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Issue 10, March 8, 2022

CDC Science Clips: Volume 14, Issue 10, March 8, 2022

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. Physiological assessment of orthostatic intolerance in chronic fatigue syndromeexternal icon
        Natelson BH, Lin JS, Blate M, Khan S, Chen Y, Unger ER.
        J Transl Med. 2022 Feb 16;20(1):95.
        BACKGROUND: Orthostatic intolerance-OI is common in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome-ME/CFS. We used a 10-min passive vertical lean test as orthostatic challenge-OC and measured changes in vitals and end tidal CO(2) (eTCO2). An abnormal physiologic response to OC was identified in 60% of the 63 patients evaluated from one to three times over several years. Hypocapnia, either resting or induced by OC, was the most frequent abnormality, followed by postural orthostatic tachycardia. OBJECTIVE: Evaluate the physiologic response of patients with ME/CFS to a standardized OC. DESIGN: Respiratory and heart rate, blood pressure and eTCO(2) were recorded twice at the end of 10-min supine rest and then every minute during the 10-min lean. Hypocapnia was eTCO(2) ≤ 32 mmHg. Orthostatic tachycardia was heart rate increase ≥ 30 beats per minute compared with resting or ≥ 120 BPM. Orthostatic hypotension was decreased systolic pressure ≥ 20 mmHg from baseline. Tachypnea was respiratory rate of  ≥ 20 breaths per minute-either supine or leaning. Questionnaire data on symptom severity, quality of life and mood were collected at visit #2. PATIENTS: 63 consecutive patients fulfilling the 1994 case definition for CFS underwent lean testing at first visit and then annually at visit 2 (n = 48) and 3 (n = 29). MEASURES: Supine hypocapnia; orthostatic tachycardia, hypocapnia or hypotension. RESULTS: The majority of ME/CFS patients (60.3%, 38/63) had an abnormality detected during a lean test at any visit (51%, 50% and 45% at visits 1, 2 and 3, respectively). Hypocapnia at rest or induced by OC was more common and more likely to persist than postural orthostatic tachycardia. Anxiety scores did not differ between those with and without hypocapnia. CONCLUSIONS: The 10-min lean test is useful in evaluation of OI in patients with ME/CFS. The most frequent abnormality, hypocapnia, would be missed without capnography.

    • Communicable Diseases
      1. Hospitalizations of children and adolescents with laboratory-confirmed COVID-19 - COVID-NET, 14 states, July 2021-January 2022external icon
        Marks KJ, Whitaker M, Anglin O, Milucky J, Patel K, Pham H, Chai SJ, Kirley PD, Armistead I, McLafferty S, Meek J, Yousey-Hindes K, Anderson EJ, Openo KP, Weigel A, Henderson J, Nunez VT, Como-Sabetti K, Lynfield R, Ropp SL, Smelser C, Barney GR, Muse A, Bennett NM, Bushey S, Billing LM, Shiltz E, Abdullah N, Sutton M, Schaffner W, Talbot HK, Chatelain R, George A, Taylor CA, McMorrow ML, Perrine CG, Havers FP.
        MMWR Morb Mortal Wkly Rep. 2022 Feb 18;71(7):271-278.
        The first U.S. case of COVID-19 attributed to the Omicron variant of SARS-CoV-2 (the virus that causes COVID-19) was reported on December 1, 2021 (1), and by the week ending December 25, 2021, Omicron was the predominant circulating variant in the United States.* Although COVID-19-associated hospitalizations are more frequent among adults,(†) COVID-19 can lead to severe outcomes in children and adolescents (2). This report analyzes data from the Coronavirus Disease 19-Associated Hospitalization Surveillance Network (COVID-NET)(§) to describe COVID-19-associated hospitalizations among U.S. children (aged 0-11 years) and adolescents (aged 12-17 years) during periods of Delta (July 1-December 18, 2021) and Omicron (December 19, 2021-January 22, 2022) predominance. During the Delta- and Omicron-predominant periods, rates of weekly COVID-19-associated hospitalizations per 100,000 children and adolescents peaked during the weeks ending September 11, 2021, and January 8, 2022, respectively. The Omicron variant peak (7.1 per 100,000) was four times that of the Delta variant peak (1.8), with the largest increase observed among children aged 0-4 years.(¶) During December 2021, the monthly hospitalization rate among unvaccinated adolescents aged 12-17 years (23.5) was six times that among fully vaccinated adolescents (3.8). Strategies to prevent COVID-19 among children and adolescents, including vaccination of eligible persons, are critical.*.

      2. Investigation of SARS-CoV-2 transmission associated with a large indoor convention - New York City, November-December 2021external icon
        Sami S, Horter L, Valencia D, Thomas I, Pomeroy M, Walker B, Smith-Jeffcoat SE, Tate JE, Kirking HL, Kyaw NT, Burns R, Blaney K, Dorabawila V, Hoen R, Zirnhelt Z, Schardin C, Uehara A, Retchless AC, Brown VR, Gebru Y, Powell C, Bart SM, Vostok J, Lund H, Kaess J, Gumke M, Propper R, Thomas D, Ojo M, Green A, Wieck M, Wilson E, Hollingshead RJ, Nunez SV, Saady DM, Porse CC, Gardner K, Drociuk D, Scott J, Perez T, Collins J, Shaffner J, Pray I, Rust LT, Brady S, Kerins JL, Teran RA, Hughes V, Sepcic V, Low EW, Kemble SK, Berkley A, Cleavinger K, Safi H, Webb LM, Hutton S, Dewart C, Dickerson K, Hawkins E, Zafar J, Krueger A, Bushman D, Ethridge B, Hansen K, Tant J, Reed C, Boutwell C, Hanson J, Gillespie M, Donahue M, Lane P, Serrano R, Hernandez L, Dethloff MA, Lynfield R, Como-Sabetti K, Lutterloh E, Ackelsberg J, Ricaldi JN.
        MMWR Morb Mortal Wkly Rep. 2022 Feb 18;71(7):243-248.
        During November 19-21, 2021, an indoor convention (event) in New York City (NYC), was attended by approximately 53,000 persons from 52 U.S. jurisdictions and 30 foreign countries. In-person registration for the event began on November 18, 2021. The venue was equipped with high efficiency particulate air (HEPA) filtration, and attendees were required to wear a mask indoors and have documented receipt of at least 1 dose of a COVID-19 vaccine.* On December 2, 2021, the Minnesota Department of Health reported the first case of community-acquired COVID-19 in the United States caused by the SARS-CoV-2 B.1.1.529 (Omicron) variant in a person who had attended the event (1). CDC collaborated with state and local health departments to assess event-associated COVID-19 cases and potential exposures among U.S.-based attendees using data from COVID-19 surveillance systems and an anonymous online attendee survey. Among 34,541 attendees with available contact information, surveillance data identified test results for 4,560, including 119 (2.6%) persons from 16 jurisdictions with positive SARS-CoV-2 test results. Most (4,041 [95.2%]), survey respondents reported always wearing a mask while indoors at the event. Compared with test-negative respondents, test-positive respondents were more likely to report attending bars, karaoke, or nightclubs, and eating or drinking indoors near others for at least 15 minutes. Among 4,560 attendees who received testing, evidence of widespread transmission during the event was not identified. Genomic sequencing of 20 specimens identified the SARS-CoV-2 B.1.617.2 (Delta) variant (AY.25 and AY.103 sublineages) in 15 (75%) cases, and the Omicron variant (BA.1 sublineage) in five (25%) cases. These findings reinforce the importance of implementing multiple, simultaneous prevention measures, such as ensuring up-to-date vaccination, mask use, physical distancing, and improved ventilation in limiting SARS-CoV-2 transmission, during large, indoor events.(†).

      3. Multistate outbreak of SARS-CoV-2 B.1.1.529 (Omicron) variant infections among persons in a social network attending a convention - New York City, November 18-December 20, 2021external icon
        Smith-Jeffcoat SE, Pomeroy MA, Sleweon S, Sami S, Ricaldi JN, Gebru Y, Walker B, Brady S, Christenberry M, Bart S, Vostok J, Meyer S, Seys S, Markelz A, Ditto N, Newbern V, Thomas FJ, Thomas D, Cabredo E, Kellner S, Brown VR, Tate JE, Kirking HL.
        MMWR Morb Mortal Wkly Rep. 2022 Feb 18;71(7):238-242.
        On December 2, 2021, the Minnesota Department of Health (MDH) notified CDC of a COVID-19 case caused by sequence-confirmed SARS-CoV-2 B.1.1.529 (Omicron) variant in a Minnesota resident (patient A), the first such case identified in the state and one of the earliest identified in the United States. Patient A had attended a large indoor convention in New York, New York with approximately 53,000 attendees from 52 U.S jurisdictions and 30 foreign countries during November 19-21, 2021, and had close contact(†) during 5 days with 29 fellow attendees. The convention required attendees to have received ≥1 COVID-19 vaccine dose and enforced mask-use while indoors. On November 22, these close contact attendees were directly and immediately notified by patient A of their exposure to SARS-CoV-2, and they sought testing over the next few days while quarantined or isolated. As part of the larger investigation into SARS-CoV-2 transmission at the convention, a subinvestigation was conducted during December by CDC, MDH, and respective state and local health departments to characterize the epidemiology of Omicron variant infection among this group of close contacts and determine the extent of secondary household transmission. Among 30 convention attendees that included patient A (the index patient) and the 29 other close contacts, 23 were interviewed, among whom all were fully vaccinated, including 11 (48%) who had received a booster dose; all 23 sought testing, and 16 (70%) received a positive SARS-CoV-2 test result. Fewer attendees who had received a booster dose before the convention received a positive test result (six of 11) compared with those who had not received a booster dose (10 of 12). The 16 attendees with positive test results had a total of 20 household contacts, 18 of whom sought testing after exposure; six received a positive test result for SARS-CoV-2. None of the persons with positive test results was hospitalized or died. There was limited convention-associated transmission identified outside of this cluster; the larger investigation included cases of both SARS-CoV-2 B.1.617.2 (Delta) and Omicron, and all Omicron cases were associated with this group (1). Data from this investigation reinforces the importance of COVID-19 booster doses in combination with early notification and other multicomponent prevention measures to limit transmission and prevent severe illness from Omicron and other SARS-CoV-2 variants.

