Issue 5, February 9, 2021

CDC Science Clips: Volume 13, Issue 5, February 9, 2021

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

  1. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Chronic Diseases and Conditions

      1. Changing spatiotemporal trends in county-level heart failure death rates in the United States, 1999 to 2018external icon
        Vaughan AS, George MG, Jackson SL, Schieb L, Casper M.
        J Am Heart Assoc. 2021 Feb 4:e018125.
        Background Amid recently rising heart failure (HF) death rates in the United States, we describe county-level trends in HF mortality from 1999 to 2018 by racial/ethnic group and sex for ages 35 to 64 years and 65 years and older. Methods and Results Applying a hierarchical Bayesian model to National Vital Statistics data representing all US deaths, ages 35 years and older, we estimated annual age-standardized county-level HF death rates and percent change by age group, racial/ethnic group, and sex from 1999 through 2018. During 1999 to 2011, ~30% of counties experienced increasing HF death rates among adults ages 35 to 64 years. However, during 2011 to 2018, 86.9% (95% CI, 85.2-88.2) of counties experienced increasing mortality. Likewise, for ages 65 years and older, during 1999 to 2005 and 2005 to 2011, 27.8% (95% CI, 25.8-29.8) and 12.6% (95% CI, 11.2-13.9) of counties, respectively, experienced increasing mortality. However, during 2011 to 2018, most counties (67.4% [95% CI, 65.4-69.5]) experienced increasing mortality. These temporal patterns by age group held across racial/ethnic group and sex. Conclusions These results provide local context to previously documented recent national increases in HF death rates. Although county-level declines were most common before 2011, some counties and demographic groups experienced increasing HF death rates during this period of national declines. However, recent county-level increases were pervasive, occurring across counties, racial/ethnic group, and sex, particularly among ages 35 to 64 years. These spatiotemporal patterns highlight the need to identify and address underlying clinical risk factors and social determinants of health contributing to these increasing trends.

      2. Progress toward achieving national targets for reducing coronary heart disease and stroke mortality: A county-level perspectiveexternal icon
        Vaughan AS, Woodruff RC, Shay CM, Loustalot F, Casper M.
        J Am Heart Assoc. 2021 Jan 30:e019562.
        Background The American Heart Association and Healthy People 2020 established objectives to reduce coronary heart disease (CHD) and stroke death rates by 20% by the year 2020, with 2007 as the baseline year. We examined county-level achievement of the targeted reduction in CHD and stroke death rates from 2007 to 2017. Methods and Results Applying a hierarchical Bayesian model to National Vital Statistics data, we estimated annual age-standardized county-level death rates and the corresponding percentage change during 2007 to 2017 for those aged 35 to 64 and ≥65 years and by urban-rural classification. For those aged ≥35 years, 56.1% (95% credible interval [CI], 54.1%-57.7%) and 39.8% (95% CI, 36.9%-42.7%) of counties achieved a 20% reduction in CHD and stroke death rates, respectively. For both CHD and stroke, the proportions of counties achieving a 20% reduction were lower for those aged 35 to 64 years than for those aged ≥65 years (CHD: 32.2% [95% CI, 29.4%-35.6%] and 64.1% [95% CI, 62.3%-65.7%]), respectively; stroke: 17.9% [95% CI, 13.9%-22.2%] and 45.6% [95% CI, 42.8%-48.3%]). Counties achieving a 20% reduction in death rates were more commonly urban counties (except stroke death rates for those aged ≥65 years). Conclusions Our analysis found substantial, but uneven, achievement of the targeted 20% reduction in CHD and stroke death rates, defined by the American Heart Association and Healthy People. The large proportion of counties not achieving the targeted reduction suggests a renewed focus on CHD and stroke prevention and treatment, especially among younger adults living outside of urban centers. These county-level patterns provide a foundation for robust responses by clinicians, public health professionals, and communities.

    • Communicable Diseases
      1. COVID-19 symptoms and SARS-CoV-2 antibody positivity in a large survey of first responders and healthcare personnel, May-July 2020external icon
        Akinbami LJ, Petersen LR, Sami S, Vuong N, Lukacs SL, Mackey L, Atas J, LaFleur BJ.
        Clin Infect Dis. 2021 Jan 30.
        A SARS-CoV-2 serosurvey among first responder/healthcare personnel showed that loss of taste/smell was most predictive of seropositivity; percent seropositivity increased with number of COVID-19 symptoms. However, 22.9% with nine symptoms were seronegative, and 8.3% with no symptoms were seropositive. These findings demonstrate limitations of symptom-based surveillance and importance of testing.

      2. Impacts of changing sexual behavior on chlamydia and gonorrhea burden among US high school students, 2007-2017external icon
        Goodreau SM, Pollock ED, Wang LY, Aslam MV, Barrios LC, Dunville RL, Rosenthal EM, Hamilton DT, Katz DA, Rosenberg ES.
        Sex Transm Dis. 2021 Jan 26.
        BACKGROUND: Rates of adolescent sexual activity have long been declining in the United States. We sought to estimate the number of cases of gonorrhea and chlamydia averted over one decade associated with these declines, and associated costs saved. METHODS: We analyzed data from the CDC's Youth Risk Behavior Survey of US high-school students from 2007-2017 and combined it with epidemiological estimates drawn from the literature to parameterize a dynamic population transmission model. We compared transmissions from observed behavioral trends to a counterfactual scenario that assumed sexual behaviors from 2007 remained constant over 10 years. We calculated outcomes by age and for three racial/ethnic groups (Hispanic, non-Hispanic Black, and non-Hispanic White adolescents) who vary on underlying burden and amount of behavioral change. RESULTS: We estimated 1,118,483 cases of chlamydia and 214,762 cases of gonorrhea were averted (19.5% of burden across all ages). This yielded $474 million (2017 dollars) savings in medical costs over the decade. The largest number of averted cases (767,543) was among Black adolescents, but the largest proportion (28.7%) was among Hispanic adolescents. CONCLUSIONS: Whatever its origins, changing sexual behavior among adolescents results in large estimated reductions in STI burden and medical costs relative to previous cohorts. Although diagnoses among adolescents have not declined at this rate, multiple explanations could make these apparently divergent trends consistent. Efforts to continue supporting effective sex education in and out of school along with STI screening for adolescents should reinforce these gains.

      3. Sexual minority persons experience health disparities associated with sexual stigma and discrimination and have a high prevalence of several health conditions that have been associated with severe coronavirus disease 2019 (COVID-19) (1,2). Current COVID-19 surveillance systems do not capture information about sexual orientation. To begin bridging the gap in knowledge about COVID-19 risk among sexual minority adults, CDC examined disparities between sexual minority and heterosexual adults in the prevalence of underlying conditions with strong or mixed evidence of associations with severe COVID-19-related illness (3), by using data from the 2017-2019 Behavioral Risk Factor Surveillance System (BRFSS).* When age, sex, and survey year are adjusted, sexual minority persons have higher prevalences than do heterosexual persons of self-reported cancer, kidney disease, chronic obstructive pulmonary disease (COPD), heart disease (including myocardial infarction, angina, or coronary heart disease), obesity, smoking, diabetes, asthma, hypertension, and stroke. Sexual minority adults who are members of racial/ethnic minority groups disproportionately affected by the pandemic also have higher prevalences of several of these health conditions than do racial/ethnic minority adults who are heterosexual. Collecting data on sexual orientation in COVID-19 surveillance and other studies would improve knowledge about disparities in infection and adverse outcomes by sexual orientation, thereby informing more equitable responses to the pandemic.

      4. Persistence with human immunodeficiency virus pre-exposure prophylaxis in the United States, 2012-2017external icon
        Huang YA, Tao G, Smith DK, Hoover KW.
        Clin Infect Dis. 2021 Feb 1;72(3):379-385.
        BACKGROUND: Daily oral pre-exposure prophylaxis (PrEP) is highly effective in preventing human immunodeficiency virus (HIV) infection if used adherently throughout periods of HIV risk. We estimated PrEP persistence among cohorts of persons with commercial or Medicaid insurance. METHODS: We analyzed data from the IBM MarketScan Research Database to identify persons aged 18-64 years who initiated PrEP between 2012 and 2017. We assessed PrEP persistence by calculating the time period that each person continued filling PrEP prescriptions until there was a gap in prescription fills > 30 days. We used Kaplan-Meier time-to-event methods to estimate the proportion of PrEP users who persisted with PrEP at 3, 6, and 12 months after initiation, and constructed Cox proportional hazards models to determine patient characteristics associated with nonpersistence. RESULTS: We studied 11 807 commercially insured and 647 Medicaid insured persons with PrEP prescriptions. Commercially insured patients persisted for a median time of 13.7 months (95% confidence interval [CI], 13.3-14.1), compared to 6.8 months (95% CI, 6.1-7.6) among Medicaid patients. Additionally, female sex, younger age, residence in rural location, and black race were associated with shorter persistence. After adjusting for covariates, we found that female sex (hazard ratio [HR], 1.81 [95% CI, 1.56-2.11]) and younger age (18-24 years: HR, 2.38 [95% CI, 2.11-2.69]) predicted nonpersistence. CONCLUSIONS: More than half of commercially insured persons who initiated PrEP persisted with it for 12 months, compared to a third of those with Medicaid. A better understanding of reasons for nonpersistence is important to support persistent PrEP use and to develop interventions designed for the diverse needs of at-risk populations.

      5. Behaviour adoption approaches during public health emergencies: implications for the COVID-19 pandemic and beyondexternal icon
        Jalloh MF, Nur AA, Nur SA, Winters M, Bedson J, Pedi D, Prybylski D, Namageyo-Funa A, Hageman KM, Baker BJ, Jalloh MB, Eng E, Nordenstedt H, Hakim AJ.
        BMJ Glob Health. 2021 Jan;6(1).
        Human behaviour will continue to play an important role as the world grapples with public health threats. In this paper, we draw from the emerging evidence on behaviour adoption during diverse public health emergencies to develop a framework that contextualises behaviour adoption vis-à-vis a combination of top-down, intermediary and bottom-up approaches. Using the COVID-19 pandemic as a case study, we operationalise the contextual framework to demonstrate how these three approaches differ in terms of their implementation, underlying drivers of action, enforcement, reach and uptake. We illustrate how blended strategies that include all three approaches can help accelerate and sustain protective behaviours that will remain important even when safe and effective vaccines become more widely available. As the world grapples with the COVID-19 pandemic and prepares to respond to (re)emerging public health threats, our contextual framework can inform the design, implementation, tracking and evaluation of comprehensive public health and social measures during health emergencies.

      6. The number of new HIV diagnoses is highest in the South. Many persons who might benefit from pre-exposure prophylaxis (PrEP) are not engaged in the HIV PrEP continuum of care. We analyzed National HIV Behavioral Surveillance data to assess engagement in the PrEP continuum of care among persons with increased HIV risk. We compared PrEP awareness, discussion with a clinical provider, and use among persons living in the South to those living elsewhere in the United States. PrEP awareness was lowest among heterosexual persons (7%), highest among men who have sex with men (85%), and 26% among persons who inject drugs. PrEP use was low among each population (≤ 35% for all cycles). There was limited evidence of differences in PrEP use between persons in southern and non-southern U.S. Efforts are needed to increase use of PrEP among each of the groups with increased HIV risk.

      7. National perinatal hepatitis B prevention program: 2009-2017external icon
        Koneru A, Fenlon N, Schillie S, Williams C, Weng MK, Nelson N.
        Pediatrics. 2021 Feb 2.
        OBJECTIVES: To assess trends and programmatic outcomes among infants born to hepatitis B surface antigen (HBsAg)-positive women from 2009 to 2017 and case-managed by the Centers for Disease Control and Prevention's national Perinatal Hepatitis B Prevention Program (PHBPP). METHODS: We analyzed 2009-2017 annual programmatic reports submitted by 56 US jurisdictions funded through the Centers for Disease Control and Prevention's PHBPP to assess characteristics of maternal-infant pairs and achievement of objectives of infant hepatitis B postexposure prophylaxis, vaccine series completion, and postvaccination serologic testing (PVST). We compared the number of maternal-infant pairs identified by the program with the number estimated born to HBsAg-positive women from 2009 to 2014 and 2015 to 2017 by using a race and/or ethnicity and maternal country of birth methodology, respectively. RESULTS: The PHBPP identified 103 825 infants born to HBsAg-positive women from 2009 to 2017, with a range of 10 956 to 12 103 infants annually. Births estimated annually to HBsAg-positive women increased nonsignificantly from 24 804 in 2009 to 26 444 in 2014 (P = .0540) and 20 678 in 2015 to 20 832 in 2017 (P = .8509). The proportion of infants identified annually increased overall from 48.1% to 52.6% (P = .0983). The proportion of case-managed infants receiving postexposure prophylaxis, at least 3 vaccine doses, and PVST increased overall from 94.7% to 97.0% (P = .0952), 83.1% to 84.7% (P = .5377) and 58.8% to 66.8% (P = .0002), respectively. CONCLUSIONS: The PHBPP has achieved success in managing infants born to HBsAg-positive women and ensuring their immunity to hepatitis B. Nonetheless, strategies are needed to close gaps between the number of infants estimated and identified, increase vaccine series completion, and increase ordering of recommended PVST for all case-managed infants.

      8. Carriage rates and antimicrobial sensitivity of pneumococci in the upper respiratory tract of children less than ten years old, in a north Indian rural communityexternal icon
        Kumar S, Purakayastha DR, Kapil A, Saha S, Dawood FS, Das BK, Amarchand R, Kumar R, Lafond KE, Jain S, Krishnan A.
        PLoS One. 2021 ;16(2):e0246522.
        Pneumococcal carriage studies are important for vaccine introduction and treatment strategies. Pneumococcal carriage rates estimated in this cohort study among children in a rural community of northern India. Between August 2012 and August 2014, trained nurses made weekly home visits to screen enrolled children aged <10 years for acute upper or lower respiratory infections (AURI/ALRI) in Ballabgarh, Haryana. Nasal swab from infants aged <1year and throat swab from children aged ≥1 year were collected. All specimens were cultured for pneumococci; isolates were serotyped and subjected to antimicrobial susceptibility testing. During the study period, 4348 nasal/throat swabs collected from children with clinical features of ARI (836 ALRI, 2492 AURI) and from 1020 asymptomatic children. Overall pneumococcal carriage was 5.1%, the highest carriage rate among children <1 year of age (22.6%). The detection rates were higher among children with ARI (5.6%; 95% CI: 4.8-6.4) than asymptomatic children (3.3%; 95% CI: 2.3-4.6). Among 220 pneumococcal isolates, 42 diverse serotypes were identified, with 6B/C (8.6%), 19A (7.2%), 19F (6.8%), 23F (6.4%), 35A/B/C (6.4%), 15B (5%), 14 (4.5%) and 11A/C/D (3.2%) accounting for 50%. Forty-five percent of the serotypes identified are included in the current formulation of 13-valent pneumococcal conjugate vaccine. Ninety-six percent of isolates were resistant to co-trimoxazole, 9% were resistant to erythromycin, and 10% had intermediate resistance to penicillin with minimum inhibitory concentration ranges (0.125 to 1.5 μg/ml). Pneumococcal detection was relatively low among children in our study community but demonstrated a diverse range of serotypes and half of these serotypes would be covered by the current formulation of 13-valent pneumococcal vaccine.

