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Issue 16, April 19, 2022

CDC Science Clips: Volume 14, Issue 16, April 19, 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.
    • Antimicrobial Resistance and Antibiotic Stewardship
      1. Drug resistance and use of long-acting ARTexternal icon
        da Silva J, Siedner M, McCluskey S, Chandiwana N, Venter F, Raizes E.
        Lancet HIV. 2022 Mar 28.

    • Chronic Diseases and Conditions
      1. Proportions and trends of adult hospitalizations with diabetes, United States, 2000-2018external icon
        Zhang Y, McKeever Bullard K, Imperatore G, Holliday CS, Benoit SR.
        Diabetes Res Clin Pract. 2022 Mar 31:109862.
        AIMS: To report the national proportions and trends of adult hospitalizations with diabetes in the United States during 2000-2018. METHODS: We used the 2000-2018 National Inpatient Sample to identify hospital discharges with any listed and primary diagnoses for diabetes, based on International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) and ICD-10-CM codes. We calculated proportions and trends of adult hospitalizations with diabetes, overall and by subpopulations. We used the Nationwide Readmissions Database to assess calendar-year and 30-day readmission rates. RESULTS: From 2000 to 2018, the proportion of hospitalizations among adults ≥18 years increased from 17.1% to 27.3% (average annual percentage change [AAPC] 2.5%; P < 0.001) for any listed diabetes codes and from 1.5% to 2.1% (AAPC 2.2%; P < 0.001) for primary diagnosis of diabetes. Men, non-Hispanic Black patients, and those from poorer zip codes had higher proportions of hospitalizations with diabetes codes. CONCLUSION: In recent years, approximately one-quarter of adult hospitalizations in the United States had a listed diabetes code, increasing about 2.5% per year from 2000 to 2018. These data are important for benchmarking purposes, especially due to disruptions in health care utilization from the COVID-19 pandemic.

      2. National health and budget impact of implementing the WHO HEARTS hypertension control program in Bangladeshexternal icon
        Pidugu A, Pickersgill S, Watkins D, Husain J, Kostova D, Farrell M, Haider M, Jubayer S, Tarannum R, Bhuiyan M, Moran AE, Choudhury S.
        Lancet Glob Health. 2022 Mar;10 Suppl 1:S23.
        BACKGROUND: About a fifth of adults in Bangladesh have hypertension; only 13% of Bangladesh adults living with hypertension have their blood pressure controlled (<140/90 mmHg). To address the growing burden of hypertension in low-income and middle-income countries, the WHO recommends implementing the HEARTS technical package. HEARTS outlines a practical approach to cardiovascular disease (CVD) prevention in primary care settings, including risk factor screening, diagnosis, treatment, and patient counseling. The Bangladesh Ministry of Health and Family Welfare and the National Heart Foundation of Bangladesh implemented the HEARTS programme in four district health complexes in Sylhet Division starting in 2019. To inform Bangladesh's health care policies, we translated Bangladesh HEARTS programme effectiveness and cost estimates into projections of national health and budget impact for nationwide programme scale-up. METHODS: We used an interactive, web-based model to project CVD deaths averted based on observed facility-based hypertension control rates and used local costs to obtain budget impact estimates of national HEARTS programme implementation. We also explored three alternative scenarios: reducing medication costs by 50%, increasing team-based care with larger roles for nurses and community health workers, and removing laboratory costs. Relative improvement in hypertension control observed in the HEARTS programme (from 26% to 46% in the four districts over 24 months) was applied to the 13% baseline national control rate resulting in a projected improvement to 33% at national scale. The costs of the hypertension programme were quantified with a standard HEARTS costing tool that was deployed in the four district health complexes. The costing tool recorded and calculated unit costs for hypertension screening, CVD risk assessment, health-care worker time or compensation, and drug prices. FINDINGS: An absolute improvement of 20 percentage points in the national hypertension control rate, from 13% to 33%, would save 9400 lives. Extrapolating local programme costs to the national level resulted in a budget of US$599 million by 2030. Reducing medication costs would lower the budget impact by 42·6%. Increasing team-based care would not substantively affect the cost. Removing laboratory costs would lower the budget by 14%. Combining these innovations would lower the projected cost by 56·9%. INTERPRETATION: Implementing the HEARTS programme in Bangladesh might improve hypertension control and save 9400 lives at a budget impact of $599 million by 2030. Increased task sharing and lower medication prices have potential to reduce costs and make reaching hypertension control goals more affordable and sustainable for Bangladesh. FUNDING: Columbia University Global & Population Health Summer Research Fellowship.

      3. Point prevalence of hip symptoms, radiographic, and symptomatic OA at five time points: The Johnston County Osteoarthritis Project, 1991-2018external icon
        Nelson AE, Hu D, Arbeeva L, Alvarez C, Cleveland RJ, Schwartz TA, Murphy LB, Helmick CG, Callahan LF, Renner JB, Jordan JM, Golightly YM.
        Osteoarthr Cartil Open. 2022 June;4(2) (no pagination).
        Objective: To describe the point prevalence of hip symptoms, radiographic hip osteoarthritis (rHOA), severe rHOA, and symptomatic rHOA (sxHOA) at five time points in the longitudinal, population-based Johnston County Osteoarthritis Project (JoCoOA). Design(s): Data were from 3068 JoCoOA participants who attended up to five study visits (1991-2018). Standardized supine pelvis radiographs were read by a single, expert musculoskeletal radiologist with high reliability. The four outcomes were: 1) self-reported hip symptoms: "On most days, do you have pain, aching, or stiffness in your right/left hip?"; 2) rHOA: Kellgren-Lawrence grade (KLG) of 2-4; 3) severe rHOA: KLG of 3-4; and 4) sxHOA: both symptoms and rHOA in the same joint. Weighted point prevalence and 95% confidence intervals (CI) were generated overall and by age group (45-54, 55-64, 65-74, 75+ years), sex, race (Black/White), and body mass index (BMI; 18.5-24.9; 25-29.9; 30+ kg/m<sup>2</sup>). Result(s): At the most recent follow-up (2017-2018), the point prevalence (%) of hip symptoms, rHOA, severe rHOA, and sxHOA were 30% (95% CI 25%, 35%), 53% (95% CI 48%, 58%), 9% (95% CI 6%, 12%), and 15% (95% CI 11%, 19%), respectively. RHOA and severe rHOA were most prevalent in those 75+ years. Women were more likely than men to have hip symptoms and sxHOA. No consistent trends were noted by race or BMI. Conclusion(s): These updated point prevalence estimates demonstrate a large and increasing burden of HOA in the general population, particularly with aging. Black and White individuals were affected similarly in this cohort. Copyright © 2022 The Authors

      4. Categorizing community type for epidemiologic evaluation of community factors and chronic disease across the United Statesexternal icon
        McAlexander TP, Algur Y, Schwartz BS, Rummo PE, Lee DC, Siegel KR, Ryan V, Lee NL, Malla G, McClure LA.
        Soc Sci Humanit Open. 2022 ;5(1).
        Existing classifications of community type do not differentiate urban cores from surrounding non-rural areas, an important distinction for analyses of community features and their impact on health. Inappropriately classified community types can introduce serious methodologic flaws in epidemiologic studies and invalid inferences from findings. To address this, we evaluate a modification of the United States Department of Agriculture's Rural Urban Commuting Area codes at the census tract, propose a four-level categorization of community type, and compare this with existing classifications for epidemiologic analyses. Compared to existing classifications, our method resulted in clearer geographic delineations of community types within urban areas.

    • Communicable Diseases
      1. Trends of notification rates and treatment outcomes of tuberculosis cases with and without HIV co-infection in eight rural districts of Uganda (2015 - 2019)external icon
        Baluku JB, Nanyonjo R, Ayo J, Obwalatum JE, Nakaweesi J, Senyimba C, Lukoye D, Lubwama J, Ward J, Mukasa B.
        BMC Public Health. 2022 Apr 5;22(1):651.
        BACKGROUND: The End TB Strategy aims to reduce new tuberculosis (TB) cases by 90% and TB-related deaths by 95% between 2015 - 2035. We determined the trend of case notification rates (CNRs) and treatment outcomes of TB cases with and without HIV co-infection in rural Uganda to provide an interim evaluation of progress towards this global target in rural settings. METHODS: We extracted retrospective programmatic data on notified TB cases and treatment outcomes from 2015 - 2019 for eight districts in rural Uganda from the District Health Information System 2. We estimated CNRs as the number of TB cases per 100,000 population. Treatment success rate (TSR) was calculated as the sum of TB cure and treatment completion for each year. Trends were estimated using the Mann-Kendall test. RESULTS: A total of 11,804 TB cases, of which 5,811 (49.2%) were HIV co-infected, were notified. The overall TB CNR increased by 3.7-fold from 37.7 to 141.3 cases per 100,000 population in 2015 and 2019 respectively. The increment was observed among people with HIV (from 204.7 to 730.2 per 100,000, p = 0.028) and HIV-uninfected individuals (from 19.9 to 78.7 per 100,000, p = 0.028). There was a decline in the TSR among HIV-negative TB cases from 82.1% in 2015 to 63.9% in 2019 (p = 0.086). Conversely, there was an increase in the TSR among HIV co-infected TB cases (from 69.9% to 81.9%, p = 0.807). CONCLUSION: The CNR increased among people with and without HIV while the TSR reduced among HIV-negative TB cases. There is need to refocus programs to address barriers to treatment success among HIV-negative TB cases.

      2. Characteristics of users of HIV self-testing in Kenya, outcomes, and factors associated with use: results from a population-based HIV impact assessment, 2018external icon
        Mwangi J, Miruka F, Mugambi M, Fidhow A, Chepkwony B, Kitheka F, Ngugi E, Aoko A, Ngugi C, Waruru A.
        BMC Public Health. 2022 Apr 2;22(1):643.
        BACKGROUND AND SETTING: About 20% of persons living with HIV aged 15-64 years did not know their HIV status in Kenya, by 2018. Kenya adopted HIV self-testing (HIVST) to help close this gap. We examined the sociodemographic characteristics and outcomes of self-reported users of HIVST as our primary outcome. METHODS: We used data from a 2018 population-based cross-sectional household survey in which we included self-reported sociodemographic and behavioral characteristics and HIV test results. To compare weighted proportions, we used the Rao-Scott χ-square test and Jackknife variance estimation. In addition, we used logistic regression to identify associations of sociodemographic, behavioral, and HIVST utilization. RESULTS: Of the 23,673 adults who reported having ever tested for HIV, 937 (4.1%) had ever self-tested for HIV. There were regional differences in HIVST, with Nyanza region having the highest prevalence (6.4%), p < 0.001. Factors independently associated with having ever self-tested for HIV were secondary education (adjusted odds ratio [aOR], 3.5 [95% (CI): 2.1-5.9]) compared to no primary education, being in the third (aOR, 1.7 [95% CI: 1.2-2.3]), fourth (aOR, 1.6 [95% CI: 1.1-2.2]), or fifth (aOR, 1.8 [95% CI: 1.2-2.7]) wealth quintiles compared to the poorest quintile and having one lifetime sexual partner (aOR, 1.8 [95% CI: 1.0-3.2]) or having ≥ 2 partners (aOR, 2.1 [95% CI: 1.2-3.7]) compared to none. Participants aged ≥ 50 years had lower odds of self-testing (aOR, 0.6 [95% CI: 0.4-1.0]) than those aged 15-19 years. CONCLUSION: Kenya has made progress in rolling out HIVST. However, geographic differences and social demographic factors could influence HIVST use. Therefore, more still needs to be done to scale up the use of HIVST among various subpopulations. Using multiple access models could help ensure equity in access to HIVST. In addition, there is need to determine how HIVST use may influence behavior change towardsaccess to prevention and HIV treatment services.