      4. Household transmission and clinical features of SARS-COV-2 infectionsexternal icon
        McLean HQ, Grijalva CG, Hanson KE, Zhu Y, Deyoe JE, Meece JK, Halasa NB, Chappell JD, Mellis AM, Reed C, Belongia EA, Talbot HK, Rolfes MA.
        Pediatrics. 2022 Feb 23.
        OBJECTIVES: Examine age differences in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission risk from primary cases and infection risk among household contacts and symptoms among those with SARS-CoV-2 infection. METHODS: People with SARS-CoV-2 infection in Nashville, Tennessee and central and western Wisconsin and their household contacts were followed daily for 14 days to ascertain symptoms and secondary transmission events. Households were enrolled between April 2020 and April 2021. Secondary infection risks (SIR) by age of the primary case and contacts were estimated using generalized estimating equations. RESULTS: The 226 primary cases were followed by 198 (49%) secondary SARS-CoV-2 infections among 404 household contacts. Age group-specific SIR among contacts ranged from 36% to 53%, with no differences by age. SIR was lower in primary cases age 12 to 17 years than from primary cases 18 to 49 years (risk ratio [RR] 0.42; 95% confidence interval [CI] 0.19-0.91). SIR was 55% and 45%, respectively, among primary case-contact pairs in the same versus different age group (RR 1.47; 95% CI 0.98-2.22). SIR was highest among primary case-contact pairs age ≥65 years (76%) and 5 to 11 years (69%). Among secondary SARS-CoV-2 infections, 19% were asymptomatic; there was no difference in the frequency of asymptomatic infections by age group. CONCLUSIONS: Both children and adults can transmit and are susceptible to SARS-CoV-2 infection. SIR did not vary by age, but further research is needed to understand age-related differences in probability of transmission from primary cases by age.

    • Community Health Services
      1. The association between health workforce availability and HIV-program outcomes in Côte d'Ivoireexternal icon
        Akoku DA, Tickell KD, Niamien KR, Kemper KE, Yacouba D, Kouyate S, Kouassi DA, Balachandra S, Swor M, Luxenberg AK, Gloyd S, Kone A.
        Hum Resour Health. 2022 Feb 19;20(1):18.
        OBJECTIVE: The purpose of this study was to assess the distribution of HIV-program staff and the extent to which their availability influences HIV programmatic and patient outcomes. METHODS: The study was a facility level cross-sectional survey. Data from October 2018 to September 2019 were abstracted from HIV program reports conducted in 18 districts of Côte d'Ivoire. The distribution of staff in clinical, laboratory, pharmacy, management, lay, and support cadres were described across high and low antiretroviral therapy (ART) volume facilities. Non-parametric regression was used to estimate the effects of cadre categories on the number of new HIV cases identified, the number of cases initiated on ART, and the proportion of patients achieving viral load suppression. RESULTS: Data from 49,871 patients treated at 216 health facilities were included. Low ART volume facilities had a median of 8.1 staff-per-100 ART patients, significantly higher than the 4.4 staff-per-100 ART patients at high-ART volume facilities. One additional laboratory staff member was associated with 4.30 (IQR: 2.00-7.48, p < 0.001) more HIV cases identified and 3.81 (interquartile range [IQR]: 1.44-6.94, p < 0.001) additional cases initiated on ART. Similarly, one additional lay worker was associated with 2.33 (IQR: 1.00-3.43, p < 0.001) new cases identified and 2.24 (IQR: 1.00-3.31, p < 0.001) new cases initiated on ART. No cadres were associated with viral suppression. CONCLUSIONS: HCWs in the laboratory and lay cadre categories were associated with an increase in HIV-positive case identification and initiation on ART. Our findings suggest that allocation of HCWs across health facilities should take into consideration the ART patient volume. Overall, increasing investment in health workforce is critical to achieve national HIV goals and reaching HIV epidemic control.

    • Disease Reservoirs and Vectors
      1. Hygienic monitoring in long-term care facilities using ATP, crAssphage, and human noroviruses to direct environmental surface cleaningexternal icon
        Cannon JL, Park GW, Anderson B, Leone C, Chao M, Vinjé J, Fraser AM.
        Am J Infect Control. 2022 Jan 6.
        BACKGROUND: Norovirus and C. difficile are associated with diarrheal illnesses and deaths in long-term care (LTC) facilities and can be transmitted by contaminated environmental surfaces. Hygienic monitoring tools such as adenosine triphosphate (ATP) bioluminescence and indicators of fecal contamination can help to identify LTC facility surfaces with cleaning deficiencies. METHODS: High-touch surfaces in 11 LTC facilities were swabbed and tested for contamination by norovirus, a fecal indicator virus, crAssphage, and ATP which detects organic debris. High levels of contamination were defined as log ATP relative light unit values or crAssphage log genomic copy values in the 75th percentile of values obtained from each facility. RESULTS: Over 90% of surfaces tested positive for crAssphage or gave failing ATP scores. Norovirus contamination was not detected. Handrails, equipment controls, and patient beds were 4 times more likely than other surfaces or locations to have high levels of crAssphage. Patient bed handrails and tables and chairs in patient lounges had high levels of both ATP and crAssphage. CONCLUSIONS: Surfaces with high levels of ATP and crAssphage were identified. Quantifying levels of contamination longitudinally and before and after cleaning might enhance infection prevention and control procedures for reducing diarrheal illnesses in LTC facilities.

    • Environmental Health
      1. Current breast milk PFAS levels in the United States and Canada: After all this time, why don't we know more?external icon
        LaKind JS, Verner MA, Rogers RD, Goeden H, Naiman DQ, Marchitti SA, Lehmann GM, Hines EP, Fenton SE.
        Environ Health Perspect. 2022 Feb;130(2):25002.
        BACKGROUND: Despite 20 y of biomonitoring studies of per- and polyfluoroalkyl substances (PFAS) in both serum and urine, we have an extremely limited understanding of PFAS concentrations in breast milk of women from the United States and Canada. The lack of robust information on PFAS concentrations in breast milk and implications for breastfed infants and their families were brought to the forefront by communities impacted by PFAS contamination. OBJECTIVES: The objectives of this work are to: a) document published PFAS breast milk concentrations in the United States and Canada; b) estimate breast milk PFAS levels from maternal serum concentrations in national surveys and communities impacted by PFAS; and c) compare measured/estimated milk PFAS concentrations to screening values. METHODS: We used three studies reporting breast milk concentrations in the United States and Canada We also estimated breast milk PFAS concentrations by multiplying publicly available serum concentrations by milk:serum partitioning ratios for perfluorooctanoic acid (PFOA), perfluorooctane sulfonate (PFOS), perfluorohexane sulfonate (PFHxS), and perfluorononanoic acid (PFNA). Measured and estimated breast milk concentrations were compared to children's drinking water screening values. DISCUSSION: Geometric means of estimated breast milk concentrations ranged over approximately two orders of magnitude for the different surveys/communities. All geometric mean and mean estimated and measured breast milk PFOA and PFOS concentrations exceeded drinking water screening values for children, sometimes by more than two orders of magnitude. For PFHxS and PFNA, all measured breast milk levels were below the drinking water screening values for children; the geometric mean estimated breast milk concentrations were close to-or exceeded-the children's drinking water screening values for certain communities. Exceeding a children's drinking water screening value does not indicate that adverse health effects will occur and should not be interpreted as a reason to not breastfeed; it indicates that the situation should be further evaluated. It is past time to have a better understanding of environmental chemical transfer to-and concentrations in-an exceptional source of infant nutrition. https://doi.org/10.1289/EHP10359.

    • Epidemiology and Surveillance
      1. Primary case inference in viral outbreaks through analysis of intra-host variant populationexternal icon
        Gussler JW, Campo D, Dimitrova Z, Skums P, Khudyakov Y.
        BMC Bioinformatics. 2022 ;23(1).
        Background: Investigation of outbreaks to identify the primary case is crucial for the interruption and prevention of transmission of infectious diseases. These individuals may have a higher risk of participating in near future transmission events when compared to the other patients in the outbreak, so directing more transmission prevention resources towards these individuals is a priority. Although the genetic characterization of intra-host viral populations can aid the identification of transmission clusters, it is not trivial to determine the directionality of transmissions during outbreaks, owing to complexity of viral evolution. Here, we present a new computational framework, PYCIVO: primary case inference in viral outbreaks. This framework expands upon our earlier work in development of QUENTIN, which builds a probabilistic disease transmission tree based on simulation of evolution of intra-host hepatitis C virus (HCV) variants between cases involved in direct transmission during an outbreak. PYCIVO improves upon QUENTIN by also adding a custom heterogeneity index and identifying the scenario when the primary case may have not been sampled. Results: These approaches were validated using a set of 105 sequence samples from 11 distinct HCV transmission clusters identified during outbreak investigations, in which the primary case was epidemiologically verified. Both models can detect the correct primary case in 9 out of 11 transmission clusters (81.8%). However, while QUENTIN issues erroneous predictions on the remaining 2 transmission clusters, PYCIVO issues a null output for these clusters, giving it an effective prediction accuracy of 100%. To further evaluate accuracy of the inference, we created 10 modified transmission clusters in which the primary case had been removed. In this scenario, PYCIVO was able to correctly identify that there was no primary case in 8/10 (80%) of these modified clusters. This model was validated with HCV; however, this approach may be applicable to other microbial pathogens. Conclusions: PYCIVO improves upon QUENTIN by also implementing a custom heterogeneity index which empowers PYCIVO to make the important No primary case prediction. One or more samples, possibly including the primary case, may have not been sampled, and this designation is meant to account for these scenarios. 2022, The Author(s).