      9. Characteristics and timing of initial virus shedding in severe acute respiratory syndrome coronavirus 2, Utah, USAexternal icon
        Lewis NM, Duca LM, Marcenac P, Dietrich EA, Gregory CJ, Fields VL, Banks MM, Rispens JR, Hall A, Harcourt JL, Tamin A, Willardson S, Kiphibane T, Christensen K, Dunn AC, Tate JE, Nabity S, Matanock AM, Kirking HL.
        Emerg Infect Dis. 2021 Feb;27(2):352-359.
        Virus shedding in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can occur before onset of symptoms; less is known about symptom progression or infectiousness associated with initiation of viral shedding. We investigated household transmission in 5 households with daily specimen collection for 5 consecutive days starting a median of 4 days after symptom onset in index patients. Seven contacts across 2 households implementing no precautionary measures were infected. Of these 7, 2 tested positive for SARS-CoV-2 by reverse transcription PCR on day 3 of 5. Both had mild, nonspecific symptoms for 1-3 days preceding the first positive test. SARS-CoV-2 was cultured from the fourth-day specimen in 1 patient and from the fourth- and fifth-day specimens in the other. We also describe infection control measures taken in the households that had no transmission. Persons exposed to SARS-CoV-2 should self-isolate, including from household contacts, wear a mask, practice hand hygiene, and seek testing promptly.

      10. Non-norovirus viral gastroenteritis outbreaks reported to the National Outbreak Reporting System, USA, 2009-2018external icon
        Mattison CP, Dunn M, Wikswo ME, Kambhampati A, Calderwood L, Balachandran N, Burnett E, Hall AJ.
        Emerg Infect Dis. 2021 Feb;27(2):560-564.
        During 2009-2018, four adenovirus, 10 astrovirus, 123 rotavirus, and 107 sapovirus gastroenteritis outbreaks were reported to the US National Outbreak Reporting System (annual median 30 outbreaks). Most were attributable to person-to-person transmission in long-term care facilities, daycares, and schools. Investigations of norovirus-negative gastroenteritis outbreaks should include testing for these viruses.

      11. An approach to integrate population mobility patterns and sociocultural factors in communicable disease preparedness and responseexternal icon
        Merrill RD, Chabi AI, McIntyre E, Kouassi JV, Alleby MM, Codja C, Tante O, Martial GT, Kone I, Ward S, Agbeko TT, Kakaı CG.
        Hum Soc Sci Comm. 2021 ;8(1).
        Complex human movement patterns driven by a range of economic, health, social, and environmental factors influence communicable disease spread. Further, cross-border movement impacts disparate public health systems of neighboring countries, making an effective response to disease importation or exportation more challenging. Despite the array of quantitative techniques and social science approaches available to analyze movement patterns, there continues to be a dearth of methods within the applied public health setting to gather and use information about community-level mobility dynamics. Population Connectivity Across Borders (PopCAB) is a rapidly-deployable toolkit to characterize multisectoral movement patterns through community engagement using focus group discussions or key informant interviews, each with participatory mapping, and apply the results to tailor preparedness and response strategies. The Togo and Benin Ministries of Health (MOH), in collaboration with the Abidjan Lagos Corridor Organization and the US Centers for Disease Control and Prevention, adapted and applied PopCAB to inform cross-border preparedness and response strategies for multinational Lassa fever outbreaks. Initially, the team implemented binational, national-level PopCAB activities in March 2017, highlighting details about a circular migration pathway across northern Togo, Benin, and Nigeria. After applying those results to respond to a cross-border Lassa fever outbreak in February 2018, the team designed an expanded PopCAB initiative in April 2018. In eight days, they trained 54 MOH staff who implemented 21 PopCAB focus group discussions in 14 cities with 224 community-level participants representing six stakeholder groups. Using the newly-identified 167 points of interest and 176 routes associated with a circular migration pathway across Togo, Benin, and Nigeria, the Togo and Benin MOH refined their cross-border information sharing and collaboration processes for Lassa fever and other communicable diseases, selected health facilities with increased community connectivity for enhanced training, and identified techniques to better integrate traditional healers in surveillance and community education strategies. They also integrated the final toolkit in national- and district-level public health preparedness plans. Integrating PopCAB in public health practice to better understand and accommodate population movement patterns can help countries mitigate the international spread of disease in support of improved global health security and International Health Regulations requirements.

      12. Performance of oropharyngeal swab testing compared with nasopharyngeal swab testing for diagnosis of coronavirus disease 2019 - United States, January 2020-February 2020external icon
        Patel MR, Carroll D, Ussery E, Whitham H, Elkins CA, Noble-Wang J, Rasheed JK, Lu X, Lindstrom S, Bowen V, Waller J, Armstrong G, Gerber S, Brooks JT.
        Clin Infect Dis. 2021 Feb 1;72(3):403-410.
        Among 146 nasopharyngeal (NP) and oropharyngeal (OP) swab pairs collected ≤7 days after illness onset, Real-Time Reverse Transcriptase Polymerase Chain Reaction assay for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 RT-PCR) diagnostic results were 95.2% concordant. However, NP swab cycle threshold values were lower (indicating more virus) in 66.7% of concordant-positive pairs, suggesting NP swabs may more accurately detect the amount of SARS-CoV-2.

      13. SARS-CoV-2 infection and mitigation efforts among office workers, Washington, DC, USAexternal icon
        Sami S, Vuong N, Miller H, Priestley R, Payne M, Licata-Portentoso G, Drobeniuc J, Petersen LR.
        Emerg Infect Dis. 2021 Feb;27(2):669-672.
        Despite mitigation efforts, 2 coronavirus disease outbreaks were identified among office workers in Washington, DC. Moderate adherence to workplace mitigation efforts was reported in a serologic survey; activities outside of the workplace were associated with infection. Adherence to safety measures are critical for returning to work during the pandemic.

      14. BACKGROUND: The nonresponse weighting adjustment of the PHIA surveys employs the weighting class method in combination with a tree analysis to identify predictors significant to response propensity. Variable selection for this type of nonresponse adjustment identifies auxiliary variables correlated with response propensity alone and produces one set of weights applicable for all analyses of the survey data. An alternative approach identifies auxiliary variables correlated to both the response probability and selected key outcome variables. This approach may identify a different set of variables for the nonresponse adjustments and may produce more efficient estimates for the key outcome variables. SETTING: The Population-based HIV Impact Assessment (PHIA) surveys from 2016-2017. METHODS: Weighting class, joint-classification, and two-step modeling. RESULTS: There was little difference among estimates produced by the alternative weighting methods and the PHIA estimates. The joint-classification method produced more efficient estimates (i.e., smaller design effects) compared to the PHIA method, while the two-step method was inconclusive. CONCLUSIONS: The efficiency of the estimates produced by the PHIA weighting method closely resembles those specifically targeted at key survey outcomes and serves well as a multi-purpose weight.

      15. Symptom profiles and progression in hospitalized and nonhospitalized patients with coronavirus disease, Colorado, USA, 2020external icon
        Vahey GM, Marshall KE, McDonald E, Martin SW, Tate JE, Midgley CM, Killerby ME, Kawasaki B, Herlihy RK, Alden NB, Staples JE.
        Emerg Infect Dis. 2021 Feb;27(2):385-395.
        To improve recognition of coronavirus disease (COVID-19) and inform clinical and public health guidance, we randomly selected 600 COVID-19 case-patients in Colorado. A telephone questionnaire captured symptoms experienced, when symptoms occurred, and how long each lasted. Among 128 hospitalized patients, commonly reported symptoms included fever (84%), fatigue (83%), cough (73%), and dyspnea (72%). Among 236 nonhospitalized patients, commonly reported symptoms included fatigue (90%), fever (83%), cough (83%), and myalgia (74%). The most commonly reported initial symptoms were cough (21%-25%) and fever (20%-25%). In multivariable analysis, vomiting, dyspnea, altered mental status, dehydration, and wheezing were significantly associated with hospitalization, whereas rhinorrhea, headache, sore throat, and anosmia or ageusia were significantly associated with nonhospitalization. General symptoms and upper respiratory symptoms occurred earlier in disease, and anosmia, ageusia, lower respiratory symptoms, and gastrointestinal symptoms occurred later. Symptoms should be considered alongside other epidemiologic factors in clinical and public health decisions regarding potential COVID-19 cases.

      16. Mental health in women living with HIV: The unique and unmet needsexternal icon
        Waldron EM, Burnett-Zeigler I, Wee V, Ng YW, Koenig LJ, Pederson AB, Tomaszewski E, Miller ES.
        J Int Assoc Provid AIDS Care. 2021 Jan-Dec;20.
        Women living with HIV (WLWH) experience depression, anxiety, and posttraumatic stress symptoms at higher rates than their male counterparts and more often than HIV-unaffected women. These mental health issues affect not only the well-being and quality of life of WLWH, but have implications for HIV management and transmission prevention. Despite these ramifications, WLWH are under-treated for mental health concerns and they are underrepresented in the mental health treatment literature. In this review, we illustrate the unique mental health issues faced by WLWH such as a high prevalence of physical and sexual abuse histories, caregiving stress, and elevated internalized stigma as well as myriad barriers to care. We examine the feasibility and outcomes of mental health interventions that have been tested in WLWH including cognitive behavioral therapy, mindfulness-based interventions, and supportive counseling. Future research is required to address individual and systemic barriers to mental health care for WLWH.

      17. Rapid transmission of severe acute respiratory syndrome coronavirus 2 in detention facility, Louisiana, USA, May-June, 2020external icon
        Wallace M, James AE, Silver R, Koh M, Tobolowsky FA, Simonson S, Gold JA, Fukunaga R, Njuguna H, Bordelon K, Wortham J, Coughlin M, Harcourt JL, Tamin A, Whitaker B, Thornburg NJ, Tao Y, Queen K, Uehara A, Paden CR, Zhang J, Tong S, Haydel D, Tran H, Kim K, Fisher KA, Marlow M, Tate JE, Doshi RH, Sokol T, Curran KG.
        Emerg Infect Dis. 2021 Feb;27(2):421-429.
        To assess transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a detention facility experiencing a coronavirus disease outbreak and evaluate testing strategies, we conducted a prospective cohort investigation in a facility in Louisiana, USA. We conducted SARS-CoV-2 testing for detained persons in 6 quarantined dormitories at various time points. Of 143 persons, 53 were positive at the initial test, and an additional 58 persons were positive at later time points (cumulative incidence 78%). In 1 dormitory, all 45 detained persons initially were negative; 18 days later, 40 (89%) were positive. Among persons who were SARS-CoV-2 positive, 47% (52/111) were asymptomatic at the time of specimen collection; 14 had replication-competent virus isolated. Serial SARS-CoV-2 testing might help interrupt transmission through medical isolation and quarantine. Testing in correctional and detention facilities will be most effective when initiated early in an outbreak, inclusive of all exposed persons, and paired with infection prevention and control.

      18. Epidemiology of pertussis in individuals of all ages hospitalised with respiratory illness in South Africa, January 2013 - December 2018external icon
        Wolter N, Cohen C, Tempia S, Walaza S, Moosa F, du Plessis M, McMorrow ML, Treurnicht FK, Hellferscee O, Dawood H, Variava E, von Gottberg A.
        Clin Infect Dis. 2021 Feb 2.
        BACKGROUND: Policy recommendations on pertussis vaccination need to be guided by data, which are limited from low- and middle-income countries. We aimed to describe the epidemiology of pertussis in South Africa, a country with high HIV prevalence and routine pertussis vaccination for six decades including the acellular vaccine since 2009. METHODS: Hospitalized patients of all ages were enrolled at five sentinel sites as part of a pneumonia surveillance program from January 2013 through December 2018. Nasopharyngeal specimens and induced sputum were tested by PCR for Bordetella pertussis. In addition, demographic and clinical information were collected. Incidence rates were calculated for 2013-2016, and multivariable logistic regression performed to identify factors associated with pertussis. RESULTS: Over the six-year period 19429 individuals were enrolled, of which 239 (1.2%) tested positive for B. pertussis. Detection rate was highest in infants aged <6 months (2.8%, 155/5524). Mean annual incidence was 17 cases per 100,000 population, with the highest incidence in children <1 year of age (228 per 100,000). Age-adjusted incidence was 65.9 per 100,000 in HIV-infected individuals compared to 8.5 per 100,000 in HIV-uninfected individuals (risk ratio 30.4, 95% confidence interval 23.0-40.2). Ten individuals (4.2%) with pertussis died; of which 7 were infants aged <6 months and 3 were immunocompromised adults. CONCLUSIONS: Pertussis continues to be a significant cause of illness and hospitalization in South Africa, despite routine vaccination. The highest burden of disease and death occurred in infants; however, HIV-infected adults were also identified as an important group at risk of B. pertussis infection.

    • Disease Reservoirs and Vectors
      1. An evaluation of Bacillus thuringiensis israelensis (AM65-52) treatment for the control of Aedes aegypti using vehicle-mounted WALS application in a densely populated urban area of Puerto Ricoexternal icon
        Harris AF, Sanchez Prats J, Nazario Maldonado N, Piovanetti Fiol C, García Pérez M, Ramírez-Vera P, Miranda-Bermúdez J, Ortiz M, DeChant P.
        Pest Manag Sci. 2020 Dec 13.
        BACKGROUND: With a shortage of effective options for control of Aedes aegypti in Puerto Rico due to widespread resistance to conventional mosquito adulticides, an alternative approach was investigated to reduce vector populations. In two areas (totaling 144 ha) of the municipality of Bayamón, Puerto Rico, Bacillus thuringiensis israelensis (Bti) AM65-52 WDG was applied at a rate of 500 g/ha using vehicle-mounted aqueous wide-area larvicide spray applications weekly for 4 weeks and then every other week for a further 16 weeks. Bioassay jars were placed in the field to monitor for deposition of Bti droplets in open spaces, and under vegetation and building coverage. Autocidal gravid ovitraps were placed throughout the field site to monitor the population of adult female Ae. aegypti in both treatment and control sites. RESULTS: Larvicide spray was successfully deposited into jars in an array of open and covered locations, as confirmed by larval bioassays. After the fourth weekly spraying, differences in autocidal gravid ovitrap densities were observed between treatment and control sites resulting in 62% (P = 0.0001) and 28% (P < 0.0001) reductions in adult female Ae. aegypti numbers. CONCLUSION: Repeated wide-area larvicide spray application of Bti AM65-52 WDG to residential areas in Puerto Rico effectively suppressed dengue vector populations. The success of this trial has led to expansion of the WALS® program to a larger area of Bayamón and other municipalities in Puerto Rico.

      2. Surveillance of ticks and tick-borne pathogens in suburban natural habitats of central Marylandexternal icon
        Milholland MT, Eisen L, Nadolny RM, Hojgaard A, Machtinger ET, Mullinax JM, Li AY.
        J Med Entomol. 2021 Jan 28.
        Lyme and other tick-borne diseases are increasing in the eastern United States and there is a lack of research on integrated strategies to control tick vectors. Here we present results of a study on tick-borne pathogens detected from tick vectors and rodent reservoirs from an ongoing 5-yr tick suppression study in the Lyme disease-endemic state of Maryland, where human-biting tick species, including Ixodes scapularis Say (Acari: Ixodidae) (the primary vector of Lyme disease spirochetes), are abundant. During the 2017 tick season, we collected 207 questing ticks and 602 ticks recovered from 327 mice (Peromyscus spp. (Rodentia: Cricetidae)), together with blood and ear tissue from the mice, at seven suburban parks in Howard County. Ticks were selectively tested for the presence of the causative agents of Lyme disease (Borrelia burgdorferi sensu lato [s.l.]), anaplasmosis (Anaplasma phagocytophilum), babesiosis (Babesia microti), ehrlichiosis (Ehrlichia ewingii, Ehrlichia chaffeensis, and 'Panola Mountain' Ehrlichia) and spotted fever group rickettsiosis (Rickettsia spp.). Peromyscus ear tissue and blood samples were tested for Bo. burgdorferi sensu stricto (s.s), A. phagocytophilum, Ba. microti, and Borrelia miyamotoi. We found 13.6% (15/110) of questing I. scapularis nymphs to be Bo. burgdorferi s.l. positive and 1.8% (2/110) were A. phagocytophilum positive among all sites. Borrelia burgdorferi s.s. was found in 71.1% (54/76) of I. scapularis nymphs removed from mice and 58.8% (194/330) of captured mice. Results from study on tick abundance and pathogen infection status in questing ticks, rodent reservoirs, and ticks feeding on Peromyscus spp. will aid efficacy evaluation of the integrated tick management measures being implemented.

