Trends in efforts to identify and track students with asthma and improve students' and parents' knowledge about asthma were stable or increased. Interest among lead health education teachers in receiving professional development on asthma trended downward in 35 of 36 states. CONCLUSIONS: Stable to upward trends suggest that a majority of schools have maintained or improved their efforts to identify and track students with asthma and increase the knowledge of students and parents about asthma. However, further improvement is needed in referral of students with asthma to health care professionals and encouraging asthma-related professional development of lead health education teachers.

    • Communicable Diseases
      1. Remote Household Observation for Noninfluenza Respiratory Viral Illnessexternal icon
        Emanuels A, Heimonen J, O'Hanlon J, Kim AE, Wilcox N, McCulloch DJ, Brandstetter E, Wolf CR, Logue JK, Han PD, Pfau B, Newman KL, Hughes JP, Jackson ML, Uyeki TM, Boeckh M, Starita LM, Nickerson DA, Bedford T, Englund JA, Chu HY.
        Clin Infect Dis. 2021 Dec 6;73(11):e4411-e4418.
        BACKGROUND: Noninfluenza respiratory viruses are responsible for a substantial burden of disease in the United States. Household transmission is thought to contribute significantly to subsequent transmission through the broader community. In the context of the coronavirus disease 2019 (COVID-19) pandemic, contactless surveillance methods are of particular importance. METHODS: From November 2019 to April 2020, 303 households in the Seattle area were remotely monitored in a prospective longitudinal study for symptoms of respiratory viral illness. Enrolled participants reported weekly symptoms and submitted respiratory samples by mail in the event of an acute respiratory illness (ARI). Specimens were tested for 14 viruses, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), using reverse-transcription polymerase chain reaction. Participants completed all study procedures at home without physical contact with research staff. RESULTS: In total, 1171 unique participants in 303 households were monitored for ARI. Of participating households, 128 (42%) included a child aged <5 years and 202 (67%) included a child aged 5-12 years. Of the 678 swabs collected during the surveillance period, 237 (35%) tested positive for 1 or more noninfluenza respiratory viruses. Rhinovirus, common human coronaviruses, and respiratory syncytial virus were the most common. Four cases of SARS-CoV-2 were detected in 3 households. CONCLUSIONS: This study highlights the circulation of respiratory viruses within households during the winter months during the emergence of the SARS-CoV-2 pandemic. Contactless methods of recruitment, enrollment, and sample collection were utilized throughout this study and demonstrate the feasibility of home-based, remote monitoring for respiratory infections.

      2. A cluster-based method to quantify individual heterogeneity in tuberculosis transmissionexternal icon
        Smith JP, Gandhi NR, Silk BJ, Cohen T, Lopman B, Raz K, Winglee K, Kammerer S, Benkeser D, Kramer M, Hill AN.
        Epidemiology. 2021 Dec 8.
        BACKGROUND: Recent evidence suggests transmission of Mycobacterium tuberculosis (Mtb) may be characterized by extreme individual heterogeneity in secondary cases (i.e., few cases account for the majority of transmission). Such heterogeneity implies outbreaks are rarer but more extensive and has profound implications in infectious disease control. However, discrete person-to-person transmission events in TB are often unobserved, precluding our ability to directly quantify individual heterogeneity in TB epidemiology. METHODS: We used a modified negative binomial branching process model to quantify the extent of individual heterogeneity using only observed transmission cluster size distribution data (i.e., the simple sum of all cases in a transmission chain) without knowledge of individual-level transmission events. The negative binomial parameter k quantifies the extent of individual heterogeneity (generally, k<1 indicates extensive heterogeneity, and as k→∞ transmission becomes more homogenous). We validated the robustness of the inference procedure considering common limitations affecting cluster-size data. Finally, we demonstrate the epidemiologic utility of this method by applying it to aggregate United States molecular surveillance data from the U.S. Centers for Disease Control and Prevention. RESULTS: The cluster-based method reliably inferred k using TB transmission cluster data despite a high degree of bias introduced into the model. We found that the TB transmission in the United States was characterized by a high propensity for extensive outbreaks (k=0.09; 95% confidence interval: 0.09, 0.10). CONCLUSION: The proposed method can accurately quantify critical parameters that govern TB transmission using simple, more easily obtainable cluster data to improve our understanding of TB epidemiology.

      3. Optimizing HIV Services for Key Populations in Public-Sector Clinics in Myanmarexternal icon
        Lemons-Lyn A, Reidy W, Myint WW, Chan KN, Abrams E, Aung ZZ, Benech I, Bingham T, Desai M, Khin EE, Lin T, Olsen H, Oo HN, Wells C, Mital S.
        J Int Assoc Provid AIDS Care. 2021 Jan-Dec;20:23259582211055933.
        Key populations, ie, female sex workers, men who have sex with men, transgender people, people who inject drugs, and people in prisons and other closed settings, experience stigma, discrimination, and structural barriers when accessing HIV prevention and care. Public health facilities in Myanmar became increasingly involved in HIV service delivery, leading to an urgent need for healthcare workers to provide client-centred, key population-friendly services. Between July 2017-June 2018, the Myanmar Ministry of Health and Sports and National AIDS Programme collaborated with ICAP at Columbia University and the US Centers for Disease Control and Prevention to implement a quasi-experimental, multicomponent intervention including healthcare worker sensitization training with pre- and post- knowledge assessments, healthcare worker and client satisfaction surveys, and structural changes. We observed modest improvements among healthcare workers (n = 50) in knowledge assessments. Classification of clients into key population groups increased and fewer clients were classified as low risk. Key population clients reported favourable perceptions of the quality and confidentiality of care through self-administered surveys. Our findings suggest public health facilities can deliver HIV services that are valued by key population clients.

      4. Influenza A(H3N2) Outbreak on a University Campus - Michigan, October-November 2021external icon
        Delahoy MJ, Mortenson L, Bauman L, Marquez J, Bagdasarian N, Coyle J, Sumner K, Lewis NM, Lauring AS, Flannery B, Patel MM, Martin ET.
        MMWR Morb Mortal Wkly Rep. 2021 Dec 10;70(49):1712-1714.
        On November 10, 2021, the Michigan Department of Health and Human Services (MDHHS) was notified of a rapid increase in influenza A(H3N2) cases by the University Health Service (UHS) at the University of Michigan in Ann Arbor. Because this outbreak represented some of the first substantial influenza activity during the COVID-19 pandemic, CDC, in collaboration with the university, MDHHS, and local partners conducted an investigation to characterize and help control the outbreak. Beginning August 1, 2021, persons with COVID-19-like* or influenza-like illness evaluated at UHS received testing for SARS-CoV-2, influenza, and respiratory syncytial viruses by rapid multiplex molecular assay.(†) During October 6-November 19, a total of 745 laboratory-confirmed influenza cases were identified.(§) Demographic information, genetic characterization of viruses, and influenza vaccination history data were reviewed. This activity was conducted consistent with applicable federal law and CDC policy.(¶).

      5. Demographic and Epidemiological Characteristics Associated With Reduced Antimicrobial Susceptibility to Neisseria gonorrhoeae in the United States, Strengthening the US Response to Resistant Gonorrhea, 2018 to 2019external icon
        Gieseker KE, Learner ER, Mauk K, Barbee LA, McNeil CJ, Hasty GL, Black JM, Johnson K, Nguyen TQ, Shrestha D, Pham CD, St Cyr S, Schlanger K, Kirkcaldy RD.
        Sex Transm Dis. 2021 Dec 1;48(12S Suppl 2):S118-s123.
        BACKGROUND: Jurisdictions participating in Strengthening the US Response to Resistant Gonorrhea (SURRG) implemented specimen collection for culture and antimicrobial susceptibility testing from a sample of persons of all genders (at multiple anatomic sites) attending sexually transmitted disease clinics and community clinics. We describe the percentage and characteristics of patients whose isolates demonstrated reduced susceptibility (RS) to azithromycin, ceftriaxone, or cefixime. METHODS: We included patients from clinics that participated in SURRG whose isolates underwent antimicrobial susceptibility testing by Etest. We defined RS as azithromycin minimum inhibitory concentrations (MICs) ≥2 μg/mL (AZM-RS), ceftriaxone MICs ≥0.125 μg/mL (CRO-RS), or cefixime MICs ≥0.25 μg/mL (CFX-RS). Patients with repeated infections appeared >1 time in the data. We calculated the frequency and percentage of patients with an isolate demonstrating RS by epidemiological characteristics. RESULTS: During the period 2018-2019, 10,013 patients from 8 jurisdictions provided 10,735 isolates. Among 10,013 patients, 11.0% (n = 1099) had ≥1 isolate with AZM-RS (range by jurisdiction, 2.5%-18.0%). Approximately 11.3% of 8771 of patients visiting sexually transmitted disease clinics and approximately 8.8% of 1242 patients visiting community clinics had an AZM-RS isolate. Nearly 6% of 1013 females had an AZM-RS isolate; among males, the percents of patients with an AZM-RS isolate were 17.7% among 4177 men who have sex only with men and 6.1% among 3581 men who have sex only with women. Few (0.4%) patients had isolates with CFX-RS (n = 40) or CRO-RS (n = 43). CONCLUSIONS: Although infections with reduced cephalosporin susceptibility were rare, AZM-RS infections were prevalent in this sample of patients in multiple jurisdictions and across gender and gender of sex partner categories.

    • Disaster Preparedness and Emergency Services
      1. State of public health emergency response leadership training: A multitiered organizational perspectiveexternal icon
        Salerno A, Li Y, Davis XM, Stennies G, Barnett DJ, Fisher MK, Biesiadecki L, Dekker D, Pham N, Pearson JL, Podgornik MN, Hunter DW, Vagi S, Hsu EB.
        Am J Disaster Med. 2021 Summer;16(3):167-177.
        OBJECTIVE: To capture organizational level information on the current state of public health emergency response leadership training. DESIGN: A web-based questionnaire. PARTICIPANTS: This multitiered assessment of health departments included two distinct respondent groups: (1) Public Health Emergency Preparedness (PHEP) Cooperative Agreement recipients (n = 34) and (2) local health departments (LHDs) (n = 169) representative of different agency sizes and populations served. RESULTS: Overall, PHEP and LHD respondents expressed a clear preference for participatory learning with practical drills/exercises and participatory workshops as the preferred training delivery modes. Compared with technical and role-specific training, leadership training was less available. For both PHEP and LHD respondents, staff availability for training is most notably limited due to lack of time. For PHEP respondents, a common factor limiting agency ability to offer training is lack of mentors/instructors, whereas for LHD respondents, it is limited funding. CONCLUSIONS: Efforts should focus on increasing accessibility and the continued development of rigorous and effective training based on practical experience in all aspects of multitiered public health emergency response leadership.

      2. Infodemics: A new challenge for public healthexternal icon
        Briand SC, Cinelli M, Nguyen T, Lewis R, Prybylski D, Valensise CM, Colizza V, Tozzi AE, Perra N, Baronchelli A, Tizzoni M, Zollo F, Scala A, Purnat T, Czerniak C, Kucharski AJ, Tshangela A, Zhou L, Quattrociocchi W.
        Cell. 2021 Dec 9;184(25):6010-6014.
        The COVID-19 information epidemic, or "infodemic," demonstrates how unlimited access to information may confuse and influence behaviors during a health emergency. However, the study of infodemics is relatively new, and little is known about their relationship with epidemics management. Here, we discuss unresolved issues and propose research directions to enhance preparedness for future health crises.