      2. Evaluation of the collaborative integrated surveillance system (ViCo) in Guatemala: a qualitative study on lessons learned and future perspectivesexternal icon
        Jaramillo J, Ning MF, Cadena L, Park M, Lo T, Zielinski-Gutierrez E, Espinosa-Bode A, Reyes M, Del Rosario Polo M, Henao O.
        BMC Public Health. 2022 Feb 18;22(1):350.
        BACKGROUND: The collaborative integrated surveillance system known as Vigilancia Integrada Comunitaria (ViCo) was implemented in 2007 to better understand and characterize the burden of diarrheal, respiratory and febrile illnesses in Guatemala. METHODS: To evaluate the usefulness of ViCo and inform a redesign of the system and new surveillance activities in the Central American region, personnel from the United States Centers for Disease Control and Prevention (CDC) conducted thirty-nine in-depth interviews from June-December 2018 with key stakeholders responsible for the design and implementation of ViCo in Guatemala. A semi-structured questionnaire adapted from the Updated CDC Guidelines for Evaluating Public Health Surveillance Systems was used for data collection. We used a grounded theory approach to explore stakeholder perceptions of ViCo and generate recommendations for improvement. Primary qualitative findings were organized based on thematic areas using ATLAS.ti version 8 software. RESULTS: Emergent themes relevant to the usefulness of ViCo were organized across strengths, weaknesses, and recommendations pertaining to the: (1) Size and Complexity of ViCo, (2) Stakeholder Expectations About the Objectives of ViCo, (3) Data Management and Structure of the Information System, (4) Local Control of Data, (5) Integration of ViCo within the Ministry of Health, and, (6) Improvement of the Operational and Design Aspects of ViCo across System, Process, and Output levels. CONCLUSIONS: Stakeholders perceived ViCo to be useful. They recommended measures to improve system performance and quality, including simplifying the surveillance system, routine data analysis and feedback, and channeling efforts towards integrating surveillance data into the national health information system. To create a well-performing surveillance system and achieve the intended objective of surveillance for public health action, ongoing evaluation and assessment of surveillance activities are necessary.

      3. All-cause versus cause-specific excess deaths for estimating influenza-associated mortality in Denmark, Spain, and the United Statesexternal icon
        Schmidt SS, Iuliano AD, Vestergaard LS, Mazagatos-Ateca C, Larrauri A, Brauner JM, Olsen SJ, Nielsen J, Salomon JA, Krause TG.
        Influenza Other Respir Viruses. 2022 Feb 23.
        BACKGROUND: Seasonal influenza-associated excess mortality estimates can be timely and provide useful information on the severity of an epidemic. This methodology can be leveraged during an emergency response or pandemic. METHOD: For Denmark, Spain, and the United States, we estimated age-stratified excess mortality for (i) all-cause, (ii) respiratory and circulatory, (iii) circulatory, (iv) respiratory, and (v) pneumonia, and influenza causes of death for the 2015/2016 and 2016/2017 influenza seasons. We quantified differences between the countries and seasonal excess mortality estimates and the death categories. We used a time-series linear regression model accounting for time and seasonal trends using mortality data from 2010 through 2017. RESULTS: The respective periods of weekly excess mortality for all-cause and cause-specific deaths were similar in their chronological patterns. Seasonal all-cause excess mortality rates for the 2015/2016 and 2016/2017 influenza seasons were 4.7 (3.3-6.1) and 14.3 (13.0-15.6) per 100,000 population, for the United States; 20.3 (15.8-25.0) and 24.0 (19.3-28.7) per 100,000 population for Denmark; and 22.9 (18.9-26.9) and 52.9 (49.1-56.8) per 100,000 population for Spain. Seasonal respiratory and circulatory excess mortality estimates were two to three times lower than the all-cause estimates. DISCUSSION: We observed fewer influenza-associated deaths when we examined cause-specific death categories compared with all-cause deaths and observed the same trends in peaks in deaths with all death causes. Because all-cause deaths are more available, these models can be used to monitor virus activity in near real time. This approach may contribute to the development of timely mortality monitoring systems during public health emergencies.

    • Food Safety
      1. Foodborne outbreak rates associated with restaurant inspection grading and posting at the point of service: Evaluation using national foodborne outbreak surveillance dataexternal icon
        Kim TN, Wildey L, Gleason B, Bleser J, Firestone MJ, Bare G, Bliss J, Dewey-Mattia D, Stueven H, Brown L, Dyjack D, Hedberg CW.
        J Food Prot. 2022 Feb 17.
        A previously conducted national survey of restaurant inspection programs associated the practice of disclosing inspection results to consumers at the restaurant point-of-service (POS) with fewer foodborne outbreaks. We used data from the national Foodborne Disease Outbreak Surveillance System (FDOSS) to assess the reproducibility of the survey results. Programs that participated in the survey accounted for approximately 23% of the single state, foodborne illness outbreaks in restaurant settings reported to FDOSS during 2016 - 2018. Agencies that disclosed inspection results at the POS reported fewer outbreaks (mean = 0.29 outbreaks per 1,000 establishments) than those that disclosed results online (0.7) or not at all (1.0). Having any grading method for inspections was associated with fewer reported outbreaks than having no grading method. Agencies that used letter grades had the lowest numbers of outbreaks per 1,000 establishments. There was a positive association (correlation coefficient, r= 0.54) between the mean number of foodborne illness complaints per 1,000 establishments, per the survey, and the mean number of restaurant outbreaks reported to FDOSS (R2= 0.29). This association was stronger for bacterial toxin-mediated outbreaks (R2= 0.35) than for norovirus (R2= 0.10) or Salmonella (R2= 0.01) outbreaks. Our cross-sectional study findings are consistent with previous observations that linked the practice of posting graded inspection results at the POS with reduced occurrence of foodborne illnesses and outbreaks associated with restaurants. Support for foodborne illness surveillance programs and food regulatory activities at local health agencies is foundational for food safety systems coordinated at state and federal levels.

    • Genetics and Genomics
      1. First laboratory confirmation and sequencing of Zaire ebolavirus in Uganda following two independent introductions of cases from the 10th Ebola Outbreak in the Democratic Republic of the Congo, June 2019external icon
        Nyakarahuka L, Mulei S, Whitmer S, Jackson K, Tumusiime A, Schuh A, Baluku J, Joyce A, Ocom F, Tusiime JB, Montgomery JM, Balinandi S, Lutwama JJ, Klena JD, Shoemaker TR.
        PLoS Negl Trop Dis. 2022 Feb 22;16(2):e0010205.
        Uganda established a domestic Viral Hemorrhagic Fever (VHF) testing capacity in 2010 in response to the increasing occurrence of filovirus outbreaks. In July 2018, the neighboring Democratic Republic of Congo (DRC) experienced its 10th Ebola Virus Disease (EVD) outbreak and for the duration of the outbreak, the Ugandan Ministry of Health (MOH) initiated a national EVD preparedness stance. Almost one year later, on 10th June 2019, three family members who had contracted EVD in the DRC crossed into Uganda to seek medical treatment. Samples were collected from all the suspected cases using internationally established biosafety protocols and submitted for VHF diagnostic testing at Uganda Virus Research Institute. All samples were initially tested by RT-PCR for ebolaviruses, marburgviruses, Rift Valley fever (RVF) virus and Crimean-Congo hemorrhagic fever (CCHF) virus. Four people were identified as being positive for Zaire ebolavirus, marking the first report of Zaire ebolavirus in Uganda. In-country Next Generation Sequencing (NGS) and phylogenetic analysis was performed for the first time in Uganda, confirming the outbreak as imported from DRC at two different time point from different clades. This rapid response by the MoH, UVRI and partners led to the control of the outbreak and prevention of secondary virus transmission.

    • Health Equity and Health Disparities
      1. OBJECTIVES: Health systems must rapidly move knowledge into practice to address disparities impacting sexual and gender minority (SGM) patients. This qualitative study explores barriers and facilitators that arose during an initiative to improve care for SGM patients in federally qualified health centres (FQHCs) from the perspectives of FQHC staff. DESIGN: Cross-sectional qualitative content analysis, using a general inductive approach, of secondary data from transcripts of intervention events offered to FQHC staff and semistructured interviews with staff and FQHC leadership during the intervention. SETTING: 10 FQHCs from nine states in the USA. PARTICIPANTS: FQHC quality improvement (QI) and clinical care staff, and leaders at each FQHC. INTERVENTIONS: The transforming care for lesbian, gay, bisexual and transgender people QI initiative combined two evidence-based programmes, Learning Collaborative (LC) and Project Extension for Community Healthcare Outcomes (ECHO), to assist primary care health centres in developing capacity to identify SGM patients, monitor their health and care, and improve disparities. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was identification of barriers and facilitators to implementing initiatives to improve care for SGM patients. The secondary outcome was clarification of how intervention participants used Project ECHO sessions versus LC meetings to obtain information that influenced implementation of the initiative at their FQHC. RESULTS: Barriers and facilitators mapped to two major themes: 'Clinical' (patients' health, wellness, and available treatment) and Health Systems and Institutional Culture (FQHC operations, and customs and social institutions within the FQHCs and in the external environment). Common 'Clinical' inquiries were for assistance with behavioural health, pre-exposure prophylaxis and transgender hormone therapy. Prevalent facilitators included workflow change and staff training, while adapting electronic health records for data collection, decision support and data extraction was the most prevalent barrier. CONCLUSIONS: Project ECHO and LC provided complimentary forums to explore clinical and operational changes needed to improve care for SGM at FQHCs.

      2. Mortality among Alaska Native adults with confirmed hepatitis C virus infection compared with the general population in Alaska, 1995-2016external icon
        Bressler SS, Bruden D, Nolen LD, Bruce MG, Towshend-Bulson L, Spradling P, McMahon BJ.
        Can J Gastroenterol Hepatol. 2022 ;2022:2573545.
        BACKGROUND: Hepatitis C virus (HCV) infection incidence rates in the United States have increased since 2010 as a byproduct of the opioid crisis despite the introduction of direct-acting antiviral agents in 2013. HCV infection is associated with higher rates of liver-related and nonhepatic causes of death. METHODS: This study compared demographic characteristics and age-adjusted death rates from 1995 to 2016 among Alaska Native (AN) adults infected with HCV (AK-HepC) to rates among the AN and non-AN adult populations living in Alaska. Liver-related disease (LRD) and other disease-specific age-adjusted death rates were compared between the populations. RESULTS: The all-cause death rate among the AK-HepC cohort was 2.2- and 3.4-fold higher than AN and non-AN adults, respectively, and remained stable over time in all populations. The LRD death rate among the AK-HepC cohort was 18- and 11-fold higher than the non-AN and AN, respectively. The liver cancer rate among the AK-HepC cohort was 26-fold higher compared to the Alaska statewide population. The AK-HepC cohort had elevated rates of death associated with nonhepatic diseases with circulatory disease having the highest rate in all populations. Among liver cancer deaths in the AK-HepC cohort, 32% had HCV listed as a contributing cause of death on the death certificate. CONCLUSIONS: Death rates in the AK-HepC cohort remained stable since 1995 and higher compared to the general population. People with HCV infection had an elevated risk for all-cause, liver-related, and nonhepatic causes of death. Hepatitis C infection may be underrepresented as a cause of mortality in the United States.