      3. Human papillomavirus prevalence in male and female university students in Gaborone, Botswanaexternal icon
        Ramogola-Masire D, McClung N, Mathoma A, Gargano JW, Nyepetsi NG, Querec TD, Onyekwuluje J, Mine M, Morroni C, Luckett R, Markowitz LE.
        Epidemiol Infect. 2022 Apr 6:1-25.

      4. Use of remnant specimens to assess use of HIV pre-exposure prophylaxis (PrEP) among populations with risk for HIV infection: A novel approachexternal icon
        Pathela P, Qasmieh S, Gandhi M, Rozen E, Okochi H, Goldstein H, Herold BC, Jamison K, Schillinger JA, Nash D.
        J Acquir Immune Defic Syndr. 2022 Mar 31.
        BACKGROUND: HIV-uninfected persons being evaluated for sexually transmitted infections (STIs) may be good HIV pre-exposure prophylaxis (PrEP) candidates. We measured PrEP use in a sentinel STI patient population. DESIGN: Cross-sectional study, New York City Sexual Health Clinics (January-June 2019). METHODS: Remnant serum samples from 644 HIV-uninfected men-who-have-sex-with-men (MSM) and 97 women diagnosed with chlamydia (CT), gonorrhea (GC) and/or early syphilis (ES) were assayed for tenofovir and emtricitabine levels using a validated liquid chromatography-mass spectrometry assay. Using paired test results and medical records, we assessed 1) prevalence and 2) correlates of PrEP use on the day of STI diagnosis (adjusted prevalence ratios [aPR]). RESULTS: PrEP use among 741 patients was 32.7% (95% CI, 29.3%-36.0%); 37.3% for MSM and 2.1% for women. PrEP use was high among White MSM (46.8%) and lowest among women. Among MSM with rectal CT/GC or ES, PrEP use was associated with age [aPR=1.7 (95% CI, 1.2-2.4) for ages 25-34 and aPR=2.0 (1.4-2.9) for ages 35-44, vs. 15-24 years]; number recent sex partners [aPR=1.4 (1.0-2.0) for 3-5 partners, aPR=2.1 (1.5-3.0) for 6-10 partners, aPR=2.2 (1.6-3.1) for >10 partners, vs. <2 partners]; having sex/needle-sharing partners with HIV [aPR=1.4 (1.1-1.7)]; and inconsistent condom use [aPR=3.3 (1.8-6.1)]. Race/ethnicity, past-year STI diagnosis, and post-exposure prophylaxis use were not associated. CONCLUSIONS: One in 3 people with newly diagnosed STIs had detectable serum PrEP, and PrEP use was exceedingly rare among women. Routinely collected remnant samples can be used to measure PrEP use in populations at high risk for HIV acquisition.

      5. Use of at-home COVID-19 tests - United States, August 23, 2021-March 12, 2022external icon
        Rader B, Gertz A, Iuliano AD, Gilmer M, Wronski L, Astley CM, Sewalk K, Varrelman TJ, Cohen J, Parikh R, Reese HE, Reed C, Brownstein JS.
        MMWR Morb Mortal Wkly Rep. 2022 Apr 1;71(13):489-494.
        COVID-19 testing provides information regarding exposure and transmission risks, guides preventative measures (e.g., if and when to start and end isolation and quarantine), identifies opportunities for appropriate treatments, and helps assess disease prevalence (1). At-home rapid COVID-19 antigen tests (at-home tests) are a convenient and accessible alternative to laboratory-based diagnostic nucleic acid amplification tests (NAATs) for SARS-CoV-2, the virus that causes COVID-19 (2-4). With the emergence of the SARS-CoV-2 B.1.617.2 (Delta) and B.1.1.529 (Omicron) variants in 2021, demand for at-home tests increased(†) (5). At-home tests are commonly used for school- or employer-mandated testing and for confirmation of SARS-CoV-2 infection in a COVID-19-like illness or following exposure (6). Mandated COVID-19 reporting requirements omit at-home tests, and there are no standard processes for test takers or manufacturers to share results with appropriate health officials (2). Therefore, with increased COVID-19 at-home test use, laboratory-based reporting systems might increasingly underreport the actual incidence of infection. Data from a cross-sectional, nonprobability-based online survey (August 23, 2021-March 12, 2022) of U.S. adults aged ≥18 years were used to estimate self-reported at-home test use over time, and by demographic characteristics, geography, symptoms/syndromes, and reasons for testing. From the Delta-predominant period (August 23-December 11, 2021) to the Omicron-predominant period (December 19, 2021-March 12, 2022)(§) (7), at-home test use among respondents with self-reported COVID-19-like illness(¶) more than tripled from 5.7% to 20.1%. The two most commonly reported reasons for testing among persons who used an at-home test were COVID-19 exposure (39.4%) and COVID-19-like symptoms (28.9%). At-home test use differed by race (e.g., self-identified as White [5.9%] versus self-identified as Black [2.8%]), age (adults aged 30-39 years [6.4%] versus adults aged ≥75 years [3.6%]), household income (>$150,000 [9.5%] versus $50,000-$74,999 [4.7%]), education (postgraduate degree [8.4%] versus high school or less [3.5%]), and geography (New England division [9.6%] versus West South Central division [3.7%]). COVID-19 testing, including at-home tests, along with prevention measures, such as quarantine and isolation when warranted, wearing a well-fitted mask when recommended after a positive test or known exposure, and staying up to date with vaccination,** can help reduce the spread of COVID-19. Further, providing reliable and low-cost or free at-home test kits to underserved populations with otherwise limited access to COVID-19 testing could assist with continued prevention efforts.

      6. Pre-exposure prophylaxis (PrEP) uptake and service delivery adaptations during the first wave of the COVID-19 pandemic in 21 PEPFAR-funded countriesexternal icon
        Kerzner M, De AK, Yee R, Keating R, Djomand G, Stash S, Rana S, Kimmel A, Eakle R, Klucking S, Patel P.
        PLoS One. 2022 ;17(4):e0266280.
        BACKGROUND: Mitigation measures for the first wave of the COVID-19 pandemic and burden on health systems created challenges for pre-exposure prophylaxis (PrEP) service delivery. We examined PrEP uptake in PEPFAR programs before and after the start of the COVID-19 pandemic. METHODS: We studied two PEPFAR program monitoring indicators, using routine Monitoring, Evaluation, Reporting (MER) indicators capturing uptake of PrEP (PrEP_NEW) and overall use of PrEP (PrEP_CURR). We also analyzed descriptive program narratives to understand successes and challenges field teams encountered after the start of the COVID-19 pandemic. To assess changes in coverage of PrEP across 21 countries, we calculated the "PrEP to need ratio" (PnR) using a published methodology. We defined the pre-COVID time period as April 1, 2019 -March 31, 2020 and the COVID time period as April 1, 2020 -March 31, 2021. FINDINGS: The total number of persons who initiated PrEP increased by 157% from 233,250 in the pre-COVID-19 period compared with 599,935 in the COVID-19 period. All countries, except five, noted significant increases in PrEP uptake. PrEP uptake among adolescent girls and young women (AGYW) increased by 159% from 80,452 AGYW in the pre-COVID-19 period to 208,607 AGYW in the COVID-19 period. There were 77,430 key populations (KP) initiated on PrEP in the pre-COVID-19 period and 209,114 KP initiated in the COVID-19 period (a 170% increase). The PnR increased 214% in the COVID-19 period across all PEPFAR-supported countries. Adaptations, such as multi-month dispensing (MMD) of PrEP; virtual demand creation activities; decentralized, community-based and virtual service delivery, were implemented to maintain PrEP services. CONCLUSIONS: PEPFAR programs continued to maintain and initiate new clients on PrEP despite the challenges posed by the COVID-19 pandemic. Adaptations such as MMD of PrEP and use of technology were vital in expanding service delivery and increasing PrEP coverage. FUNDING: This project has been supported by the U.S. President's Emergency Plan for AIDS Relief.

    • Community Health Services
      1. Evaluation of the latent tuberculosis care cascade among public health clinics in the United Statesexternal icon
        Holzman SB, Perry A, Saleeb P, Pyan A, Keh C, Salcedo K, Narita M, Ahmed A, Miller TL, Pettit AC, Khurana R, Whipple M, Katz D, Largen A, Krueger A, Shah M.
        Clin Infect Dis. 2022 Apr 1.
        BACKGROUND: Tuberculosis (TB) elimination within the United States (US) will require scaling up TB preventive services. Many public health departments offer care for latent tuberculosis infection (LTBI), though gaps in the LTBI care cascade are not well quantified. An understanding of these gaps will be required to design targeted public health interventions. METHODS: We conducted a cohort study through the Tuberculosis Epidemiologic Studies Consortium (TBESC) within 15 local health department (LHD) TB clinics across the US. Data was abstracted on individuals receiving LTBI care during 2016-2017 through chart review. Our primary objective was to quantify the LTBI care cascade, beginning with LTBI testing and extending through treatment completion. RESULTS: Among 23,885 participants tested by LHDs, 46% (11,009) were male with a median age of 31 (IQR 20-46). A median of 35% of participants were US-born at each site (IQR 11-78). Overall, 16,689 (70%) received a tuberculin skin test (TST), 6,993 (29%) received a Quantiferon (QFT), and 1,934 (8%) received a T-SPOT.TB; 5% (1,190) had more than one test. Among those tested, 2,877 (12%) had at least one positive test result (3% among US-born, and 23% among non-US-born, p<0.01). Of 2,515 (11%) of the total participants diagnosed with LTBI, 1,073 (42%) initiated therapy, of whom 817 (76%) completed treatment (32% of those with LTBI diagnosis). CONCLUSIONS: Significant gaps were identified along the LTBI care cascade, with less than half of individuals diagnosed with LTBI initiating therapy. Further research is needed to better characterize the factors impeding LTBI diagnosis, treatment initiation, and treatment completion.

    • Environmental Health
      1. Correlates of non-persistent endocrine disrupting chemical mixtures among reproductive-aged Black women in Detroit, Michiganexternal icon
        Schildroth S, Wise LA, Wesselink AK, Bethea TN, Fruh V, Taylor KW, Calafat AM, Baird DD, Henn BC.
        Chemosphere. 2022 Mar 28:134447.
        Some studies indicate that Black women have higher exposure to multiple non-persistent endocrine disrupting chemicals (EDCs) than white women, but little is known about correlates of exposure to EDC mixtures. Using baseline data from a prospective cohort study of reproductive-aged Black women (N = 751), we characterized profiles of EDC mixtures and identified correlates of exposure. At baseline, we quantified biomarkers of 16 phthalates, 7 phenols, 4 parabens, and triclocarban in urine and collected covariate data through self-administered questionnaires and interviews. We used principal component (PC) analysis and k-means clustering to describe EDC mixture profiles. Associations between correlates and PCs were estimated as the mean difference (β) in PC scores, while associations between correlates and cluster membership were estimated as the odds ratio (OR) of cluster membership. Personal care product use was consistently associated with profiles of higher biomarker concentrations of non-persistent EDCs. Use of nail polish, menstrual and vaginal products (e.g., vaginal powder, vaginal deodorant), and sunscreen was associated with a mixture of phthalate and some phenol biomarkers using both methods. Current vaginal ring use, a form of hormonal contraception placed inside the vagina, was strongly associated with higher concentrations of high molecular weight phthalate biomarkers (k-means clustering: OR = 2.42, 95% CI = 1.28, 4.59; PCA: β = -0.32, 95% CI = -0.71, 0.07). Several dietary, reproductive, and demographic correlates were also associated with mixtures of EDC biomarkers. These findings suggest that personal care product use, diet, and contraceptive use may be sources of exposure to multiple non-persistent EDCs among reproductive-aged Black women. Targeted interventions to reduce exposure to multiple EDCs among Black women are warranted.