    • Disease Reservoirs and Vectors
      1. Marburg virus (MARV), the causative agent of Marburg virus disease, emerges sporadically in sub-Saharan Africa and is often fatal in humas. The natural reservoir for this zoonotic virus is the frugivorous Egyptian rousette bat (Rousettus aegyptiacus) that when infected, sheds virus in the highest amounts in oral secretions and urine. Being fruit bats, these animals forage nightly for ripened fruit throughout the year, including those types often preferred by humans. During feeding, they continually discard partially eaten fruit on the ground that could then be consumed by other Marburg virus susceptible animals or humans. In this study, using qRT-PCR and virus isolation, we tested fruit discarded by Egyptian rousette bats experimentally infected with a natural bat isolate of Marburg virus. We then separately tested viral persistence on fruit varieties commonly cultivated in sub-Saharan Africa using a recombinant Marburg virus expressing the fluorescent ZsGreen1. Marburg virus RNA was repeatedly detected on fruit in the food bowls of the infected bats and viable MARV was recovered from inoculated fruit for up to 6 h. © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

    • Drug Safety
      1. OBJECTIVE: This study aimed to evaluate trends in the use of obesogenic medications among adults. METHODS: Cross-sectional data on adults aged ≥20 years are from the 1999 to 2018 National Health and Nutrition Examination Survey (n = 52,340). Obesogenic medications were defined according to the 2015 Endocrine Society guidelines on the pharmacological management of obesity. Weight status was categorized according to BMI. Trends in prior 30-day use were evaluated. RESULTS: In NHANES 2017-2018, 20.3% of US adults used an obesogenic medication. Beta-blockers (9.8%) and antidiabetics (5.7%) were the most common; antipsychotics (1.0%) were the least common. Most common indications were disorders of glucose metabolism, hypertension, neuralgia or neuritis, heart disease, and musculoskeletal pain and/or inflammation. From 1999 to 2018, the proportional use of obesogenic medications increased for anticonvulsants (34.4% to 55.0%) but decreased for antidepressants (32.1% to 18.8%), antidiabetics (82.9% to 52.5%), and beta-blockers (83.9% to 80.7%). The proportional use of obesogenic medications was not associated with weight status, except for antipsychotics. CONCLUSIONS: Use of obesogenic medications was common. Differences in the proportional use of obesogenic medication may reflect changing availability of obesogenic versus nonobesogenic medications over time. The decision to prescribe a nonobesogenic alternative, if one exists, is guided by weighing the risks and benefits of available treatments.

    • Environmental Health
      1. Orbiting Sample Tiger Team Recommendation on Orbiting Sample Cleanlinessexternal icon
        Cockell CS, Chatale R, Clement B, Davila AF, Freeman KH, French K, Glavin DP, Hays LE, Hummel K, Meyer MA, Pratt L, Salvo C, Seasly E, Tsang W.
        Astrobiology. 2021 Dec 14.
        The National Aeronautics and Space Administration-European Space Agency (NASA-ESA) Mars Sample Return (MSR) campaign involves the collection of samples on Mars by the Perseverance (Mars 2020) rover and their return to Earth. To accomplish this, the Orbiting Sample container (OS) will be sent to Mars to accommodate the collected samples then launched from Mars and returned to Earth, where the samples will be removed for examination in the Sample Return Facility (SRF). Crucial to this entire sequence will be establishment of the required level of cleanliness inside the OS. In February 2021, the NASA Headquarters' Mars Sample Return Program and Office of Planetary Protection assembled an MSR OS Tiger Team (OSTT) to discuss the appropriate cleanliness level options of the interior of the OS. The team's remit was primarily focused on evaluating the trade-offs between Planetary Protection cleanliness levels 4a and 4b. These cleanliness levels are determined by the Committee on Space Research (COSPAR) planetary protection regulations, where 4a requires < 300 bacterial spores/m2 and < 3 x 105 bacterial spores on the spacecraft (in this case, the interior of the OS) and 4b mandates the more stringent requirement of < 30 bacterial spores on the spacecraft. This report documents the consensus opinion submitted by the OSTT that recommended the interior of the OS be cleaned to a 4a requirement with any feasible added effort toward 4b. This report provides, as well, the rationale for that decision.

      2. Gestational exposure to polybrominated diphenyl ethers and social skills and problem behaviors in adolescents: The HOME studyexternal icon
        Hartley K, MacDougall MC, Terrizzi B, Xu Y, Cecil KM, Chen A, Braun JM, Lanphear BP, Newman NC, Vuong AM, Sjödin A, Yolton K.
        Environ Int. 2021 Dec 10;159:107036.
        BACKGROUND: Polybrominated diphenyl ethers (PBDEs) are persistent environmental pollutants used as flame retardants. Gestational PBDE exposure has been associated with a variety of behavior problems in children, but little is known about its impact into adolescence, particularly on social skills, which are important for achieving social competence, establishing identity, and forming lasting relationships. OBJECTIVE: We investigated associations between gestational exposure to PBDEs and social skills and problem behaviors in early adolescence in a longitudinal pregnancy and birth cohort in Cincinnati, Ohio (recruited 2003-2006). METHODS: We measured maternal serum concentrations of five PBDE congeners during gestation. At age 12, we measured social skills and problem behaviors scores for 243 adolescents using self- and caregiver-report on the Social Skills Improvement System (SSiS). We used multivariable linear regression models to estimate associations between maternal PBDE concentrations and SSiS scores, controlling for potential covariates. We report associations for the five congeners and a summary exposure variable (∑(5)BDE: the sum of BDE- 28, 47, 99, 100, and 153, n = 197). RESULTS: We found sex-specific associations of ∑(5)BDE concentrations with adolescent-reported Problem Behaviors (∑(5)BDE × sex p(int) = 0.02) and caregiver-reported Social Skills (∑(5)BDE × sex p(int) = 0.02). In sex-stratified models, log(10) transformed data revealed increased maternal ∑(5)BDE concentration among males was associated with decreased caregiver-reported Social Skills composite score (β = -10.2, 95% CI: -19.5, -1.0), increased adolescent-reported Problem Behaviors composite score (β = 12.1, 95% CI: 5.4, 18.8), and increased caregiver-reported Problem Behaviors composite score (β = 6.2, 95% CI: 0.7, 11.7). Further analysis on SSiS subscales revealed similar patterns in significant associations among males. There were no statistically significant associations in stratified models among females despite higher ∑(5)BDE exposure (Female GM=40.15 ng/g lipid, GSE=1.10; Male GM=35.30 ng/g lipid, GSE=1.09). DISCUSSION: We found gestational PBDE exposure in males was associated with poorer behavioral outcomes, extending previous findings among this cohort into early adolescence.

    • Epidemiology and Surveillance
      1. Data collection for outbreak investigations: process for defining a minimal data set using a Delphi approachexternal icon
        Perrocheau A, Brindle H, Roberts C, Murthy S, Shetty S, Martin AI, Marks M, Schenkel K.
        BMC Public Health. 2021 Dec 13;21(1):2269.
        BACKGROUND: Timely but accurate data collection is needed during health emergencies to inform public health responses. Often, an abundance of data is collected but not used. When outbreaks and other health events occur in remote and complex settings, operatives on the ground are often required to cover multiple tasks whilst working with limited resources. Tools that facilitate the collection of essential data during the early investigations of a potential public health event can support effective public health decision-making. We proposed to define the minimum set of quantitative information to collect whilst using electronic device or not. Here we present the process used to select the minimum information required to describe an outbreak of any cause during its initial stages and occurring in remote settings. METHODS: A working group of epidemiologists took part in two rounds of a Delphi process to categorise the variables to be included in an initial outbreak investigation form. This took place between January-June 2019 using an online survey. RESULTS: At a threshold of 75 %, consensus was reached for nineteen (23.2%) variables which were all classified as 'essential'. This increased to twenty-six (31.7%) variables when the threshold was reduced to 60% with all but one variable classified as 'essential'. Twenty-five of these variables were included in the 'Time zero initial case investigation' '(T0)' form which was shared with the members of the Rapid Response Team Knowledge Network for field testing and feedback. The form has been readily available online by WHO since September 2019. CONCLUSION: This is the first known Delphi process used to determine the minimum variables needed for an outbreak investigation. The subsequent development of the T0 form should help to improve the efficiency and standardisation of data collection during emergencies and ultimately the quality of the data collected during field investigation.

      2. COVID-19 Contact Tracing Outcomes in Washington State, August and October 2020external icon
        Bonacci RA, Manahan LM, Miller JS, Moonan PK, Lipparelli MB, DiFedele LM, Davis LB, Lash RR, Oeltmann JE.
        Front Public Health. 2021 ;9:782296.
        Introduction: Case investigation and contact tracing are important tools to limit the spread of SARS-CoV-2, particularly when implemented efficiently. Our objective was to evaluate participation in and timeliness of COVID-19 contact tracing and whether these measures changed over time. Methods: We retrospectively assessed COVID-19 case investigation and contact tracing surveillance data from the Washington State centralized program for August 1-31, 2020 and October 1-31, 2020. We combined SARS-CoV-2 testing reports with contact tracing data to compare completeness, reporting of contacts, and program timeliness. Results: For August and October respectively, 4,600 (of 12,521) and 2,166 (of 16,269) individuals with COVID-19 were referred to the state program for case investigation. Investigators called 100% of referred individuals; 65% (August) and 76% (October) were interviewed. Of individuals interviewed, 33% reported contacts in August and 45% in October, with only mild variation by age, sex, race/ethnicity, and urbanicity. In August, 992 individuals with COVID-19 reported a total of 2,584 contacts (mean, 2.6), and in October, 739 individuals reported 2,218 contacts (mean, 3.0). Among contacts, 86% and 78% participated in interviews for August and October. The median time elapsed from specimen collection to contact interview was 4 days in August and 3 days in October, and from symptom onset to contact interview was 7 days in August and 6 days in October. Conclusions: While contact tracing improved with time, the proportion of individuals disclosing contacts remained below 50% and differed minimally by demographic characteristics. The longest time interval occurred between symptom onset and test result notification. Improving elicitation of contacts and timeliness of contact tracing may further decrease SARS-CoV-2 transmission.