      3. Borrelia burgdorferi sensu stricto DNA in field-collected Haemaphysalis longicornis ticks, Pennsylvania, United Statesexternal icon
        Price KJ, Graham CB, Witmier BJ, Chapman HA, Coder BL, Boyer CN, Foster E, Maes SE, Bai Y, Eisen RJ, Kyle AD.
        Emerg Infect Dis. 2021 Feb;27(2):608-611.
        We collected questing Haemaphysalis longicornis ticks from southeastern counties of Pennsylvania, USA. Of 263 ticks tested by PCR for pathogens, 1 adult female was positive for Borrelia burgdorferi sensu stricto, yielding a 0.4% infection rate. Continued monitoring of this invasive tick is essential to determine its public health role.

    • Environmental Health
      1. Decreases in young children who received blood lead level testing during COVID-19 - 34 jurisdictions, January-May 2020external icon
        Courtney JG, Chuke SO, Dyke K, Credle K, Lecours C, Egan KB, Leonard M.
        MMWR Morb Mortal Wkly Rep. 2021 Feb 5;70(5):155-161.
        Exposure to lead, a toxic metal, can result in severe effects in children, including decreased ability to learn, permanent neurologic damage, organ failure, and death. CDC and other health care organizations recommend routine blood lead level (BLL) testing among children as part of well-child examinations to facilitate prompt identification of elevated BLL, eliminate source exposure, and provide medical and other services (1). To describe BLL testing trends among young children during the coronavirus disease 2019 (COVID-19) pandemic, CDC analyzed data reported from 34 state and local health departments about BLL testing among children aged <6 years conducted during January-May 2019 and January-May 2020. Compared with testing in 2019, testing during January-May 2020 decreased by 34%, with 480,172 fewer children tested. An estimated 9,603 children with elevated BLL were missed because of decreased BLL testing. Despite geographic variability, all health departments reported fewer children tested for BLL after the national COVID-19 emergency declaration (March-May 2020). In addition, health departments reported difficulty conducting medical follow-up and environmental investigations for children with elevated BLLs because of staffing shortages and constraints on home visits associated with the pandemic. Providers and public health agencies need to take action to ensure that children who missed their scheduled blood lead screening test, or who required follow-up on an earlier high BLL, be tested as soon as possible and receive appropriate care.

      2. Detection of brevetoxin in human plasma by ELISAexternal icon
        Cunningham BR, Coleman RM, Schaefer AM, Hamelin EI, Johnson RC.
        J Anal Toxicol. 2021 Jan 30.
        Florida red tides have become more common and persistent in and around the Gulf of Mexico. When in bloom, red tides can produce brevetoxins in high concentrations, leading to human exposures primarily through contaminated food and ocean spray. The research described here includes adapting and validating a commercial brevetoxin water test kit for human plasma testing. Pooled plasma was fortified with a model brevetoxin, brevetoxin 3, at concentrations from 0.00500 to 3.00 ng/mL to generate calibration curves and quality control samples. The quantitative detection range was determined to be 0.0400-2.00 ng/mL brevetoxin 3 equivalents with inter- and intraday accuracies ranging from 94.0% to 109% and relative standard deviations <20%, which is within the US Food and Drug Administration guidelines for receptor-binding assays. Additionally, cross-reactivity was tested using 4 of the 10 known brevetoxins and 12 paralytic shellfish toxins. The cross-reactivity varied from 0.173% to 144% for the commercially available brevetoxin standards and 0% for the commercially available paralytic shellfish toxin standards. Fifty individual unexposed human plasma samples were measured to determine the limit of detection and endogenous interferences to the test. The validated method was used to test 31 plasma samples collected from humans potentially exposed to brevetoxins, detecting 11 positives. This method has been proven useful to measure human exposure to brevetoxins and can be applied to future exposure events.

    • Global Health
      1. Several studies describe the health of recently resettled refugee populations in the US beyond the first 8 months after arrival. This review summarizes the results of these studies. Scientific articles from five databases published from January 2008 to March 2019 were reviewed. Articles were included if study subjects included any of the top five US resettlement populations during 2008-2018 and if data described long-term physical health outcomes beyond the first 8 months after arrival in the US. Thirty-three studies met the inclusion criteria (1.5%). Refugee adults had higher odds of having a chronic disease compared with non-refugee immigrant adults, and an increased risk for diabetes compared with US-born controls. The most commonly reported chronic diseases among Iraqi, Somali, and Bhutanese refugee adults included diabetes and hypertension. Clinicians should consider screening and evaluating for chronic conditions in the early resettlement period. Further evaluations can build a more comprehensive, long-term health profile of resettled refugees to inform public health practice.

    • Health Disparities
      1. Racial and ethnic disparities in the prevalence of stress and worry, mental health conditions, and increased substance use among adults during the COVID-19 pandemic - United States, April and May 2020external icon
        McKnight-Eily LR, Okoro CA, Strine TW, Verlenden J, Hollis ND, Njai R, Mitchell EW, Board A, Puddy R, Thomas C.
        MMWR Morb Mortal Wkly Rep. 2021 Feb 5;70(5):162-166.
        In 2019, approximately 51 million U.S. adults aged ≥18 years reported any mental illness,* and 7.7% reported a past-year substance use disorder(†) (1). Although reported prevalence estimates of certain mental disorders, substance use, or substance use disorders are not generally higher among racial and ethnic minority groups, persons in these groups are often less likely to receive treatment services (1). Persistent systemic social inequities and discrimination related to living conditions and work environments, which contribute to disparities in underlying medical conditions, can further compound health problems faced by members of racial and ethnic minority groups during the coronavirus disease 2019 (COVID-19) pandemic and worsen stress and associated mental health concerns (2,3). In April and May 2020, opt-in Internet panel surveys of English-speaking U.S. adults aged ≥18 years were conducted to assess the prevalence of self-reported mental health conditions and initiation of or increases in substance use to cope with stress, psychosocial stressors, and social determinants of health. Combined prevalence estimates of current depression, initiating or increasing substance use, and suicidal thoughts/ideation were 28.6%, 18.2%, and 8.4%, respectively. Hispanic/Latino (Hispanic) adults reported a higher prevalence of psychosocial stress related to not having enough food or stable housing than did adults in other racial and ethnic groups. These estimates highlight the importance of population-level and tailored interventions for mental health promotion and mental illness prevention, substance use prevention, screening and treatment services, and increased provision of resources to address social determinants of health. How Right Now (Qué Hacer Ahora) is an evidence-based and culturally appropriate communications campaign designed to promote and strengthen the emotional well-being and resiliency of populations adversely affected by COVID-19-related stress, grief, and loss (4).

      2. Social determinants of health and race disparities in kidney transplantexternal icon
        Wesselman H, Ford CG, Leyva Y, Li X, Chang CH, Dew MA, Kendall K, Croswell E, Pleis JR, Ng YH, Unruh ML, Shapiro R, Myaskovsky L.
        Clin J Am Soc Nephrol. 2021 Jan 28.
        BACKGROUND AND OBJECTIVES: Black patients have a higher incidence of kidney failure but lower rate of deceased- and living-donor kidney transplantation compared with White patients, even after taking differences in comorbidities into account. We assessed whether social determinants of health (e.g., demographics, cultural, psychosocial, knowledge factors) could account for race differences in receiving deceased- and living-donor kidney transplantation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Via medical record review, we prospectively followed 1056 patients referred for kidney transplant (2010-2012), who completed an interview soon after kidney transplant evaluation, until their kidney transplant. We used multivariable competing risk models to estimate the cumulative incidence of receipt of any kidney transplant, deceased-donor transplant, or living-donor transplant, and the factors associated with each outcome. RESULTS: Even after accounting for social determinants of health, Black patients had a lower likelihood of kidney transplant (subdistribution hazard ratio, 0.74; 95% confidence interval, 0.55 to 0.99) and living-donor transplant (subdistribution hazard ratio, 0.49; 95% confidence interval, 0.26 to 0.95), but not deceased-donor transplant (subdistribution hazard ratio, 0.92; 95% confidence interval, 0.67 to 1.26). Black race, older age, lower income, public insurance, more comorbidities, being transplanted before changes to the Kidney Allocation System, greater religiosity, less social support, less transplant knowledge, and fewer learning activities were each associated with a lower probability of any kidney transplant. Older age, more comorbidities, being transplanted before changes to the Kidney Allocation System, greater religiosity, less social support, and fewer learning activities were each associated with a lower probability of deceased-donor transplant. Black race, older age, lower income, public insurance, higher body mass index, dialysis before kidney transplant, not presenting with a potential living donor, religious objection to living-donor transplant, and less transplant knowledge were each associated with a lower probability of living-donor transplant. CONCLUSIONS: Race and social determinants of health are associated with the likelihood of undergoing kidney transplant.

    • Health Economics
      1. BACKGROUND: Traumatic brain injury (TBI) is a serious public health problem in the United States. Each year, TBIs substantially contribute to health care costs, which vary by severity. This is important to consider given the variability in recovery time by severity. RESEARCH DESIGN: This study quantifies the annual incremental health care costs of nonfatal TBI in 2016 for the US population covered by a private health insurance, Medicaid, or Medicare health plan. This study uses MarketScan and defines severity with the abbreviated injury scale for the head and neck region. Nonfatal health care costs were compared by severity. RESULTS: The estimated 2016 overall health care cost attributable to nonfatal TBI among MarketScan enrollees was $40.6 billion. Total estimated annual health care cost attributable to TBI for low severity TBIs during the first year postinjury were substantially higher than costs for middle and high severity TBIs among those with private health insurance and Medicaid. CONCLUSIONS: This study presents economic burden estimates for TBI that underscore the importance of developing strategies to prevent TBIs, regardless of severity. Although middle and high severity TBIs were more costly at the individual level, low severity TBIs, and head injuries diagnosed as "head injury unspecified" resulted in higher total estimated annual health care costs attributable to TBI.

      2. National estimates of healthcare costs associated with multidrug-resistant bacterial infections among hospitalized patients in the United Statesexternal icon
        Nelson RE, Hatfield KM, Wolford H, Samore MH, Scott RD, Reddy SC, Olubajo B, Paul P, Jernigan JA, Baggs J.
        Clin Infect Dis. 2021 Jan 29;72(Supplement_1):S17-s26.
        BACKGROUND: Treating patients with infections due to multidrug-resistant pathogens often requires substantial healthcare resources. The purpose of this study was to report estimates of the healthcare costs associated with infections due to multidrug-resistant bacteria in the United States (US). METHODS: We performed retrospective cohort studies of patients admitted for inpatient stays in the Department of Veterans Affairs healthcare system between January 2007 and October 2015. We performed multivariable generalized linear models to estimate the attributable cost by comparing outcomes in patients with and without positive cultures for multidrug-resistant bacteria. Finally, we multiplied these pathogen-specific, per-infection attributable cost estimates by national counts of infections due to each pathogen from patients hospitalized in a cohort of 722 US hospitals from 2017 to generate estimates of the population-level healthcare costs in the US attributable to these infections. RESULTS: Our analysis cohort consisted of 16 676 patients with community-onset infections and 172 712 matched controls and 8246 patients with hospital-onset infections and 66 939 matched controls. The highest cost was seen in hospital-onset invasive infections, with attributable costs (95% confidence intervals) ranging from $30 998 ($25 272-$36 724) for methicillin-resistant Staphylococcus aureus to $74 306 ($20 377-$128 235) for carbapenem-resistant (CR) Acinetobacter. The highest attributable costs for community-onset invasive infections were seen in CR Acinetobacter ($62 396; $20 370-$104 422). Treatment of these infections cost an estimated $4.6 billion ($4.1 billion-$5.1 billion) in 2017 in the US for community- and hospital-onset infections combined. CONCLUSIONS: We found that antimicrobial-resistant infections led to substantial healthcare costs.

      3. Use of commercial claims data for evaluating trends in Lyme disease diagnoses, United States, 2010-2018external icon
        Schwartz AM, Kugeler KJ, Nelson CA, Marx GE, Hinckley AF.
        Emerg Infect Dis. 2021 ;27(2):499-507.
        We evaluated MarketScan, a large commercial insurance claims database, for its potential use as a stable and consistent source of information on Lyme disease diagnoses in the United States. The age, sex, and geographic composition of the enrolled population during 2010-2018 remained proportionally stable, despite fluctuations in the number of enrollees. Annual incidence of Lyme disease diagnoses per 100,000 enrollees ranged from 49 to 88, ≈6-8 times higher than that observed for cases reported through notifiable disease surveillance. Age and sex distributions among Lyme disease diagnoses in MarketScan were similar to those of cases reported through surveillance, but proportionally more diagnoses occurred outside of peak summer months, among female enrollees, and outside high-incidence states. Misdiagnoses, particularly in low-incidence states, may account for some of the observed epidemiologic differences. Commercial claims provide a stable data source to monitor trends in Lyme disease diagnoses, but certain important characteristics warrant further investigation.

    • Healthcare Associated Infections
      1. Candida auris colonization after discharge to a community setting: New York City, 2017-2019external icon
        Bergeron G, Bloch D, Murray K, Kratz M, Parton H, Ackelsberg J, Antwi M, Del Rosso P, Dorsinville M, Kubinson H, Lash M, Rand S, Adams E, Zhu Y, Erazo R, Chaturvedi S, Weiss D.
        Open Forum Infect Dis. 2021 Jan;8(1):ofaa620.
        BACKGROUND: Patients colonized with multidrug-resistant Candida auris and discharged to a community setting can subsequently seek care in a different healthcare facility and might be a source of nosocomial transmission of C auris. METHODS: We designed a case management pilot program for a cohort of New York City residents who had a history of positive C auris culture identified during clinical or screening activities in healthcare settings and discharged to a community setting during 2017-2019. Approximately every 3 months, case managers coordinated C auris colonization assessments, which included swabs of groin, axilla, and body sites yielding C auris previously. Patients eligible to become serially negative were those with ≥2 C auris colonization assessments after initial C auris identification. Clinical characteristics of serially negative and positive patients were compared. RESULTS: The cohort included 75 patients. Overall, 45 patients were eligible to become serially negative and had 552 person-months of follow-up. Of these 45 patients, 28 patients were serially negative (62%; rate 5.1/100 person-months), 8 were serially positive, and 9 could not be classified as either. There were no clinical characteristics that were significantly different between serially negative and positive patients. The median time from initial C auris identification to being serially negative at assessments was 8.6 months (interquartile range, 5.7-10.8 months). CONCLUSIONS: A majority of patients, assessed at least twice after C auris identification, no longer had C auris detectable on serial colonization assessments.