      2. Current status and future directions for a neurotoxicity hazard assessment framework that integrates in silico approachesexternal icon
        Crofton KM, Bassan A, Behl M, Chushak YG, Fritsche E, Gearhart JM, Marty MS, Mumtaz M, Pavan M, Ruiz P, Sachana M, Selvam R, Shafer TJ, Stavitskaya L, Szabo DT, Szabo ST, Tice RR, Wilson D, Woolley D, Myatt GJ.
        Comput Toxicol. 2022 ;22.
        Neurotoxicology is the study of adverse effects on the structure or function of the developing or mature adult nervous system following exposure to chemical, biological, or physical agents. The development of more informative alternative methods to assess developmental (DNT) and adult (NT) neurotoxicity induced by xenobiotics is critically needed. The use of such alternative methods including in silico approaches that predict DNT or NT from chemical structure (e.g., statistical-based and expert rule-based systems) is ideally based on a comprehensive understanding of the relevant biological mechanisms. This paper discusses known mechanisms alongside the current state of the art in DNT/NT testing. In silico approaches available today that support the assessment of neurotoxicity based on knowledge of chemical structure are reviewed, and a conceptual framework for the integration of in silico methods with experimental information is presented. Establishing this framework is essential for the development of protocols, namely standardized approaches, to ensure that assessments of NT and DNT based on chemical structures are generated in a transparent, consistent, and defendable manner. © 2022 Elsevier B.V.

      3. Monitoring different social media platforms to report unplanned school closures due to wildfires in California, October and December 2017external icon
        Buchanan BM, Evans HI, Chukwudebe NP, Duncan EA, Yin J, Adhikari BB, Zhou X, Tse ZT, Chowell G, Meltzer MI, Fung IC.
        Disaster Med Public Health Prep. 2022 Mar 31:1-7.
        OBJECTIVE: Researchers at the Centers for Disease Control and Prevention monitor unplanned school closure (USC) reports through online systematic searches (OSS) to assist public health emergency responses. We counted the additional reports identified through social media along with OSS to improve USC monitoring. METHODS: Facebook and Twitter data of public-school districts and private schools in counties affected by California wildfires in October and December of 2017 and January of 2018 were retrieved. We computed descriptive statistics and performed multivariable logistic regression for both OSS and social media data. RESULTS: Among the 362 public-school districts in wildfire-affected counties, USCs were identified for 115 (32%) districts, of which OSS identified 104 (90%), Facebook, 59 (52%), and Twitter, 37 (32%). These data correspond to 4622 public schools, among which USCs were identified for 888 (19.2%) schools, of which OSS identified 722 (81.3%), Facebook, 496 (55.9%), and Twitter, 312 (35.1%). Among 1289 private schools, USCs were identified for 104 schools, of which OSS identified 47 (45.2%), Facebook, 67 (64.4%), and Twitter, 29 (27.9%). USC announcements identified via social media, in addition to those via OSS, were 11 public school districts, 166 public schools, and 57 private schools. CONCLUSION: Social media complements OSS as additional resources for USC monitoring during disasters.

      4. Electronic cigarette, or vaping, products are used to heat an e-liquid to form an aerosol (liquid droplets suspended in gas) that the user inhales; a portion of this aerosol deposits in their respiratory tract and the remainder is exhaled, thereby potentially creating opportunity for secondhand exposure to bystanders (e.g., in homes, automobiles, and workplaces). Particle size, a critical factor in respiratory deposition (and therefore potential for secondhand exposure), could be influenced by e-liquid composition. Hence, the purposes of this study were to (1) test the influence of laboratory-prepared e-liquid composition [ratio of propylene glycol (PG) to vegetable glycerin (VG) humectants, nicotine, and flavorings] on particle size distribution and (2) model respiratory dosimetry. All e-liquids were aerosolized using a second-generation reference e-cigarette. We measured particle size distribution based on mass using a low-flow cascade impactor (LFCI) and size distribution based on number using real-time mobility sizers. Mass median aerodynamic diameters (MMADs) of aerosol from e-liquids that contained only humectants were significantly larger compared with e-liquids that contained flavorings or nicotine (p = 0.005). Humectant ratio significantly influenced MMADs; all aerosols from e-liquids prepared with 70:30 PG:VG were significantly larger compared with e-liquids prepared with 30:70 PG:VG (p = 0.017). In contrast to the LFCI approach, the high dilution and sampling flow rate of a fast mobility particle sizer strongly influenced particle size measurements (i.e., all calculated MMAD values were < 75 nm). Dosimetry modeling using LFCI data indicated that a portion of inhaled particles will deposit throughout the respiratory tract, though statistical differences in aerosol MMADs among e-liquid formulations did not translate into large differences in deposition estimates. A portion of inhaled aerosol will be exhaled and could be a source for secondhand exposure. Use of laboratory-prepared e-liquids and a reference e-cigarette to standardize aerosol generation and a LFCI to measure particle size distribution without dilution represents an improved method to characterize physical properties of volatile aerosol particles and permitted determination of MMAD values more representative of e-cigarette aerosol in situ, which in turn, can help to improve dose modeling for users and bystanders.

      5. Pre-and postnatal fine particulate matter exposure and childhood cognitive and adaptive functionexternal icon
        McGuinn LA, Wiggins LD, Volk HE, Di Q, Moody EJ, Kasten E, Schwartz J, Wright RO, Schieve LA, Windham GC, Daniels JL.
        Int J Environ Res Public Health. 2022 ;19(7).
        Increasing evidence exists for an association between early life fine particulate matter (PM2.5 ) exposure and several neurodevelopmental outcomes, including autism spectrum disorder (ASD); however, the association between PM2.5 and adaptive and cognitive function remains poorly understood. Participants included 658 children with ASD, 771 with a non-ASD developmental disorder, and 849 population controls from the Study to Explore Early Development. Adaptive functioning was assessed in ASD cases using the Vineland Adaptive Behavior Scales (VABS); cognitive functioning was assessed in all groups using the Mullen Scales of Early Learning (MSEL). A satellite-based model was used to assign PM2.5 exposure averages during pregnancy, each trimester, and the first year of life. Linear regression was used to estimate beta coefficients and 95% confidence intervals, adjusting for maternal age, education, prenatal tobacco use, race-ethnicity, study site, and season of birth. PM2.5 exposure was associated with poorer VABS scores for several domains, including daily living skills and socialization. Associations were present between prenatal PM2.5 and lower MSEL scores for all groups combined; results were most prominent for population controls in stratified analyses. These data suggest that early life PM2.5 exposure is associated with specific aspects of cognitive and adaptive functioning in children with and without ASD. © 2022 by the authors. Licensee MDPI, Basel, Switzerland.

    • Epidemiology and Surveillance
      1. A cohort study measuring SARS-CoV-2 seroconversion and serial viral testing in university studentsexternal icon
        Lee CC, Segaloff HE, Cole D, Rosenblum HG, Morgan CN, Somers T, Desamu-Thorpe R, Foster MA, Currie D, Ruff J, Payne D, Whyte TJ, Abedi GR, Bigouette JP, Kahrs J, Langolf K, Remington P, Sterkel A, Kelly P, Westergaard RP, Bateman AC, Hsu CH, Tate JE, Kirking HL.
        BMC Infect Dis. 2022 Mar 31;22(1):314.
        BACKGROUND: To improve understanding of the antibody response to SARS-CoV-2 infection, we examined seroprevalence, incidence of infection, and seroconversion among a cohort of young adults living on university campuses during the fall of 2020. METHODS: At the beginning (semester start) and end (semester end) of an 11-week period, serum collected from 107 students was tested using the qualitative Abbott Architect SARS-CoV-2 IgG and AdviseDx SARS-CoV-2 IgG II assays. Results were matched to interim weekly surveillance viral testing and symptom data. RESULTS: With the SARS-CoV-2 IgG assay, 15 (14.0%) students were seropositive at semester start; 29 (27.1%) students were seropositive at semester end; 10 (9.3%) were seropositive at both times. With the AdviseDx SARS-CoV-2 IgG II assay, 17 (16.3%) students were seropositive at semester start, 37 (35.6%) were seropositive at semester end, and 16 (15.3%) were seropositive at both times. Overall, 23 students (21.5%) had positive viral tests during the semester. Infection was identified by serial testing in a large majority of individuals who seroconverted using both assays. Those seropositive at semester end more frequently reported symptomatic infections (56.5%) than asymptomatic infections (30.4%). CONCLUSION: Differences between antibody targets were observed, with more declines in antibody index values below the threshold of positivity with the anti-nucleocapsid assay compared to the anti-spike assay. Serology testing, combined with serial viral testing, can detect seroconversions, and help understand the potential correlates of protection provided by antibodies to SARS-CoV-2.

    • Food Safety
      1. Large outbreak of Jimsonweed (Datura stramonium) poisoning due to consumption of contaminated humanitarian relief food: Uganda, March-April 2019external icon
        Mutebi RR, Ario AR, Nabatanzi M, Kyamwine IB, Wibabara Y, Muwereza P, Eurien D, Kwesiga B, Bulage L, Kabwama SN, Kadobera D, Henderson A, Callahan JH, Croley TR, Knolhoff AM, Mangrum JB, Handy SM, McFarland MA, Sam JL, Harris JR, Zhu BP.
        BMC Public Health. 2022 Mar 30;22(1):623.
        BACKGROUND: Jimsonweed (Datura stramonium) contains toxic alkaloids that cause gastrointestinal and central nervous system symptoms when ingested. This can be lethal at high doses. The plant may grow together with leguminous crops, mixing with them during harvesting. On 13 March 2019, more than 200 case-patients were admitted to multiple health centres for acute gastrointestinal and neurologic symptoms. We investigated to determine the cause and magnitude of the outbreak and recommended evidence-based control and prevention measures. METHODS: We defined a suspected case as sudden onset of confusion, dizziness, convulsions, hallucinations, diarrhoea, or vomiting with no other medically plausible explanations in a resident of Napak or Amudat District from 1 March-30 April 2019. We reviewed medical records and canvassed all villages of the eight affected subcounties to identify cases. In a retrospective cohort study conducted in 17 villages that reported the earliest cases, we interviewed 211 residents about dietary history during 11-15 March. We used modified Poisson regression to assess suspected food exposures. Food samples underwent chemical (heavy metals, chemical contaminants, and toxins), proteomic, DNA, and microbiological testing in one national and three international laboratories. RESULTS: We identified 293 suspected cases; five (1.7%) died. Symptoms included confusion (62%), dizziness (38%), diarrhoea (22%), nausea/vomiting (18%), convulsions (12%), and hallucinations (8%). The outbreak started on 12 March, 2-12 h after Batch X of fortified corn-soy blend (CSB +) was distributed. In the retrospective cohort study, 66% of 134 persons who ate CSB + , compared with 2.2% of 75 who did not developed illness (RR(adj) = 22, 95% CI = 6.0-81). Samples of Batch X distributed 11-15 March contained 14 tropane alkaloids, including atropine (25-50 ppm) and scopolamine (1-10 ppm). Proteins of Solanaceae seeds and Jimsonweed DNA were identified. No other significant laboratory findings were observed. CONCLUSION: This was the largest documented outbreak caused by food contamination with tropane alkaloids. Implicated food was immediately withdrawn. Routine food safety and quality checks could prevent future outbreaks.