      3. An Evaluation of the Text Illness Monitoring (TIM) Platform for COVID-19: A Cross-Sectional Online Survey of Public Health Usersexternal icon
        Joseph HA, Ingber SZ, Austin C, Westnedge C, Strona FV, Lee L, Shah AB, Roper L, Anita P.
        JMIR Public Health Surveill. 2021 Nov 30.
        BACKGROUND: The U.S. public health response to the 2019 Novel Coronavirus (COVID-19) pandemic has required contact tracing and symptom monitoring at an unprecedented scale. The Centers for Disease Control and Prevention and several partners created a text illness monitoring (TIM) platform in 2015 to assist U.S. public health jurisdictions with symptom monitoring for potential novel influenza virus outbreaks. Since May 2020, 142 federal, state, and local public health agencies have deployed TIM for COVID-19 symptom monitoring. OBJECTIVE: We evaluated the utility, benefits, and challenges of TIM to help guide decision making for improvements and expansion to support future public health emergency response efforts. METHODS: We conducted a brief online survey of previous and current TIM administrators (admin users) from November 28, 2020 through December 21, 2020. Closed- and open-ended questions inquired about the onboarding process, decision to use TIM, groups monitored with TIM, comparison of TIM to other symptom monitoring systems, technical challenges and satisfaction with TIM, and user support. A total of 1,479 admin users were invited to participate. RESULTS: Ninety-seven admin users from 43 agencies responded to the survey. Most admin users represented the Indian Health Service (36.1%), state health departments (26.8%), and local or county health departments (18.6%), and almost all were current users of TIM (90.4%). Among the agencies represented,11 (25.6%) used TIM for monitoring staff exclusively, 13 (30.2%) monitored community members exclusively, and 19 (44.2%) monitored both staff and community members. Agencies most frequently used TIM to monitor symptom development in contacts of cases among community members (65.1%, 28/43), followed by symptom development among staff (62.8%, 27/43) and among staff contacts of cases (55.8%, 24/43). Agencies also reported using TIM to monitor patients with COVID-19 for the worsening of symptoms among staff (48.8%, 21/43) and community members (41.9%, 18/43). When asked to compare TIM to previous monitoring systems, 78.4% (40/51) of respondents rated TIM more favorably than their previous monitoring system, 19.6% (10/51) said there was no difference, and 2.0% (1/51) rated the previous monitoring system more favorably than TIM. Most respondents found TIM favorable in terms of time burden, staff burden, timeliness of the data, and the ability to monitor large population sizes. TIM compared negatively to other systems in terms of effort to enroll participants (persons TIM monitors) and accuracy of the data. Most (89.4%, 76/85) reported they would highly or somewhat recommend TIM to others for symptom monitoring. CONCLUSIONS: This evaluation of TIM showed that agencies used TIM for a variety of purposes and rated TIM favorably compared to previously used monitoring systems. We also identified opportunities to improve TIM; for example, enhancing the flexibility of alert deliveries would better meet admin users' varying needs. We also suggest continuous program evaluation practices to assess and respond to implementation gaps.

      4. Community-Based Testing Sites for SARS-CoV-2 - United States, March 2020-November 2021external icon
        Miller MF, Shi M, Motsinger-Reif A, Weinberg CR, Miller JD, Nichols E.
        MMWR Morb Mortal Wkly Rep. 2021 Dec 10;70(49):1706-1711.
        Immediately following the March 13, 2020 declaration of COVID-19 as a national emergency (1), the U.S. government began implementing national testing programs for epidemiologic surveillance, monitoring of frontline workers and populations at higher risk for acquiring COVID-19, and identifying and allocating limited testing resources. Effective testing supports identification of COVID-19 cases; facilitates isolation, quarantine, and timely treatment measures that limit the spread of SARS-CoV-2 (the virus that causes COVID-19); and guides public health officials about the incidence of COVID-19 in a community. A White House Joint Task Force, co-led by the Department of Health and Human Services (HHS) and the Federal Emergency Management Agency (FEMA), created the Community-Based Testing Sites (CBTS) program working with state and local partners (2). This report describes the timeline, services delivered, and scope of the CBTS program. During March 19, 2020-April 11, 2021, the CBTS program conducted 11,661,923 SARS-CoV-2 tests at 8,319 locations across the United States and its territories, including 402,223 (3.5%) administered through Drive-Through Testing, 10,129,142 (86.9%) through Pharmacies+ Testing, and 1,130,558 (9.7%) through Surge Testing programs. Tests administered through the CBTS program yielded 1,176,959 (10.1%) positive results for SARS-CoV-2. Among tested persons with available race data,* positive test results were highest among American Indian or Alaska Native (14.1%) and Black persons (10.4%) and lowest among White persons (9.9%), Asian persons (7.3%), and Native Hawaiian or Other Pacific Islanders (6.4%). Among persons with reported ethnicity, 25.3% were Hispanic, 15.9% of whom received a positive test result. Overall, 82.0% of test results were returned within 2 days, but the percentage of test results returned within 2 days was as low as 40.7% in July 2020 and 59.3% in December 2020 during peak testing periods. Strong partnerships enabled a rapid coordinated response to establish the federally supported CBTS program to improve access to no-charge diagnostic testing, including for frontline workers, symptomatic persons and close contacts, and persons living in high-prevalence areas. In April 2021, the CBTS Pharmacies+ Testing and Surge Testing programs were expanded into the Increasing Community Access to Testing (ICATT) program. As of November 12, 2021, the CBTS and ICATT programs conducted approximately 26.6 million tests with approximately 10,000 active testing sites. Although the CBTS program represented a relatively small portion of overall U.S. SARS-CoV-2 testing, with its successful partnerships and adaptability, the CBTS program serves as a model to guide current community-based screening, surveillance, and disease control programs, and responses to future public health emergencies.

    • Genetics and Genomics
      1. The association between mosaicism type and cognitive and behavioral functioning among males with fragile X syndromeexternal icon
        Meng L, Kaufmann WE, Frye RE, Ong K, Kaminski JW, Velinov M, Berry-Kravis E.
        Am J Med Genet A. 2021 .
        Mosaicism in fragile X syndrome (FXS) refers to two different FMR1 allele variations: size mosaicism represents different numbers of CGG repeats between the two alleles, such that in addition to a full mutation allele there is an allele in the normal or premutation range of CGG repeats, while methylation mosaicism indicates whether a full-mutation allele is fully or partially methylated. The present study explored the association between mosaicism type and cognitive and behavioral functioning in a large sample of males 3 years and older (n = 487) with FXS, participating in the Fragile X Online Registry with Accessible Research Database. Participants with methylation mosaicism were less severely cognitively affected as indicated by a less severe intellectual disability rating, higher intelligence quotient and adaptive behavior score, and lower social impairment score. In contrast, the presence of size mosaicism was not significantly associated with better cognitive and behavioral outcomes than full mutation. Our findings suggest that methylation mosaicism is associated with better cognitive functioning and adaptive behavior and less social impairment. Further research could assess to what extent these cognitive and behavioral differences depend on molecular diagnostic methods and the impact of mosaicism on prognosis of individuals with FXS. © 2021 Wiley Periodicals LLC.

      2. Whole-Genome Sequencing to Identify Missed Rifampicin and Isoniazid Resistance Among Tuberculosis Isolates-Chennai, India, 2013-2016external icon
        Tamilzhalagan S, Shanmugam S, Selvaraj A, Suba S, Suganthi C, Moonan PK, Surie D, Sathyanarayanan MK, Gomathi NS, Jayabal L, Sachdeva KS, Selvaraju S, Swaminathan S, Tripathy SP, Hall PJ, Ranganathan UD.
        Front Microbiol. 2021 ;12:720436.
        India has a high burden of drug-resistant tuberculosis (DR TB) and many cases go undetected by current drug susceptibility tests (DSTs). This study was conducted to identify rifampicin (RIF) and isoniazid (INH) resistance associated genetic mutations undetected by current clinical diagnostics amongst persons with DR TB in Chennai, India. Retrospectively stored 166 DR TB isolates during 2013-2016 were retrieved and cultured in Löwenstein-Jensen medium. Whole genome sequencing (WGS) and MGIT DST for RIF and INH were performed. Discordant genotypic and phenotypic sensitivity results were repeated for confirmation and the discrepant results considered final. Further, drug resistance-conferring mutations identified through WGS were analyzed for their presence as targets in current WHO-recommended molecular diagnostics. WGS detected additional mutations for rifampicin and isoniazid resistance than WHO-endorsed line probe assays. For RIF, WGS was able to identify an additional 10% (15/146) of rpoB mutant isolates associated with borderline rifampicin resistance compared to MGIT DST. WGS could detect additional DR TB cases than commercially available and WHO-endorsed molecular DST tests. WGS results reiterate the importance of the recent WHO revised critical concentrations of current MGIT DST to detect low-level resistance to rifampicin. WGS may help inform effective treatment selection for persons at risk of, or diagnosed with, DR TB.

      3. Novel and extendable genotyping system for human respiratory syncytial virus based on whole-genome sequence analysisexternal icon
        Chen J, Qiu X, Avadhanula V, Shepard SS, Kim DK, Hixson J, Piedra PA, Bahl J.
        Influenza Other Respir Viruses. 2021 Dec 10.
        BACKGROUND: Human respiratory syncytial virus (RSV) is one of the leading causes of respiratory infections, especially in infants and young children. Previous RSV sequencing studies have primarily focused on partial sequencing of G gene (200-300 nucleotides) for genotype characterization or diagnostics. However, the genotype assignment with G gene has not recapitulated the phylogenetic signal of other genes, and there is no consensus on RSV genotype definition. METHODS: We conducted maximum likelihood phylogenetic analysis with 10 RSV individual genes and whole-genome sequence (WGS) that are published in GenBank. RSV genotypes were determined by using phylogenetic analysis and pair-wise node distances. RESULTS: In this study, we first statistically examined the phylogenetic incongruence, rate variation for each RSV gene sequence and WGS. We then proposed a new RSV genotyping system based on a comparative analysis of WGS and the temporal distribution of strains. We also provide an RSV classification tool to perform RSV genotype assignment and a publicly accessible up-to-date instance of Nextstrain where the phylogenetic relationship of all genotypes can be explored. CONCLUSIONS: This revised RSV genotyping system will provide important information for disease surveillance, epidemiology, and vaccine development.

      4. Cryptosporidium felis differs from other Cryptosporidium spp. in codon usageexternal icon
        Li J, Guo Y, Roellig DM, Li N, Feng Y, Xiao L.
        Microb Genom. 2021 Dec;7(12).
        Cryptosporidium spp. are important enteric pathogens in a wide range of vertebrates including humans. Previous comparative analysis revealed conservation in genome composition, gene content, and gene organization among Cryptosporidium spp., with a progressive reductive evolution in metabolic pathways and invasion-related proteins. In this study, we sequenced the genome of zoonotic pathogen Cryptosporidium felis and conducted a comparative genomic analysis. While most intestinal Cryptosporidium species have similar genomic characteristics and almost complete genome synteny, fewer protein-coding genes and some sequence inversions and translocations were found in the C. felis genome. The C. felis genome exhibits much higher GC content (39.6 %) than other Cryptosporidium species (24.3-32.9 %), especially at the third codon position (GC3) of protein-coding genes. Thus, C. felis has a different codon usage, which increases the use of less energy costly amino acids (Gly and Ala) encoded by GC-rich codons. While the tRNA usage is conserved among Cryptosporidium species, consistent with its higher GC content, C. felis uses a unique tRNA for GTG for valine instead of GTA in other Cryptosporidium species. Both mutational pressures and natural selection are associated with the evolution of the codon usage in Cryptosporidium spp., while natural selection seems to drive the codon usage in C. felis. Other unique features of the C. felis genome include the loss of the entire traditional and alternative electron transport systems and several invasion-related proteins. Thus, the preference for the use of some less energy costly amino acids in C. felis may lead to a more harmonious parasite-host interaction, and the strengthened host-adaptation is reflected by the further reductive evolution of metabolism and host invasion-related proteins.