      2. This case study is part of a series centered on the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) health care-associated infection (HAI) surveillance definitions. The intent of the case study series is to foster standardized application of the NHSN HAI surveillance definitions among infection preventionists and to promote accurate determination of HAI events. These cases reflect some of the complex patient scenarios that infection preventionists have encountered in their daily surveillance of HAIs using NHSN definitions. Objectives have been previously published.(1).

      3. SARS-CoV-2 infections among recent organ recipients, March-May 2020, United Statesexternal icon
        Jones JM, Kracalik I, Rana MM, Nguyen A, Keller BC, Mishkin A, Hoopes C, Kaleekal T, Humar A, Vilaro J, Im G, Smith L, Justice A, Leaumont C, Lindstrom S, Whitaker B, La Hoz RM, Michaels MG, Klassen D, Kuhnert W, Basavaraju SV.
        Emerg Infect Dis. 2021 Feb;27(2):552-555.
        We conducted public health investigations of 8 organ transplant recipients who tested positive for severe acute respiratory syndrome coronavirus 2 infection. Findings suggest the most likely source of transmission was community or healthcare exposure, not the organ donor. Transplant centers should educate transplant candidates and recipients about infection prevention recommendations.

      4. Environmental contamination of contact precaution and non-contact precaution patient rooms in six acute care facilitiesexternal icon
        Tanner WD, Leecaster MK, Zhang Y, Stratford KM, Mayer J, Visnovsky LD, Alhmidi H, Cadnum JL, Jencson AL, Koganti S, Bennett CP, Donskey CJ, Noble-Wang J, Reddy SC, Rose LJ, Watson L, Ide E, Wipperfurth T, Safdar N, Arasim M, Macke C, Roman P, Krein SL, Loc-Carrillo C, Samore MH.
        Clin Infect Dis. 2021 Jan 29;72(Supplement_1):S8-s16.
        BACKGROUND: Environmental contamination is an important source of hospital multidrug-resistant organism (MDRO) transmission. Factors such as patient MDRO contact precautions (CP) status, patient proximity to surfaces, and unit type likely influence MDRO contamination and bacterial bioburden levels on patient room surfaces. Identifying factors associated with environmental contamination in patient rooms and on shared unit surfaces could help identify important environmental MDRO transmission routes. METHODS: Surfaces were sampled from MDRO CP and non-CP rooms, nursing stations, and mobile equipment in acute care, intensive care, and transplant units within 6 acute care hospitals using a convenience sampling approach blinded to cleaning events. Precaution rooms had patients with clinical or surveillance tests positive for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, carbapenem-resistant Enterobacteriaceae or Acinetobacter within the previous 6 months, or Clostridioides difficile toxin within the past 30 days. Rooms not meeting this definition were considered non-CP rooms. Samples were cultured for the above MDROs and total bioburden. RESULTS: Overall, an estimated 13% of rooms were contaminated with at least 1 MDRO. MDROs were detected more frequently in CP rooms (32% of 209 room-sample events) than non-CP rooms (12% of 234 room-sample events). Surface bioburden did not differ significantly between CP and non-CP rooms or MDRO-positive and MDRO-negative rooms. CONCLUSIONS: CP room surfaces are contaminated more frequently than non-CP room surfaces; however, contamination of non-CP room surfaces is not uncommon and may be an important reservoir for ongoing MDRO transmission. MDRO contamination of non-CP rooms may indicate asymptomatic patient MDRO carriage, inadequate terminal cleaning, or cross-contamination of room surfaces via healthcare personnel hands.

    • Immunity and Immunization
      1. A randomized phase 4 study of immunogenicity and safety after monovalent oral type 2 sabin poliovirus vaccine challenge in children vaccinated with inactivated poliovirus vaccine in Lithuaniaexternal icon
        Bandyopadhyay AS, Gast C, Brickley EB, Rüttimann R, Clemens R, Oberste MS, Weldon WC, Ackerman ME, Connor RI, Wieland-Alter WF, Wright P, Usonis V.
        J Infect Dis. 2021 Jan 4;223(1):119-127.
        BACKGROUND: Understanding immunogenicity and safety of monovalent type 2 oral poliovirus vaccine (mOPV2) in inactivated poliovirus vaccine (IPV)-immunized children is of major importance in informing global policy to control circulating vaccine-derived poliovirus outbreaks. METHODS: In this open-label, phase 4 study (NCT02582255) in 100 IPV-vaccinated Lithuanian 1-5-year-olds, we measured humoral and intestinal type 2 polio neutralizing antibodies before and 28 days after 1 or 2 mOPV2 doses given 28 days apart and measured stool viral shedding after each dose. Parents recorded solicited adverse events (AEs) for 7 days after each dose and unsolicited AEs for 6 weeks after vaccination. RESULTS: After 1 mOPV2 challenge, the type 2 seroprotection rate increased from 98% to 100%. Approximately 28 days after mOPV2 challenge 34 of 68 children (50%; 95% confidence interval, 38%-62%) were shedding virus; 9 of 37 (24%; 12%-41%) were shedding 28 days after a second challenge. Before challenge, type 2 intestinal immunity was undetectable in IPV-primed children, but 28 of 87 (32%) had intestinal neutralizing titers ≥32 after 1 mOPV2 dose. No vaccine-related serious or severe AEs were reported. CONCLUSIONS: High viral excretion after mOPV2 among exclusively IPV-vaccinated children was substantially lower after a subsequent dose, indicating induction of intestinal immunity against type 2 poliovirus.

      2. Vaccines work: a reason for celebration and renewed commitmentexternal icon
        Cohen AL, Patel MK, Cherian T.
        Lancet. 2021 Jan 30;397(10272):351-353.

      3. Early COVID-19 first-dose vaccination coverage among residents and staff members of skilled nursing facilities participating in the Pharmacy Partnership for Long-Term Care Program - United States, December 2020-January 2021external icon
        Gharpure R, Guo A, Bishnoi CK, Patel U, Gifford D, Tippins A, Jaffe A, Shulman E, Stone N, Mungai E, Bagchi S, Bell J, Srinivasan A, Patel A, Link-Gelles R.
        MMWR Morb Mortal Wkly Rep. 2021 Feb 5;70(5):178-182.
        Residents and staff members of long-term care facilities (LTCFs), because they live and work in congregate settings, are at increased risk for infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1,2). In particular, skilled nursing facilities (SNFs), LTCFs that provide skilled nursing care and rehabilitation services for persons with complex medical needs, have been documented settings of COVID-19 outbreaks (3). In addition, residents of LTCFs might be at increased risk for severe outcomes because of their advanced age or the presence of underlying chronic medical conditions (4). As a result, the Advisory Committee on Immunization Practices has recommended that residents and staff members of LTCFs be offered vaccination in the initial COVID-19 vaccine allocation phase (Phase 1a) in the United States (5). In December 2020, CDC launched the Pharmacy Partnership for Long-Term Care Program* to facilitate on-site vaccination of residents and staff members at enrolled LTCFs. To evaluate early receipt of vaccine during the first month of the program, the number of eligible residents and staff members in enrolled SNFs was estimated using resident census data from the National Healthcare Safety Network (NHSN(†)) and staffing data from the Centers for Medicare & Medicaid Services (CMS) Payroll-Based Journal.(§) Among 11,460 SNFs with at least one vaccination clinic during the first month of the program (December 18, 2020-January 17, 2021), an estimated median of 77.8% of residents (interquartile range [IQR] = 61.3%- 93.1%) and a median of 37.5% (IQR = 23.2%- 56.8%) of staff members per facility received ≥1 dose of COVID-19 vaccine through the Pharmacy Partnership for Long-Term Care Program. The program achieved moderately high coverage among residents; however, continued development and implementation of focused communication and outreach strategies are needed to improve vaccination coverage among staff members in SNFs and other long-term care settings.

      4. Shared clinical decision-making recommendations for adult immunization: What do physicians think?external icon
        Kempe A, Lindley MC, O'Leary ST, Crane LA, Cataldi JR, Brtnikova M, Beaty BL, Matlock DD, Gorman C, Hurley LP.
        J Gen Intern Med. 2021 Feb 2.
        BACKGROUND: In 2019, the Advisory Committee on Immunization Practices (ACIP) incorporated the terminology "shared clinical decision-making" (SDM) into recommendations for two adult vaccines. OBJECTIVE: To assess among general internal medicine physicians (GIMs) and family physicians (FPs) nationally (1) attitudes about and experience with ACIP SDM recommendations, (2) knowledge of insurance reimbursement for vaccines with SDM recommendations, (3) how SDM recommendations are incorporated into vaccine forecasting software, and (4) physician and practice characteristics associated with not knowing how to implement SDM. DESIGN: Survey conducted in October 2019-January 2020 by mail or internet based on preference. PARTICIPANTS: Networks of GIMs and FPs recruited from American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) who practice ≥ 50% in primary care. Post-stratification quota sampling performed to ensure networks similar to ACP and AAFP memberships. MAIN MEASURES: Responses on 4-point Likert scales (attitudes/experiences), true/false options (knowledge), and categorical response options (forecasting). Multivariable modeling with outcome of "not knowing how to implement SDM" conducted. KEY RESULTS: Response rate was 64% (617/968). Most physicians strongly/somewhat agreed SDM requires more time than routine recommendations (90%FP; 95%GIM, p = 0.02) and that they need specific talking points to guide SDM discussions (79%FP; 84%GIM, p = NS). There was both support for SDM recommendations for certain vaccines (81%FP; 75%GIM, p = 0.06) and agreement that SDM creates confusion (64%FP; 76%GIM, p = 0.001). Only 41%FP and 43%GIM knew vaccines recommended for SDM would be covered by most health insurance. Overall, 38% reported SDM recommendations are displayed as "recommended" and 23% that they did not result in any recommendation in forecasting software. In adjusted multivariable models, GIMs [risk ratio 1.44 (1.15-1.81)] and females [1.28 (1.02-1.60)] were significantly associated with not knowing how to implement SDM recommendations CONCLUSIONS: To be successful in a primary care setting, SDM for adult vaccination will require thoughtful implementation with decision-making support for patients and physicians.

      5. Since 2014, the World Health Organization (WHO) member states have been annually reporting vaccine hesitancy reasons, using the WHO/UNICEF Joint Reporting Form (JRF). The Vaccine Hesitancy Matrix (VHM), developed by a WHO strategic advisory group of experts, can serve as an important tool to categorize vaccine hesitancy reasons reported in the JRF. We aimed to describe the reasons for vaccine hesitancy reported globally from 2014 to 2017 to ascertain trends over time and understand the comparability of using the VHM to classify hesitancy reasons from 2014 to 2016 based on previously published literature. We conducted a quantitative content analysis to code and categorize vaccine hesitancy reasons reported in the JRF from 2014 to 2017. Vaccine hesitancy trends were consistent from 2014 to 2017, where vaccine hesitancy reasons were mainly related to "individual and group level influences" (59%) followed by "contextual influences" (25%), and "vaccine- or vaccination-specific issues" (16%). Comparability of our approach to categorize vaccine hesitancy to the previously published JRF data showed that results were mostly but not entirely consistent. Major differences in categorizing vaccine hesitancy were noted between two specific reasons - "experience with past vaccination" (under "individual and group influences") and "risk/benefit- scientific evidence" (under "vaccine and vaccination-specific issues"); this was usually due to lack of clear definitions in some sub-categories and generic responses reported in the JRF. The JRF hesitancy module may benefit from modifications to improve the data quality. Understanding global vaccine hesitancy is crucial and JRF can serve as an important tool, especially with the potential introduction of a COVID-19 vaccine.

      6. Evaluation of recombinant herpes zoster vaccine for primary immunization of varicella-seronegative transplant recipientsexternal icon
        LʼHuillier AG, Hirzel C, Ferreira VH, Ierullo M, Ku T, Selzner N, Schiff J, Juvet S, Miao C, Schmid DS, Humar A, Kumar D.
        Transplantation. 2021 Jan 19.
        BACKGROUND: Immunization of VZV-seronegative solid organ transplant (SOT) patients using the live-attenuated varicella vaccine is generally contraindicated, leaving no widely applicable immunization option. The recombinant subunit herpes zoster vaccine (RZV) is indicated for VZV seropositive persons to prevent shingles but could potentially also protect VZV-seronegative persons against varicella. We performed a safety and immunogenicity evaluation of RZV in VZV-seronegative SOT recipients as an option for protection. METHODS: VZV-seronegative adult SOT patients with no history of varicella/shingles vaccine or disease were given 2 doses of RZV vaccine 2-6 months apart. Blood was drawn prevaccination (V1), prior to the second dose (V2) and 4 weeks after second dose (V3). Humoral (anti-gE) and cell-mediated immunity was evaluated, with polyfunctional cells defined as cells producing ≥2 cytokines. RESULTS: Among 31 eligible VZV-seronegative SOT patients screened, 23 were enrolled. Median age was 38 years and median time since transplant procedure was 38 years. The most frequent transplant types were liver (35%) and lung (30%). Median anti-gE levels significantly increased from V1 to V3 (p=0001) and V2 to V3 (p<0001), even though only 55% had a positive seroresponse. Median polyfunctional CD4 T-cells counts increased from V1 to V2 (54/10 vs 104/10 cells; p=0041), and from V2 to V3 (380/10; p=0002). Most adverse events were mild with no rejection episodes. CONCLUSION: RZV was safe and elicited significant humoral and cellular responses in VZV-seronegative SOT patients, and has the potential to be considered as a preventive strategy against primary varicella.

      7. Impact of the human papillomavirus (HPV) vaccine supply shortage on Tanzania's national HPV vaccine introductionexternal icon
        Li AJ, Kyesi F, Mwengee W, Mphuru A, Giattas MR, Shayo B, Nshunju R, Lyimo D, Loharikar A.
        Vaccine. 2021 Jan 25.

      8. Antibody landscape analysis following influenza vaccination and natural infection in humans with a high-throughput multiplex influenza antibody detection assayexternal icon
        Li ZN, Liu F, Gross FL, Kim L, Ferdinands J, Carney P, Chang J, Stevens J, Tumpey T, Levine MZ.
        mBio. 2021 Feb 2;12(1).
        To better understand the antibody landscape changes following influenza virus natural infection and vaccination, we developed a high-throughput multiplex influenza antibody detection assay (MIADA) containing 42 recombinant hemagglutinins (rHAs) (ectodomain and/or globular head domain) from pre-2009 A(H1N1), A(H1N1)pdm09, A(H2N2), A(H3N2), A(H5N1), A(H7N7), A(H7N9), A(H7N2), A(H9N2), A(H13N9), and influenza B viruses. Panels of ferret antisera, 227 paired human sera from vaccinees (children and adults) in 5 influenza seasons (2010 to 2018), and 17 paired human sera collected from real-time reverse transcription-PCR (rRT-PCR)-confirmed influenza A(H1N1)pdm09, influenza A(H3N2), or influenza B virus-infected adults were analyzed by the MIADA. Ferret antisera demonstrated clear strain-specific antibody responses to exposed subtype HA. Adults (19 to 49 years old) had broader antibody landscapes than young children (<3 years old) and older children (9 to 17 years old) both at baseline and post-vaccination. Influenza vaccination and infection induced the strongest antibody responses specific to HA(s) of exposed strain/subtype viruses and closely related strains; they also induced cross-reactive antibodies to an unexposed influenza virus subtype(s), including novel viruses. Subsequent serum adsorption confirmed that the cross-reactive antibodies against novel subtype HAs were mainly induced by exposures to A(H1N1)/A(H3N2) influenza A viruses. In contrast, adults infected by influenza B viruses mounted antibody responses mostly specific to two influenza B virus lineage HAs. Median fluorescence intensities (MFIs) and seroconversion in MIADA had good correlations with the titers and seroconversion measured by hemagglutination inhibition and microneutralization assays. Our study demonstrated that antibody landscape analysis by the MIADA can be used for influenza vaccine evaluations and characterization of influenza virus infections.IMPORTANCE Repeated influenza vaccination and natural infections generate complex immune profiles in humans that require antibody landscape analysis to assess immunity and evaluate vaccines. However, antibody landscape analyses are difficult to perform using traditional assays. Here, we developed a high-throughput, serum-sparing, multiplex influenza antibody detection assay (MIADA) and analyzed the antibody landscapes following influenza vaccination and infection. We showed that adults had broader antibody landscapes than children. Influenza vaccination and infection not only induced the strongest antibody responses to the hemagglutinins of the viruses of exposure, but also induced cross-reactive antibodies to novel influenza viruses that can be removed by serum adsorption. There is a good correlation between the median fluorescence intensity (MFI) measured by MIADA and hemagglutination inhibition/microneutralization titers. Antibody landscape analysis by the MIADA can be used in influenza vaccine evaluations, including the development of universal influenza vaccines and the characterization of influenza virus infections.