    • Genetics and Genomics
      1. Exome sequencing identifies variants in infants with sacral agenesisexternal icon
        Pitsava G, Feldkamp ML, Pankratz N, Lane J, Kay DM, Conway KM, Hobbs C, Shaw GM, Reefhuis J, Jenkins MM, Almli LM, Moore C, Werler M, Browne ML, Cunniff C, Olshan AF, Pangilinan F, Brody LC, Sicko RJ, Finnell RH, Bamshad MJ, McGoldrick D, Nickerson DA, Mullikin JC, Romitti PA, Mills JL.
        Birth Defects Res. 2022 Apr;114(7):215-227.
        BACKGROUND: Sacral agenesis (SA) consists of partial or complete absence of the caudal end of the spine and often presents with additional birth defects. Several studies have examined gene variants for syndromic forms of SA, but only one has examined exomes of children with non-syndromic SA. METHODS: Using buccal cell specimens from families of children with non-syndromic SA, exomes of 28 child-parent trios (eight with and 20 without a maternal diagnosis of pregestational diabetes) and two child-father duos (neither with diagnosis of maternal pregestational diabetes) were exome sequenced. RESULTS: Three children had heterozygous missense variants in ID1 (Inhibitor of DNA Binding 1), with CADD scores >20 (top 1% of deleterious variants in the genome); two children inherited the variant from their fathers and one from the child's mother. Rare missense variants were also detected in PDZD2 (PDZ Domain Containing 2; N = 1) and SPTBN5 (Spectrin Beta, Non-erythrocytic 5; N = 2), two genes previously suggested to be associated with SA etiology. Examination of variants with autosomal recessive and X-linked recessive inheritance identified five and two missense variants, respectively. Compound heterozygous variants were identified in several genes. In addition, 12 de novo variants were identified, all in different genes in different children. CONCLUSIONS: To our knowledge, this is the first study reporting a possible association between ID1 and non-syndromic SA. Although maternal pregestational diabetes has been strongly associated with SA, the missense variants in ID1 identified in two of three children were paternally inherited. These findings add to the knowledge of gene variants associated with non-syndromic SA and provide data for future studies.

    • Health Behavior and Risk
      1. During 2007-2019, the percentage of HIV Outpatient Study participants reporting anal or vaginal condomless sex in the past 6 months ranged from a low of 17% among heterosexual males to 59% for men who have sex with men (MSM). MSM reported having had condomless sex more frequently than heterosexual males and females and were the only group in which an increase in condomless sex was observed during the study period (from 39 to 59%). Although persons with undetectable HIV viral load have effectively no risk of transmitting HIV sexually (U = U), there is still the potential risk of transmission or acquisition of other sexually transmitted infections (STIs) when engaging in condomless sex. Continuing education about risks of HIV and STI transmission as well as ongoing screening for and treatment of STIs, retention in HIV treatment, and support for sexual health are critical components of care for people living with HIV.

    • Health Communication and Education
      1. BACKGROUND: The internet has become an increasingly popular medium for parents to obtain health information. More studies investigating the impact of paid digital marketing campaigns for parents on promoting children's healthy development are needed. OBJECTIVE: This study aims to explore the outcomes of a paid digital marketing campaign, which occurred from 2018 to 2020, to promote messages about parent-engaged developmental monitoring and ultimately direct parents to the Centers for Disease Control and Prevention's (CDC's) Milestone Tracker app, a mobile health (mHealth) app developed by the CDC. METHODS: The paid digital marketing campaign occurred in 3 phases from 2018 to 2020. In each phase, 24 to 36 marketing messages, in English and Spanish, were created and disseminated using Google's Universal App Campaigns and Facebook Ads Manager. Outcomes were measured using impressions, clicks, and install data. Return on investment was measured using click-through rate (CTR), cost per click, and cost per install metrics. RESULTS: The Google-driven marketing messages garnered a total of 4,879,722 impressions (n=1,991,250, 40.81% for English and n=2,888,472, 59.19% for Spanish). The messages resulted in a total of 73,956 clicks (n=44,328, 59.94% for English and n=29,628, 40.06% for Spanish), with a total average CTR of 1.52% (2.22% for English and 1.03% for Spanish). From these clicks, there were 13,707 installs (n=9765, 71.24% for English and n=3942, 28.76% for Spanish) of the CDC's Milestone Tracker app on Google Play Store. The total average cost per install was US $0.93 across all phases. The phase 3 headline "Track your child's development" generated the highest CTR of 3.23% for both English and Spanish audiences. The Facebook-driven marketing messages garnered 2,434,320 impressions (n=1,612,934, 66.26% for English and n=821,386, 33.74% for Spanish). The messages resulted in 44,698 clicks (n=33,353, 74.62% for English and n=11,345, 25.38% for Spanish), with an average CTR of 1.84% (2.07% for English and 1.38% for Spanish). In all 3 phases, animated graphics generated the greatest number of clicks among both English and Spanish audiences on Facebook when compared with other types of images. CONCLUSIONS: These paid digital marketing campaigns can increase targeted message exposure about parent-engaged developmental monitoring and direct a parent audience to an mHealth app. Digital marketing platforms provide helpful metrics that can be used to assess the reach, engagement, and cost-effectiveness of this effort. The results from this study suggest that paid digital marketing can be an effective strategy and can inform future digital marketing activities to promote mHealth apps targeting parents of young children.

    • Health Equity and Health Disparities
      1. Blood pressure control among non-Hispanic Black adults is lower than non-Hispanic White adults despite similar treatment with anti-hypertensive medication: NHANES 2013-2018external icon
        Hayes DK, Jackson SL, Li Y, Wozniak G, Tsipas S, Hong Y, Thompson-Paul AM, Wall HK, Gillespie C, Egan BM, Ritchey MD, Loustalot F.
        Am J Hypertens. 2022 Apr 5.
        BACKGROUND: Controlled blood pressure can prevent or reduce adverse health outcomes. Social and structural determinants may contribute to the disparity that despite equivalent proportions on anti-hypertensive medication, non-Hispanic Black (Black) adults have lower blood pressure control and more cardiovascular events than non-Hispanic White (White) adults. METHODS: Data from 2013-2018 National Health and Nutrition Examination Survey were pooled to assess control among Black and White adults by anti-hypertensive medication use and selected characteristics using the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Blood Pressure Guideline definition (systolic blood pressure <130 mm Hg and diastolic blood pressure <80 mm Hg) among 4,739 adults. RESULTS: Among those treated with anti-hypertensive medication, an estimated 34.9% of Black and 45.0% of White adults had controlled blood pressure. Control was lower for Black and White adults among most subgroups of age, sex, education, insurance status, usual source of care, and poverty-income ratio. Black adults had higher use of diuretics (28.5%--Black adults vs. 23.5%--White adults) and calcium channel blockers (24.2%--Black adults vs. 14.7%--White adults) compared to White adults. Control among Black adults was lower than White adults across all medication classes including diuretics (36.1%--Black adults vs. 47.3%--White adults), calcium channel blockers (30.2%--Black adults vs. 40.1%--White adults), and number of medication classes used. CONCLUSIONS: Sub-optimal blood pressure control rates and disparities warrant increased efforts to improve control, which could include addressing social and structural determinants along with emphasizing implementation of the 2017 ACC/AHA Blood Pressure Guideline into clinical practice.

    • Healthcare Associated Infections
      1. Tuberculosis attributed to transmission within healthcare facilities, Botswana-The Kopanyo Studyexternal icon
        Smith JP, Modongo C, Moonan PK, Dima M, Matsiri O, Fane O, Click ES, Boyd R, Finlay A, Surie D, Tobias JL, Zetola NM, Oeltmann JE.
        Infect Control Hosp Epidemiol. 2022 Apr 6:1-7.
        OBJECTIVE: Healthcare facilities are a well-known high-risk environment for transmission of M. tuberculosis, the etiologic agent of tuberculosis (TB) disease. However, the link between M. tuberculosis transmission in healthcare facilities and its role in the general TB epidemic is unknown. We estimated the proportion of overall TB transmission in the general population attributable to healthcare facilities. METHODS: We combined data from a prospective, population-based molecular epidemiologic study with a universal electronic medical record (EMR) covering all healthcare facilities in Botswana to identify biologically plausible transmission events occurring at the healthcare facility. Patients with M. tuberculosis isolates of the same genotype visiting the same facility concurrently were considered an overlapping event. We then used TB diagnosis and treatment data to categorize overlapping events into biologically plausible definitions. We calculated the proportion of overall TB cases in the cohort that could be attributable to healthcare facilities. RESULTS: In total, 1,881 participants had TB genotypic and EMR data suitable for analysis, resulting in 46,853 clinical encounters at 338 healthcare facilities. We identified 326 unique overlapping events involving 370 individual patients; 91 (5%) had biologic plausibility for transmission occurring at a healthcare facility. A sensitivity analysis estimated that 3%-8% of transmission may be attributable to healthcare facilities. CONCLUSIONS: Although effective interventions are critical in reducing individual risk for healthcare workers and patients at healthcare facilities, our findings suggest that development of targeted interventions aimed at community transmission may have a larger impact in reducing TB.

    • Immunity and Immunization
      1. Mathematical modeling to inform vaccination strategies and testing approaches for coronavirus disease 2019 (COVID-19) in nursing homesexternal icon
        Kahn R, Holmdahl I, Reddy S, Jernigan J, Mina MJ, Slayton RB.
        Clin Infect Dis. 2022 Mar 1;74(4):597-603.
        BACKGROUND: Nursing home residents and staff were included in the first phase of coronavirus disease 2019 vaccination in the United States. Because the primary trial endpoint was vaccine efficacy (VE) against symptomatic disease, there are limited data on the extent to which vaccines protect against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the ability to infect others (infectiousness). Assumptions about VE against infection and infectiousness have implications for changes to infection prevention guidance for vaccinated populations, including testing strategies. METHODS: We use a stochastic agent-based Susceptible-Exposed-Infectious (Asymptomatic/Symptomatic)-Recovered model of a nursing home to simulate SARS-CoV-2 transmission. We model 3 scenarios, varying VE against infection, infectiousness, and symptoms, to understand the expected impact of vaccination in nursing homes, increasing staff vaccination coverage, and different screening testing strategies under each scenario. RESULTS: Increasing vaccination coverage in staff decreases total symptomatic cases in the nursing home (among staff and residents combined) in each VE scenario. In scenarios with 50% and 90% VE against infection and infectiousness, increasing staff coverage reduces symptomatic cases among residents. If vaccination only protects against symptoms, and asymptomatic cases remain infectious, increased staff coverage increases symptomatic cases among residents. However, this is outweighed by the reduction in symptomatic cases among staff. Higher frequency testing-more than once weekly-is needed to reduce total symptomatic cases if the vaccine has lower efficacy against infection and infectiousness, or only protects against symptoms. CONCLUSIONS: Encouraging staff vaccination is not only important for protecting staff, but might also reduce symptomatic cases in residents if a vaccine confers at least some protection against infection or infectiousness.

      2. Costs of seasonal influenza vaccination in South Africaexternal icon
        Fraser H, Tombe-Mdewa W, Kohli-Lynch C, Hofman K, Tempia S, McMorrow M, Lambach P, Ramkrishna W, Cohen C, Hutubessy R, Edoka I.
        Influenza Other Respir Viruses. 2022 Mar 30.
        BACKGROUND: Influenza accounts for a substantial number of deaths and hospitalisations annually in South Africa. To address this disease burden, the South African National Department of Health introduced a trivalent inactivated influenza vaccination programme in 2010. METHODS: We adapted and populated the WHO Seasonal Influenza Immunization Costing Tool (WHO SIICT) with country-specific data to estimate the cost of the influenza vaccination programme in South Africa. Data were obtained through key-informant interviews at different levels of the health system and through a review of existing secondary data sources. Costs were estimated from a public provider perspective and expressed in 2018 prices. We conducted scenario analyses to assess the impact of different levels of programme expansion and the use of quadrivalent vaccines on total programme costs. RESULTS: Total financial and economic costs were estimated at approximately USD 2.93 million and USD 7.91 million, respectively, while financial and economic cost per person immunised was estimated at USD 3.29 and USD 8.88, respectively. Expanding the programme by 5% and 10% increased economic cost per person immunised to USD 9.36 and USD 9.52 in the two scenarios, respectively. Finally, replacing trivalent inactivated influenza vaccine (TIV) with quadrivalent vaccine increased financial and economic costs to USD 4.89 and USD 10.48 per person immunised, respectively. CONCLUSION: We adapted the WHO SIICT and provide estimates of the total costs of the seasonal influenza vaccination programme in South Africa. These estimates provide a basis for planning future programme expansion and may serve as inputs for cost-effectiveness analyses of seasonal influenza vaccination programmes.