      3. Multiple imputation of missing race and ethnicity in CDC COVID-19 case-level surveillance dataexternal icon
        Zhang G, Rose CE, Zhang Y, Li R, Lee FC, Massetti G, Adams LE.
        International Journal of Statistics in Medical Research. 2022 ;11:1-11.
        The COVID-19 pandemic has resulted in a disproportionate burden on racial and ethnic minority groups, but incompleteness in surveillance data limits understanding of disparities. CDC’s case-based surveillance system contains case-level information on most COVID-19 cases in the United States. Data analyzed in this paper contain COVID-19 cases with case-level information through September 25, 2020, which represent 70.9% of all COVID-19 cases reported to CDC during the period. Case-level surveillance data are used to investigate COVID-19 disparities by race/ethnicity, sex, and age. However, demographic information on race and ethnicity is missing for a substantial percentage of COVID-19 cases (e.g., 35.8% and 47.2% of cases analyzed were missing race and ethnicity information, respectively). Our goal in this study was to impute missing race and ethnicity to derive more accurate incidence and incidence rate ratio (IRR) estimates for different racial and ethnic groups, and evaluate the results from imputation compared to complete case analysis, which involves removing cases with missing race/ethnicity information from the analysis. Two multiple imputation (MI) models were developed. Model 1 imputes race using six binary race variables, and Model 2 imputes race as a composite multinomial variable. Our evaluation found that compared with complete case analysis, MI reduced biases and improved coverage on incidence and IRR estimates for all race/ethnicity groups, except for the Non- Hispanic Multiple/other group. Our research highlights the importance of supplementing complete case analysis with additional methods of analysis to better describe racial and ethnic disparities. When race and ethnicity data are missing, multiple imputation may provide more accurate incidence and IRR estimates to monitor these disparities in tandem with efforts to improve the collection of race and ethnicity information for pandemic surveillance. © 2022

      4. Cervical precancers and cancers attributed to HPV types by race and ethnicity: Implications for vaccination, screening, and managementexternal icon
        Mix J, Saraiya M, Hallowell BD, Befano B, Cheung LC, Unger ER, Gargano JW, Markowitz LE, Castle PE, Raine-Bennett T, Walker J, Zuna R, Schiffman M, Wentzensen N, Gage JC.
        J Natl Cancer Inst. 2022 Feb 17.
        BACKGROUND: Racial and ethnic variations in attribution of cervical precancer and cancer to HPV types may result in different HPV vaccine protection, screening test coverage, and clinical management. METHODS: Pooling data from seven U.S. studies, we calculated the proportional attribution of precancers and cancers to HPV types using HPV DNA typing from diagnosis. All statistical tests were 2-sided. RESULTS: For all racial and ethnic groups, most cervical intraepithelial neoplasia grade 3 (CIN3) (n = 5,526) and squamous cell carcinoma (SCC) cases (n = 1,138) were attributed to types targeted by the 9-valent vaccine. A higher proportion of CIN3s were attributed to non-vaccine HPV types among non-Hispanic Black women (15.8%) compared with non-Hispanic Asian or Pacific Islander (9.7%, P=.002), non-Hispanic White (9.2%, P<.001), and Hispanic women (11.3%, P=.004). The proportion of SCCs attributed to 9-valent types was similar by race and ethnicity (90.4%-93.8%, P = .80). A higher proportion of CIN3s were attributed to non-vaccine HPV35 among non-Hispanic Black (9.0%) compared with non-Hispanic Asian or Pacific Islander (2.2%), non-Hispanic White (2.5%), and Hispanic women (3.0%, all P<.001). Compared with CIN3, the proportion of SCCs attributed to HPV35 among Non-Hispanic Black women (3.2%) was lower and closer to other groups (0.3%-2.1%, P = .70). CONCLUSION: The 9-valent HPV vaccine will prevent nearly all cervical precancers and invasive cancers among major racial and ethnic groups in the United States. Adding HPV35 to vaccines could prevent a small percentage of CIN3s and SCCs, with greater potential impact for CIN3s among Black women. HPV screening tests target high-risk HPV types, including HPV35. Future genotyping triage strategies could consider the importance of HPV35 and other HPV16 related types.

    • Immunity and Immunization
      1. INTRODUCTION: Parental vaccine hesitancy can be a barrier to routine childhood immunization and contribute to greater risk for vaccine-preventable diseases. This study examines the impact of parental vaccine hesitancy on childhood vaccination rates. METHODS: This study assessed the association of parental vaccine hesitancy on child vaccination coverage with ≥4 doses of diphtheria, tetanus toxoid, and acellular pertussis vaccine; ≥1 dose of measles, mumps, and rubella vaccine; up-to-date rotavirus vaccine; and combined 7-vaccine series coverage for a sample of children aged 19-35 months using data from the 2018 and 2019 National Immunization Survey-Child (N=7,645). Adjusted differences in multivariable analyses of vaccination coverage were estimated among vaccine hesitant and nonhesitant parents and population attributable risk fraction of hesitancy on undervaccination, defined as not being up to date for each vaccine. RESULTS: Almost a quarter of parents reported being vaccine hesitant, with the highest proportion of vaccine hesitancy among parents of children who are non-Hispanic Black (37.0%) or Hispanic (30.1%), mothers with a high school education or less (31.9%), and households living below the poverty level (35.6%). Childhood vaccination coverage for all vaccines was lower for children of hesitant than nonhesitant parents, and the population attributable fraction of hesitancy on undervaccination ranged from 15% to 25%, with the highest percentage for ≥1 dose of measles, mumps, and rubella vaccine. CONCLUSIONS: Parental vaccine hesitancy may contribute up to 25% of undervaccination among children aged 19-35 months. Implementation of strategies to address parental vaccine hesitancy is needed to improve vaccination coverage for children and minimize their risk of vaccine-preventable diseases.

      2. A rapid survey of state and territorial public health partnerships with faith-based organizations to promote COVID-19 vaccinationexternal icon
        Santibañez S, Ottewell A, Harper-Hardy P, Ryan E, Christensen H, Smith N.
        Am J Public Health. 2022 Mar;112(3):397-400.
        During the COVID-19 pandemic, media accounts emerged describing faith-based organizations (FBOs) working alongside health departments to support the COVID-19 response. In May 2021, the Department of Health and Human Services, Centers for Disease Control and Prevention, and the Association of State and Territorial Health Officials (ASTHO) sent an electronic survey to the 59 ASTHO member jurisdictions and four major US cities to assess state and territorial engagement with FBOs. Findings suggest that public health officials in many jurisdictions were able to work effectively with FBOs during the COVID-19 pandemic to provide essential education and mitigation tools to diverse communities. (Am J Public Health. 2022;112(3):397-400. https://doi.org/10.2105/AJPH.2021.306620).

      3. Recommended adult immunization schedule, United States, 2022external icon
        Murthy N, Wodi AP, Bernstein H, Ault KA.
        Ann Intern Med. 2022 Feb 18.

      4. HPV prevalence among young adult women living with and without HIV in Botswana for future HPV vaccine impact monitoringexternal icon
        McClung N, Mathoma A, Gargano JW, Nyepetsi NG, Querec TD, Onyekwuluje J, Mine M, Morroni C, Luckett R, Markowitz LE, Ramogola-Masire D.
        BMC Infect Dis. 2022 Feb 22;22(1):176.
        INTRODUCTION: In 2015, Botswana introduced quadrivalent human papillomavirus (HPV) vaccine for girls aged 9-13 years. To establish a baseline HPV prevalence for future HPV vaccine impact monitoring, we evaluated HPV prevalences among the youngest unvaccinated women in Botswana and compared HPV prevalences among women living with HIV (WLHIV) and without HIV. METHODS: Women aged 18-22 years were recruited from the University of Botswana and HIV clinics in Gaborone from October 2019-January 2021. Demographic and behavioral characteristics were self-reported during structured interviews; HIV clinical characteristics were abstracted from medical charts. Self-collected vaginal swabs were tested for 28 HPV types using Seegene Anyplex II HPV28. We compared prevalence of any HPV, high risk (HR)-HPV, and quadrivalent HPV vaccine types (HPV6/11/16/18) among WLHIV and women without HIV and evaluated risk factors for prevalence of HR-HPV. RESULTS: A total of 306 WLHIV and 500 women without HIV were recruited. Compared to women without HIV, WLHIV were more likely to be sexually experienced (86.6% versus 74.4%) and have ≥ 3 lifetime sex partners (55.3% versus 27.8%). All HPV type prevalences were significantly higher among WLHIV compared to women without HIV, including prevalence of any HPV (82.7% versus 63.0%), HR-HPV (72.9% versus 53.8%), and quadrivalent vaccine HPV types (34.3% versus 21.0%). Among WLHIV, there were no differences between those perinatally and non-perinatally infected for HPV prevalences, number of HPV types detected, CD4 count, or viral load. CONCLUSIONS: Over one-third of WLHIV and nearly a quarter of those without HIV had vaccine-type HPV detected. This study supports need for the national HPV vaccination program in Botswana and provides important baseline data for future evaluation of impact of the program.

      5. mRNA COVID-19 vaccine effectiveness against SARS-CoV-2 infection in a prospective community cohort, rural Wisconsin, November 2020 to December 2021external icon
        McLean HQ, McClure DL, King JP, Meece JK, Pattinson D, Neumann G, Kawaoka Y, Rolfes MA, Belongia EA.
        Influenza Other Respir Viruses. 2022 Feb 18.
        Reduced COVID-19 vaccine effectiveness (VE) has been observed with increasing predominance of SARS-CoV-2 Delta (B.1.617.2) variant. Two-dose VE against laboratory-confirmed SARS-CoV-2 infection (symptomatic and asymptomatic) was estimated using Cox proportional hazards models with time-varying vaccination status in a prospective rural community cohort of 1266 participants aged ≥12 years. Between November 3, 2020 and December 7, 2021, VE was 56% for mRNA COVID-19 vaccines overall, 65% for Moderna, and 50% for Pfizer-BioNTech. VE when Delta predominated (June to December 2021) was 54% for mRNA COVID-19 vaccines overall, 59% for Moderna, and 52% for Pfizer-BioNTech.