      9. Demographic characteristics of persons vaccinated during the first month of the COVID-19 vaccination program - United States, December 14, 2020-January 14, 2021external icon
        Painter EM, Ussery EN, Patel A, Hughes MM, Zell ER, Moulia DL, Scharf LG, Lynch M, Ritchey MD, Toblin RL, Murthy BP, Harris LQ, Wasley A, Rose DA, Cohn A, Messonnier NE.
        MMWR Morb Mortal Wkly Rep. 2021 Feb 5;70(5):174-177.
        In December 2020, two COVID-19 vaccines (Pfizer-BioNTech and Moderna) were authorized for emergency use in the United States for the prevention of coronavirus disease 2019 (COVID-19).* Because of limited initial vaccine supply, the Advisory Committee on Immunization Practices (ACIP) prioritized vaccination of health care personnel(†) and residents and staff members of long-term care facilities (LTCF) during the first phase of the U.S. COVID-19 vaccination program (1). Both vaccines require 2 doses to complete the series. Data on vaccines administered during December 14, 2020-January 14, 2021, and reported to CDC by January 26, 2021, were analyzed to describe demographic characteristics, including sex, age, and race/ethnicity, of persons who received ≥1 dose of COVID-19 vaccine (i.e., initiated vaccination). During this period, 12,928,749 persons in the United States in 64 jurisdictions and five federal entities(§) initiated COVID-19 vaccination. Data on sex were reported for 97.0%, age for 99.9%, and race/ethnicity for 51.9% of vaccine recipients. Among persons who received the first vaccine dose and had reported demographic data, 63.0% were women, 55.0% were aged ≥50 years, and 60.4% were non-Hispanic White (White). More complete reporting of race and ethnicity data at the provider and jurisdictional levels is critical to ensure rapid detection of and response to potential disparities in COVID-19 vaccination. As the U.S. COVID-19 vaccination program expands, public health officials should ensure that vaccine is administered efficiently and equitably within each successive vaccination priority category, especially among those at highest risk for infection and severe adverse health outcomes, many of whom are non-Hispanic Black (Black), non-Hispanic American Indian/Alaska Native (AI/AN), and Hispanic persons (2,3).

      10. Seasonal influenza vaccine in pregnant women: Views and experiences of obstetrician-gynecologistsexternal icon
        SteelFisher GK, Caporello HL, Broussard CS, Schafer TJ, Ben-Porath EN, Blendon RJ.
        J Womens Health (Larchmt). 2021 Feb 2.
        Background: Seasonal influenza vaccination rates among pregnant women remain well below the Healthy People 2020 target of 80%. Obstetrician-gynecologist (OB/GYN) recommendations are a critical means of encouraging pregnant women to get vaccinated, but there are limited data about their views. Materials and Methods: A nationally representative survey of 506 practicing OB/GYNs was completed between October 26, 2015, and May 8, 2016. Analyses included univariate distributions and comparisons based on age, size of practice, and academic affiliation using all-pairs, dependent t-tests. Results: A majority of OB/GYNs report they "strongly recommend" seasonal influenza vaccination for their pregnant patients in the first (79%) or second and third trimesters (81%). Among those who do not strongly recommend the flu vaccine in the first trimester, many say this is because of their own concerns (28%) or their patients' concerns (44%) about safety. Older OB/GYNs, those in smaller practices, and those without academic affiliation were less likely to recommend the vaccine and more likely to have safety concerns. For example, 72% of those age 60+ strongly recommended the vaccine in the second and third trimester, compared with 86% of those ages 30-44 and 83% of those ages 45-59 (p < 0.05 for all comparisons). Conclusions: OB/GYNs across the country largely support seasonal flu vaccination among pregnant women. Nonetheless, safety is a concern for them and their patients. Outreach to support clinician decisions and conversations with pregnant patients may be most needed among older physicians, those in smaller practices, and those without academic affiliation.

      11. Assessing the burden of congenital rubella syndrome in China and evaluating mitigation strategies: a metapopulation modelling studyexternal icon
        Su Q, Feng Z, Hao L, Ma C, Hagan JE, Grant GB, Wen N, Fan C, Yang H, Rodewald LE, Wang H, Glasser JW.
        Lancet Infect Dis. 2021 Jan 27.
        BACKGROUND: A rubella vaccine was licensed in China in 1993 and added to the Expanded Programme on Immunization in 2008, but a national cross-sectional serological survey during 2014 indicates that many adolescents remain susceptible. Maternal infections during the first trimester often cause miscarriages, stillbirths, and, among livebirths, congenital rubella syndrome. We aimed to evaluate possible supplemental immunisation activities (SIAs) to accelerate elimination of rubella and congenital rubella syndrome. METHODS: We analysed residual samples from the national serological survey done in 2014, data from monthly rubella surveillance reports from 2005 and 2016, and additional publications through a systematic review. Using an age-structured population model with provincial strata, we calculated the reproduction numbers and evaluated the gradient of the metapopulation effective reproduction number with respect to potential supplemental immunisation rates. We corroborated these analytical results and estimated times-to-elimination by simulating SIAs among adolescents (ages 10-19 years) and young adults (ages 20-29 years) using a model with regional strata. We estimated the incidence of rubella and burden of congenital rubella syndrome by simulating transmission in a relatively small population lacking only spatial structure. FINDINGS: By 2014, childhood immunisation had reduced rubella's reproduction number from 7·6 to 1·2 and SIAs among adolescents were the optimal elimination strategy. We found that less than 10% of rubella infections were reported; that although some women with symptomatic first-trimester infections might have elected to terminate their pregnancies, 700 children could have been born with congenital rubella syndrome during 2014; and that timely SIAs would avert outbreaks that, as susceptible adolescents reached reproductive age, could greatly increase the burden of this syndrome. INTERPRETATION: Our findings suggest that SIAs among adolescents would most effectively reduce congenital rubella syndrome as well as eliminate rubella, owing both to fewer infections in the immunised population and absence of infections that those immunised would otherwise have caused. Metapopulation models with realistic mixing are uniquely capable of assessing such indirect effects. FUNDING: WHO and National Science Foundation.

      12. In 2016, Sanofi Pasteur (S-P) experienced a manufacturing disruption of yellow fever vaccine (YF-Vax), the only U.S.-licensed YF-Vax, depleting the U.S. supply by mid-2017. Sanofi Pasteur received approval to import Stamaril, S-P's French-manufactured YF-Vax, for use in 260 U.S. civilian clinics under an expanded access investigational new drug program (EAP). The CDC also broadened its YF-Vax indication in early 2018. Our objective was to assess usage at participating Global TravEpiNet (GTEN) clinics, a U.S. CDC-supported national consortium of clinical sites that administer vaccines, during this period of limited availability and changing recommendations. We analyzed 2012-2018 GTEN data for YF-Vax usage, unavailability, and reasons for refusal. We also performed a brief voluntary survey of GTEN sites to better understand their experience during the shortage. Yellow fever vaccine unavailability at certain GTEN clinics was intermittent and recurrent, starting months before total depletion. Unavailability at GTEN clinics peaked weeks before the total depletion. Compared with historic norms, YF-Vax usage following initial vaccine availability limitations did not change until vaccine recommendations were broadened. Refusal of recommended YF-Vax also decreased during this period. Queried sites participating in the EAP felt their supply of vaccine was adequate. Our analysis suggests that in response to depletion of a travel vaccine, an EAP can make an unlicensed product available, patients will participate in such a program, and the program can respond to expanding recommendations for vaccine usage.

    • Informatics
      1. Including diverse participants in biomedical research is essential to reduce health disparities. We assessed the inclusion of Asians in original research studies conducted in North America and published from 2015-2016 in six high-impact generalist journals: New England Journal of Medicine, Journal of the American Medical Association (JAMA), JAMA Internal Medicine, JAMA Pediatrics, Annals of Internal Medicine, and Pediatrics. We determined race reporting method, participant percentage, and reporting of outcomes or implications of findings for Asians and Asian subgroups. Of 1077 studies, 263 articles (24.4%) identified Asians as a distinct race/ethnicity; the median percentage of Asians per study was 3.8%. Of the 263 articles, 28 (10.6%) studies reported outcomes for Asians; nine (3.4%) articles included information about Asian subgroups. Asians are underrepresented in high-impact medical research studies in North America. Efforts to improve study enrollment, data collection, and reporting of findings of Asians in studies remain essential to improve health outcomes for this population.

    • Injury and Violence
      1. Vital Signs: Prevalence of multiple forms of violence and increased health risk behaviors and conditions among youths - United States, 2019external icon
        David-Ferdon C, Clayton HB, Dahlberg LL, Simon TR, Holland KM, Brener N, Matjasko JL, D'Inverno AS, Robin L, Gervin D.
        MMWR Morb Mortal Wkly Rep. 2021 Feb 5;70(5):167-173.
        INTRODUCTION: Experiencing violence, especially multiple types of violence, can have a negative impact on youths' development. These experiences increase the risk for future violence and other health problems associated with the leading causes of morbidity and mortality among adolescents and adults. METHODS: Data from the 2019 national Youth Risk Behavior Survey were used to determine the prevalence of high school students' self-reported experiences with physical fighting, being threatened with a weapon, physical dating violence, sexual violence, and bullying. Logistic regression models adjusting for sex, grade, and race/ethnicity were used to test the strength of associations between experiencing multiple forms of violence and 16 self-reported health risk behaviors and conditions. RESULTS: Approximately one half of students (44.3%) experienced at least one type of violence; more than one in seven (15.6%) experienced two or more types during the preceding 12 months. Experiencing multiple types of violence was significantly more prevalent among females than among males and among students identifying as gay, lesbian, or bisexual or not sure of their sexual identity than among heterosexual students. Experiencing violence was significantly associated with higher prevalence of all examined health risks and conditions. Relative to youths with no violence experiences, adjusted health risk and condition prevalence estimates were up to seven times higher among those experiencing two types of violence and up to 21 times higher among those experiencing three or more types of violence. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Many youths experience multiple types of violence, with potentially lifelong health impacts. Violence is preventable using proven approaches that address individual, family, and environmental risks. Prioritizing violence prevention is strategic to promoting adolescent and adult health.

      2. Trends in US emergency department visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemicexternal icon
        Holland KM, Jones C, Vivolo-Kantor AM, Idaikkadar N, Zwald M, Hoots B, Yard E, D'Inverno A, Swedo E, Chen MS, Petrosky E, Board A, Martinez P, Stone DM, Law R, Coletta MA, Adjemian J, Thomas C, Puddy RW, Peacock G, Dowling NF, Houry D.
        JAMA Psychiatry. 2021 Feb 3.
        IMPORTANCE: The coronavirus disease 2019 (COVID-19) pandemic, associated mitigation measures, and social and economic impacts may affect mental health, suicidal behavior, substance use, and violence. OBJECTIVE: To examine changes in US emergency department (ED) visits for mental health conditions (MHCs), suicide attempts (SAs), overdose (OD), and violence outcomes during the COVID-19 pandemic. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data from the Centers for Disease Control and Prevention's National Syndromic Surveillance Program to examine national changes in ED visits for MHCs, SAs, ODs, and violence from December 30, 2018, to October 10, 2020 (before and during the COVID-19 pandemic). The National Syndromic Surveillance Program captures approximately 70% of US ED visits from more than 3500 EDs that cover 48 states and Washington, DC. MAIN OUTCOMES AND MEASURES: Outcome measures were MHCs, SAs, all drug ODs, opioid ODs, intimate partner violence (IPV), and suspected child abuse and neglect (SCAN) ED visit counts and rates. Weekly ED visit counts and rates were computed overall and stratified by sex. RESULTS: From December 30, 2018, to October 10, 2020, a total of 187 508 065 total ED visits (53.6% female and 46.1% male) were captured; 6 018 318 included at least 1 study outcome (visits not mutually exclusive). Total ED visit volume decreased after COVID-19 mitigation measures were implemented in the US beginning on March 16, 2020. Weekly ED visit counts for all 6 outcomes decreased between March 8 and 28, 2020 (March 8: MHCs = 42 903, SAs = 5212, all ODs = 14 543, opioid ODs = 4752, IPV = 444, and SCAN = 1090; March 28: MHCs = 17 574, SAs = 4241, all ODs = 12 399, opioid ODs = 4306, IPV = 347, and SCAN = 487). Conversely, ED visit rates increased beginning the week of March 22 to 28, 2020. When the median ED visit counts between March 15 and October 10, 2020, were compared with the same period in 2019, the 2020 counts were significantly higher for SAs (n = 4940 vs 4656, P = .02), all ODs (n = 15 604 vs 13 371, P < .001), and opioid ODs (n = 5502 vs 4168, P < .001); counts were significantly lower for IPV ED visits (n = 442 vs 484, P < .001) and SCAN ED visits (n = 884 vs 1038, P < .001). Median rates during the same period were significantly higher in 2020 compared with 2019 for all outcomes except IPV. CONCLUSIONS AND RELEVANCE: These findings suggest that ED care seeking shifts during a pandemic, underscoring the need to integrate mental health, substance use, and violence screening and prevention services into response activities during public health crises.