      5. Genetic diversity of Anopheles stephensi in Ethiopia provides insight into patterns of spreadexternal icon
        Carter TE, Yared S, Getachew D, Spear J, Choi SH, Samake JN, Mumba P, Dengela D, Yohannes G, Chibsa S, Murphy M, Dissanayake G, Flately C, Lopez K, Janies D, Zohdy S, Irish SR, Balkew M.
        Parasit Vectors. 2021 Dec 11;14(1):602.
        BACKGROUND: The recent detection of the South Asian malaria vector Anopheles stephensi in the Horn of Africa (HOA) raises concerns about the impact of this mosquito on malaria transmission in the region. Analysis of An. stephensi genetic diversity and population structure can provide insight into the history of the mosquito in the HOA to improve predictions of future spread. We investigated the genetic diversity of An. stephensi in eastern Ethiopia, where detection suggests a range expansion into this region, in order to understand the history of this invasive population. METHODS: We sequenced the cytochrome oxidase subunit I (COI) and cytochrome B gene (CytB) in 187 An. stephensi collected from 10 sites in Ethiopia in 2018. Population genetic, phylogenetic, and minimum spanning network analyses were conducted for Ethiopian sequences. Molecular identification of blood meal sources was also performed using universal vertebrate CytB sequencing. RESULTS: Six An. stephensi COI-CytB haplotypes were observed, with the highest number of haplotypes in the northeastern sites (Semera, Bati, and Gewana towns) relative to the southeastern sites (Kebridehar, Godey, and Degehabur) in eastern Ethiopia. We observed population differentiation, with the highest differentiation between the northeastern sites compared to central sites (Erer Gota, Dire Dawa, and Awash Sebat Kilo) and the southeastern sites. Phylogenetic and network analysis revealed that the HOA An. stephensi are more genetically similar to An. stephensi from southern Asia than from the Arabian Peninsula. Finally, molecular blood meal analysis revealed evidence of feeding on cows, goats, dogs, and humans, as well as evidence of multiple (mixed) blood meals. CONCLUSION: We show that An. stephensi is genetically diverse in Ethiopia and with evidence of geographical structure. Variation in the level of diversity supports the hypothesis for a more recent introduction of An. stephensi into southeastern Ethiopia relative to the northeastern region. We also find evidence that supports the hypothesis that HOA An. stephensi populations originate from South Asia rather than the Arabian Peninsula. The evidence of both zoophagic and anthropophagic feeding support the need for additional investigation into the potential for livestock movement to play a role in vector spread in this region.

    • Health Disparities
      1. Associations of self-reported chronic obstructive pulmonary disease with indicators of economic instability and stress - 16 states, 2017external icon
        Carlson SA, Wheaton AG, Liu Y, Moore LV, Eke PI, Croft JB, Greenlund KJ, Thomas CW.
        Chronic Illn. 2021 Nov 23:17423953211059144.
        OBJECTIVES: To examine the association between chronic obstructive pulmonary disease status and indicators of economic instability and stress to better understand the magnitude of these issues in persons with chronic obstructive pulmonary disease. METHODS: Analyzed 2017 Behavioral Risk Factor Surveillance System data from 16 states that administered the 'Social Determinants of Health' module, which included economic instability and stress measures (N = 101,461). Associations between self-reported doctor-diagnosed chronic obstructive pulmonary disease status and each measure were examined using multinomial logistic models. RESULTS: Adults with chronic obstructive pulmonary disease were more likely (p < 0.001) than adults without to report not having enough money at month end (21.0% vs. 7.9%) or just enough money (44.9% vs. 37.2%); being unable to pay mortgage, rent, or utility bills (19.2% vs. 8.8%); and that often or sometimes food did not last or could not afford to eat balanced meals (37.9% vs. 20.6%), as well as stress all or most of the time (27.3% vs. 11.6%). Associations were attenuated although remained significant after adjustments for sociodemographic and health characteristics. DISCUSSION: Financial, housing, and food insecurity and frequent stress were more prevalent in adults with chronic obstructive pulmonary disease than without. Findings highlight the importance of including strategies to address challenges related to economic instability and stress in chronic obstructive pulmonary disease management programs.

      2. Home quality and child health: Analysis of the Survey of Income and Program Participationexternal icon
        Boch SJ, Chisolm DJ, Kaminski JW, Kelleher KJ.
        J Child Health Care. 2021 Dec;25(4):603-615.
        Housing is considered a core social determinant of health (SDH) through mechanisms such as the quality, affordability, and location of the home. However, few nationally representative studies examine these mechanisms simultaneously with child health and healthcare use. To determine the associations between home quality and child health, a series of logistic regression analyses was employed using the Survey of Income and Program Participation (SIPP). The 2014 SIPP sample is a multistage, stratified sample of 53,070 housing units from 820 sample areas designed to represent the civilian, noninstitutionalized population of the United States. The analytic sample included 12,964 children aged 2-14 years. Poor housing quality was defined as whether the home had holes in the floor, cracks in the ceiling, plumbing issues, and/or pest problems. Outcome measures included child health status, number of medical visits, and hospitalizations. The results indicated that poor housing quality was associated with poorer health (OR = 1.16, 95% CI = 1.05-1.27) and a greater number of medical visits (OR = 1.11, 95% CI = 1.03, 1.20) after controlling for number of persons per household, neighborhood safety, nonmetropolitan status, parent's ability to afford housing-related expenses, and other SDH. Future work investigating and intervening on the SDH in children could specifically include the quality and contexts in which homes are situated.



    • Health Economics
      1. Prospective Analysis of Minimum Pricing Policies to Reduce Excessive Alcohol Use and Related Harms in U.S. Statesexternal icon
        LeClercq J, Bernard S, Mucciaccio F, Esser MB.
        J Stud Alcohol Drugs. 2021 Nov;82(6):710-719.
        OBJECTIVE: Increasing the price of alcohol is an effective strategy for reducing excessive consumption and alcohol-related harms. Limited research is available on how the establishment of a minimum price for alcoholic beverages might be an effective strategy to reduce this health risk behavior and what impact that might have in the United States. This study describes alcohol minimum pricing (MP) policy options for consideration in the United States, assesses implementation feasibility and effectiveness, and discusses implications for implementation. METHOD: Three alcohol pricing policy options for reducing excessive drinking were compared in this prospective analysis: alcohol taxation (status quo in states), minimum unit pricing (MUP) by unit of alcohol (e.g., 0.6 oz. [14 g] of pure alcohol), and MP by specified amount of an alcoholic beverage type (e.g., liter of beer). For each policy, five implementation-related domains were analyzed: political feasibility, public acceptability, implementation cost, health equity, and legal feasibility. Effectiveness was also evaluated based on literature. RESULTS: Alcohol MP policies, particularly MUP, could be feasible to implement and cost-efficient for reducing excessive alcohol consumption and related harms in the United States. MP policies are likely to have modest public acceptability in the United States. Although the political feasibility of MP policies is uncertain and would likely vary across states, international research suggests that MP might be a feasible pricing strategy that can be used in conjunction with alcohol taxes. CONCLUSIONS: Alcohol MP can be part of a comprehensive approach for reducing excessive drinking and related harms; however, factors such as state-level differences in alcohol control regulation may influence policy implementation.

    • Healthcare Associated Infections
      1. Impact of Statewide Prevention and Reduction of Clostridioides difficile (SPARC), a Maryland public health-academic collaborative: an evaluation of a quality improvement interventionexternal icon
        Rock C, Perlmutter R, Blythe D, Bork J, Claeys K, Cosgrove SE, Dzintars K, Fabre V, Harris AD, Heil E, Hsu YJ, Keller S, Maragakis LL, Milstone AM, Morgan DJ, Dullabh P, Ubri PS, Rotondo C, Brooks R, Leekha S.
        BMJ Qual Saf. 2021 Dec 9.
        To evaluate changes in Clostridioides difficile incidence rates for Maryland hospitals that participated in the Statewide Prevention and Reduction of C. difficile (SPARC) collaborative. Pre-post, difference-in-difference analysis of non-randomised intervention using four quarters of preintervention and six quarters of postintervention National Healthcare Safety Network data for SPARC hospitals (April 2017 to March 2020) and 10 quarters for control hospitals (October 2017 to March 2020). Mixed-effects negative binomial models were used to assess changes over time. Process evaluation using hospital intervention implementation plans, assessments and interviews with staff at eight SPARC hospitals. Maryland, USA. All Maryland acute care hospitals; 12 intervention and 36 control hospitals. Participation in SPARC, a public health-academic collaborative made available to Maryland hospitals, with staggered enrolment between June 2018 and August 2019. Hospitals with higher C. difficile rates were recruited via email and phone. SPARC included assessments, feedback reports and ongoing technical assistance. Primary outcomes were C. difficile incidence rate measured as the quarterly number of C. difficile infections per 10 000 patient-days (outcome measure) and SPARC intervention hospitals' experiences participating in the collaborative (process measures). SPARC invited 13 hospitals to participate in the intervention, with 92% (n=12) participating. The 36 hospitals that did not participate served as control hospitals. SPARC hospitals were associated with 45% greater C. difficile reduction as compared with control hospitals (incidence rate ratio=0.55, 95% CI 0.35 to 0.88, p=0.012). Key SPARC activities, including access to trusted external experts, technical assistance, multidisciplinary collaboration, an accountability structure, peer-to-peer learning opportunities and educational resources, were associated with hospitals reporting positive experiences with SPARC. SPARC intervention hospitals experienced 45% greater reduction in C. difficile rates than control hospitals. A public health-academic collaborative might help reduce C. difficile and other hospital-acquired infections in individual hospitals and at state or regional levels.

      2. We analyzed administrative data to determine the one-year incidence of invasive fungal infections (IFI) in patients initiating small molecule kinase inhibitor (SMKI) therapy. IFI incidence by SMKI ranged from 0.0 to 10.6%, with patients on midostaurin having the highest incidence. Thirty-eight (3.0%) of 1286 patients on ibrutinib developed an IFI.

      3. Ebola virus disease nosocomial infections in the Democratic Republic of the Congo: a descriptive study of cases during the 2018-2020 outbreakexternal icon
        Baller A, Padoveze MC, Mirindi P, Hazim CE, Lotemo J, Pfaffmann J, Ndiaye A, Carter S, Chabrat MD, Mangala S, Banzua B, Umutoni C, Niang NR, Kabego L, Ouedraogo A, Houdjo B, Mwesha D, Ousman KB, Kolwaite A, Blaney DD, Choi MJ, Pallawo R, Legand A, Park B, Formenty P, Montgomery JM, Gueye AS, Allegranzi B, Yao NK, Fall IS.
        Int J Infect Dis. 2021 Dec 6.
        OBJECTIVES: To describe the characteristics of cases of Ebola virus disease (EVD) nosocomial infections (NIs) in the Democratic Republic of the Congo, July 2018-May 2020, to inform future interventions. METHODS: We identified cases of NI during EVD outbreak response surveillance, and conducted a retrospective analysis of cases according to demographic characteristics and health facility (HF) type. RESULTS: Of 3481 cases of EVD, 579 (16.6%) were NIs, 332 of which occurred in women (57.3%). Patients and visitors accounted for 419 cases (72.4%), of which 79 (18.9%) were aged from 6 to ≤ 18 years and 108 (25.8%) were aged ≤ 5 years. Health workers (HWs) accounted for the remaining 160 (27.6%) NI cases. Case fatality rate (CFR) among HWs (66/160; 41.3%) was significantly lower than among patients and visitors (292/419; 69.7%) (p < 0.001). CFR was higher among those aged 6-18 years (54/79; 68.4%) and ≤ 5 years (89/108; 82.4%). Referral HFs (> 39 beds) had the highest prevalence of EVD NI (148/579; 25.6%). Among HFs with at least one case of NI, 50.0% (98/196) were privately owned. CONCLUSIONS: nurses and traditional healers should be targeted for IPC training, and supportive supervision provided to HFs to mitigate EVD transmission.