      6. BACKGROUND: Since rotavirus vaccines became available in the United States in 2006, there have been reductions in rotavirus hospitalizations, changes in seasonality, and the emergence of a biennial trend of rotavirus activity. Reductions in other pathogens have been associated with COVID-19 mitigation measures. We assessed ongoing rotavirus disease trends during the COVID-19 pandemic. METHODS: We report a 3-week moving average of the number of rotavirus tests, positive tests, and the percent positivity from laboratories reporting to the National Respiratory and Enteric Virus Surveillance System (NREVSS) from July 2000-June 2021. To complement NREVSS data, we analyzed Google internet search interest in "rotavirus" from July 2004 to June 2021. RESULTS: Declines in rotavirus activity following vaccine introduction and the biennial trend are evident through the 2018-2019 surveillance year. In 2019-2021, rotavirus test positivity was below the historic ranges during the months of typically high rotavirus activity and precipitous declines were noted in March 2020. CONCLUSIONS: In the 15 years since rotavirus vaccine was introduced, the number of laboratory-detected rotavirus infections has been consistently lower than during the pre-vaccine era. During the COVID-19 pandemic, rotavirus activity was suppressed. There may be many rotavirus susceptible children during the 2021-2022 rotavirus season.

      7. Waning 2-dose and 3-dose effectiveness of mRNA vaccines against COVID-19-associated emergency department and urgent care encounters and hospitalizations among adults during periods of Delta and Omicron variant predominance - vision network, 10 states, August 2021-January 2022external icon
        Ferdinands JM, Rao S, Dixon BE, Mitchell PK, DeSilva MB, Irving SA, Lewis N, Natarajan K, Stenehjem E, Grannis SJ, Han J, McEvoy C, Ong TC, Naleway AL, Reese SE, Embi PJ, Dascomb K, Klein NP, Griggs EP, Konatham D, Kharbanda AB, Yang DH, Fadel WF, Grisel N, Goddard K, Patel P, Liao IC, Birch R, Valvi NR, Reynolds S, Arndorfer J, Zerbo O, Dickerson M, Murthy K, Williams J, Bozio CH, Blanton L, Verani JR, Schrag SJ, Dalton AF, Wondimu MH, Link-Gelles R, Azziz-Baumgartner E, Barron MA, Gaglani M, Thompson MG, Fireman B.
        MMWR Morb Mortal Wkly Rep. 2022 Feb 18;71(7):255-263.
        CDC recommends that all persons aged ≥12 years receive a booster dose of COVID-19 mRNA vaccine ≥5 months after completion of a primary mRNA vaccination series and that immunocompromised persons receive a third primary dose.* Waning of vaccine protection after 2 doses of mRNA vaccine has been observed during the period of the SARS-CoV-2 B.1.617.2 (Delta) variant predominance(†) (1-5), but little is known about durability of protection after 3 doses during periods of Delta or SARS-CoV-2 B.1.1.529 (Omicron) variant predominance. A test-negative case-control study design using data from eight VISION Network sites(§) examined vaccine effectiveness (VE) against COVID-19 emergency department/urgent care (ED/UC) visits and hospitalizations among U.S. adults aged ≥18 years at various time points after receipt of a second or third vaccine dose during two periods: Delta variant predominance and Omicron variant predominance (i.e., periods when each variant accounted for ≥50% of sequenced isolates).(¶) Persons categorized as having received 3 doses included those who received a third dose in a primary series or a booster dose after a 2 dose primary series (including the reduced-dosage Moderna booster). The VISION Network analyzed 241,204 ED/UC encounters** and 93,408 hospitalizations across 10 states during August 26, 2021-January 22, 2022. VE after receipt of both 2 and 3 doses was lower during the Omicron-predominant than during the Delta-predominant period at all time points evaluated. During both periods, VE after receipt of a third dose was higher than that after a second dose; however, VE waned with increasing time since vaccination. During the Omicron period, VE against ED/UC visits was 87% during the first 2 months after a third dose and decreased to 66% among those vaccinated 4-5 months earlier; VE against hospitalizations was 91% during the first 2 months following a third dose and decreased to 78% ≥4 months after a third dose. For both Delta- and Omicron-predominant periods, VE was generally higher for protection against hospitalizations than against ED/UC visits. All eligible persons should remain up to date with recommended COVID-19 vaccinations to best protect against COVID-19-associated hospitalizations and ED/UC visits.

      8. Effectiveness of maternal vaccination with mRNA COVID-19 vaccine during pregnancy against COVID-19-associated hospitalization in infants aged <6 months - 17 states, July 2021-January 2022external icon
        Halasa NB, Olson SM, Staat MA, Newhams MM, Price AM, Boom JA, Sahni LC, Cameron MA, Pannaraj PS, Bline KE, Bhumbra SS, Bradford TT, Chiotos K, Coates BM, Cullimore ML, Cvijanovich NZ, Flori HR, Gertz SJ, Heidemann SM, Hobbs CV, Hume JR, Irby K, Kamidani S, Kong M, Levy ER, Mack EH, Maddux AB, Michelson KN, Nofziger RA, Schuster JE, Schwartz SP, Smallcomb L, Tarquinio KM, Walker TC, Zinter MS, Gilboa SM, Polen KN, Campbell AP, Randolph AG, Patel MM.
        MMWR Morb Mortal Wkly Rep. 2022 Feb 18;71(7):264-270.
        COVID-19 vaccination is recommended for persons who are pregnant, breastfeeding, trying to get pregnant now, or who might become pregnant in the future, to protect them from COVID-19.(§) Infants are at risk for life-threatening complications from COVID-19, including acute respiratory failure (1). Evidence from other vaccine-preventable diseases suggests that maternal immunization can provide protection to infants, especially during the high-risk first 6 months of life, through passive transplacental antibody transfer (2). Recent studies of COVID-19 vaccination during pregnancy suggest the possibility of transplacental transfer of SARS-CoV-2-specific antibodies that might provide protection to infants (3-5); however, no epidemiologic evidence currently exists for the protective benefits of maternal immunization during pregnancy against COVID-19 in infants. The Overcoming COVID-19 network conducted a test-negative, case-control study at 20 pediatric hospitals in 17 states during July 1, 2021-January 17, 2022, to assess effectiveness of maternal completion of a 2-dose primary mRNA COVID-19 vaccination series during pregnancy against COVID-19 hospitalization in infants. Among 379 hospitalized infants aged <6 months (176 with COVID-19 [case-infants] and 203 without COVID-19 [control-infants]), the median age was 2 months, 21% had at least one underlying medical condition, and 22% of case- and control-infants were born premature (<37 weeks gestation). Effectiveness of maternal vaccination during pregnancy against COVID-19 hospitalization in infants aged <6 months was 61% (95% CI = 31%-78%). Completion of a 2-dose mRNA COVID-19 vaccination series during pregnancy might help prevent COVID-19 hospitalization among infants aged <6 months.

      9. Safety monitoring of COVID-19 vaccine booster doses among adults - United States, September 22, 2021-February 6, 2022external icon
        Hause AM, Baggs J, Marquez P, Myers TR, Su JR, Blanc PG, Gwira Baumblatt JA, Woo EJ, Gee J, Shimabukuro TT, Shay DK.
        MMWR Morb Mortal Wkly Rep. 2022 Feb 18;71(7):249-254.
        During September 22, 2021-February 6, 2022, approximately 82.6 million U.S. residents aged ≥18 years received a COVID-19 vaccine booster dose.* The Food and Drug Administration (FDA) has authorized a booster dose of either the same product administered for the primary series (homologous) or a booster dose that differs from the product administered for the primary series (heterologous). These booster authorizations apply to all three COVID-19 vaccines used in the United States (1-3).(†) The Advisory Committee on Immunization Practices (ACIP) recommended preferential use of an mRNA COVID-19 vaccine (mRNA-1273 [Moderna] or BNT162b2 [Pfizer-BioNTech]) for a booster, even for persons who received the Ad26.COV2.S (Janssen [Johnson & Johnson]) COVID-19 vaccine for their single-dose primary series.(§) To characterize the safety of COVID-19 vaccine boosters among persons aged ≥18 years during September 22, 2021-February 6, 2022, CDC reviewed adverse events and health impact assessments following receipt of a booster that were reported to v-safe, a voluntary smartphone-based safety surveillance system for adverse events after COVID-19 vaccination, and adverse events reported to the Vaccine Adverse Event Reporting System (VAERS), a passive vaccine safety surveillance system managed by CDC and FDA. Among 721,562 v-safe registrants aged ≥18 years who reported receiving a booster, 88.8% received homologous COVID-19 mRNA vaccination. Among registrants who reported a homologous COVID-19 mRNA booster dose, systemic reactions were less frequent following the booster (58.4% [Pfizer-BioNTech] and 64.4% [Moderna], respectively) than were those following dose 2 (66.7% and 78.4%, respectively). The adjusted odds of reporting a systemic reaction were higher following a Moderna COVID-19 vaccine booster, irrespective of the vaccine received for the primary series. VAERS has received 39,286 reports of adverse events after a COVID-19 mRNA booster vaccination for adults aged ≥18 years, including 36,282 (92.4%) nonserious and 3,004 (7.6%) serious events. Vaccination providers should educate patients that local and systemic reactions are expected following a homologous COVID-19 mRNA vaccine booster; however, these reactions appear less common than those following dose 2 of an mRNA-based vaccine. CDC and FDA will continue to monitor vaccine safety and provide data to guide vaccine recommendations and protect public health.

      10. Advisory Committee on Immunization Practices recommended immunization schedule for adults aged 19 years or older - United States, 2022external icon
        Murthy N, Wodi AP, Bernstein H, McNally V, Cineas S, Ault K.
        MMWR Morb Mortal Wkly Rep. 2022 Feb 18;71(7):229-233.
        At its November 2021 meeting, the Advisory Committee on Immunization Practices* (ACIP) approved the Recommended Adult Immunization Schedule for Ages 19 Years or Older, United States, 2022. The 2022 adult immunization schedule summarizes ACIP recommendations, including several changes to the cover page, tables, and notes from the 2021 immunization schedule.(†) In addition, the 2022 adult immunization schedule provides an appendix that lists the contraindications to and precautions for all routinely recommended vaccines in the schedule. This schedule can be found on the CDC immunization schedule website (https://www.cdc.gov/vaccines/schedules). Health care providers are advised to use the cover page, tables, notes, and appendix together. This adult immunization schedule is recommended by ACIP (https://www.cdc.gov/vaccines/acip) and approved by CDC (https://www.cdc.gov), the American College of Physicians (https://www.acponline.org), the American Academy of Family Physicians (https://www.aafp.org), the American College of Obstetricians and Gynecologists (https://www.acog.org), the American College of Nurse-Midwives (https://www.midwife.org), the American Academy of Physician Associates (https://www.aapa.org), and the Society for Healthcare Epidemiology of America (https://www.shea-online.org).