    • Laboratory Sciences
      1. Sensitivity of dried blood spot testing for detection of congenital cytomegalovirus infectionexternal icon
        Dollard SC, Dreon M, Hernandez-Alvarado N, Amin MM, Wong P, Lanzieri TM, Osterholm EA, Sidebottom A, Rosendahl S, McCann MT, Schleiss MR.
        JAMA Pediatr. 2021 Feb 1:e205441.
        IMPORTANCE: The sensitivity of dried blood spots (DBS) to identify newborns with congenital cytomegalovirus (cCMV) infection has not been evaluated in screening studies using the current, higher-sensitivity methods for DBS processing. OBJECTIVE: To assess the sensitivity of DBS polymerase chain reaction (PCR) for newborn screening for cCMV infection using saliva as the reference standard for screening, followed by collection of a urine sample for confirmation of congenital infection. DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study took place at 5 newborn nurseries and 3 neonatal intensive care units in the Minneapolis/Saint Paul area in Minnesota from April 2016 to June 2019. Newborns enrolled with parental consent were screened for cCMV using DBS obtained for routine newborn screening and saliva collected 1 to 2 days after birth. Dried blood spots were tested for CMV DNA by PCR at both the University of Minnesota (UMN) and the US Centers for Disease Control and Prevention (CDC). Saliva swabs were tested by CMV DNA PCR at the UMN laboratory only. Newborns who screened positive by saliva or DBS had a diagnostic urine sample obtained by primary care professionals, tested by PCR within 3 weeks of birth. Analysis began July 2019. EXPOSURES: Detection of CMV from a saliva swab using a PCR assay. MAIN OUTCOMES AND MEASURES: Number of children with urine-confirmed cCMV and the proportion of them who were CMV positive through DBS screening. RESULTS: Of 12 554 individuals enrolled through June 2019 (of 25 000 projected enrollment), 56 newborns were confirmed to have cCMV (4.5 per 1000 [95% CI, 3.3-5.7]). Combined DBS results from either UMN or CDC had a sensitivity of 85.7% (48 of 56; 95% CI, 74.3%-92.6%), specificity of 100.0% (95% CI, 100.0%-100.0%), positive predictive value (PPV) of 98.0% (95% CI, 89.3%-99.6%), and negative predictive value (NPV) of 99.9% (95% CI, 99.9%-100.0%). Dried blood spot results from UMN had a sensitivity of 73.2% (95% CI, 60.4%-83.0%), specificity of 100.0% (100.0%-100.0%), PPV of 100.0% (95% CI, 91.4%-100.0%), and NPV of 99.9% (95% CI, 99.8%-99.9%). Dried blood spot results from CDC had a sensitivity of 76.8% (95% CI, 64.2%-85.9%), specificity of 100.0% (95% CI, 100.0%-100.0%), PPV of 97.7% (95% CI, 88.2%-99.6%), and NPV of 99.9% (95% CI, 99.8%-99.9%). Saliva swab results had a sensitivity of 92.9% (52 of 56; 95% CI, 83.0%-97.2%), specificity of 99.9% (95% CI, 99.9%-100.0%), PPV of 86.7% (95% CI, 75.8%-93.1%), and NPV of 100.0% (95% CI, 99.9%-100.0%). CONCLUSIONS AND RELEVANCE: This study demonstrates relatively high analytical sensitivity for DBS compared with previous studies that performed population-based screening. As more sensitive DNA extraction and PCR methods continue to emerge, DBS-based testing should remain under investigation as a potential low-cost, high-throughput option for cCMV screening.

      2. Genomic diversity of Burkholderia pseudomallei in Ceara, Brazilexternal icon
        Gee JE, Gulvik CA, Castelo-Branco D, Sidrim JJ, Rocha MF, Cordeiro RA, Brilhante RS, Bandeira T, Patrício I, Alencar LP, da Costa Ribeiro AK, Sheth M, Deka MA, Hoffmaster AR, Rolim D.
        mSphere. 2021 Feb 3;6(1).
        Burkholderia pseudomallei is a Gram-negative bacterium that causes the sapronotic disease melioidosis. An outbreak in 2003 in the state of Ceara, Brazil, resulted in subsequent surveillance and environmental sampling which led to the recognition of B. pseudomallei as an endemic pathogen in that area. From 2003 to 2015, 24 clinical and 12 environmental isolates were collected across Ceara along with one from the state of Alagoas. Using next-generation sequencing, multilocus sequence typing, and single nucleotide polymorphism analysis, we characterized the genomic diversity of this collection to better understand the population structure of B. pseudomallei associated with Ceara. We found that the isolates in this collection form a distinct subclade compared to other examples from the Western Hemisphere. Substantial genetic diversity among the clinical and environmental isolates was observed, with 14 sequence types (STs) identified among the 37 isolates. Of the 31,594 core single-nucleotide polymorphisms (SNPs) identified, a high proportion (59%) were due to recombination. Because recombination events do not follow a molecular clock, the observation of high occurrence underscores the importance of identifying and removing recombination SNPs prior to evolutionary reconstructions and inferences in public health responses to B. pseudomallei outbreaks. Our results suggest long-term B. pseudomallei prevalence in this recently recognized region of melioidosis endemicity.IMPORTANCE B. pseudomallei causes significant morbidity and mortality, but its geographic prevalence and genetic diversity are not well characterized, especially in the Western Hemisphere. A better understanding of the genetic relationships among clinical and environmental isolates will improve knowledge of the population structure of this bacterium as well as the ability to conduct epidemiological investigations of cases of melioidosis.

      3. Pharmacokinetics and efficacy of a potential smallpox therapeutic, brincidofovir, in a lethal monkeypox virus animal modelexternal icon
        Hutson CL, Kondas AV, Mauldin MR, Doty JB, Grossi IM, Morgan CN, Ostergaard SD, Hughes CM, Nakazawa Y, Kling C, Martin BE, Ellison JA, Carroll DD, Gallardo-Romero NF, Olson VA.
        mSphere. 2021 Feb 3;6(1).
        Smallpox, caused by Variola virus (VARV), was eradicated in 1980; however, VARV bioterrorist threats still exist, necessitating readily available therapeutics. Current preparedness activities recognize the importance of oral antivirals and recommend therapeutics with different mechanisms of action. Monkeypox virus (MPXV) is closely related to VARV, causing a highly similar clinical human disease, and can be used as a surrogate for smallpox antiviral testing. The prairie dog MPXV model has been characterized and used to study the efficacy of antipoxvirus therapeutics, including recently approved TPOXX (tecovirimat). Brincidofovir (BCV; CMX001) has shown antiviral activity against double-stranded DNA viruses, including poxviruses. To determine the exposure of BCV following oral administration to prairie dogs, a pharmacokinetics (PK) study was performed. Analysis of BCV plasma concentrations indicated variability, conceivably due to the outbred nature of the animals. To determine BCV efficacy in the MPXV prairie dog model, groups of animals were intranasally challenged with 9 × 10(5) plaque-forming units (PFU; 90% lethal dose [LD(90)]) of MPXV on inoculation day 0 (ID0). Animals were divided into groups based on the first day of BCV treatment relative to inoculation day (ID-1, ID0, or ID1). A trend in efficacy was noted dependent upon treatment initiation (57% on ID-1, 43% on ID0, and 29% on ID1) but was lower than demonstrated in other animal models. Analysis of the PK data indicated that BCV plasma exposure (maximum concentration [C (max)]) and the time of the last quantifiable concentration (AUC(last)) were lower than in other animal models administered the same doses, indicating that suboptimal BCV exposure may explain the lower protective effect on survival.IMPORTANCE Preparedness activities against highly transmissible viruses with high mortality rates have been highlighted during the ongoing coronavirus disease 2019 (COVID-19) pandemic. Smallpox, caused by variola virus (VARV) infection, is highly transmissible, with an estimated 30% mortality. Through an intensive vaccination campaign, smallpox was declared eradicated in 1980, and routine smallpox vaccination of individuals ceased. Today's current population has little/no immunity against VARV. If smallpox were to reemerge, the worldwide results would be devastating. Recent FDA approval of one smallpox antiviral (tecovirimat) was a successful step in biothreat preparedness; however, orthopoxviruses can become resistant to treatment, suggesting the need for multiple therapeutics. Our paper details the efficacy of the investigational smallpox drug brincidofovir in a monkeypox virus (MPXV) animal model. Since brincidofovir has not been tested in vivo against smallpox, studies with the related virus MPXV are critical in understanding whether it would be protective in the event of a smallpox outbreak.

      4. Streptococcus pseudopneumoniae: Use of whole-genome sequences to validate species identification methodsexternal icon
        Jensen CS, Iversen KH, Dargis R, Shewmaker P, Rasmussen S, Christensen JJ, Nielsen XC.
        J Clin Microbiol. 2021 Jan 21;59(2).
        A correct identification of Streptococcus pseudopneumoniae is a prerequisite for investigating the clinical impact of the bacterium. The identification has traditionally relied on phenotypic methods. However, these phenotypic traits have been shown to be unreliable, with some S. pseudopneumoniae strains giving conflicting results. Therefore, sequence-based identification methods have increasingly been used for identification of S. pseudopneumoniae In this study, we used 64 S. pseudopneumoniae strains, 59 S. pneumoniae strains, 22 S. mitis strains, 24 S. oralis strains, 6 S. infantis strains, and 1 S. peroris strain to test the capability of three single genes (rpoB, gyrB, and recA), two multilocus sequence analysis (MLSA) schemes, the single nucleotide polymorphism (SNP)-based phylogeny tool CSI phylogeny, a k-mer-based identification method (KmerFinder), average nucleotide identity (ANI) using fastANI, and core genome analysis to identify S. pseudopneumoniae Core genome analysis and CSI phylogeny were able to cluster all strains into distinct clusters related to their respective species. It was not possible to identify all S. pseudopneumoniae strains correctly using only one of the single genes. The MLSA schemes were unable to identify some of the S. pseudopneumoniae strains, which could be misidentified. KmerFinder identified all S. pseudopneumoniae strains but misidentified one S. mitis strain as S. pseudopneumoniae, and fastANI differentiated between S. pseudopneumoniae and S. pneumoniae using an ANI cutoff of 96%.

      5. It is imperative to understand the behavior of enveloped viruses during water treatment to better protect public health, especially in the light of evidence of detection of coronaviruses in wastewater. We report bench-scale experiments evaluating the extent and mechanisms of removal and/or inactivation of a coronavirus surrogate (ϕ6 bacteriophage) in water by conventional FeCl(3) coagulation and Fe(0) electrocoagulation. Both coagulation methods achieved ∼5-log removal/inactivation of ϕ6 in 20 min. Enhanced removal was attributed to the high hydrophobicity of ϕ6 imparted by its characteristic phospholipid envelope. ϕ6 adhesion to freshly precipitated iron (hydr)oxide also led to envelope damage causing inactivation in both coagulation techniques. Fourier transform infrared spectroscopy revealed oxidative damages to ϕ6 lipids only for electrocoagulation consistent with electro-Fenton reactions. Monitoring ϕ6 dsRNA by a novel reverse transcription quantitative polymerase chain reaction (RT-qPCR) method quantified significantly lower viral removal/inactivation in water compared with the plaque assay demonstrating that relying solely on RT-qPCR assays may overstate human health risks arising from viruses. Transmission electron microscopy and computationally generated electron density maps of ϕ6 showed severe morphological damages to virus' envelope and loss of capsid volume accompanying coagulation. Both conventional and electro- coagulation appear to be highly effective in controlling enveloped viruses during surface water treatment.

      6. Laboratory evaluation of two point-of-care detection systems for early and accurate detection of influenza viruses in the Lao People's Democratic Republicexternal icon
        Kittikraisak W, Khamphaphongphane B, Xayadeth S, Som Oulay V, Khanthamaly V, Sengvilaipaseuth O, Davis CT, Yang G, Zanders N, Mott JA, Xangsayarath P.
        Int J Infect Dis. 2020 Dec 24;104:214-221.
        BACKGROUND: We evaluated molecular-based point-of-care influenza virus detection systems in a laboratory prior to a field evaluation of on-site specimen testing. METHODS: The performance characteristics of 1) insulated isothermal polymerase chain reaction (PCR) on a POCKIT™ device and 2) real-time reverse transcription-PCR (rRT-PCR) on a MyGo Mini™ device were evaluated using human clinical specimens, beta-propiolactone-inactivated influenza viruses, and RNA controls. The rRT-PCR carried out on a CXF-96™ real-time detection system was used as a gold standard for comparison. RESULTS: Both systems demonstrated 100% sensitivity and specificity and test results were in 100% agreement with the gold standard. POCKIT™ only correctly identified influenza A (M gene) in clinical specimens due to the unavailability of typing and subtyping reagents for human influenza viruses, while MyGo Mini™ had either a one log higher or the same sensitivity in detecting influenza viruses in clinical specimens compared to the gold standard. For inactivated viruses and/or viral RNA, the analytic sensitivity of POCKIT™ was shown to be comparable to, or more sensitive, than the gold standard. The analytic sensitivity of MyGo Mini™ had mixed results depending on the types and subtypes of influenza viruses. CONCLUSIONS: The performance of the two systems in a laboratory is promising and supports further evaluation in field settings.

      7. BACKGROUND: Diagnosis of invasive fungal infections from formalin-fixed paraffin-embedded (FFPE) tissues by PCR amplification is a developing technology. One of the difficulties of establishing a validated protocol for this testing is that the gold standard, culture, is much less sensitive than the test being validated. OBJECTIVES: To validate FFPE PCR as a refence laboratory identification methodology in the absence of abundant gold standard specimens. METHODS: In this validation, PCR from FFPE tissue was compared to other diagnostic methods for genus/species identification. Four different groups of correlative data from FFPE tissues were used to validate this procedure. Thirteen specimens had culture or serology results and FFPE PCR results, 49 specimens had both immunohistochemistry (IHC) identification and FFPE PCR results, 118 specimens had histological evidence of fungal elements, 64 of which also had FFPE PCR results, and 36 fungal mock tissues or fungal negative tissues were used. RESULTS: The sensitivity determined from the tissues with positive fungal histopathology was 54%. The specificity of the cases for which there were both culture and FFPE PCR results was 100%. For the correlation with IHC, the specificity was 98%. For the mock tissues and fungal-negative tissues the calculated analytical sensitivity was 94%, specificity was 95% and accuracy was 94%. CONCLUSIONS: By uniquely combining various data sources this study provides a comprehensive framework for how validation can be achieved in the absence of a gold standard and outlines the excellent performance of PCR from FFPE tissue, despite relatively the low sensitivity when compared to histopathology.

      8. Japanese quail (Coturnix japonica) as a novel model to study the relationship between the avian microbiome and microbial endocrinology-based host-microbe interactionsexternal icon
        Lyte JM, Keane J, Eckenberger J, Anthony N, Shrestha S, Marasini D, Daniels KM, Caputi V, Donoghue AM, Lyte M.
        Microbiome. 2021 Feb 2;9(1):38.
        BACKGROUND: Microbial endocrinology, which is the study of neuroendocrine-based interkingdom signaling, provides a causal mechanistic framework for understanding the bi-directional crosstalk between the host and microbiome, especially as regards the effect of stress on health and disease. The importance of the cecal microbiome in avian health is well-recognized, yet little is understood regarding the mechanisms underpinning the avian host-microbiome relationship. Neuroendocrine plasticity of avian tissues that are focal points of host-microbiome interaction, such as the gut and lung, has likewise received limited attention. Avian in vivo models that enable the study of the neuroendocrine dynamic between host and microbiome are needed. As such, we utilized Japanese quail (Coturnix japonica) that diverge in corticosterone response to stress to examine the relationship between stress-related neurochemical concentrations at sites of host-microbe interaction, such as the gut, and the cecal microbiome. RESULTS: Our results demonstrate that birds which contrast in corticosterone response to stress show profound separation in cecal microbial community structure as well as exhibit differences in tissue neurochemical concentrations and structural morphologies of the gut. Changes in neurochemicals known to be affected by the microbiome were also identified in tissues outside of the gut, suggesting a potential relationship in birds between the cecal microbiome and overall avian physiology. CONCLUSIONS: The present study provides the first evidence that the structure of the avian cecal microbial community is shaped by selection pressure on the bird for neuroendocrine response to stress. Identification of unique region-dependent neurochemical changes in the intestinal tract following stress highlights environmental stressors as potential drivers of microbial endocrinology-based mechanisms of avian host-microbiome dialogue. Together, these results demonstrate that tissue neurochemical concentrations in the avian gut may be related to the cecal microbiome and reveal the Japanese quail as a novel avian model in which to further examine the mechanisms underpinning these relationships. Video abstract.