      3. Impact of 13-valent pneumococcal conjugate vaccine on invasive pneumococcal disease among adults with HIV-United States, 2008-2018external icon
        Kobayashi M, Matanock A, Xing W, Adih WK, Li J, Gierke R, Almendares O, Reingold A, Alden N, Petit S, Farley MM, Harrison LH, Holtzman C, Baumbach J, Thomas A, Schaffner W, McGee L, Pilishvili T.
        J Acquir Immune Defic Syndr. 2022 May 1;90(1):6-14.
        BACKGROUND: People with HIV (PWH) are at increased risk for invasive pneumococcal disease (IPD). Thirteen-valent pneumococcal conjugate vaccine (PCV13) was recommended for use in US children in 2010 and for PWH aged 19 years or older in 2012. We evaluated the population-level impact of PCV13 on IPD among PWH and non-PWH aged 19 years or older. METHODS: We identified IPD cases from 2008 to 2018 through the Active Bacterial Core surveillance platform. We estimated IPD incidence using the National HIV Surveillance System and US Census Bureau data. We measured percent changes in IPD incidence from 2008 to 2009 to 2017-2018 by HIV status, age group, and vaccine serotype group, including serotypes in recently licensed 15-valent (PCV15) and 20-valent (PCV20) PCVs. RESULTS: In 2008-2009 and 2017-2018, 8.4% (552/6548) and 8.0% (416/5169) of adult IPD cases were among PWH, respectively. Compared with non-PWH, a larger proportion of IPD cases among PWH were in adults aged 19-64 years (94.7%-97.4% vs. 56.0%-60.1%) and non-Hispanic Black people (62.5%-73.0% vs. 16.7%-19.2%). Overall and PCV13-type IPD incidence in PWH declined by 40.3% (95% confidence interval: -47.7 to -32.3) and 72.5% (95% confidence interval: -78.8 to -65.6), respectively. In 2017-2018, IPD incidence was 16.8 (overall) and 12.6 (PCV13 type) times higher in PWH compared with non-PWH; PCV13, PCV15/non-PCV13, and PCV20/non-PCV15 serotypes comprised 21.5%, 11.2%, and 16.5% of IPD in PWH, respectively. CONCLUSIONS: Despite reductions post-PCV13 introduction, IPD incidence among PWH remained substantially higher than among non-PWH. Higher-valent PCVs provide opportunities to reduce remaining IPD burden in PWH.

      4. mRNA vaccine effectiveness against COVID-19 hospitalization among solid organ transplant recipientsexternal icon
        Kwon JH, Tenforde MW, Gaglani M, Talbot HK, Ginde AA, McNeal T, Ghamande S, Douin DJ, Casey JD, Mohr NM, Zepeski A, Shapiro NI, Gibbs KW, Files DC, Hager DN, Shehu A, Prekker ME, Caspers SD, Exline MC, Botros M, Gong MN, Li A, Mohamed A, Johnson NJ, Srinivasan V, Steingrub JS, Peltan ID, Brown SM, Martin ET, Khan A, Hough CL, Busse LW, Duggal A, Wilson JG, Perez C, Chang SY, Mallow C, Rovinski R, Babcock HM, Lauring AS, Felley L, Halasa N, Chappell JD, Grijalva CG, Rice TW, Womack KN, Lindsell CJ, Hart KW, Baughman A, Olson SM, Schrag S, Kobayashi M, Verani JR, Patel MM, Self WH.
        J Infect Dis. 2022 Apr 6.
        BACKGROUND: The study objective was to evaluate 2 and 3 dose COVID-19 mRNA vaccine effectiveness (VE) in preventing COVID-19 hospitalization among adult solid organ transplant (SOT) recipients. METHODS: 21-site case-control analysis of 10,425 adults hospitalized March-December 2021. Cases were hospitalized with COVID-19; controls were hospitalized for an alternative diagnosis (SARS-CoV-2 negative). Participants were classified as: SOT recipient (n=440), other immunocompromising condition (n=1684), or immunocompetent (n=8301). VE against COVID-19 associated hospitalization was calculated as 1-adjusted odds ratio of prior vaccination among cases compared with controls. RESULTS: Among SOT recipients, VE was 29% (95% CI: -19 to 58%) for 2 doses and 77% (95% CI: 48 to 90%) for 3 doses. Among patients with other immunocompromising conditions, VE was 72% (95% CI: 64 to 79%) for 2 doses and 92% (95% CI: 85 to 95%) for 3 doses. Among immunocompetent patients, VE was 88% (95% CI: 87 to 90%) for 2 doses and 96% (95% CI: 83 to 99%) for 3 doses. CONCLUSION: Effectiveness of COVID-19 mRNA vaccines was lower for SOT recipients than immunocompetent people and those with other immunocompromising conditions. Among SOT recipients, vaccination with 3 doses of an mRNA vaccine led to substantially greater protection than 2 doses.

      5. Assessment of provision of COVID-19 vaccination in dialysis clinics and patient vaccination coverageexternal icon
        Patel PR, Tanz LJ, Hamilton E, Swanzy K, Hymes JL, Giullian J, Novosad SA.
        JAMA Intern Med. 2022 Apr 4.

      6. A Streptococcus pneumoniae lineage usually associated with pneumococcal conjugate vaccine (PCV) serotypes is the most common cause of serotype 35B invasive disease in South Africa, following routine use of PCVexternal icon
        Ndlangisa KM, du Plessis M, Lo S, de Gouveia L, Chaguza C, Antonio M, Kwambana-Adams B, Cornick J, Everett DB, Dagan R, Hawkins PA, Beall B, Corso A, Grassi Almeida SC, Ochoa TJ, Obaro S, Shakoor S, Donkor ES, Gladstone RA, Ho PL, Paragi M, Doiphode S, Srifuengfung S, Ford R, Moïsi J, Saha SK, Bigogo G, Sigauque B, Eser Ö K, Elmdaghri N, Titov L, Turner P, Kumar KL, Kandasamy R, Egorova E, Ip M, Breiman RF, Klugman KP, McGee L, Bentley SD, von Gottberg A, The Global Pneumococcal Sequencing C.
        Microb Genom. 2022 Apr;8(4).
        Pneumococcal serotype 35B is an important non-conjugate vaccine (non-PCV) serotype. Its continued emergence, post-PCV7 in the USA, was associated with expansion of a pre-existing 35B clone (clonal complex [CC] 558) along with post-PCV13 emergence of a non-35B clone previously associated with PCV serotypes (CC156). This study describes lineages circulating among 35B isolates in South Africa before and after PCV introduction. We also compared 35B isolates belonging to a predominant 35B lineage in South Africa (GPSC5), with isolates belonging to the same lineage in other parts of the world. Serotype 35B isolates that caused invasive pneumococcal disease in South Africa in 2005-2014 were characterized by whole-genome sequencing (WGS). Multi-locus sequence types and global pneumococcal sequence clusters (GPSCs) were derived from WGS data of 63 35B isolates obtained in 2005-2014. A total of 262 isolates that belong to GPSC5 (115 isolates from South Africa and 147 from other countries) that were sequenced as part of the global pneumococcal sequencing (GPS) project were included for comparison. Serotype 35B isolates from South Africa were differentiated into seven GPSCs and GPSC5 was most common (49 %, 31/63). While 35B was the most common serotype among GPSC5/CC172 isolates in South Africa during the PCV13 period (66 %, 29/44), 23F was the most common serotype during both the pre-PCV (80 %, 37/46) and PCV7 period (32 %, 8/25). Serotype 35B represented 15 % (40/262) of GPSC5 isolates within the global GPS database and 75 % (31/40) were from South Africa. The predominance of the GPSC5 lineage within non-vaccine serotype 35B, is possibly unique to South Africa and warrants further molecular surveillance of pneumococci.

      7. Effectiveness of homologous and heterologous COVID-19 booster doses following 1 Ad.26.COV2.S (Janssen [Johnson & Johnson]) vaccine dose against COVID-19-associated emergency department and urgent care encounters and hospitalizations among adults - VISION Network, 10 States, December 2021-March 2022external icon
        Natarajan K, Prasad N, Dascomb K, Irving SA, Yang DH, Gaglani M, Klein NP, DeSilva MB, Ong TC, Grannis SJ, Stenehjem E, Link-Gelles R, Rowley EA, Naleway AL, Han J, Raiyani C, Benitez GV, Rao S, Lewis N, Fadel WF, Grisel N, Griggs EP, Dunne MM, Stockwell MS, Mamawala M, McEvoy C, Barron MA, Goddard K, Valvi NR, Arndorfer J, Patel P, Mitchell PK, Smith M, Kharbanda AB, Fireman B, Embi PJ, Dickerson M, Davis JM, Zerbo O, Dalton AF, Wondimu MH, Azziz-Baumgartner E, Bozio CH, Reynolds S, Ferdinands J, Williams J, Schrag SJ, Verani JR, Ball S, Thompson MG, Dixon BE.
        MMWR Morb Mortal Wkly Rep. 2022 Apr 1;71(13):495-502.
        CDC recommends that all persons aged ≥18 years receive a single COVID-19 vaccine booster dose ≥2 months after receipt of an Ad.26.COV2.S (Janssen [Johnson & Johnson]) adenovirus vector-based primary series vaccine; a heterologous COVID-19 mRNA vaccine is preferred over a homologous (matching) Janssen vaccine for booster vaccination. This recommendation was made in light of the risks for rare but serious adverse events following receipt of a Janssen vaccine, including thrombosis with thrombocytopenia syndrome and Guillain-Barré syndrome(†) (1), and clinical trial data indicating similar or higher neutralizing antibody response following heterologous boosting compared with homologous boosting (2). Data on real-world vaccine effectiveness (VE) of different booster strategies following a primary Janssen vaccine dose are limited, particularly during the period of Omicron variant predominance. The VISION Network(§) determined real-world VE of 1 Janssen vaccine dose and 2 alternative booster dose strategies: 1) a homologous booster (i.e., 2 Janssen doses) and 2) a heterologous mRNA booster (i.e., 1 Janssen dose/1 mRNA dose). In addition, VE of these booster strategies was compared with VE of a homologous booster following mRNA primary series vaccination (i.e., 3 mRNA doses). The study examined 80,287 emergency department/urgent care (ED/UC) visits(¶) and 25,244 hospitalizations across 10 states during December 16, 2021-March 7, 2022, when Omicron was the predominant circulating variant.** VE against laboratory-confirmed COVID-19-associated ED/UC encounters was 24% after 1 Janssen dose, 54% after 2 Janssen doses, 79% after 1 Janssen/1 mRNA dose, and 83% after 3 mRNA doses. VE for the same vaccination strategies against laboratory-confirmed COVID-19-associated hospitalizations were 31%, 67%, 78%, and 90%, respectively. All booster strategies provided higher protection than a single Janssen dose against ED/UC visits and hospitalizations during Omicron variant predominance. Vaccination with 1 Janssen/1 mRNA dose provided higher protection than did 2 Janssen doses against COVID-19-associated ED/UC visits and was comparable to protection provided by 3 mRNA doses during the first 120 days after a booster dose. However, 3 mRNA doses provided higher protection against COVID-19-associated hospitalizations than did other booster strategies during the same time interval since booster dose. All adults who have received mRNA vaccines for their COVID-19 primary series vaccination should receive an mRNA booster dose when eligible. Adults who received a primary Janssen vaccine dose should preferentially receive a heterologous mRNA vaccine booster dose ≥2 months later, or a homologous Janssen vaccine booster dose if mRNA vaccine is contraindicated or unavailable. Further investigation of the durability of protection afforded by different booster strategies is warranted.