      4. Inactivating Effects of Common Laboratory Disinfectants, Fixatives, and Temperatures on the Eggs of Soil Transmitted Helminthsexternal icon
        Kines KJ, Fox M, Ndubuisi M, Verocai GG, Cama V, Bradbury RS.
        Microbiol Spectr. 2021 Dec 15:e0182821.
        Soil-transmitted helminths (STH) are important and widespread intestinal pathogens of humans and animals. It is presently unknown which inactivating procedures may be universally effective for safe transport, preservation, and disinfection of STH-contaminated specimens, and this lack of knowledge may expose laboratory staff to higher risk of laboratory-acquired infections (LAI's). There are limited data on the efficacy of commonly used disinfectants and fecal fixatives for inactivating the eggs of STH. This work tested five disinfectants for surface cleanup, four storage temperature conditions, and six transport/storage fixatives, to inactivate eggs of three species of STH of animal origin (Ascaris suum "roundworm," Trichuris vulpis "whipworm" and Ancylostoma caninum "hookworm") as surrogates for human STH. Among disinfectants, exposure to 10% povidone-iodine for ≥5 min inactivated 100% of the three species tested, while 5 min exposure to 95% ethanol inactivated T. vulpis and A. caninum eggs. All of the fixatives tested had inactivation effects on A. caninum hookworm eggs within 24 h of exposure, except potassium dichromate, which required 48 h. 95% ethanol for ≥48 h inactivated eggs from all three STH species. Freezing at ≤-20°C for ≥24 h inactivated eggs of T. vulpis and A. caninum, but only freezing at -80°C for ≥24 h inactivated >99% eggs, including A. suum. This work provides an evidence base for health and safety guidelines and mitigation strategies for the handling, storage, and disposal of stool samples containing STH eggs in laboratory, health care, childcare, or veterinary settings. IMPORTANCE This study systematically evaluates common laboratory disinfectants and storage conditions for their effectiveness in inactivating the infective stages of soil-transmitted helminths (STH). Animal-infecting proxy species were chosen to represent three major groups of STH that infect humans: roundworms, whipworms, and hookworms. Previously published work in this area typically focuses on a particular inactivation method, either for a single STH species, or on a subset of closely related species. Because prediagnostic fecal specimens must be regarded as potentially infectious with a mix of species, such information may be of limited utility in a working laboratory. We provide a straightforward summary of storage and disinfection methods that can achieve complete inactivation across a range of STH species, which represents a significant advance for clinical, veterinary and research laboratory biosafety.

    • Immunity and Immunization
      1. INTRODUCTION: Since human papillomavirus vaccine introduction, incidence rates of cervical precancers have decreased; however, the vaccine's impact on noncervical anogenital precancers has not been shown. These precancers are identified opportunistically and are not collected routinely by most cancer registries. METHODS: This study examined the incidence rates of high-grade (intraepithelial lesions grade 3) vulvar, vaginal, and anal precancers among persons aged 15-39 years using 2000-2017 data from select cancer registries covering 27.8% of the U.S. population that required reporting of these precancers. Trends in incidence rates were evaluated with Joinpoint regression. Analyses were conducted in 2020. RESULTS: High-grade vulvar precancer rates declined by 21.0% per year after human papillomavirus vaccine introduction among females aged 15-19 years. In addition, high-grade vaginal precancer rates declined by 19.1% per year among females aged 15-29 years after human papillomavirus vaccine introduction. Compared with that in the prevaccine period when high-grade anal precancer rates were increasing, anal precancer rates after human papillomavirus vaccine introduction were stable among females aged 15-29 years and among males aged 30-39 years. Among males aged 15-29 years, the rates increased over the entire period but less so after human papillomavirus vaccine introduction. CONCLUSIONS: Opportunistically-detected high-grade vulvar and vaginal precancers among females aged 15-29 years decreased and anal precancers stabilized in years after the introduction of the human papillomavirus vaccine, which is suggestive of the impact of the vaccine on noncervical human papillomavirus cancers.

      2. SARS-CoV-2 Delta outbreak among fully vaccinated nursing home residents likely initiated by a fully vaccinated staff member - Connecticut, July-August 2021external icon
        Bart SM, Harizaj A, Pearson CL, Conteh T, Grogan E, Downing R, Kirking HL, Tate JE, Jernigan JA, Leung V.
        Clin Infect Dis. 2021 Dec 10.
        During July-August 2021, a COVID-19 outbreak involving 21 residents (all fully vaccinated) and 10 staff (9 fully vaccinated) occurred in a Connecticut nursing home. The outbreak was likely initiated by a fully vaccinated staff member and propagated by fully vaccinated persons. Prior COVID-19 was protective among vaccinated residents.

      3. BACKGROUND: Rotavirus vaccine impact on rotavirus hospitalizations is not well documented globally. We performed a systematic review to estimate the number of rotavirus hospitalizations that (1) occur annually, (2) are currently prevented by rotavirus vaccines, and (3) could be prevented with improved vaccine coverage and universal vaccine introduction. METHODS: We systematically reviewed articles indexed in the PubMed database published from January 1, 2000, to December 31, 2019. We included all primary peer-reviewed studies with rotavirus hospitalization rates for children below 5 years that reported data prior to vaccine introduction, utilized at least one continuous year of data collection, and collected hospitalization data after 2000 using active surveillance. We grouped pre-vaccine country estimates by childhood mortality strata and calculated the median rate among each group. We then assigned the mortality stratum-specific hospitalization rates to each country and calculated the number of rotavirus hospitalizations by country, mortality strata, and World Health Organization region. RESULTS: Our search strategy identified 4590 manuscripts, of which 32 were included in the final dataset. In 2019, an estimated 1 760 113 (interquartile range [IQR]: 1 422 645-2 925 372) rotavirus hospitalizations occurred globally, with 524 871 (IQR: 415 987-814 835) prevented by rotavirus vaccination. With universal introduction of rotavirus vaccines and increased vaccine coverage, we estimate that an additional 751 609 (IQR: 607 671-1 318 807) rotavirus hospitalizations can be prevented annually. CONCLUSIONS: This analysis highlights the continued burden of rotavirus hospitalizations among children below 5 years. A large, preventable proportion of this burden could be eliminated by expanding introductions to new countries and increasing rotavirus vaccine coverage to levels seen with other childhood vaccinations.


      5. Update on Vaccine-Derived Poliovirus Outbreaks - Worldwide, January 2020-June 2021external icon
        Alleman MM, Jorba J, Henderson E, Diop OM, Shaukat S, Traoré MA, Wiesen E, Wassilak SG, Burns CC.
        MMWR Morb Mortal Wkly Rep. 2021 Dec 10;70(49):1691-1699.
        As of May 1, 2016, use of oral poliovirus vaccine (OPV) type 2 for routine and supplementary immunization activities ceased after a synchronized global switch from trivalent OPV (tOPV; containing Sabin strain types 1, 2, and 3) to bivalent OPV (bOPV; containing Sabin strain types 1 and 3) subsequent to the certified eradication of wild type poliovirus (WPV) type 2 in 2015 (1-3). Circulating vaccine-derived poliovirus (cVDPV) outbreaks* occur when transmission of Sabin strain poliovirus is prolonged in underimmunized populations, allowing viral genetic reversion to neurovirulence, resulting in cases of paralytic polio (1-3). Since the switch, monovalent OPV type 2 (mOPV2, containing Sabin strain type 2) has been used for response to cVDPV type 2 (cVDPV2) outbreaks; tOPV is used if cVDPV2 co-circulates with WPV type 1, and bOPV is used for cVDPV type 1 (cVDPV1) or type 3 (cVDPV3) outbreaks (1-4). In November 2020, the World Health Organization (WHO) Emergency Use Listing procedure authorized limited use of type 2 novel OPV (nOPV2), a vaccine modified to be more genetically stable than the Sabin strain, for cVDPV2 outbreak response (3,5). In October 2021, the Strategic Advisory Group of Experts on Immunization (WHO's principal advisory group) permitted wider use of nOPV2; however, current nOPV2 supply is limited (6). This report updates that of July 2019-February 2020 to describe global cVDPV outbreaks during January 2020-June 2021 (as of November 9, 2021)(†) (3). During this period, there were 44 cVDPV outbreaks of the three serotypes affecting 37 countries. The number of cVDPV2 cases increased from 366 in 2019 to 1,078 in 2020 (7). A goal of the Global Polio Eradication Initiative's (GPEI) 2022-2026 Strategic Plan is to better address the challenges to early CVDPV2 outbreak detection and initiate prompt and high coverage outbreak responses with available type 2 OPV to interrupt transmission by the end of 2023 (8).

      6. Comparative Effectiveness and Antibody Responses to Moderna and Pfizer-BioNTech COVID-19 Vaccines among Hospitalized Veterans - Five Veterans Affairs Medical Centers, United States, February 1-September 30, 2021external icon
        Bajema KL, Dahl RM, Evener SL, Prill MM, Rodriguez-Barradas MC, Marconi VC, Beenhouwer DO, Holodniy M, Lucero-Obusan C, Brown ST, Tremarelli M, Epperson M, Mills L, Park SH, Rivera-Dominguez G, Morones RG, Ahmadi-Izadi G, Deovic R, Mendoza C, Jeong C, Schrag SJ, Meites E, Hall AJ, Kobayashi M, McMorrow M, Verani JR, Thornburg NJ, Surie D.
        MMWR Morb Mortal Wkly Rep. 2021 Dec 10;70(49):1700-1705.
        The mRNA COVID-19 vaccines (Moderna and Pfizer-BioNTech) provide strong protection against severe COVID-19, including hospitalization, for at least several months after receipt of the second dose (1,2). However, studies examining immune responses and differences in protection against COVID-19-associated hospitalization in real-world settings, including by vaccine product, are limited. To understand how vaccine effectiveness (VE) might change with time, CDC and collaborators assessed the comparative effectiveness of Moderna and Pfizer-BioNTech vaccines in preventing COVID-19-associated hospitalization at two periods (14-119 days and ≥120 days) after receipt of the second vaccine dose among 1,896 U.S. veterans at five Veterans Affairs medical centers (VAMCs) during February 1-September 30, 2021. Among 234 U.S. veterans fully vaccinated with an mRNA COVID-19 vaccine and without evidence of current or prior SARS-CoV-2 infection, serum antibody levels (anti-spike immunoglobulin G [IgG] and anti-receptor binding domain [RBD] IgG) to SARS-CoV-2 were also compared. Adjusted VE 14-119 days following second Moderna vaccine dose was 89.6% (95% CI = 80.1%-94.5%) and after the second Pfizer-BioNTech dose was 86.0% (95% CI = 77.6%-91.3%); at ≥120 days VE was 86.1% (95% CI = 77.7%-91.3%) for Moderna and 75.1% (95% CI = 64.6%-82.4%) for Pfizer-BioNTech. Antibody levels were significantly higher among Moderna recipients than Pfizer-BioNTech recipients across all age groups and periods since vaccination; however, antibody levels among recipients of both products declined between 14-119 days and ≥120 days. These findings from a cohort of older, hospitalized veterans with high prevalences of underlying conditions suggest the importance of booster doses to help maintain long-term protection against severe COVID-19.(†).