      11. Advisory Committee on Immunization Practices recommended immunization schedule for children and adolescents aged 18 years or younger - United States, 2022external icon
        Wodi AP, Murthy N, Bernstein H, McNally V, Cineas S, Ault K.
        MMWR Morb Mortal Wkly Rep. 2022 Feb 18;71(7):234-237.
        At its November 2021 meeting, the Advisory Committee on Immunization Practices* (ACIP) approved the Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger-United States, 2022. The 2022 child and adolescent immunization schedule, found on the CDC immunization schedule website (https://www.cdc.gov/vaccines/schedules), summarizes ACIP recommendations, including several changes from the 2021 immunization schedule(†) on the cover page, tables, and notes. The 2022 child and adolescent schedule also includes a newly created appendix that lists the contraindications and precautions for all vaccine types in the schedule. Health care providers are advised to use the tables, notes, and appendix together. This immunization schedule is recommended by ACIP (https://www.cdc.gov/vaccines/acip) and approved by CDC (https://www.cdc.gov), the American Academy of Pediatrics (https://www.aap.org), the American Academy of Family Physicians (https://www.aafp.org), the American College of Obstetricians and Gynecologists (http://www.acog.org), the American College of Nurse-Midwives (https://www.midwife.org), the American Academy of Physician Associates (https://www.aapa.org), and the National Association of Pediatric Nurse Practitioners (https://www.napnap.org).

      12. The efficacy and safety of rotavirus vaccines in countries in Africa and Asia with high child mortalityexternal icon
        Henschke N, Bergman H, Hungerford D, Cunliffe NA, Grais RF, Kang G, Parashar UD, Wang SA, Neuzil KM.
        Vaccine. 2022 Feb 17.
        Rotavirus remains a leading cause of diarrhoeal morbidity and mortality in young children and rotavirus vaccines are critical for reducing global disease burden. This report addresses the performance of rotavirus vaccines in countries with high child mortality. We performed a sensitivity analysis as part of a systematic review on rotavirus vaccines to inform development of World Health Organization vaccine recommendations. The efficacy of four prequalified vaccines against severe rotavirus gastroenteritis was similar across high mortality settings in Asia and Africa. Within the first year following vaccination, vaccine efficacy for the four vaccines ranged from 48% to 57% while in the second year, efficacy ranged from 29% to 54%. The four vaccines showed no increase in intussusception risk in these settings. All four vaccines appear to prevent significant numbers of severe rotavirus gastroenteritis episodes with no measurable increase in intussusception risk in high mortality settings in Africa and Asia.

      13. Cost of human papillomavirus vaccine delivery at district and health facility levels in Zimbabwe: A school-based vaccination program targeting multiple cohortsexternal icon
        Hidle A, Brennan T, Garon J, An Q, Loharikar A, Marembo J, Manangazira P, Mejia N, Abimbola T.
        Vaccine. 2022 Feb 15.
        BACKGROUND: After a pilot project in 2014-15 Zimbabwe introduced the human papillomavirus (HPV) vaccine nationally in 2018 for girls aged 10-14 years through a primarily school-based vaccination campaign with two doses administered at 12-month intervals. In 2019, a first dose was delivered to a new cohort of girls in grade 5 of girls age 10 years if out-of-school (OOS), along with a second dose to the 2018 multiple cohorts. Additional effort was made to identify and mobilize OOS girls by Village Health Workers (VHWs) in the community. Zimbabwe reported 1,569,905 doses of HPV vaccine administered during the 2018 and 2019 campaigns. This analysis evaluated the cost of Zimbabwe's national HPV vaccine introduction. METHODS: A retrospective, incremental, ingredients-based cost analysis from the provider perspective was conducted in 2018 and 2019. Financial and economic cost data were collected at district and health facility levels using a two-stage cluster sampling approach and four cost dimensions: program activity, resource input, payer, and administrative level. Costs are presented in 2020 US$ in total and per dose. RESULTS: The total weighted costs for combined district and health facility administrative levels were US$ 828,731 (financial) and US$ 2,060,943 (economic). For service delivery, the total weighted cost per dose was US$ 0.16 (financial) and US$ 0.59 (economic). The program activities with the largest share of total weighted financial cost were training (37% of total) and service delivery (30%), while the largest shares of total weighted economic costs were service delivery (45%) and training (19%). Efforts by VHWs to reach OOS girls resulted in an additional US$ 2.99 in financial cost per dose and US$ 7.79 in economic cost per dose. CONCLUSION: The service delivery cost per dose was lower than that documented in the pilot program cost analysis in Zimbabwe and studies elsewhere, reflecting a campaign delivery approach that spread fixed costs over a large vaccination cohort. The additional cost of reaching OOS girls with the HPV vaccine was documented for the first time in low- and middle-income countries, which may provide information on potential costs for other countries.

      14. Progress in control and elimination of rubella and congenital rubella syndrome worldwide, 2012-2020external icon
        Zimmerman L, Knapp J, Antoni S, Grant G, Reef S.
        Weekly Epidemiological Record. 2022 ;97(6):33-40.
        The article reports on updates in the efforts by the World Health Organization (WHO) to control and eliminate rubella and congenital rubella syndrome around the world in 2012-2020 under its Global Vaccine Action Plan. Topics include the effectiveness of the single dose rubella-containing vaccine (RCV) against rubella and the strategy in introducing RCV in national immunization programmes.

    • Injury and Violence
      1. Maltreatment related hospitalizations among children ages 17 years and younger: New York State, 2011-2013external icon
        Ghazaryan L, Xiong K, Kroelinger C, Rankin K, Sappenfield O, Kacica M.
        Matern Child Health J. 2022 Feb 21.
        BACKGROUND: Child maltreatment is an important societal and public health problem. However, there are limited data on the epidemiology of maltreatment related hospitalizations. OBJECTIVE: The objective of this study was to describe maltreatment related hospitalizations among children ages 17 and younger in New York State (NYS). METHODS: Using 2011-2013 statewide planning and research cooperative system (SPARCS) inpatient hospital discharge data, maltreatment related hospitalizations among children ages 17 years and younger were identified using international classification of diseases, ninth revision, clinical modification codes for diagnoses and external cause of injury. Distributions of demographic and inpatient care characteristics were compared between hospitalizations for maltreatment and those for other causes, and between different types of maltreatment, using chi-square tests (for categorical variables) and t-tests (for continuous variables). RESULTS: During 2011-2013, a total of 853 maltreatment related hospitalizations among 836 children ages 17 years and younger were documented in NYS SPARCS. Infants (children < 1) had the highest rates of hospitalization. Overall, physical abuse was the most prevalent maltreatment type reported. CONCLUSIONS: This is the first study in NYS to describe the epidemiology of child maltreatment hospitalizations; it establishes a statewide baseline for this public health and societal issue.

    • Laboratory Sciences
      1. OBJECTIVES: Interferon-γ release assays (IGRAs), including T-SPOT.TB (TSPOT) and QuantiFERON Gold In-Tube (QFT), are important diagnostic tools for tuberculosis infection, yet little work has been done to study the performance of these tests in populations prioritized for tuberculosis testing in the United States, especially other than healthcare personnel. METHODS: Participants were enrolled as part of a large, prospective cohort of people at high risk of tuberculosis infection or progression to tuberculosis disease. All participants were administered a tuberculin skin test (TST), TSPOT, and QFT test. A subset of participants had their QFT (N=919) and TSPOT (N=885) tests repeated when they returned to get their TST read 2-3 days later (repeat study). 531 participants had a TSPOT performed twice on the same sample taken at the same time (split study). RESULTS: The QFT repeat test interpretations were discordant (one test positive and the other negative) for 6.4% of participants (59/919) while the TSPOT tests were discordant for 60/885 (6.8%) participants in the repeat study and 41/531 (7.7%) participants in the split study. There was a high degree of variability in the quantitative test results for both QFT and TSPOT, and discordance was not associated with both test results being near the established cutoffs. Furthermore, the proportion of discordance was similar when comparing the participants in both the TSPOT repeat and TSPOT split studies. CONCLUSIONS: Both QFT and TSPOT were 6-8% discordant. Results should be interpreted with caution, particularly when seeing a conversion or reversion in serial testing.

      2. BACKGROUND: Standardized practices are needed in the analysis of inflammation biomarker values outside limits of detection (LOD) when used for inflammation correction of nutritional biomarkers. OBJECTIVE: We assessed the direction and extent to which serum C-reactive protein (CRP) and alpha-1-acid-glycoprotein (AGP) values outside LODs (<0.05 mg/L and >4.0 g/L, respectively) affect inflammation regression correction of serum ferritin and compared approaches to addressing such values when estimating inflammation-adjusted ferritin and iron deficiency (ID). METHODS: Examined 29 cross-sectional datasets from 7 countries with reproductive-age women (15-49y) (n = 12,944), preschool-age children (6-59m) (n = 18,208) and school-age children (6-14y) (n = 4,625). For each dataset, we compared 6 analytic approaches for addressing CRP <LOD: listwise deletion, single imputation (lower, middle, or upper bound; LOD/√2; random number), with multiple imputation (MI). For each approach, inflammation-adjusted ferritin and ID using BRINDA regression correction were estimated. We calculated deviance of each estimate from that given by MI within each dataset and performed fixed effects multivariate meta-regression with analytic approach as moderator to compare the reliability of each approach to MI. RESULTS: Across datasets, observations outside LOD ranged from 0.0 to 35.0% of CRP values and 0.0 to 2.5% of AGP values. Pooled deviance estimates for mean ferritin (µg/L) and ID (percentage points) were: listwise deletion -0.46 (95%CI: -0.76, -0.16) and 0.14 (-0.43, 0.72), lower bound 0.45 (0.14, 0.76) and -0.36 (-0.91, 0.20), middle bound -0.21 (-0.51, 0.09) and 0.22 (-0.34, 0.79), LOD/√(2) -0.26 (-0.57, 0.04) and 0.25 (-0.31, 0.81), upper bound -0.31 (-0.61, -0.01) and 0.30 (-0.27, 0.86), and random number -0.08 (-0.38, 0.22) and 0.11 (-0.46, 0.67). There was moderation by approach in the ferritin model (p<0.001). CONCLUSIONS: Findings demonstrate the need for standardized analyses of inflammation biomarker values outside LODs and suggest that random number single imputation may be a reliable and feasible alternative to MI for CRP <LOD.