      8. Universal hepatitis B vaccination in adults aged 19-59 years: Updated Recommendations of the Advisory Committee on Immunization Practices - United States, 2022external icon
        Weng MK, Doshani M, Khan MA, Frey S, Ault K, Moore KL, Hall EW, Morgan RL, Campos-Outcalt D, Wester C, Nelson NP.
        MMWR Morb Mortal Wkly Rep. 2022 Apr 1;71(13):477-483.
        Hepatitis B (HepB) vaccines have demonstrated safety, immunogenicity, and efficacy during the past 4 decades (1,2). However, vaccination coverage among adults has been suboptimal, limiting further reduction in hepatitis B virus (HBV) infections in the United States. This Advisory Committee on Immunization Practices (ACIP) recommendation expands the indicated age range for universal HepB vaccination to now include adults aged 19-59 years. Removing the risk factor assessment previously recommended to determine vaccine eligibility in this adult age group (2) could increase vaccination coverage and decrease hepatitis B cases.

      9. Protection with a third dose of mRNA vaccine against SARS-CoV-2 variants in frontline workersexternal icon
        Yoon SK, Hegmann KT, Thiese MS, Burgess JL, Ellingson K, Lutrick K, Olsho LE, Edwards LJ, Sokol B, Caban-Martinez AJ, Schaefer-Solle N, Jones JM, Tyner H, Hunt A, Respet K, Gaglani M, Dunnigan K, Rose S, Naleway A, Groom H, Kuntz J, Fowlkes AL, Thompson MG, Yoo YM.
        N Engl J Med. 2022 Apr 6.

      10. Defining the risk of SARS-CoV-2 variants on immune protectionexternal icon
        DeGrace MM, Ghedin E, Frieman MB, Krammer F, Grifoni A, Alisoltani A, Alter G, Amara RR, Baric RS, Barouch DH, Bloom JD, Bloyet LM, Bonenfant G, Boon AC, Boritz EA, Bratt DL, Bricker TL, Brown L, Buchser WJ, Carreño JM, Cohen-Lavi L, Darling TL, Davis-Gardner ME, Dearlove BL, Di H, Dittmann M, Doria-Rose NA, Douek DC, Drosten C, Edara VV, Ellebedy A, Fabrizio TP, Ferrari G, Florence WC, Fouchier RA, Franks J, García-Sastre A, Godzik A, Gonzalez-Reiche AS, Gordon A, Haagmans BL, Halfmann PJ, Ho DD, Holbrook MR, Huang Y, James SL, Jaroszewski L, Jeevan T, Johnson RM, Jones TC, Joshi A, Kawaoka Y, Kercher L, Koopmans MP, Korber B, Koren E, Koup RA, LeGresley EB, Lemieux JE, Liebeskind MJ, Liu Z, Livingston B, Logue JP, Luo Y, McDermott AB, McElrath MJ, Meliopoulos VA, Menachery VD, Montefiori DC, Mühlemann B, Munster VJ, Munt JE, Nair MS, Netzl A, Niewiadomska AM, O'Dell S, Pekosz A, Perlman S, Pontelli MC, Rockx B, Rolland M, Rothlauf PW, Sacharen S, Scheuermann RH, Schmidt SD, Schotsaert M, Schultz-Cherry S, Seder RA, Sedova M, Sette A, Shabman RS, Shen X, Shi PY, Shukla M, Simon V, Stumpf S, Sullivan NJ, Thackray LB, Theiler J, Thomas PG, Trifkovic S, Türeli S, Turner SA, Vakaki MA, van Bakel H, VanBlargan LA, Vincent LR, Wallace ZS, Wang L, Wang M, Wang P, Wang W, Weaver SC, Webby RJ, Weiss CD, Wentworth DE, Weston SM, Whelan SP, Whitener BM, Wilks SH, Xie X, Ying B, Yoon H, Zhou B, Hertz T, Smith DJ, Diamond MS, Post DJ, Suthar MS.
        Nature. 2022 Mar 31.
        The global emergence of many severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants jeopardizes the protective antiviral immunity induced following infection or vaccination. To address the public health threat caused by the increasing SARS-CoV-2 genomic diversity, the National Institute of Allergy and Infectious Diseases (NIAID) within the National Institutes of Health (NIH) established the SARS-CoV-2 Assessment of Viral Evolution (SAVE) program. This effort was designed to provide a real-time risk assessment of SARS-CoV-2 variants potentially impacting transmission, virulence, and resistance to convalescent and vaccine-induced immunity. The SAVE program serves as a critical data-generating component of the United States Government SARS-CoV-2 Interagency Group to assess implications of SARS-CoV-2 variants on diagnostics, vaccines, and therapeutics and for communicating public health risk. Here we describe the coordinated approach used to identify and curate data about emerging variants, their impact on immunity, and effects on vaccine protection using animal models. We report the development of reagents, methodologies, models, and pivotal findings facilitated by this collaborative approach and identify future challenges. This program serves as a template for the response against rapidly evolving pandemic pathogens by monitoring viral evolution in the human population to identify variants that could erode the effectiveness of countermeasures.

      11. Assessing the impact of the routine childhood hepatitis B immunization program and the need for hepatitis B vaccine birth dose in Sierra Leone, 2018external icon
        Breakwell L, Marke D, Kaiser R, Tejada-Strop A, Pauly MD, Jabbi S, Yambasu S, Kabore HJ, Stewart B, Sesay T, Samba TT, Hayden T, Kamili S, Jambai A, Drobeniuc J, Singh T, Tohme RA, Wasley A.
        Vaccine. 2022 Mar 28.
        Sierra Leone is highly endemic for hepatitis B virus (HBV) infection and thus recommends three doses of hepatitis B vaccine (HepB3) from 6 weeks of age but does not recommend a birth dose (HepB-BD) to prevent mother-to-child transmission (MTCT). We evaluated impact of the existing HepB3 schedule and risk for MTCT of HBV. We conducted a community-based serosurvey among 4-30-month-olds, their mothers, and 5-9-year-olds in three districts in Sierra Leone. Participants had an HBV surface antigen (HBsAg) rapid test; all HBsAg-positive and one HBsAg-negative mother per cluster were tested for HBV markers. We collected children's HepB3 vaccination history. Among 1889 children aged 4-30 months, HepB3 coverage was 85% and 20 (1·3% [95% CI 0·8-2·0]) were HBsAg-positive, of whom 70% had received HepB3. Among 2025 children aged 5-9 years, HepB3 coverage was 77% and 32 (1·6% [1·1-2·3]) were HBsAg-positive, of whom 56% had received HepB3. Of 1776 mothers, 169 (9·8% [8·1-11·7]) were HBsAg-positive. HBsAg prevalence was 5·9% among children of HBsAg-positive mothers compared to 0·7% among children of HBsAg-negative mothers (adjusted OR = 10·6 [2·8-40·8]). HBsAg positivity in children was associated with maternal HBsAg (p = 0·026), HBV e antigen (p < 0·001), and HBV DNA levels ≥ 200 000 IU/mL (p < 0·001). HBsAg prevalence was lower among children than mothers, for whom HepB was not available, suggesting routine infant HepB vaccination has lowered HBV burden. Since HBsAg positivity in children was strongly associated with maternal HBV infection and most of the HBsAg-positive children in the survey received HepB3, HepB-BD may prevent MTCT and chronic HBV infection.

      12. Delivering inactivated poliovirus vaccine (IPV) with oral poliovirus vaccine (OPV) in campaigns has been explored to accelerate the control of type 2 circulating vaccine-derived poliovirus (cVDPV) outbreaks. A review of scientific literature suggests that among populations with high prevalence of OPV failure, a booster with IPV after at least two doses of OPV may close remaining humoral and mucosal immunity gaps more effectively than an additional dose of trivalent OPV. However, IPV alone demonstrates minimal advantage on humoral immunity compared with monovalent and bivalent OPV, and cannot provide the intestinal immunity that prevents infection and spread to those individuals not previously exposed to live poliovirus of the same serotype (i.e. type 2 for children born after the switch from trivalent to bivalent OPV in April 2016). A review of operational data from polio campaigns shows that addition of IPV increases the cost and logistic complexity of campaigns. As a result, campaigns in response to an outbreak often target small areas. Large campaigns require a delay to ensure logistics are in place for IPV delivery, and may need implementation in phases that last several weeks. Challenges to delivery of injectable vaccines through house-to-house visits also increases the risk of missing the children who are more likely to benefit from IPV: those with difficult access to routine immunization and other health services. Based upon this information, the Strategic Advisory Group of Experts in immunization (SAGE) recommended in October 2020 the following strategies: provision of a second dose of IPV in routine immunization to reduce the risk and number of paralytic cases in countries at risk of importation or new emergences; and use of type 2 OPV in high-quality campaigns to interrupt transmission and avoid seeding new type 2 cVDPV outbreaks.

    • Injury and Violence
      1. Disclosure and help-seeking behaviors related to sexual and physical violence in childhood and adolescence: Results from the Namibia Violence Against Children and Youth Surveyexternal icon
        Velloza J, Davies L, Ensminger A, Theofelus FM, Andjamba H, Kamuingona R, Nakuta J, Uiras W, Massetti G, Coomer R, Wolkon A, Forster N, O'Malley G.
        Child Abuse Negl. 2022 Apr 2;128:105624.
        BACKGROUND: Violence disclosure and help-seeking can mitigate adverse health effects associated with childhood violence, but little is known about facilitators and barriers of disclosure and help-seeking behaviors in sub-Saharan Africa. OBJECTIVE: To understand factors associated with disclosure and help-seeking to inform care. PARTICIPANTS AND SETTING: Participants aged 13-24 years old in the 2019 Namibia Violence Against Children and Youth Survey (VACS). METHODS: We assessed the prevalence of victimization, disclosure, and help-seeking and examined factors associated with violence disclosure and help-seeking, separately, by gender. RESULTS: 4211 girls and 980 boys participated in the Namibia VACS. The prevalence of childhood sexual violence differed significantly by gender (15.7% among girls, 9.8% among boys), but physical violence prevalence did not differ by gender. Among victims of sexual violence, 57.3% of girls disclosed and 10.4% sought help, compared with only 30.7% and 3.2% of boys. Among victims of physical violence, 61.1% of girls and 53.4% of boys disclosed, and 16.9% of girls and 17.7% of boys sought help. Older age, social support, and experiencing more types of violence were associated with sexual violence disclosure among boys, but none of these factors were associated with sexual violence disclosure among girls. Lower education, perpetrator type, and witnessing violence were associated with physical violence disclosure among girls, while peer support and perpetrator type were associated with physical violence disclosure among boys. CONCLUSIONS: Factors associated with childhood violence differed by gender and violence type in Namibia, highlighting a need for gender-specific violence services to facilitate violence disclosure and help-seeking.