      7. Evaluating public acceptability of a potential Lyme disease vaccine using a population-based, cross-sectional survey in high incidence areas of the United Statesexternal icon
        Hook SA, Hansen AP, Niesobecki SA, Meek JI, Bjork JK, Kough EM, Peterson MS, Schiffman EK, Rutz HJ, Rowe AJ, White JL, Peel JL, Biggerstaff BJ, Hinckley AF.
        Vaccine. 2021 Dec 8.
        BACKGROUND: Lyme disease incidence is increasing, despite current prevention options. New Lyme disease vaccine candidates are in development, however, investigation of the acceptability of a Lyme disease vaccine among potential consumers is needed prior to any vaccine coming to market. We conducted a population-based, cross-sectional study to estimate willingness to receive a potential Lyme disease vaccine and factors associated with willingness. METHODS: The web-based survey was administered to a random sample of Connecticut, Maryland, Minnesota, and New York residents June-July 2018. Survey-weighted descriptive statistics were conducted to estimate the proportion willing to receive a potential Lyme disease vaccine. Multivariable multinomial logistic regression models were used to quantify the association of sociodemographic characteristics and Lyme disease vaccine attitudes with willingness to be vaccinated. RESULTS: Surveys were completed by 3313 respondents (6% response rate). We estimated that 64% of residents were willing to receive a Lyme disease vaccine, while 30% were uncertain and 7% were unwilling. Compared to those who were willing, those who were uncertain were more likely to be parents, adults 45-65 years old, non-White, have less than a bachelor's degree, or have safety concerns about a potential Lyme disease vaccine. Those who were unwilling were also more likely to be non-White, have less than a bachelor's degree, or have safety concerns about a potential Lyme disease vaccine. In addition, the unwilling had low confidence in vaccines in general, had low perceived risk of contracting Lyme disease, and said they would not be influenced by a positive recommendation from a healthcare provider. DISCUSSION: Overall, willingness to receive a Lyme disease vaccine was high. Effective communication by clinicians regarding safety and other vaccine parameters to those groups who are uncertain will be critical for increasing vaccine uptake and reducing Lyme disease incidence.

    • Injury and Violence
      1. Association of Logic's hip hop song "1-800-273-8255" with Lifeline calls and suicides in the United States: interrupted time series analysisexternal icon
        Niederkrotenthaler T, Tran US, Gould M, Sinyor M, Sumner S, Strauss MJ, Voracek M, Till B, Murphy S, Gonzalez F, Spittal MJ, Draper J.
        Bmj. 2021 Dec 13;375:e067726.
        OBJECTIVE: To assess changes in daily call volumes to the US National Suicide Prevention Lifeline and in suicides during periods of wide scale public attention to the song "1-800-273-8255" by American hip hop artist Logic. DESIGN: Time series analysis. SETTING: United States, 1 January 2010 to 31 December 2018. PARTICIPANTS: Total US population. Lifeline calls and suicide data were obtained from Lifeline and the Centers for Disease Control and Prevention. MAIN OUTCOME MEASURES: Daily Lifeline calls and suicide data before and after the release of the song. Twitter posts were used to estimate the amount and duration of attention the song received. Seasonal autoregressive integrated moving average time series models were fitted to the pre-release period to estimate Lifeline calls and suicides. Models were fitted to the full time series with dummy variables for periods of strong attention to the song. RESULTS: In the 34 day period after the three events with the strongest public attention (the song's release, the MTV Video Music Awards 2017, and Grammy Awards 2018), Lifeline received an excess of 9915 calls (95% confidence interval 6594 to 13 236), an increase of 6.9% (95% confidence interval 4.6% to 9.2%, P<0.001) over the expected number. A corresponding model for suicides indicated a reduction over the same period of 245 suicides (95% confidence interval 36 to 453) or 5.5% (95% confidence interval 0.8% to 10.1%, P=0.02) below the expected number of suicides. CONCLUSIONS: Logic's song "1-800-273-8255" was associated with a large increase in calls to Lifeline. A reduction in suicides was observed in the periods with the most social media discourse about the song.

      2. Purpose: Adverse childhood experiences (ACEs) are a global public health concern. Little research exists on the prevalence and health consequences of ACEs in Zambia. The current study examined associations between individual and cumulative ACEs, mental distress, and suicide risk among Zambian youth. Methods: Data from Zambia Violence Against Children and Youth Survey were used (18-24 years old, n=1034). Bivariate and adjusted logistic models were performed with independent variables (i.e., experienced physical violence (PV), sexual violence (SV), and emotional violence (EV); witnessed intimate partner violence (IPV) and community violence (CV); orphan status; cumulative ACE exposure) and dependent variables (i.e., mental distress and suicide risk). Adjusted models controlled for demographic and social characteristics. Results: 76.8% of Zambian youth experienced one or more ACEs, and more than 30% witnessed CV (38.4%) or IPV (30.2%), or experienced PV (35.1%), prior to age 18. 27.5% were orphans, and less than 20% experienced EV (17.3%) or SV (15.4%) in childhood. 42.4% experienced mental distress in the past 30 days, and 12.5% reported lifetime suicidal thoughts or suicide attempts. PV, EV, cumulative ACE exposure, older age, being single, and stronger friendships were significantly related to experiencing mental distress. Cumulative ACEs exposure was associated with significantly higher suicide risk. Conclusions: Preventing ACEs can reduce mental distress and suicide risk among Zambian youth. Youth with cumulative ACE exposure can be prioritized for mental health intervention. More research is warranted to investigate the broad-based prevention of ACEs, especially PV and EV, and protective factors that can promote resilience among youth who have experienced ACEs.

    • Nutritional Sciences
      1. Validation of MINORMIX Approach for Estimation of Low Birthweight Prevalence Using a Rural Nepal datasetexternal icon
        Chang KT, Carter ED, Mullany LC, Khatry SK, Cousens S, An X, Krasevec J, LeClerq SC, Munos MK, Katz J.
        J Nutr. 2021 Dec 9.
        BACKGROUND: The Global Nutrition Target of reducing low birthweight (LBW) by at least 30% between 2012 and 2025 has led to renewed interest in producing accurate, population-based, national low birthweight (LBW) estimates. Low- and middle-income countries rely on household surveys for birthweight data. These data are frequently incomplete and exhibit strong "heaping". Standard survey adjustment methods produce estimates with residual bias. The global database used to report against the LBW Global Nutrition Target adjusts survey data using a new MINORMIX approach: 1) multiple imputation to address missing birthweights, followed by 2) use of a two-component normal mixture model to account for heaping of birthweights. OBJECTIVE: We evaluated the performance of the MINORMIX birthweight adjustment approach and alternative methods against gold-standard measured birthweights in rural Nepal. DESIGN: As part of a community-randomized trial in rural Nepal, we measured "gold-standard" birthweights at birth and returned 1-24 months later to collect maternally reported birthweights using standard survey methods. We compared estimates of LBW from maternally reported data derived using: 1) the new MINORMAX approach; 2) the previously used Blanc-Wardlaw adjustment; 3) no adjustment for missingness or heaping against our gold-standard. We also assessed the independent contribution of multiple imputation and curve fitting to LBW adjustment. RESULTS: Our gold-standard found 27.7% of newborns were LBW. The unadjusted LBW estimate based on maternal report with simulated missing birthweights was 14.5% (95%CI: 11.6-18.0%). Application of the Blanc-Wardlaw adjustment increased the LBW estimate to 20.6%. The MINORMIX approach produced an estimate of 26.4% (95%CI: 23.5-29.3%) LBW, closest to and with bounds encompassing the measured point estimate. CONCLUSIONS: In a rural Nepal validation dataset, the MINORMIX method generated a more accurate LBW estimate than the previously applied adjustment method. This supports the use of the MINORMIX method to produce estimates for tracking the LBW Global Nutrition Target. Clinical Trial Registry: NCT01177111 at https://clinicaltrials.gov/ct2/show/NCT01177111.

      2. A nation-wide study on the common reasons for infant formula supplementation among healthy, term, breastfed infants in US hospitalsexternal icon
        Bookhart LH, Anstey EH, Kramer MR, Perrine CG, Reis-Reilly H, Ramakrishnan U, Young MF.
        Matern Child Nutr. 2021 Dec 14:e13294.
        In-hospital infant formula supplementation of breastfed infants reduces breastfeeding duration, yet little is known about common reasons for infant formula supplementation. We examined the three most common reasons for in-hospital infant formula supplementation of healthy, term, breastfed infants in the US reported by hospital staff. Hospital data were obtained from the 2018 Maternity Practices in Infant Nutrition and Care survey (n = 2045), which is completed by hospital staff. An open-ended question on the top three reasons for in-hospital infant formula supplementation was analyzed using thematic qualitative analysis and the frequencies for each reason were reported. The top three most common reasons for in-hospital infant formula supplementation reported by hospital staff included medical indications (70.0%); maternal request/preference/feelings (55.9%); lactation management-related issues (51.3%); physical but non-medically indicated reasons (36.1%); social influences (18.8%); perceived cultural/societal/demographic factors (8.2%) and medical staff/institutional practices (4.7%). These findings suggest that a variety of factors should be considered to address unnecessary infant formula supplementation. Lactation management support delivered in a timely and culturally sensitive manner and targeted to mother-infant dyads with potential medical and physical indications may reduce unnecessary in-hospital infant formula supplementation.

    • Occupational Safety and Health
      1. Characterizing exposure to benzene, toluene, and naphthalene in firefighters wearing different types of new or laundered PPEexternal icon
        Mayer AC, Fent KW, Wilkinson A, Chen IC, Kerber S, Smith DL, Kesler RM, Horn GP.
        Int J Hyg Environ Health. 2021 Dec 10;240:113900.
        The fire service has become more aware of the potential for adverse health outcomes due to occupational exposure to hazardous combustion byproducts. Because of these concerns, personal protective equipment (PPE) manufacturers have developed new protection concepts like particulate-blocking hoods to reduce firefighters' exposures. Additionally, fire departments have implemented exposure reduction interventions like routine laundering of PPE after fire responses. This study utilized a fireground exposure simulator (FES) with 24 firefighters performing firefighting activities on three consecutive days wearing one of three PPE ensembles (stratified by hood design and treatment of PPE): 1) new knit hood, new turnout jacket and new turnout pants 2) new particulate-blocking hood, new turnout jacket and new turnout pants or 3) laundered particulate-blocking hood, laundered turnout jacket and laundered turnout pants. As firefighters performed the firefighting activities, personal air sampling on the outside and inside the turnout jacket was conducted to quantify exposures to volatile organic compounds (VOCs) and naphthalene. Pre- and immediately post-fire exhaled breath samples were collected to characterize the absorption of VOCs. Benzene, toluene, and naphthalene were found to diffuse through and/or around the turnout jacket, as inside jacket benzene concentrations were often near levels reported outside the turnout jacket (9.7-11.7% median benzene reduction from outside the jacket to inside the jacket). The PPE ensemble did not appear to affect the level of contamination found inside the jacket for the compounds evaluated here. Benzene concentrations in exhaled breath increased significantly from pre to post-fire for all three groups (p-values < 0.05). The difference of pre-to post-fire benzene exhaled breath concentrations were positively associated with inside jacket and outside jacket benzene concentrations, even though self-contained breathing apparatus (SCBA) were worn during each response. This suggests the firefighters can absorb these compounds via the dermal route.