      3. Symptomatic plasmodium vivax infection in Rwandaexternal icon
        McCaffery JN, Munyaneza T, Uwimana A, Nace D, Lucchi N, Halsey ES, Rogier E.
        Open Forum Infect Dis. 2022 Mar;9(3):ofac025.
        We report a Plasmodium vivax infection in a Rwandan child misdiagnosed with Plasmodium falciparum and administered artemether-lumefantrine. Antigen detection revealed an absence of P falciparum histidine-rich protein 2 (HRP2) and presence of Plasmodium vivax lactate dehydrogenase. Nested and real-time polymerase chain reactions verified that the sample only contained P vivax deoxyribonucleic acid.

    • Maternal and Child Health

      1. SARS-CoV-2 spread and hospitalisations in paediatric patients during the omicron surgeexternal icon
        Belay ED, Godfred-Cato S.
        Lancet Child Adolesc Health. 2022 Feb 18.

      2. Effect of biannual azithromycin distribution on antibody responses to malaria, bacterial, and protozoan pathogens in Nigerexternal icon
        Arzika AM, Maliki R, Goodhew EB, Rogier E, Priest JW, Lebas E, O'Brien KS, Le V, Oldenburg CE, Doan T, Porco TC, Keenan JD, Lietman TM, Martin DL, Arnold BF.
        Nat Commun. 2022 Feb 21;13(1):976.
        The MORDOR trial in Niger, Malawi, and Tanzania found that biannual mass distribution of azithromycin to children younger than 5 years led to a 13.5% reduction in all-cause mortality (NCT02048007). To help elucidate the mechanism for mortality reduction, we report IgG responses to 11 malaria, bacterial, and protozoan pathogens using a multiplex bead assay in pre-specified substudy of 30 communities in the rural Niger placebo-controlled trial over a three-year period (n = 5642 blood specimens, n = 3814 children ages 1-59 months). Mass azithromycin reduces Campylobacter spp. force of infection by 29% (hazard ratio = 0.71, 95% CI: 0.56, 0.89; P = 0.004) but serological measures show no significant differences between groups for other pathogens against a backdrop of high transmission. Results align with a recent microbiome study in the communities. Given significant sequelae of Campylobacter infection among preschool aged children, our results support an important mechanism through which biannual mass distribution of azithromycin likely reduces mortality in Niger.

    • Occupational Safety and Health - Mining
      1. BACKGROUND: Fatigue negatively impacts mineworker health and safety. In this paper, we identify fatigue interventions tested on industrial shiftworkers and explore their effects and the factors that may influence application in an industrial setting such as a mine site. METHODS: This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. A structured, systematic search of the literature was conducted to identify relevant studies published between 1980 and 2020. Researchers independently conducted article screening and study quality appraisals against pre-established criteria, and then extracted data and conducted a narrative synthesis of the included studies. RESULTS: Seven intervention studies, out of 1651 articles initially screened, were retained for narrative synthesis. Four studies tested the alerting effects of bright-light treatment, one evaluated the effectiveness of blue-light blocking glasses at improving daytime sleep quality and nighttime vigilance, and two examined whether sleep hygiene and alertness management trainings improved sleep quality or alertness. There was substantial evidence for the use of bright-light treatments to improve night shiftworker alertness, but insufficient evidence to draw conclusions about the effectiveness of blue-light blocking glasses and sleep hygiene and alertness management trainings due to the small number of studies included. Shiftworkers were mostly male and employed in industrial subsectors such as production and manufacturing, oil and gas, and transportation. No mining-specific intervention studies were identified. CONCLUSIONS: Future research is needed to identify effective fatigue risk management interventions for the mining industry as well as best practices for implementing these interventions with mineworkers.

      2. In underground coal mines, the drilling process in roof bolting operation could generate excessive amount of respirable coal and quartz dusts. Improper drilling control might also pose safety hazard and interrupt production. Therefore, an automated, high-efficiency drilling control system with safety features can be beneficial to the bolter personnel. In this research, a comprehensive drilling control algorithm has been developed to reduce the generation of respirable dust and to increase the drilling energy efficiency based on laboratory drilling test results and safety considerations. Specific energy is used to evaluate the energy efficiency. In addition, the ratio between specific energy and rock uniaxial compressive strength can be used as a basis for determining the rational drilling bite depth—typically a determined high one permissible by the driller power and drill steel. The test results show that to achieve and maintain a desired drilling bite depth for good drilling performance, a combination of relatively low rotational rate and a rationally high penetration is preferred. By monitoring the drilling rate, the system is able to evaluate the bit wear condition and improve drilling safety. In this paper, the developed drilling control algorithm for achieving a rational drilling bite depth is demonstrated. By adapting this drilling control algorithm, the drilling efficiency and bit condition can be monitored in real time, so the system can maintain a relatively high energy efficiency, generate less respirable dust, and avoid drilling failure. © 2022, This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.

    • Parasitic Diseases
      1. Destruction of Schistosoma mansoni sporocysts in Biomphalaria glabrata after phytochemical exposureexternal icon
        Friani G, Costa VA, Mota E, Faro MJ, Souza S, Figueiredo M, Gôlo PS, Mello-Silva CC.
        An Acad Bras Cienc. 2022 ;94(2):e20190676.
        Schistosomiasis is a neglected tropical disease and affects over 200 million people worldwide. The snail Biomphalaria glabrata is one of the intermediate hosts of S. mansoni. The aim of this work was to verify the action of Euphorbia milii var. hislopii latex in the hemocytes profile and histopathology of B. glabrata infected by S. mansoni. Uninfected and infected snails were exposed to sublethal concentration of E. milii latex for 24 hours (1.0 mg/L). The survival rate was 88.5% for the uninfected snails and 66.6% for the infected and exposed snails. In the snails infected by S. mansoni, the exposure to E. milii latex promoted proliferation of hemocytes in the tentacles, mantle, digestive gland and kidney. In the digestive gland and the kidney, granulomatous reactions occurred around the sporocysts and caused their destruction. The number of circulating hemocytes from the group infected and exposed to E. milii latex was significantly higher than in the other groups. Three types of hemocytes were found: hyalinocytes, granulocytes and blast-like cells. We conclude that the E. milii latex influenced the cellular immune response of the susceptible B. glabrata strain to infection by S. mansoni, promoting the destruction of parasites.

      2. Detecting asymptomatic carriage of Plasmodium falciparum in southern Ghana: utility of molecular and serological diagnostic toolsexternal icon
        Agbana HB, Rogier E, Lo A, Abukari Z, Jones S, Gyan B, Aidoo M, Amoah LE.
        Malar J. 2022 Feb 19;21(1):57.
        BACKGROUND: Asymptomatic malaria infections can serve as potential reservoirs for malaria transmission. The density of parasites contained in these infections range from microscopic to submicroscopic densities, making the accurate detection of asymptomatic parasite carriage highly dependent on the sensitivity of the tools used for the diagnosis. This study sought to evaluate the sensitivities of a variety of molecular and serological diagnostic tools at determining the prevalence of asymptomatic Plasmodium falciparum parasite infections in two communities with varying malaria parasite prevalence. METHODS: Whole blood was collected from 194 afebrile participants aged between 6 and 70 years old living in a high (Obom) and a low (Asutsuare) malaria transmission setting of Ghana. Thick and thin blood smears, HRP2 based malaria rapid diagnostic test (RDT) and filter paper dried blood spots (DBS) were prepared from each blood sample. Genomic DNA was extracted from the remaining blood and used in Plasmodium specific photo-induced electron transfer polymerase chain reaction (PET-PCR) and Nested PCR, whilst the HRP2 antigen content of the DBS was estimated using a bead immunoassay. A comparison of malaria parasite prevalence as determined by each method was performed. RESULTS: Parasite prevalence in the high transmission site of Obom was estimated at 71.4%, 61.9%, 60%, 37.8% and 19.1% by Nested PCR, the HRP2 bead assay, PET-PCR, HRP2-RDT and microscopy respectively. Parasite prevalence in the low transmission site of Asutsuare was estimated at 50.1%, 11.2%, 5.6%, 0% and 2.2% by Nested PCR, the HRP2 bead assay, PET-PCR, RDT and microscopy, respectively. The diagnostic performance of Nested PCR, PET-PCR and the HRP2 bead assay was similar in Obom but in Asutsuare, Nested PCR had a significantly higher sensitivity than PET-PCR and the HRP2 bead assay, which had similar sensitivity. CONCLUSIONS: Nested PCR exhibited the highest sensitivity by identifying the highest prevalence of asymptomatic P. falciparum in both the high and low parasite prevalence settings. However, parasite prevalence estimated by the HRP2 bead assay and PET-PCR had the highest level of inter-rater agreement relative to all the other tools tested and have the advantage of requiring fewer processing steps relative to Nested PCR and producing quantitative results.

    • Public Health Leadership and Management
      1. How management and leadership training can impact a health system: Evaluation findings from a public health management training program in Cambodiaexternal icon
        Horváth C, Hong K, Wheeler P, Ir P, Chhea C, Kinzer MH, Ly V, Willacy E.
        Front Public Health. 2021 ;9:784198.
        In 2017, the National Institute of Public Health in Cambodia collaborated with the U.S. Centers for Disease Control and Prevention to provide management and leadership training for 20 managers and senior staff from 10 health centers. We conducted a mixed methods evaluation of the program's outcomes and impact on the graduates and health centers. From June 2018 (baseline) to January 2019 (endpoint), we collected data from a competency assessment, observational visits, and interviews. From baseline to endpoint, all 20 participants reported increased competence in seven management areas. Comparing baseline and endpoint observational visits, we found improvements in leadership and governance, health workforce, water, sanitation, and hygiene, and health centers' use of medical products and technologies. When evaluating the improvements made by participants against the World Health Organization's key components of a well-functioning health system, the program positively contributed toward building four of the six components-leadership and governance, health information systems, human resources for health, and service delivery. While these findings are specific to the context of Cambodian health centers, we hope this evaluation adds to the growing body of research around the impact of skilled public health management on health systems.