      2. Factors associated with bullying victimization and bullying perpetration in children and adolescents with ADHD: 2016 to 2017 National Survey of Children's Healthexternal icon
        Cuba Bustinza C, Adams RE, Claussen AH, Vitucci D, Danielson ML, Holbrook JR, Charania SN, Yamamoto K, Nidey N, Froehlich TE.
        J Atten Disord. 2022 Apr 5:10870547221085502.
        OBJECTIVE: To identify characteristics associated with bullying involvement in pediatric ADHD. METHODS: Data from the 2016 to 2017 National Survey of Children's Health for children aged 6 to 17 years with ADHD were evaluated to assess the association between parent-reported bullying victimization or perpetration and the following potential predictors: demographic characteristics, family factors, school factors, and child conditions/behaviors. RESULTS: Among children with ADHD, 46.9% were bullying victims and 16.2% were perpetrators. Factors associated with victimization included having family financial strain, developmental delay or intellectual disability, friendship difficulties, and school reports about problems. Factors linked to perpetration included being male, receiving government assistance, lack of school engagement, school reports about problems, and having difficulties with friendships, staying calm, and arguing. CONCLUSIONS: Children with ADHD frequently were bullying victims and sometimes bullying perpetrators. Factors related to family financial strain, developmental disabilities, emotional regulation, peer relationships, and school functioning may help to identify risk for bullying and opportunities for anti-bullying interventions.

      3. National prevalence of physical and sexual violence and its relationship to sexual behaviors are unknown among men who have sex with men (MSM). We estimated 12-month prevalence of physical and sexual violence and assessed relationships between violence and sexual behaviors among MSM. Data were obtained from National HIV Behavioral Surveillance 2017 that used time-space sampling methods to recruit and interview MSM in 22 U.S. cities. Weighted percentages with 95% confidence intervals (CI) were reported. Adjusted prevalence ratios (aPR) and 95% CIs were calculated using logistic regression with predicted marginal means. Overall, 10.2% (95% CI: 9.3%-11.2%) of MSM experienced physical violence only, 3.2% (95% CI: 2.7%-3.7%) experienced sexual violence only, and 2.3% (95% CI: 1.9%-2.7%) experienced both types of violence, in the past 12 months. Compared to MSM who did not experience violence, those who did reported higher percentages of unemployment, poverty, homelessness, same-sex discrimination, non-injection drug use, and binge drinking. Violence was not independently associated with condomless anal sex among MSM. MSM who experienced both types of violence were more likely than those who did not experience violence to have had four or more male sex partners (aPR=1.18, 95% CI: 1.02-1.37). MSM who experienced both types of violence (aPR=2.49, 95% CI: 1.52-4.09), sexual violence (aPR=2.27, 95% CI: 1.47-3.52), or physical violence (aPR=1.76, 95% CI: 1.27-2.44) were more likely than those who did not experience violence to have had exchange sex. Recent physical violence and sexual violence are common among MSM. Findings highlight the importance of violence screening and suggest the need for tailored interventions that improve the safety and economic security of MSM who experience violence, including those who exchange sex.

      4. The accurate measurement of violence depends on high-quality data collected using methods that ensure participant confidentiality, privacy, and safety. To assess survey participants' emotional distress, discomfort, and self-perceived value of participating in the Honduras (2017), El Salvador (2017), Cote d'Ivoire (2018), and Lesotho (2018) Violence Against Children and Youth Surveys, which include sensitive topics such as sexual, physical, and emotional violence, we investigated individual self-reported distress and perceived value of participation by age, sex, and other demographic factors. We also examined the associations between past experiences of violence and both self-reported distress and perceived value of survey participation. Few individuals reported distress or concerns about disclosure. Across countries, 82.9% (Cote d'Ivoire) to 96.1% (Honduras) of participants indicated they were not afraid that someone might overhear their answers, 82.5% (Cote d'Ivoire) to 98.0% (El Salvador) said participation was not upsetting or stressful, and 93.3% (Cote d'Ivoire) to 98.6% (Honduras) said participation was worthwhile. The value of these interviews may exceed the negative feelings that some questions potentially elicit and can contribute to improved responses to victims.

    • Laboratory Sciences
      1. Improving transparency-A call to include social housing information in biomedical research articles involving nonhuman primatesexternal icon
        Pomerantz O, Baker KC, Bellanca RU, Bloomsmith MA, Coleman K, Hutchinson EK, Pierre PJ, Weed JL.
        Am J Primatol. 2022 Apr 1:e23378.
        The social setting of animal subjects in the research environment has known effects on a variety of dependent measures used in biomedical research. Proper evaluation of the robustness of published research is dependent upon transparent, detailed, and accurate reporting of research methods, including the animals' social housing conditions. However, to date, most research articles utilizing nonhuman primates (NHPs) provide only partial data on this topic, hampering transparency, and reproducibility. Therefore, we call for the inclusion of information pertaining to the social aspects of the animals' housing conditions in publications involving NHPs to improve transparency. We argue that including this information in scientific publications is crucial for the interpretation of research findings in the appropriate context and for understanding unexplained variability in study findings. Finally, the inclusion of this information in publications will additionally familiarize scientists with how other researchers conducting similar studies are housing their animals and will encourage them to consider the implications of various housing conditions on their research outcomes.

      2. Performance of Xpert Ultra nasopharyngeal swab for identification of tuberculosis deaths in northern Tanzaniaexternal icon
        Costales C, Crump JA, Mremi AR, Amsi PT, Kalengo NH, Kilonzo KG, Kinabo G, Lwezaula BF, Lyamuya F, Marandu A, Mbwasi R, Mmbaga BT, Mosha C, Carugati M, Madut DB, Nelson AM, Maze MJ, Matkovic E, Zaki SR, Maro VP, Rubach MP.
        Clin Microbiol Infect. 2022 Mar 28.
        OBJECTIVES: Numerous tuberculosis deaths remain undetected in low-resource endemic settings. With autopsy-confirmed tuberculosis as our standard, we assessed the diagnostic performance of Xpert MTB/RIF Ultra (Ultra; Cepheid) on nasopharyngeal specimens collected post-mortem. METHODS: From October 2016 through May 2019, we enrolled pediatric and adult medical deaths to a prospective autopsy study at two referral hospitals in northern Tanzania with next-of-kin authorization. We swabbed the posterior nasopharynx prior to autopsy, and tested the samples later by Ultra. At autopsy we collected lung, liver, and, when possible, cerebrospinal fluid for mycobacterial culture and histopathology. Confirmed tuberculosis was defined as Mycobacterium tuberculosis complex recovery by culture with consistent tissue histopathology findings; decedents with only histopathology findings, including acid-fast staining or immunohistochemistry, were defined as probable tuberculosis. MEASUREMENTS AND MAIN RESULTS: Of 205 decedents, 78 (38.0%) were female and median (range) age was 45 (<1,96) years. Twenty-seven (13.2%) were found to have tuberculosis at autopsy, 22 (81.5%) confirmed and 5 (18.5%) probable. Ultra detected M. tuberculosis complex from the nasopharynx in 21 (77.8%) of 27 TB cases, (sensitivity 70.4% [95% CI 49.8 - 86.2%], specificity 98.9% [95% CI 96.0 - 99.9%]. Among confirmed TB, the sensitivity increased to 81.8% (95% CI 59.7 - 94.8%). Tuberculosis was not included as a death certificate diagnosis in fourteen (66.7%) of the 21 MTBc detections by Ultra. CONCLUSIONS: Nasopharyngeal Ultra was highly specific for identifying in-hospital tuberculosis deaths, including unsuspected tuberculosis deaths. This approach may improve tuberculosis death enumeration in high-burden countries.

      3. The identification of viral particles within a tissue specimen requires specific knowledge of viral ultrastructure and replication, as well as a thorough familiarity with normal subcellular organelles. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has underscored how challenging the task of identifying coronavirus by electron microscopy (EM) can be. Numerous articles have been published mischaracterizing common subcellular structures, including clathrin- or coatomer- coated vesicles, multivesicular bodies, and rough endoplasmic reticulum, as coronavirus particles in SARS-CoV-2 positive patient tissue specimens. To counter these misinterpretations, we describe the morphological features of coronaviruses that should be used to differentiate coronavirus particles from subcellular structures. Further, as many of the misidentifications of coronavirus particles have stemmed from attempts to attribute tissue damage to direct infection by SARS-CoV-2, we review articles describing ultrastructural changes observed in specimens from SARS-CoV-2-infected individuals that do not necessarily provide EM evidence of direct viral infection. Ultrastructural changes have been observed in respiratory, cardiac, kidney, and intestinal tissues, highlighting the widespread effects that SARS-CoV-2 infection may have on the body, whether through direct viral infection or mediated by SARS-CoV-2 infection-induced inflammatory and immune processes.

      4. Validation of xMAP SARS-CoV-2 multi-antigen IgG assay in Nigeriaexternal icon
        Iriemenam NC, Ige FA, Greby SM, Mpamugo A, Abubakar AG, Dawurung AB, Esiekpe MK, Thomas AN, Okoli MU, Awala SS, Ugboaja BN, Achugbu CC, Odoh I, Nwatu FD, Olaleye T, Akayi L, Akinmulero OO, Dattijo J, Onokevbagbe E, Okunoye O, Mba N, Agala NP, Uwandu M, Aniedobe M, Stafford KA, Abimiku A, Hamada Y, Swaminathan M, Okoye MI, Steinhardt LC, Audu R.
        PLoS One. 2022 ;17(4):e0266184.
        OBJECTIVE: There is a need for reliable serological assays to determine accurate estimates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroprevalence. Most single target antigen assays have shown some limitations in Africa. To assess the performance of a multi-antigen assay, we evaluated a commercially available SARS-CoV-2 Multi-Antigen IgG assay for human coronavirus disease 2019 (COVID-19) in Nigeria. METHODS: Validation of the xMAP SARS-CoV-2 Multi-Antigen IgG assay was carried out using well-characterized SARS-CoV-2 reverse transcription polymerase chain reactive positive (97) and pre-COVID-19 pandemic (86) plasma panels. Cross-reactivity was assessed using pre-COVID-19 pandemic plasma specimens (213) from the 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS). RESULTS: The overall sensitivity of the xMAP SARS-CoV-2 Multi-Antigen IgG assay was 75.3% [95% CI: 65.8%- 82.8%] and specificity was 99.0% [95% CI: 96.8%- 99.7%]. The sensitivity estimate increased to 83.3% [95% CI: 70.4%- 91.3%] for specimens >14 days post-confirmation of diagnosis. However, using the NAIIS pre-pandemic specimens, the false positivity rate was 1.4% (3/213). CONCLUSIONS: Our results showed overall lower sensitivity and a comparable specificity with the manufacturer's validation. There appears to be less cross-reactivity with NAIIS pre-pandemic COVID-19 specimens using the xMAP SARS-CoV-2 Multi-Antigen IgG assay. In-country SARS-CoV-2 serology assay validation can help guide the best choice of assays in Africa.

    • Maternal and Child Health
      1. Recurrent SARS-CoV-2 RNA detection after COVID-19 illness onset during pregnancyexternal icon
        Griffin I, Woodworth KR, Galang RR, Burkel VK, Neelam V, Siebman S, Barton J, Manning SE, Aveni K, Longcore ND, Harvey EM, Ngo V, Mbotha D, Chicchelly S, Lush M, Eckert V, Dzimira P, Sokale A, Valencia-Prado M, Azziz-Baumgartner E, MacNeil A, Gilboa SM, Tong VT.
        Emerg Infect Dis. 2022 Apr;28(4):873-876.
        The Surveillance for Emerging Threats to Mothers and Babies Network conducts longitudinal surveillance of pregnant persons in the United States with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection during pregnancy. Of 6,551 infected pregnant persons in this analysis, 142 (2.2%) had positive RNA tests >90 days and up to 416 days after infection.