      9. Development of a clinical assay to measure chlorinated tyrosine in hair and tissue samples using a mouse chlorine inhalation exposure modelexternal icon
        Pantazides BG, Crow BS, Quiñones-González J, Perez JW, Harvilchuck JA, Wallery JJ, Hu TC, Thomas JD, Johnson RC, Blake TA.
        Anal Bioanal Chem. 2021 Jan 28.
        Chlorine is a toxic industrial chemical with a history of use as a chemical weapon. Chlorine is also produced, stored, and transported in bulk making it a high-priority pulmonary threat in the USA. Due to the high reactivity of chlorine, few biomarkers exist to identify exposure in clinical and environmental samples. Our laboratory evaluates acute chlorine exposure in clinical samples by measuring 3-chlorotyrosine (Cl-Tyr) and 3,5-dichlorotyrosine (Cl(2)-Tyr) using liquid chromatography tandem mass spectrometry (LC-MS/MS). Individuals can have elevated biomarker levels due to their environment and chronic health conditions, but levels are significantly lower in individuals exposed to chlorine. Historically these biomarkers have been evaluated in serum, plasma, blood, and bronchoalveolar lavage (BAL) fluid. We report the expansion into hair and lung tissue samples using our newly developed tissue homogenization protocol which fits seamlessly with our current chlorinated tyrosine quantitative assay. Furthermore, we have updated the chlorinated tyrosine assay to improve throughput and ruggedness and reduce sample volume requirements. The improved assay was used to measure chlorinated tyrosine levels in 198 mice exposed to either chlorine gas or air. From this animal study, we compared Cl-Tyr and Cl(2)-Tyr levels among three matrices (i.e., lung, hair, and blood) and found that hair had the most abundant chlorine exposure biomarkers. Furthermore, we captured the first timeline of each analyte in the lung, hair, and blood samples. In mice exposed to chlorine gas, both Cl-Tyr and Cl(2)-Tyr were present in blood and lung samples up to 24 h and up to 30 days in hair samples.

      10. Nuclear industry advancements and growing concerns about environmental contamination and terrorist activity have increased interest in quantifying radioisotopes in environmental and human samples. Increased presence in the environment, ease of entry into the food chain, nuclear medicine applications, and the possibility of radiological terrorism incidents can lead to human intake of these radionuclides (Radionuclides/Radiation Protection/US EPA (2020).; Radiation from the Earth (Terrestrial Radiation) (2015) Radiation and Your Health, Centers for Disease Control and Prevention. 7 December. A universal method to screen for and quantify individual radionuclides as well as both levels of alpha and beta emitters would address these concerns.

      11. NanoString technology for human papillomavirus typingexternal icon
        Rajeevan MS, Patel S, Li T, Unger ER.
        Viruses. 2021 Jan 27;13(2).
        High-throughput HPV typing assays with increased automation, faster turnaround and type-specific digital readout would facilitate studies monitoring the impact of HPV vaccination. We evaluated the NanoString nCounter(®) platform for detection and digital readout of 48 HPV types in a single reaction. NanoString (NS) used proprietary software to design CodeSets: type-specific probe pairs targeting 48 HPV types and the globin gene. We tested residual DNA extracts from epidemiologic specimens and defined samples (HPV plasmids at 10 to 10(4) copies/reaction) directly (No-PCR) as well as after L1 consensus PCR of 45 (PCR-45) or 15 cycles (PCR-15). Assay and interpretation followed NS recommendations. We evaluated analytic performance by comparing NanoString results for types included in prior assays: Roche Linear Array (LA) or HPV TypeSeq assay. No-PCR results on 40 samples showed good type-specific agreement with LA (k = 0.621) but sensitivity was 65% with lower limit of detection (LOD) at 10(4) plasmid copies. PCR-45 results showed almost perfect type-specific agreement with LA (k = 0.862), 82% sensitivity and LOD at 10 copies. PCR-15 results on 75 samples showed substantial type-specific agreement with LA (k = 0.796, 92% sensitivity) and TypeSeq (k = 0.777, 87% sensitivity), and LOD at 10 copies of plasmids. This proof-of-principle study demonstrates the efficacy of the NS platform with HPV CodeSet for type-specific detection using a low number of PCR cycles (PCR-15). Studies are in progress to evaluate assay reproducibility and analytic validation with a larger number of samples.

      12. Organophosphorus pesticides are the most used pesticides in the United States. Most organophosphorus pesticides are composed of a phosphate (or phosphorothioate or phosphorodithioate) moiety and a variable organic group. Organophosphorus pesticides are scrutinized by regulatory bodies and agencies because of their toxicity or suspected carcinogenicity. Upon exposure, organophosphorus pesticides and their metabolites eliminate in urine; these urinary biomarkers are useful to evaluate human exposure. We developed a method using stable isotope dilution, ion chromatography tandem mass spectrometry for quantification in urine of 6 O,O-dialkylphosphates, metabolites of organophosphorus insecticides, and glyphosate, the most used herbicide in the United States. With simple and minimal sample preparation, the analytical method is selective and sensitive (limits of detection are 0.2-0.8 μg/L), accurate (>85%) and precise (relative standard deviation <20%), depending on the analyte. To assess the suitability of the method in real exposure scenarios, we analyzed samples collected anonymously from subjects with suspected exposure to pesticides (n = 40) or who had been on an organic diet (n = 50). We detected glyphosate in 80% of subjects reporting an organic diet and in 78% of those with suspected glyphosate exposure; concentrations ranged from <0.2 to 28.6 μg/L. Median concentrations were 0.39 μg/L for the organic diet group and 0.40 μg/L for individuals with suspected exposure. Interestingly, interquartile ranges were considerably higher among those reporting pesticide exposure (0.63 μg/L) than those consuming organic diets (0.42 μg/L). These data suggest that the method meets typical validation benchmark values and is sensitive to investigate background exposures in the general population.

    • Medicine
      1. Assessment of performance of blood banks in India: A national level cross sectional studyexternal icon
        Asirvatham ES, Mammen JJ, Lakshman J, Sarman CJ, Charles B, Upadhyaya S, Rajan S.
        Indian J Hematol Blood Transfus. 2021 .
        India lacks comprehensive information about blood transfusion systems, which could help ensure universal access to safe blood through evidence-based strategies and programs. We conducted the first national assessment of blood bank systems, services, practices, and performance in India. We conducted a cross-sectional survey of all 2626 blood banks and assessed the administrative, technical, and quality aspects in 2016. In addition to descriptive analysis, we compared the means of different variables using independent t-test or ANOVA and a generalized linear model. We performed linear regression analysis between the collection of blood per 100 people and the number of blood banks per million people. The disaggregated mean score of quality management system and overall performance are presented by different groups. Besides, we graded the performance based on tertile classification, as low, medium and high-performance blood banks. Of the 2493 blood banks that participated in the study, most were public (38%) or not-for-profit(38%), and 51% had component separation facilities. Of the 11.65 million units of blood collected annually, 72% was through voluntary blood donation. There were 2.2 blood banks per one million people, collecting around one unit per 100 persons annually with wide variation between states. The mean overall performance score was 62(95% confidence interval [CI]:61.6–62.5), and the mean quality management system score was 57.4(95% CI:56.8–58.0), with significant variation across different categories of blood banks. This assessment provides critical information for developing evidence-based policies, programs, and monitoring systems to improve the performance of blood transfusion services in India.

    • Nutritional Sciences
      1. Analytical performance specifications for 25-hydroxyvitamin D examinationsexternal icon
        Cavalier E, Fraser CG, Bhattoa HP, Heijboer AC, Makris K, Ulmer CZ, Vesper HW, Vasikaran S, Lukas P, Delanaye P, Carobene A.
        Nutrients. 2021 Jan 28;13(2).
        Currently the 25-hydroxy vitamin D (25(OH)D) concentration is thought to be the best estimate of the vitamin D status of an individual. Unfortunately, its measurement remains complex, despite recent technological advances. We evaluated the biological variation (BV) of 25(OH)D in order to set analytical performance specifications (APS) for measurement uncertainty (MU). Six European laboratories recruited 91 healthy participants. The 25(OH)D concentrations in K(3)-EDTA plasma were examined weekly for up to 10 weeks in duplicate on a Lumipulse G1200 (Fujirebio, Tokyo, Japan). The linear regression of the mean 25(OH)D concentrations at each blood collection showed that participants were not in a steady state. The dissection of the 10-sample collection into two subsets, namely collections 1-5 and 6-10, did not allow for correction of the lack of homogeneity: estimates of the within-subject BV ranged from 5.8% to 7.1% and the between-subject BV ranged from 25.0% to 39.2%. Methods that would differentiate a difference induced by 25(OH)D supplementation at p < 0.05 should have MU < 13.6%, while at p < 0.01, the MU should be <9.6%. The development of APS using BV assumes a steady state of patients. The findings in this study suggest that patients are not in steady state. Therefore, APS that are based on MU appear to be more appropriate.

      2. BACKGROUND: One newly proposed approach to determining eligibility of children aged 6-59 months for therapeutic feeding programs (TFPs) is to use mid-upper arm circumference (MUAC) < 115 mm, bilateral oedema or Weight-for-Age Z-score (WAZ) < - 3 as admission criteria (MUAC+SWAZ). We explored potential consequences of this approach on the eligibility for treatment, as compared with the existing WHO normative guidance. We also compared sensitivity and specificity parameters of this approach for detecting wasted children to the previously described "Expanded MUAC" approach. METHODS: We analyzed data from 558 population representative cross-sectional cluster surveys conducted since 2007. We retrieved all children classified as severe acute malnutrition (SAM), moderate acute malnutrition (MAM), and those who are both wasted and stunted (WA + ST), and calculated proportions of previously eligible children who would now be excluded from treatment, as well as proportions of non-malnourished children among those who would become eligible. We also analyzed the expected changes in the number and demographics (sex, age) of the selected populations of children according to the different admission approaches. RESULTS: Both MUAC+SWAZ and Expanded MUAC case detection approaches substantially increase the sensitivity in detecting SAM, as compared to an approach which restricts detection of SAM cases to MUAC< 115 mm and oedema. Improved sensitivity however is attained at the expense of specificity and would require a very large increase of the size of TFPs, while still missing a non-negligible proportion (20-25%) of the SAM caseload. While our results confirm the sensitivity of the MUAC+SWAZ case detection approach in detecting WA + ST (over 80%), they show, on the other hand, that about half of the additional target detected by using SWAZ criterion will be neither SAM nor WA + ST. CONCLUSIONS: These results suggest that recently promoted approaches to case detection inflate TFPs' targets through the allocation of treatment to large numbers of children who have not been shown to require this type of support, including a significant proportion of non-acutely malnourished children in the MUAC+SWAZ approach. Considering the scarcity of resources for the implementation of TFPs, the rationale of abandoning the use of WHZ and of these alternative case detection strategies need to be critically reviewed.

      3. Association of usual sodium intake with obesity among US children and adolescents, NHANES 2009-2016external icon
        Zhao L, Ogden CL, Yang Q, Jackson SL, Loria CM, Galuska DA, Wiltz JL, Merritt R, Cogswell ME.
        Obesity (Silver Spring). 2021 Feb 2.
        OBJECTIVE: The purpose of this study was to investigate the association of sodium intake with obesity in US children and adolescents. METHODS: Cross-sectional data were analyzed for 9,026 children and adolescents in the National Health and Nutrition Examination Survey (NHANES) 2009-2016. Usual sodium intake was estimated from 24-hour dietary recalls using a measurement error model. Logistic regression was used to assess the association of sodium intake with overweight/obesity, obesity, and central obesity (waist to height ratio [WtHR] ≥ 0.5; waist circumferences (WC) ≥ age- and sex-specific 90th percentile). RESULTS: Mean (SE) sodium intake was 3,010  (9) and 3,404  (20) mg/d for children and adolescents, respectively. The adjusted odds ratio (AOR) comparing Q4 versus Q1 (87.5th vs. 12.5th percentile of sodium intake) among children was 1.98 (95% CI: 1.19-3.28) for overweight/obesity, 2.20 (1.30-3.73) for obesity, 2.10 (1.12-3.95) for WC ≥ 90th percentile, and 1.68 (0.95-2.97) for WtHR ≥ 0.5, adjusting for demographics, energy, and sugar-sweetened beverage intake. Among adolescents, AOR was 1.81 (0.98-3.37) for overweight/obesity, 1.71 (0.82-3.56) for obesity, 1.62 (0.71-3.66) for WC ≥ 90th percentile, and 1.73 (0.85-3.50) for WtHR ≥ 0.5. CONCLUSIONS: Sodium intake was positively associated with overweight/obesity, obesity, and central obesity among US children independent of energy and SSB intake, but the association did not reach significance among adolescents.

    • Occupational Safety and Health
      1. Saw safety: risk in the real worldexternal icon
        Current RS, Main BW, Main M.
        Prof Saf. 2020 Nov;65(11):24-32.
        KEY TAKEAWAYS: Injuries related to the use of stationary saws constitute a significant portion of workplace injuries. This article reports the results of a field study on stationary saw use. It discusses current industry and OSHA safety standards for stationary saws; assessment of risks associated with the use of stationary saws at 15 sites; and lessons learned from the comparison of the theory and practice of using stationary saws. The results of the study show that many risk reduction measures are not used in practice, and that some operators believe that the risk of using a guard is higher than not using a guard. The article discusses the implications of these findings to operators and employers.

      2. Risk of cancer associated with low-dose radiation exposure: comparison of results between the INWORKS nuclear workers study and the A-bomb survivors studyexternal icon
        Leuraud K, Richardson DB, Cardis E, Daniels RD, Gillies M, Haylock R, Moissonnier M, Schubauer-Berigan MK, Thierry-Chef I, Kesminiene A, Laurier D.
        Radiat Environ Biophys. 2021 Jan 21.
        The Life Span Study (LSS) of Japanese atomic bomb survivors has served as the primary basis for estimates of radiation-related disease risks that inform radiation protection standards. The long-term follow-up of radiation-monitored nuclear workers provides estimates of radiation-cancer associations that complement findings from the LSS. Here, a comparison of radiation-cancer mortality risk estimates derived from the LSS and INWORKS, a large international nuclear worker study, is presented. Restrictions were made, so that the two study populations were similar with respect to ages and periods of exposure, leading to selection of 45,625 A-bomb survivors and 259,350 nuclear workers. For solid cancer, excess relative rates (ERR) per gray (Gy) were 0.28 (90% CI 0.18; 0.38) in the LSS, and 0.29 (90% CI 0.07; 0.53) in INWORKS. A joint analysis of the data allowed for a formal assessment of heterogeneity of the ERR per Gy across the two studies (P = 0.909), with minimal evidence of curvature or of a modifying effect of attained age, age at exposure, or sex in either study. There was evidence in both cohorts of modification of the excess absolute risk (EAR) of solid cancer by attained age, with a trend of increasing EAR per Gy with attained age. For leukemia, under a simple linear model, the ERR per Gy was 2.75 (90% CI 1.73; 4.21) in the LSS and 3.15 (90% CI 1.12; 5.72) in INWORKS, with evidence of curvature in the association across the range of dose observed in the LSS but not in INWORKS; the EAR per Gy was 3.54 (90% CI 2.30; 5.05) in the LSS and 2.03 (90% CI 0.36; 4.07) in INWORKS. These findings from different study populations may help understanding of radiation risks, with INWORKS contributing information derived from cohorts of workers with protracted low dose-rate exposures.