    • Reproductive Health
      1. Assisted reproductive technology surveillance - United States, 2018external icon
        Sunderam S, Kissin DM, Zhang Y, Jewett A, Boulet SL, Warner L, Kroelinger CD, Barfield WD.
        MMWR Surveill Summ. 2022 Feb 18;71(4):1-19.
        PROBLEM/CONDITION: Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to have multiple births because multiple embryos might be transferred. Multiple births can pose substantial risks for both mothers and infants, including obstetric complications, preterm birth (<37 weeks), and low birthweight (<2,500 g). This report provides state-specific information for the United States (including the District of Columbia and Puerto Rico) on ART procedures performed in 2018 and compares birth outcomes that occurred in 2018 (resulting from ART procedures performed in 2017 and 2018) with outcomes for all infants born in the United States in 2018. PERIOD COVERED: 2018. DESCRIPTION OF SYSTEM: In 1995, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (Public Law 102-493 [October 24, 1992]). Data are collected through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. This report includes data from the 50 U.S. states, the District of Columbia, and Puerto Rico. RESULTS: In 2018, a total of 203,119 ART procedures (range: 196 in Alaska to 26,028 in California) were performed in 456 U.S. fertility clinics and reported to CDC. These procedures resulted in 73,831 live-birth deliveries (range: 76 in Puerto Rico and Wyoming to 9,666 in California) and 81,478 infants born (range: 84 in Wyoming to 10,620 in California). Nationally, among women aged 15-44 years, the rate of ART procedures performed was 3,135 per 1 million women. ART use exceeded 1.5 times the national rate in seven states (Connecticut, Illinois, Maryland, Massachusetts, New Jersey, New York, and Rhode Island) and the District of Columbia. ART use rates exceeded the national rate in an additional seven states (California, Delaware, Hawaii, New Hampshire, Utah, Vermont, and Virginia). Nationally, among all ART transfer procedures, the average number of embryos transferred was similar across age groups (1.3 among women aged <35 years, 1.3 among women aged 35-37 years, and 1.4 among women aged >37 years). The national single-embryo transfer (SET) rate among all embryo-transfer procedures was 74.1% among women aged <35 years (range: 28.2% in Puerto Rico to 89.5% in Delaware), 72.8% among women aged 35-37 years (range: 30.6% in Puerto Rico to 93.7% in Delaware), and 66.4% among women aged >37 years (range: 27.1% in Puerto Rico to 85.3% in Delaware). In 2018, ART contributed to 2.0% of all infants born in the United States (range: 0.4% in Puerto Rico to 5.1% in Massachusetts) from procedures performed in 2017 and 2018. Approximately 78.6% of ART-conceived infants were singleton infants. Overall, ART contributed to 12.5% of all multiple births, including 12.5% of all twin births and 13.3% of all triplets and higher-order births. ART-conceived twins accounted for approximately 97.1% (15,532 of 16,001) of all ART-conceived multiple births. The percentage of multiple births was higher among infants conceived with ART (21.4%) than among all infants born in the total birth population (3.3%). Approximately 20.7% (15,532 of 74,926) of ART-conceived infants were twins, and 0.6% (469 of 74,926) were triplets and higher-order multiples. Nationally, infants conceived with ART contributed to 4.2% of all low birthweight (<2,500 g) infants. Among ART-conceived infants, 18.3% were low birthweight compared with 8.3% among all infants. ART-conceived infants contributed to 5.1% of all preterm (gestational age <37 weeks) infants. The percentage of preterm births was higher among infants conceived with ART (26.1%) than among all infants born in the total birth population (10.0%). The percentage of low birthweight among singletons was 8.3% among ART-conceived infants and 6.6% among all infants born. The percentage of preterm births among ART-conceived singleton infants was 14.9% compared with 8.3% among all singleton infants. The percentages of small for gestational age infants was 7.3% among ART-conceived infants compared with 9.4% among all infants. INTERPRETATION: Although singleton infants accounted for the majority of ART-conceived infants, multiple births from ART varied substantially among states and nationally, contributing to >12% of all twins, triplets, and higher-order multiple infants born in the United States. Because multiple births are associated with higher rates of prematurity than singleton births, the contribution of ART to poor birth outcomes continues to be noteworthy. Although SET rates increased among all age groups, variations in SET rates among states and territories remained, which might reflect variations in embryo-transfer practices among fertility clinics and might in part account for variations in multiple birth rates among states and territories. PUBLIC HEALTH ACTION: Reducing the number of embryos transferred and increasing use of SET, when clinically appropriate, can help reduce multiple births and related adverse health consequences for both mothers and infants. Whereas risks to mothers from multiple-birth pregnancy include higher rates of caesarean delivery, gestational hypertension, and gestational diabetes, infants from multiple births are at increased risk for numerous adverse sequelae such as preterm birth, birth defects, and developmental disabilities. Long-term follow-up of ART infants through integration of existing maternal and infant health surveillance systems and registries with data available from NASS might be useful for monitoring adverse outcomes on a population basis.

    • Veterinary Medicine
      1. OBJECTIVE: To understand large animal veterinarians' knowledge of select zoonotic diseases that cause livestock abortions and identify barriers to using personal protective equipment (PPE). SAMPLE: A convenience sample of 469 veterinarians currently working with livestock. PROCEDURES: We sent an electronic survey invitation to large animal veterinarians through various veterinary organizations. Respondents answered questions addressing knowledge and prior experience with select abortion-associated zoonotic diseases, resources available for infection control, attitudes and barriers to PPE use, and demographics. RESULTS: Median participant age was 49 years (range, 22 to 82 years), and 54% (235/438) were male. Half of veterinarians (185/348) were contacted 5 or fewer times per year to consult on livestock abortions. No veterinarians surveyed answered all questions on zoonotic disease transmission correctly. Personal protective equipment access varied, from 99% (289/290) having access to gloves to 20% (59/290) having access to respirators. Concerns for spreading disease to other animals (136/289 [47%]) and to other humans (108/287 [38%]) ranked as the most common reported motivators for PPE use. Reported barriers to PPE use among survey participants were the inconvenience of taking PPE into the field (101/286 [35%]) and the inconvenience of wearing PPE (97/286 [34%]). Access to PPE was not correlated with PPE use. CLINICAL RELEVANCE: Surveyed veterinarians had limited knowledge of transmission of select abortion-associated zoonotic diseases. Incomplete understanding might lead to inappropriate PPE selection, preventable disease exposure, or missed opportunities for client education. Inconvenience was a primary reason PPE was not used.

    • Zoonotic and Vectorborne Diseases
      1. Three human rabies deaths attributed to bat exposures — United States, August 2021
        Kunkel A, Minhaj FS, Whitehill F, Austin C, Hahn C, Kieffer AJ, Mendez L, Miller J, Tengelsen LA, Gigante CM, Orciari LA, Rao AK, Wallace RM.
        MMWR Recommendations and Reports. 2022 ;71(1):31-32.
        During September 28–November 10, 2021, CDC confirmedthree human rabies deaths in the United States, all in personswho did not seek postexposure prophylaxis (PEP) after batexposures that occurred during August 2021. This increase inbat-associated human rabies deaths in the United States followedonly three deaths during the previous 48 months. Thecases during fall 2021 occurred in two adults and one child,all male, from Idaho, Illinois, and Texas. Initial symptomsincluded pain and paresthesia near the site of exposure progressingto dysphagia, altered mental status, paralysis, seizurelikeactivity, and autonomic instability. All three patients hadrecognized direct contact (e.g., bite or collision) with a batapproximately 3–7 weeks before symptom onset and diedapproximately 2–3 weeks after symptom onset. The deathswere associated with three bat species: Lasionycteris noctivagans(silver-haired bat), Tadarida brasiliensis (Mexican free-tailedbat), and Eptesicus fuscus (big brown bat) (Figure). All threespecies are common in the United States and have been implicatedin previous rabies cases. One patient submitted the bat responsible for exposure for testing but refused PEP, despitethe bat testing positive for rabies virus, due to a long-standingfear of vaccines. The other two patients did not realize the riskfor rabies from their exposures, either because they did notnotice a bite or scratch or did not recognize bats as a potentialsource of rabies. Case and contact investigations were led bythe appropriate state and local health departments, and allhuman laboratory testing occurred at CDC. This activity wasreviewed by CDC and conducted consistent with applicablefederal law and CDC policy.* © 2022, MMWR Recommendations and Reports. All Rights Reserved.

      2. Mortality from congenital Zika syndrome - nationwide cohort study in Brazilexternal icon
        Paixao ES, Cardim LL, Costa MC, Brickley EB, de Carvalho-Sauer RC, Carmo EH, Andrade RF, Rodrigues MS, Veiga RV, Costa LC, Moore CA, França GV, Smeeth L, Rodrigues LC, Barreto ML, Teixeira MG.
        N Engl J Med. 2022 Feb 24;386(8):757-767.
        BACKGROUND: Prenatal exposure to Zika virus has potential teratogenic effects, with a wide spectrum of clinical presentation referred to as congenital Zika syndrome. Data on survival among children with congenital Zika syndrome are limited. METHODS: In this population-based cohort study, we used linked, routinely collected data in Brazil, from January 2015 through December 2018, to estimate mortality among live-born children with congenital Zika syndrome as compared with those without the syndrome. Kaplan-Meier curves and survival models were assessed with adjustment for confounding and with stratification according to gestational age, birth weight, and status of being small for gestational age. RESULTS: A total of 11,481,215 live-born children were followed to 36 months of age. The mortality rate was 52.6 deaths (95% confidence interval [CI], 47.6 to 58.0) per 1000 person-years among live-born children with congenital Zika syndrome, as compared with 5.6 deaths (95% CI, 5.6 to 5.7) per 1000 person-years among those without the syndrome. The mortality rate ratio among live-born children with congenital Zika syndrome, as compared with those without the syndrome, was 11.3 (95% CI, 10.2 to 12.4). Among infants born before 32 weeks of gestation or with a birth weight of less than 1500 g, the risks of death were similar regardless of congenital Zika syndrome status. Among infants born at term, those with congenital Zika syndrome were 14.3 times (95% CI, 12.4 to 16.4) as likely to die as those without the syndrome (mortality rate, 38.4 vs. 2.7 deaths per 1000 person-years). Among infants with a birth weight of 2500 g or greater, those with congenital Zika syndrome were 12.9 times (95% CI, 10.9 to 15.3) as likely to die as those without the syndrome (mortality rate, 32.6 vs. 2.5 deaths per 1000 person-years). The burden of congenital anomalies, diseases of the nervous system, and infectious diseases as recorded causes of deaths was higher among live-born children with congenital Zika syndrome than among those without the syndrome. CONCLUSIONS: The risk of death was higher among live-born children with congenital Zika syndrome than among those without the syndrome and persisted throughout the first 3 years of life. (Funded by the Ministry of Health of Brazil and others.).

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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