      2. Spatiotemporal gait parameters while cross-slope residential roof walkingexternal icon
        Breloff SP, Carey RE, Wade C, Waddell DE.
        Int J Ind Ergon. 2022 ;87.
        Falls from residential roofs account for 80% of roofing industry fatalities. Furthermore, roofing work represents 44.7% of work in residual construction specialty trades and residential roofers count for 2.1% of overall workers in construction, with an anticipated growth in roofers of 14.9% by 2024. The purpose of the study was to evaluate the alterations in spatiotemporal gait parameters while traversing along a 6/12 pitched residential roof segment. Eighteen of the nineteen calculated spatiotemporal variables were statistically, significantly changed by walking across a 6/12 pitched simulated residential roof. The study clearly demonstrates that spatiotemporal gait variables increase and decrease while traversing across a residential roof. The changes in spatiotemporal parameters might suggest alterations to a person's balance system resulting in an increased risk of falling. The knowledge generated in the current study will be relevant to the residential roofing industry when it can be used in educational materials to increase awareness of how a roofer's altered gait while working on a pitched roof may increase their falling risk. © 2021

      3. Notes from the Field: Deployment of an Electronic Self-Administered Survey to Assess Human Health Effects of an Industrial Chemical Facility Fire - Winnebago County, Illinois, June-July 2021external icon
        Surasi K, Nakayama JY, Johnson M, Martell S, Patrick S, Owen LR, Horton DK, Orr M.
        MMWR Morb Mortal Wkly Rep. 2021 Dec 10;70(49):1715-1716.

      4. Work-related fatigue has been estimated by the National Safety Council to cost employers approximately $151 billion annually in reduced productivity related to sleep deficiencies, sleep disorders, and shift work. However, this is just a fraction of the true cost, as chronic sleep deprivation and nonstandard work schedules have been linked with increased risk of depression, obesity, cardiovascular disease, cancer, and other illnesses with ultimate effects on work productivity, worker health, and safety. Fatigue can slow reaction times, reduce attention or concentration, limit short-term memory, and impair judgment, increasing the risk for fatigue-related incidents such as work injuries. Work-related fatigue can also have a devastating public safety impact, particularly in occupations with high-risk consequences. For example, the nuclear meltdown at Three Mile Island and the grounding of the Exxon Valdez oil tanker are two major disasters in which human fatigue was cited as a contributing factor. On a more frequent scale, tired workers drive on public roads, raising public health and safety concerns. Specifically, drowsy driving increases the risk for motor vehicle crashes by 250 percent and results in $109 billion in societal costs every year due to fatalities and injuries from fatigue-related crashes (see publications from SLEEP and the Governors Highway Safety Association, listed under &quot;Resources&quot; below). Overnight, rotating, or irregular shifts; long work hours; and resulting sleep impairment or disruption often contribute to work-related fatigue. It has been estimated that almost 30 percent of U.S. workers are employed in schedules that are outside a &quot;regular daytime shift&quot; and 37 percent of workers get less than the recommended seven hours of sleep (see data from NIOSH Worker Health Charts and a consensus statement published in the Journal of Clinical Sleep Medicine in the &quot;Resources&quot; section). According to research published in Occupational and Environmental Medicine, while just over 50 percent of night shift workers report not getting sufficient sleep, almost 33 percent of day shift workers also report obtaining less than seven hours of sleep per night-numbers that suggest this problem can affect any worker, regardless of work schedule. A survey of causes and consequences of employee fatigue published by the National Safety Council found that 43 percent of U.S. workers do not get enough sleep such that it affects their ability to perform critical tasks, which can affect not only their safety at work but also that of their coworkers. The same survey found that 90 percent of employers felt that work-related fatigue had negatively impacted their organizations in terms of reduced productivity and absenteeism. Half of surveyed employers reported they would adjust an employee's schedules or tasks to reduce the risk of fatigue-related, safety-critical events. However, more than 70 percent said that they typically issue a warning or disciplinary action, suggesting that workplace mitigation strategies for fatigue may more often involve reactive, punitive measures rather than prescriptive or preemptive organizational control strategies. Fatigue is pervasive and nondiscriminating, potentially affecting any worker at any job in any organization. However, despite its high prevalence and increased risk of severe and widespread adverse occupational health and safety consequences, fatigue is not treated with the same industrial hygiene approach as other workplace hazards.

      5. COVID-19 vaccine perceptions and uptake in a national prospective cohort of essential workersexternal icon
        Lutrick K, Groom H, Fowlkes AL, Groover KD, Gaglani M, Rivers P, Naleway AL, Nguyen K, Herring M, Dunnigan K, Phillips A, Parker J, Mayo Lamberte J, Prather K, Thiese MS, Baccam Z, Tyner H, Yoon S.
        Vaccine. 2021 Dec 11.
        INTRODUCTION: In a multi-center prospective cohort of essential workers, we assessed knowledge, attitudes, and practices (KAP) by vaccine intention, prior SARS-CoV-2 positivity, and occupation, and their impact on vaccine uptake over time. METHODS: Initiated in July 2020, the HEROES-RECOVER cohort provided socio-demographics and COVID-19 vaccination data. Using two follow-up surveys approximately three months apart, COVID-19 vaccine KAP, intention, and receipt was collected; the first survey categorized participants as reluctant, reachable, or endorser. RESULTS: A total of 4,803 participants were included in the analysis. Most (70%) were vaccine endorsers, 16% were reachable, and 14% were reluctant. By May 2021, 77% had received at least one vaccine dose. KAP responses strongly predicted vaccine uptake, particularly positive attitudes about safety (aOR = 5.46, 95% CI: 1.4-20.8) and effectiveness (aOR = 5.0, 95% CI: 1.3-19.1). Participants' with prior SARS-CoV-2 infection were 22% less likely to believe the COVID-19 vaccine was effective compared with uninfected participants (aOR 0.78, 95% CI: 0.64-0.96). This was even more pronounced in first responders compared with other occupations, with first responders 42% less likely to believe in COVID-19 vaccine effectiveness (aOR = 0.58, 95% CI 0.40-0.84). Between administrations of the two surveys, 25% of reluctant, 56% reachable, and 83% of endorser groups received the COVID-19 vaccine. The reachable group had large increases in positive responses for questions about vaccine safety (10% of vaccinated, 34% of unvaccinated), and vaccine effectiveness (12% of vaccinated, 27% of unvaccinated). DISCUSSION: Our study demonstrates attitudes associated with COVID-19 vaccine uptake and a positive shift in attitudes over time. First responders, despite potential high exposure to SARS-CoV-2, and participants with a history of SARS-CoV-2 infection were more vaccine reluctant. CONCLUSIONS: Perceptions of the COVID-19 vaccine can shift over time. Targeting messages about the vaccine's safety and effectiveness in reducing SARS-CoV-2 virus infection and illness severity may increase vaccine uptake for reluctant and reachable participants.

      6. Sampling for SARS-COV-2 aerosols in hospital patient roomsexternal icon
        Lane MA, Walawender M, Webster AS, Brownsword EA, Ingersoll JM, Miller C, Waggoner J, Uyeki TM, Lindsley WG, Kraft CS.
        Viruses. 2021 ;13(12).
        Evidence varies as to how far aerosols spread from individuals infected with SARS-CoV-2 in hospital rooms. We investigated the presence of aerosols containing SARS-CoV-2 inside of dedicated COVID-19 patient rooms. Three National Institute for Occupational Safety and Health BC 251 two-stage cyclone samplers were set up in each patient room for a six-hour sampling period. Samplers were place on tripods, which each held two samplers at various heights above the floor. Extracted samples underwent reverse transcription polymerase chain reaction for selected gene regions of the SARS-CoV-2 virus nucleocapsid. Patient medical data were compared between participants in rooms where virus-containing aerosols were detected and those where they were not. Of 576 aerosols samples collected from 19 different rooms across 32 participants, 3% (19) were positive for SARS-CoV-2, the majority from near the head and foot of the bed. Seven of the positive samples were collected inside a single patient room. No significant differences in participant clinical characteristics were found between patients in rooms with positive and negative aerosol samples. SARS-CoV-2 viral aerosols were detected from the patient rooms of nine participants (28%). These findings provide reassurance that personal protective equipment that was recommended for this virus is appropriate given its spread in hospital rooms. © 2021 by the authors. Licensee MDPI, Basel, Switzerland.

    • Public Health Leadership and Management
      1. Retention of knowledge and clinical competence among Ugandan mid-level health providers 1 year after intensive clinical mentorship in TB and HIV managementexternal icon
        Senjovu DK, Naikoba S, Mugabe P, Kadengye DT, McCarthy C, Riley PL, Dalal S.
        Hum Resour Health. 2021 Dec 9;19(1):150.
        INTRODUCTION: Clinical mentorship is effective in improving knowledge and competence of health providers and may be a useful task sharing approach for improving antiretroviral therapy. However, the endurance of the effect of clinical mentorship is uncertain. METHODS: The midlevel health providers who participated in a cluster-randomized trial of one-on-one, on-site, clinical mentorship in tuberculosis and HIV for 8 h a week, every 6 weeks over 9 months were followed to determine if the gains in knowledge and competence that occurred after the intervention were sustained 6- and 12-months post-intervention. In December 2014 and June 2015, their knowledge and clinical competence were respectively assessed using vignettes and a clinical observation tool of patient care. Multilevel mixed effects regression analysis was used to compare the differences in mean scores for knowledge and clinical competence between times 0, 1, 2, and 3 by arm. RESULTS: At the end of the intervention phase of the trial, the mean gain in knowledge scores and clinical competence scores in the intervention arm was 13.4% (95% confidence interval ([CI]: 7.2, 19.6), and 27.8% (95% CI: 21.1, 34.5) respectively, with no changes seen in the control arm. Following the end of the intervention; knowledge mean scores in the intervention arm did not significantly decrease at 6 months (0.6% [95% CI - 1.4, 2.6]) or 12 months (- 2.8% [95% CI: - 5.9, 0.3]) while scores in the control arm significantly increased at 6 months (6.6% [95% CI: 4.4, 8.9]) and 12 months (7.9% [95% CI: 5.4, 10.5]). Also, no significant decrease in clinical competence mean scores for intervention arm was seen at 6 month (2.8% [95% CI: - 1.8, 7.5] and 12 months (3.7% [95% CI: - 2.4, 9.8]) while in the control arm, a significant increase was seen at 6 months (5.8% [95% CI: 1.2, 10.3] and 12 months (11.5% [95% CI: 7.6, 15.5]). CONCLUSIONS: Mentees sustained the competence and knowledge gained after the intervention for a period of one year. Although, there was an increase in knowledge in the control group over the follow-up period, MLP in the intervention arm experienced earlier and sustained gains. One-on-one clinical mentorship should be scaled-up as a task-sharing approach to improve clinical care. Trial Registration The study received ethics approvals from 3 institutions-the US Centers for Disease Control and Prevention Institutional Review Board (USA), the Institutional Review Board "JCRC's HIV/AIDS Research Committee" IRB#1-IRB00001515 with Federal Wide Assurance number (FWA00009772) based in Kampala and the Uganda National Council of Science and Technology (Uganda) which approves all scientific protocols to be implemented in Uganda.


      3. Established by the Centers for Disease Control and Prevention (CDC), the goal of the CDC Undergraduate Public Health Scholars (CUPS) program is to expose students underrepresented in public health and medicine to careers in public health; ultimately, increasing the membership of these groups in these fields including biomedical sciences. CDC implemented a retrospective outcome evaluation of 1,047 students who participated in the program from 2012 to 2017. Seventy-four percent (775) of students responded to the survey that captures their academic attainment and employment status, as well as their perception of the program’s and mentors’ influence on their career path. As of 2020, 639 (83.4%) of 775 participants have enrolled in an advanced degree program, with over 80% of 639 participants pursuing degrees in biomedical sciences, public health, or health care (BSPHHC)–related fields. Two thirds (374/566) of participants who reported they had ever been employed in a career position are working/have worked in BSPHHC-related fields. Overall, 77.4% (600) of 775 participants reported either the program or the mentors, or both were extremely or very influential to their career path. Students claimed the CUPS program had “opened their eyes,” inspired their interest, cultivated their passion for the field of public health, and fueled their drive to find solutions to and in social determinants of health and contribute to health equity. The opportunity to gain work and research experience through internship placements in CUPS has “opened doors” to first jobs and advanced education and training opportunities for many students. © 2021 Society for Public.