      3. New technique to evaluate decontamination methods for filtering facepiece respiratorsexternal icon
        Vo E, Appavoo SR, Xu S, Horvatin M, Zhuang Z.
        Am J Infect Control. 2021 Jan 29.
        BACKGROUND: A major concern among health care experts is a shortage of N95 filtering facepiece respirators (FFRs) during a pandemic. One option for mitigating an FFR shortage is to decontaminate and reuse the devices. The focus of this study was to develop a new evaluation technique based on three major decontamination requirements: 1) inactivating viruses, 2) not altering the respirator properties, and 3) not leaving any toxic byproduct on the FFR. METHODS: Hydrophilic and hydrophobic FFRs were contaminated with MS2 virus. In the solution-based deposition, the virus-containing liquid droplets were spiked directly onto FFRs, while in the vapor-based and aerosol-based depositions, the viral particles were loaded onto FFRs using a bio-aerosol testing system. Ultraviolet germicidal irradiation (UVGI) and moist heat (MH) decontamination methods were used for inactivation of viruses applied to FFRs. RESULTS: Both UVGI and MH methods inactivated viruses (> 5-log reduction of MS2 virus; in 92% of both method experiments, the virus was reduced to levels below the detection limit), did not alter the respirator properties, and did not leave any toxic byproduct on the FFRs. CONCLUSIONS: Both UVGI and MH methods could be considered as promising decontamination candidates for inactivation of viruses for respirator reuse during shortages.

    • Parasitic Diseases
      1. Combined epidemiologic and entomologic survey to detect urban malaria transmission, Guinea, 2018external icon
        Sayre D, Camara A, Barry Y, Deen TB, Camara D, Dioubaté M, Camara I, Keita K, Diakité N, Lo Y, Bah I, Camara HF, Condé MS, Fofana A, Sarr A, Lama E, Irish S, Plucinski M.
        Emerg Infect Dis. 2021 Feb;27(2):599-602.
        Malaria incidence is generally lower in cities than rural areas. However, reported urban malaria incidence may not accurately reflect the level of ongoing transmission, which has potentially large implications for prevention efforts. To guide mosquito net distribution, we assessed the extent of malaria transmission in Conakry, Guinea, in 2018. We found evidence of active malaria transmission.

    • Reproductive Health
      1. Assessment of incidence and factors associated with severe maternal morbidity after delivery discharge among women in the USexternal icon
        Chen J, Cox S, Kuklina EV, Ferre C, Barfield W, Li R.
        JAMA Netw Open. 2021 Feb 1;4(2):e2036148.
        IMPORTANCE: Previous efforts to examine severe maternal morbidity (SMM) in the US have focused on delivery hospitalizations. Little is known about de novo SMM that occurs after delivery discharge. OBJECTIVE: To investigate the incidence, timing, factors, and maternal characteristics associated with de novo SMM after delivery discharge among women in the US. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort study, data from the IBM MarketScan Multi-State Medicaid database and the IBM MarketScan Commercial Claims and Encounters database were used to construct a sample of women aged 15 to 44 years who delivered between January 1, 2010, and September 30, 2014. Severe maternal morbidity was reported by the timing of diagnosis, and the associated maternal characteristics were examined. Women in the Medicaid and commercial insurance sample were classified into 3 distinct outcome groups: (1) those without any SMM during the delivery hospitalization and the postdelivery period (reference group), (2) those who exhibited at least 1 factor associated with SMM during the delivery hospitalization, and (3) those who exhibited any factor associated with de novo SMM after delivery discharge (defined as SMM that was first diagnosed in the inpatient setting during the 6 weeks [or 42 days] after discharge from the delivery hospitalization, conditional on no factor associated with SMM being identified during delivery). Data were analyzed from February to July 2020. EXPOSURES: Timing of SMM diagnosis. MAIN OUTCOMES AND MEASURES: Women with SMM were identified using diagnosis and procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification for the 21 factors associated with SMM that were developed by the Centers for Disease Control and Prevention. RESULTS: A total of 2 667 325 women in the US with delivery hospitalizations between 2010 and 2014 were identified; of those, 809 377 women (30.3%) had Medicaid insurance (30.3%; mean [SD] age, 25.6 [5.5] years; 51.1% White), and 1 857 948 women (69.7%; mean [SD] age, 30.6 [5.4] years; 36.4% from the southern region of the US) had commercial insurance. Among those with Medicaid insurance, 17 584 women (2.2%) experienced SMM during the delivery hospitalization, and 3265 women (0.4%) experienced de novo SMM after delivery discharge. Among those with commercial insurance, 32 079 women (1.7%) experienced SMM during the delivery hospitalization, and 5275 women (0.3%) experienced de novo SMM after hospital discharge. A total of 5275 SMM cases (14.1%) and 3265 SMM cases (15.7%) among women with commercial and Medicaid insurance, respectively, developed de novo within 6 weeks after hospital discharge; of those, 3993 cases (75.7%) in the commercial insurance cohort and 2399 cases (73.5%) in the Medicaid cohort were identified in the first 2 weeks after discharge. The most common factors associated with SMM varied based on the timing of diagnosis. In the Medicaid population, non-Hispanic Black women (adjusted odds ratio [aOR], 1.53; 95% CI, 1.48-1.58), Hispanic women (aOR, 1.46; 95% CI, 1.37-1.57), and women of other races or ethnicities (aOR, 1.40; 95% CI, 1.33-1.47) had higher rates of SMM during delivery hospitalization than non-Hispanic White women; however, only the disparity between Black and White women (aOR, 1.69; 95% CI, 1.57-1.81) persisted into the postdischarge period. CONCLUSIONS AND RELEVANCE: In this study, 14.1% of SMM cases in the Medicaid cohort and 15.7% of SMM cases in the commercial insurance cohort first occurred after the delivery hospitalization, with notable disparities in factors and maternal characteristics associated with the development of SMM. These findings suggest a need to expand the focus of SMM assessment to the postdelivery discharge period.

    • Substance Use and Abuse
      1. Acrolein and other toxicant exposures in relation to cardiovascular disease among marijuana and tobacco smokers in a longitudinal cohort of HIV-positive and negative adultsexternal icon
        Lorenz DR, Misra V, Chettimada S, Uno H, Wang L, Blount BC, De Jesús VR, Gelman BB, Morgello S, Wolinsky SM, Gabuzda D.
        EClinicalMedicine. 2021 ;31.
        Background: Marijuana smoke contains some of the same toxicants present in tobacco smoke. Marijuana smoking is prevalent among HIV+ individuals, but few studies have characterized smoke-related toxicants or associated health outcomes in exclusive marijuana users. Methods: This longitudinal study included 245 participants over age 40 (76% HIV+). 33 plasma and 28 urine metabolites of nicotine, ∆-9-trans-tetrahydrocannabinol, polycyclic aromatic hydrocarbons, and volatile organic compounds were assayed by liquid or gas chromatography/mass spectrometry. Exposures and health outcomes were assessed from surveys and medical records. Findings: At baseline, 18% of participants were marijuana-only smokers, 20% tobacco-only smokers, and 24% dual marijuana-tobacco smokers (median (IQR) age 53 (47–60) years, 78% male, 54% white race). Marijuana smoking was independently associated with elevated plasma naphthalenes, 2-hydroxyfluorene sulfate, 4-vinylphenol sulfate, and o-cresol sulfate (p<0·05) and urine acrylonitrile and acrylamide metabolites (p<0·05), but levels were lower than those associated with tobacco smoking. Acrolein metabolite N-Acetyl-S-(3-hydroxypropyl)-L-cysteine (3HPMA) was significantly elevated in plasma and urine in tobacco-only and dual but not marijuana-only smokers, and correlated with nicotine metabolites (p<0·05). The highest tertile of 3HPMA was associated with increased cardiovascular disease diagnoses independent of tobacco smoking, traditional risk factors, and HIV status (odds ratio [95% CI] 3·34 [1·31–8·57]; p = 0·012). Interpretation: Smoke-related toxicants, including acrylonitrile and acrylamide metabolites, are detectable in exclusive marijuana smokers, but exposures are lower compared with tobacco or dual smokers. Acrolein exposure is increased by tobacco smoking but not exclusive marijuana smoking in HIV+ and HIV- adults, and contributes to cardiovascular disease in tobacco smokers. Funding: U.S. NIH.

      2. Volatile organic compounds in mainstream smoke of sixty domestic little cigar productsexternal icon
        Vu AT, Hassink MD, Taylor KM, McGuigan M, Blasiole A, Valentin-Blasini L, Williams K, Watson CH.
        Chem Res Toxicol. 2021 Jan 29.
        The mainstream smoke yields of five volatile organic compounds (VOCs) were determined from 60 commercial U.S. little cigar products under ISO 3308 and Canadian Intense (CI) smoking regimens on linear smoking machines using a gas sampling bag collection. The five VOCs, 1,3-butadiene, acrylonitrile, benzene, isoprene, and toluene were analyzed using an automated GC/MS analytical method validated for measuring various VOCs in mainstream smoke. The VOCs range in amounts from micrograms to milligrams per little cigar. VOC deliveries vary considerably among the little cigar products under the ISO smoking regimen primarily due to varying filter ventilation. Under the CI smoking regimen where filter ventilation is blocked, the delivery range narrows, although individual and total VOC yields are approximately 2 fold higher than those under the ISO smoking regimen. Correlation analysis reveals strong associations between acrylonitrile and 1,3-butadiene or toluene under the ISO smoking regimen. Compared to cigarettes, little cigars delivered substantially higher VOC mainstream smoke yields under both ISO and CI smoking regimens. Moreover, little cigar smoke also contains higher VOCs than cigarette smoke when adjusted for mass of tobacco.

      3. Receipt of cessation treatments among Medicaid enrollees trying to quit smokingexternal icon
        Wang X, Babb S, Xu X, Ku L, Glover-Kudon R, Armour BS.
        Nicotine Tob Res. 2021 Feb 2.
        INTRODUCTION: Cigarette smoking prevalence is higher among adults enrolled in Medicaid than adults with private health insurance. State Medicaid coverage of cessation treatments has been gradually improving in recent years; however, the extent to which this has translated into increased use of these treatments by Medicaid enrollees remains unknown. AIMS AND METHODS: Using Medicaid Analytic eXtract (MAX) files, we estimated state-level receipt of smoking cessation treatments and associated spending among Medicaid fee-for service (FFS) enrollees who try to quit. MAX data are the only national person-level data set available for the Medicaid program. We used the most recent MAX data available for each state and the District of Columbia (ranging from 2010 to 2014) for this analysis. RESULTS: Among the 37 states with data, an average of 9.4% of FFS Medicaid smokers with a past-year quit attempt had claims for cessation medications, ranging from 0.2% (Arkansas) to 32.9% (Minnesota). Among the 20 states with data, an average of 2.7% of FFS Medicaid smokers with a past-year quit attempt received cessation counseling, ranging from 0.1% (Florida) to 5.6% (Missouri). Estimated Medicaid spending for cessation medications and counseling for these states totaled just over $13 million. If all Medicaid smokers who tried to quit were to have claims for cessation medications, projected annual Medicaid expenditures would total $0.8 billion, a small fraction of the amount ($45.9 billion) that Medicaid spends annually on treating smoking-related disease. CONCLUSIONS: The receipt of cessation medications and counseling among FFS Medicaid enrollees was low and varied widely across states. IMPLICATIONS: Few studies have examined use of cessation treatments among Medicaid enrollees. We found that many FFS Medicaid smokers made quit attempts, but few had claims for proven cessation treatments, especially counseling. The receipt of cessation treatments among FFS Medicaid enrollees varied widely across states, suggesting opportunities for additional promotion of the full range of Medicaid cessation benefits. Continued monitoring of Medicaid enrollees' use of cessation treatments could inform state and national efforts to help more Medicaid enrollees quit smoking.

    • Zoonotic and Vectorborne Diseases
      1. Zika virus-associated birth defects, Costa Rica, 2016-2018external icon
        Benavides-Lara A, la Paz Barboza-Arguello M, González-Elizondo M, Hernández-deMezerville M, Brenes-Chacón H, Ramírez-Rojas M, Ramírez-Hernández C, Arjona-Ortegón N, Godfred-Cato S, Valencia D, Moore CA, Soriano-Fallas A.
        Emerg Infect Dis. 2021 Feb;27(2).

      2. Estimating the frequency of Lyme disease diagnoses, United States, 2010-2018external icon
        Kugeler KJ, Schwartz AM, Delorey MJ, Mead PS, Hinckley AF.
        Emerg Infect Dis. 2021 Feb;27(2):616-619.
        By using commercial insurance claims data, we estimated that Lyme disease was diagnosed and treated in ≈476,000 patients in the United States annually during 2010-2018. Our results underscore the need for accurate diagnosis and improved prevention.

      3. High incidence of human brucellosis in a rural pastoralist community in Kenya, 2015external icon
        Munyua P, Osoro E, Hunsperger E, Ngere I, Muturi M, Mwatondo A, Marwanga D, Ngere P, Tiller R, Onyango CO, Njenga K, Widdowson MA.
        PLoS Negl Trop Dis. 2021 Feb 1;15(2):e0009049.
        BACKGROUND: Brucellosis occurs globally with highly variable incidence in humans from very low in North America and Western Europe to high in the Middle East and Asia. There are few data in Sub-Saharan Africa. This study estimated the incidence of human brucellosis in a pastoralist community in Kenya. METHODS: Between February 2015 and January 2016, we enrolled persons living in randomly selected households in Kajiado County. Free health care was offered at three facilities in the study area. Those who met the study clinical case definition completed a standardized questionnaire on demographics, clinical history and presentation. A blood sample was collected and tested by Rose Bengal test (RBT), then later tested at the Kenya Medical Research Institute laboratory for Brucella IgG and IgM by ELISA. Those who tested positive by both RBT and ELISA (IgG or IgM antibodies) were classified as confirmed while those that only tested positive for IgG or IgM antibodies were classified as probable. Further, sera were tested by polymerase chain reaction using a TaqMan Array Card (TAC) for a panel of pathogens causing AFI including Brucella spp. Annual incidence of brucellosis was calculated as the number of confirmed cases in one year/total number in the study population. RESULTS: We enrolled a cohort of 4746 persons in 804 households. Over half (52.3%) were males and the median age was 18 years (Interquartile range (IQR) 9 months- 32 years). A total of 236 patients were enrolled at three health facilities; 64% were females and the median age was 40.5 years (IQR 28-53 years). Thirty-nine (16.5%) were positive for Brucella antibodies by IgG ELISA, 5/236 (2.1%) by IgM ELISA and 4/236 (1.7%) by RBT. Ten percent 22/217 were positive by TAC. We confirmed four (1.7%) brucellosis cases giving an annual incidence of 84/100,000 persons/year (95% CI 82, 87). The incidence did not significantly vary by gender, age and location of residence. CONCLUSION: We report a high incidence of brucellosis in humans among members of this pastoralist community. Brucellosis was the most common cause febrile illness in this community.

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DISCLAIMER: Articles listed in the CDC Science Clips are selected by the Stephen B. Thacker CDC Library to provide current awareness of the public health literature. An article's inclusion does not necessarily represent the views of the Centers for Disease Control and Prevention nor does it imply endorsement of the article's methods or findings. CDC and DHHS assume no responsibility for the factual accuracy of the items presented. The selection, omission, or content of items does not imply any endorsement or other position taken by CDC or DHHS. Opinion, findings and conclusions expressed by the original authors of items included in the Clips, or persons quoted therein, are strictly their own and are in no way meant to represent the opinion or views of CDC or DHHS. References to publications, news sources, and non-CDC Websites are provided solely for informational purposes and do not imply endorsement by CDC or DHHS.

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