    • Reproductive Health
      1. The prevalence of unintended pregnancy and its association with HIV status among pregnant women in South Africa, a national antenatal survey, 2019external icon
        Woldesenbet S, Kufa T, Lombard C, Manda S, Morof D, Cheyip M, Ayalew K, Puren A.
        Sci Rep. 2021 Dec 9;11(1):23740.
        To describe the prevalence of unintended pregnancy and its association with HIV status among pregnant women in South Africa. A cross-sectional survey was conducted between October and mid-November 2019 among pregnant women aged 15-49 years in 1589 selected public antenatal care facilities. Pregnancy intention was assessed using two questions from the London Measure of Unplanned Pregnancy. Survey logistic regression examined factors associated with unintended pregnancy. Among 34,946 participants, 51.6% had an unintended pregnancy. On multivariable analysis, the odds of unintended pregnancy was higher among women who knew their HIV-positive status before pregnancy but initiated treatment after the first antenatal visit (adjusted odds ratio [aOR], 1.5 [95% confidence interval (CI):1.2-1.8]), women who initiated treatment before pregnancy (aOR, 1.3 [95% CI:1.2-1.3]), and women with a new HIV diagnosis during pregnancy (aOR, 1.2 [95% CI:1.1-1.3]) compared to HIV-negative women. Women who were single, in a non-cohabiting or a cohabiting relationship, and young women (15-24 years) had significantly higher risk of unintended pregnancy compared to married women and women aged 30-49 years, respectively. A comprehensive approach, including regular assessment of HIV clients' pregnancy intention, and adolescent and youth-friendly reproductive health services could help prevent unintended pregnancy.

    • Social and Behavioral Sciences
      1. Adolescent Mental Health, Connectedness, and Mode of School Instruction During COVID-19external icon
        Hertz M, Kilmer G, Verlenden J, Liddon N, Rasberry C, Barrios L, Ethier K.
        J Adolesc Health. 2022 ;70(1):57-63.
        BACKGROUND: Because COVID-19 was declared a pandemic in March 2020, nearly 93% of U.S. students engaged in some distance learning. These school disruptions may negatively influence adolescent mental health. Protective factors, like feeling connected to family or school may demonstrate a buffering effect, potentially moderating negative mental health outcomes. The purpose of the study is to test our hypothesis that mode of school instruction influences mental health and determine if school and family connectedness attenuates these relationships. METHODS: The COVID Experiences Survey was administered online or via telephone from October to November 2020 in adolescents ages 13–19 using National Opinion Research Center’s AmeriSpeak Panel, a probability-based panel recruited using random address–based sampling with mail and telephone nonresponse follow-up. The final sample included 567 adolescents in grades 7–12 who received virtual, in-person, or combined instruction. Unadjusted and adjusted associations among four mental health outcomes and instruction mode were measured, and associations with school and family connectedness were explored for protective effects. RESULTS: Students attending school virtually reported poorer mental health than students attending in-person. Adolescents receiving virtual instruction reported more mentally unhealthy days, more persistent symptoms of depression, and a greater likelihood of seriously considering attempting suicide than students in other modes of instruction. After demographic adjustments school and family connectedness each mitigated the association between virtual versus in-person instruction for all four mental health indicators. CONCLUSION: As hypothesized, mode of school instruction was associated with mental health outcomes, with adolescents receiving in-person instruction reporting the lowest prevalence of negative mental health indicators. School and family connectedness may play a critical role in buffering negative mental health outcomes.

    • Substance Use and Abuse
      1. BACKGROUND AND AIMS: Tracking specific drugs contributing to drug overdose deaths is limited when relying on death certificate (DC) data alone. This study aimed to determine whether integrating DC data with medical examiner/coroner reports, including postmortem toxicology and death investigation findings, would enhance identification of 1) heroin and pharmaceutical morphine involvement in overdose deaths and 2) fentanyl source (illicitly manufactured vs. pharmaceutical). DESIGN: Retrospective analysis of heroin, pharmaceutical morphine, illicitly manufactured fentanyl (IMF), and pharmaceutical fentanyl involvement in fatal overdoses. DC and toxicology data were compared with enhanced definitions integrating overdose scene, witness, and toxicology evidence. SETTING: United States: 38 states and the District of Columbia, participating in Centers for Disease Control and Prevention (CDC)-funded opioid overdose death surveillance. CASES: Opioid overdose decedents from funded jurisdictions; deaths during January 1, 2018-December 31, 2019. MEASUREMENTS: Using medical examiner/coroner report data, deaths with 6-acetylmorphine and/or morphine detected by postmortem toxicology were defined as confirmed, probable, or suspected heroin deaths, or probable pharmaceutical morphine deaths. Fentanyl was defined as probable or suspected IMF or probable pharmaceutical fentanyl. FINDINGS: The enhanced definition defined 18,393 deaths as confirmed, probable, or suspected heroin deaths (including 2,678 with morphine listed as cause of death on the DC), and 404 as probable pharmaceutical morphine deaths. Among deaths with fentanyl detected, 89.3% were defined as probable or suspected IMF and 1.0% as probable pharmaceutical fentanyl. Fentanyl source could not be determined for 9.7% of deaths. CONCLUSIONS: Integrating drug overdose scene, witness, and toxicology findings can improve identification of specific drugs contributing to overdose deaths and enhance overdose intervention targeting.

      2. Tobacco Cessation Behaviors Among U.S. Middle and High School Students, 2020external icon
        Zhang L, Gentzke A, Trivers KF, VanFrank B.
        J Adolesc Health. 2022 ;70(1):147-154.
        Purpose: The landscape of youth tobacco product use has changed dramatically in recent years; however, little is known about current youth cessation behaviors. This study aims to assess prevalence and correlates of quit intentions and past-year quit attempts among U.S. middle and high school students who report current use of any tobacco product, cigarettes, and e-cigarettes. Methods: Data came from the 2020 National Youth Tobacco Survey, a nationally representative cross-sectional school-based survey of students in grades 6–12. Weighed prevalence estimates of quit intentions and past-year quit attempts among users of any tobacco product, cigarettes, and e-cigarettes are presented. Multivariable-adjusted logistic regression with predictive marginals was used to assess sociodemographic correlates of quit intentions and quit attempts for each tobacco product user group. Results: Quit intentions were reported by 62.5% of current users of any tobacco product, 68.1% of cigarette smokers, and 63.9% of e-cigarette users. Similarly, past-year quit attempts were reported by 65.4% of current users of any tobacco product, 65.8% of cigarettes smokers, and 67.4% for e-cigarette users. Harm perceptions toward tobacco, nicotine dependency, and the use of ≥2 tobacco products were significantly correlated with quit intentions, quit attempts, or both among different tobacco product user groups. Conclusions: Most students who use tobacco products want to quit and have attempted to do so. Development of youth-focused cessation interventions, particularly those addressing the most commonly used products, could potentially accelerate progress in a comprehensive approach to youth tobacco prevention and control. © 2021

      3. Serum Concentrations of Cotinine and Trans-3'-Hydroxycotinine in US Adults: Results From Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health Studyexternal icon
        Sosnoff CS, Caron K, Akins JR, Dortch K, Hunter RE, Pine BN, Feng J, Blount BC, Li Y, van Bemmel DM, Kimmel HL, Edwards KC, Goniewicz ML, Hatsukami DK, de Castro BR, Bernert JT, Arnstein S, Borek N, Deng-Bryant Y, Mishina E, Lawrence C, Hyland A, Hecht SS, Conway KP, Pirkle JL, Wang L.
        Nicotine Tob Res. 2021 Nov 19.
        INTRODUCTION: The Population Assessment of Tobacco and Health (PATH) Study is a nationally representative cohort of tobacco product users and nonusers. The study's main purpose is to obtain longitudinal epidemiologic data on tobacco use and exposure among the US population. AIMS AND METHODS: Nicotine biomarkers-cotinine (COT) and trans-3'-hydroxycotinine (HCT)-were measured in blood samples collected from adult daily tobacco users and nonusers during Wave 1 of the PATH Study (2013-2014; n = 5012; one sample per participant). Participants' tobacco product use and exposure to secondhand smoke were categorized based on questionnaire responses. Nonusers were subdivided into never users and recent former users. Daily tobacco users were classified into seven tobacco product use categories: exclusive users of cigarette, smokeless tobacco, electronic cigarette, cigar, pipe, and hookah, as well as polyusers. We calculated sample-weighted geometric mean (GM) concentrations of cotinine, HCT, and the nicotine metabolite ratio (NMR) and evaluated their associations with tobacco use with adjustment for potential confounders. RESULTS: The GMs (95% confidence intervals) of COT and HCT concentrations for daily tobacco users were 196 (184 to 208) and 72.5 (67.8 to 77.4) ng/mL, and for nonusers they were 0.033 (0.028 to 0.037) and 0.021 (0.018 to 0.023) ng/mL. Exclusive smokeless tobacco users had the highest COT concentrations of all user groups examined. The GM NMR in daily users was 0.339 (95% confidence interval: 0.330 to 0.350). CONCLUSIONS: These nationally representative estimates of serum nicotine biomarkers could be the basis for reference ranges characterizing nicotine exposure for daily tobacco users and nonusers in the US adult population. IMPLICATIONS: This report summarizes the serum nicotine biomarker measurements in Wave 1 of the PATH Study. We are reporting the first estimates of HCT in serum for daily tobacco users and nonusers in the noninstitutionalized, civilian US adult population; the first nationally representative serum COT estimates for daily exclusive users of different tobacco products and daily polyusers; and the first nationally representative estimate of the serum NMR in daily tobacco users by age, race/ethnicity, and sex.

    • Zoonotic and Vectorborne Diseases
      1. Perceived risk of mosquito-borne arboviruses in the continental United Statesexternal icon
        Lozano S, Day J, Ortega L, Silver M, Connelly R.
        Pathogens. 2021 ;10(12).
        The United States experienced local transmission of West Nile Virus (WNV) for the first time in 1999, and Zika Virus (ZIKV) in 2016. These introductions captured the public’s attention in varying degrees. The research presented here analyzes the disproportional perception of ZIKV risk compared to WNV transmission risk, by the public and vector control personnel. The risk perception of vector control was measured through purposive sampled interviews (24 interviews in 13 states; May 2020–June 2021), while the public’s perception was estimated from news publications (January 2000–December 2020), and Google searches (January 2004–December 2020). Over time, we observed a decrease in the frequency of press reporting and Google searches of both viruses with decreasing annual peaks in the summer. The highest peak of ZIKV news, and searches, surpassed that of WNV. We observed clear differences in the contents of the headlines for both viruses. We propose that the main reason in risk perception differences between the viruses were psychological. Zika infections (mosquito-borne and sexually transmitted) can result in devastating symptoms in fetuses and newborns, observations that frequently appeared in ZIKV-related headlines. Our results highlight the likely influence the news media has on risk perception and the need for public health agencies to play active roles in the conversation, helping disseminate timely and accurate information. Understanding the factors that shape risk perceptions of vector-borne diseases will hopefully lead to better use of resources by providing better guidance. © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).


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