      2. From 2009‒2015 to 2016‒2019, the proportion of U.S. infants with congenital cytomegalovirus (cCMV) treated with valganciclovir roughly doubled for infants enrolled with employer-sponsored insurance (from 16% to 29%) and Medicaid (from 16% to 36%). The proportion treated with valganciclovir increased for all cCMV disease severity groups.

      3. Prioritising health-care strategies to reduce childhood mortality, insights from Child Health and Mortality Prevention Surveillance (CHAMPS): a longitudinal studyexternal icon
        Madewell ZJ, Whitney CG, Assefa N, Bassat Q, Arifeen SE, Gurley ES, Jambai A, Kotloff KL, Madhi SA, Mandomando I, Ogbuanu IU, Onyango D, Scott JA, Sow SO, Barr BA, Blau DM.
        Lancet Glob Health. 2022 Mar;10 Suppl 1:S8.
        BACKGROUND: Globally, mortality in children younger than 5 years has been decreasing over the past few decades, but high under-5 mortality persists across regions of sub-Saharan Africa and southern Asia. Interventions-such as improved quality of clinical and antenatal care, better access to emergency obstetrical procedures, better triage and risk stratification, better immunisation coverage, or infection control measures-could substantially reduce deaths, but it is unclear which strategies could save the most lives. We aimed to use data from the Child Health and Mortality Prevention Surveillance (CHAMPS) network to examine which health-care and public health improvements could have prevented the most deaths. METHODS: We used standardised, population-based, mortality surveillance data collected by CHAMPS from seven sites (Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa) to understand preventable causes of death in children younger than 5 years. Deaths were investigated with minimally invasive tissue sampling, a post-mortem approach using biopsy needles for sampling key organs and body fluids. For each death, an expert panel reviewed case data to determine whether the death was preventable and (if preventable) provided recommendations as to how the death could have been avoided. We evaluated which health system improvements could have prevented the most deaths among those who underwent minimally invasive tissue sampling for each age group: stillbirths, neonatal deaths (aged <28 days), and infant or child deaths (aged 1 month to <5 years). FINDINGS: We included 1982 eligible deaths (with minimally invasive tissue sampling performed) that occurred between Dec 9, 2016, and Feb 29, 2020, including 556 stillbirths, 828 neonatal deaths, and 598 child deaths. Of these 1982 deaths across all seven CHAMPS sites, 393 (71%) stillbirths, 583 (70%) neonatal deaths, and 487 (81%) child deaths were deemed preventable. The most recommended measures to prevent deaths were improvements in antenatal or obstetric care (recommended for 44% of stillbirths and 31% of neonatal deaths), clinical management and quality of care (stillbirths 26%, neonates 32%, children 46%), health-seeking behaviour (children 24%), and health education (children 22%). Given that 70% of under-5 deaths are stillbirths and neonatal deaths, an intervention that focuses on these age groups (eg, improved antenatal care) could prevent the most under-5 deaths. INTERPRETATION: These data indicate areas in which greater focus on improving existing systems could prevent the most deaths. Investments in interventions such as better access to antenatal care, improvements in clinical practice, and public education campaigns could substantially reduce child mortality. FUNDING: Bill & Melinda Gates Foundation (OPP1126780).

      4. Influenza vaccination during pregnancy and risk of selected major structural non-cardiac birth defects, National Birth Defects Prevention Study 2006-2011external icon
        Palmsten K, Suhl J, Conway KM, Kharbanda EO, Ailes EC, Cragan JD, Nestoridi E, Papadopoulos EA, Kerr SM, Young SG, DeStefano F, Romitti PA.
        Pharmacoepidemiol Drug Saf. 2022 Apr 2.
        PURPOSE: To assess associations between influenza vaccination during etiologically-relevant windows and selected major structural non-cardiac birth defects. STUDY DESIGN: We analyzed data from the National Birth Defects Prevention Study, a multisite, population-based case-control study, for 8233 case children diagnosed with a birth defect and 4937 control children without a birth defect with delivery dates during 2006-2011. For all analyses except for neural tube defects (NTDs), we classified mothers who reported influenza vaccination one month before through the third pregnancy month as exposed; the exposure window for NTDs was one month before through the first pregnancy month. For defects with five or more exposed case children, we used logistic regression to estimate propensity score-adjusted odds ratios (aORs) and 95% confidence intervals (CIs), adjusting for estimated delivery year and season; maternal age; race/ethnicity; plurality; smoking and alcohol use; low folate intake; and, for NTDs, folate antagonist medications. RESULTS: There were 334 (4.1%) case and 197 (4.0%) control mothers who reported influenza vaccination from one month before through the third pregnancy month. Adjusted ORs ranged from 0.53 for omphalocele to 1.74 for duodenal atresia/stenosis. Most aORs (11 of 19) were ≤1 and all adjusted CIs included the null. The unadjusted CIs for two defects, hypospadias and craniosynostosis, excluded the null. These estimates were attenuated upon covariate adjustment (hypospadias aOR: 1.25 (95% CI 0.89, 1.76); craniosynostosis aOR: 1.23 (95% CI: 0.88, 1.74)). CONCLUSIONS: Results for several non-cardiac major birth defects add to the existing evidence supporting the safety of inactivated influenza vaccination during pregnancy. Under-reporting of vaccination may have biased estimates downward. This article is protected by copyright. All rights reserved.

    • Occupational Safety and Health
      1. BACKGROUND: Occupational exposure and increased body mass index (BMI) are associated with respiratory symptoms. This study investigated whether the association of a respiratory burden score with changes in BMI as well as changes in occupational exposure to vapours, gas, dust and fumes (VGDF) varied in subjects with and without asthma and in both sexes over a 5-year period. METHODS: In a 5-year follow-up of a population-based study, 6350 subjects completed a postal questionnaire in 2013 and 2018. A respiratory burden score based on self-reported respiratory symptoms, BMI and frequency of occupational exposure to VGDF were calculated at both times. The association between change in respiratory burden score and change in BMI or VGDF exposure was assessed using stratified regression models. RESULTS: Changes in respiratory burden score and BMI were associated with a β-coefficient of 0.05 (95% CI 0.04 to 0.07). This association did not vary significantly by sex, with 0.05 (0.03 to 0.07) for women and 0.06 (0.04 to 0.09) for men. The association was stronger among those with asthma (0.12; 0.06 to 0.18) compared with those without asthma (0.05; 0.03 to 0.06) (p=0.011). The association of change in respiratory burden score with change in VGDF exposure gave a β-coefficient of 0.15 (0.05 to 0.19). This association was somewhat greater for men versus women, with coefficients of 0.18 (0.12 to 0.24) and 0.13 (0.07 to 0.19), respectively (p=0.064). The estimate was similar among subjects with asthma (0.18; -0.02 to 0.38) and those without asthma (0.15; 0.11 to 0.19). CONCLUSIONS: Increased BMI and exposure to VGDF were associated with increased respiratory burden scores. The change due to increased BMI was not affected by sex, but subjects with asthma had a significantly larger change than those without. Increased frequency of VGDF exposure was associated with increased respiratory burden score but without statistically significant differences with respect to sex or asthma status.

      2. Musculoskeletal Disorders (MSDs) remain a major concern for workers in the healthcare industry. Healthcare workers are at high risk of work-related MSDs mainly caused by overexertion from manually handling patients. Exoskeletons may be a useful tool to help reduce the risk of MSDs during patient handling. As a review study, we surveyed articles focusing on applying exoskeletons to patient handling tasks specifically. We also reviewed relevant government databases and other studies related to Safe Patient Handling and Mobility (SPHM) programs and exoskeleton applications in general. The exoskeletons specifically designed for patient handling were found to be sparse. To have a better understanding of the needs and challenges of developing and using exoskeletons for reducing risks of work-related MSDs in healthcare workers during patient handling, this critical review (1) provided an overview of the existing issues and projected future burdens related to work-related MSDs during patient handling tasks, (2) recognized current and potential roles and applications of existing exoskeletons, and (3) identified challenges and needs for future exoskeleton products. In conclusion, we do not expect exoskeletons to replace the existing SPHM programs, but rather play a complementary role to these multi-pronged programs. We expect that emerging exoskeleton products can be introduced to uncontrolled or specialized healthcare environments. There are various expectations and requirements for an exoskeleton used in different healthcare settings. Additionally, introducing certain types of exoskeletons for patients to assist them during treatment and rehabilitation may help reduce the MSD risks to the healthcare workers. © 2022

    • Parasitic Diseases
      1. Evaluation of the protective efficacy of a spatial repellent to reduce malaria incidence in children in western Kenya compared to placebo: study protocol for a cluster-randomized double-blinded control trial (the AEGIS program)external icon
        Ochomo EO, Gimnig JE, Bhattarai A, Samuels AM, Kariuki S, Okello G, Abong'o B, Ouma EA, Kosgei J, Munga S, Njagi K, Odongo W, Liu F, Grieco JP, Achee NL.
        Trials. 2022 Apr 5;23(1):260.
        BACKGROUND: Spatial repellents are widely used for prevention of mosquito bites and evidence is building on their public health value, but their efficacy against malaria incidence has never been evaluated in Africa. To address this knowledge gap, a trial to evaluate the efficacy of Mosquito Shield™, a spatial repellent incorporating transfluthrin, was developed for implementation in Busia County, western Kenya where long-lasting insecticidal net coverage is high and baseline malaria transmission is moderate to high year-round. METHODS: This trial is designed as a cluster-randomized, placebo-controlled, double-blinded clinical trial. Sixty clusters will be randomly assigned in a 1:1 ratio to receive spatial repellent or placebo. A total of 6120 children aged ≥6 months to 10 years of age will be randomly selected from the study clusters, enrolled into an active cohort (baseline, cohort 1, and cohort 2), and sampled monthly to determine time to first infection by smear microscopy. Each cohort following the implementation of the intervention will be split into two groups, one to estimate direct effect of the spatial repellent and the other to estimate degree of diversion of mosquitoes and malaria transmission to unprotected persons. Malaria incidence in each cohort will be estimated and compared (primary indicator) to determine benefit of using a spatial repellent in a high, year-round malaria transmission setting. Mosquitoes will be collected monthly using CDC light traps to determine if there are entomological correlates of spatial repellent efficacy that may be useful for the evaluation of new spatial repellents. Quarterly human landing catches will assess behavioral effects of the intervention. DISCUSSION: Findings will serve as the first cluster-randomized controlled trial powered to detect spatial repellent efficacy to reduce malaria in sub-Saharan Africa where transmission rates are high, insecticide-treated nets are widely deployed, and mosquitoes are resistant to insecticides. Results will be submitted to the World Health Organization Vector Control Advisory Group for assessment of public health value towards an endorsement to recommend inclusion of spatial repellents in malaria control programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04766879 . Registered February 23, 2021.

    • Public Health Leadership and Management
      1. Improving hand hygiene practices in two regional hospitals in Kenya using a continuous quality improvement (CQI) approachexternal icon
        Kibira J, Kihungi L, Ndinda M, Wesangula E, Mwangi C, Muthoni F, Augusto O, Owiso G, Ndegwa L, Luvsansharav UO, Bancroft E, Rabinowitz P, Lynch J, Njoroge A.
        Antimicrob Resist Infect Control. 2022 Apr 4;11(1):56.
        BACKGROUND: Hand hygiene (HH) is central in prevention of health care-associated infections. In low resource settings, models to improve HH compliance are needed. We implemented a continuous quality improvement (CQI) program targeting HH in two hospitals in Kenya. OBJECTIVE: To determine the impact of the HH CQI program and identify factors associated with HH compliance between 2018 and 2019. METHODS: A CQI project targeting the improvement of hand hygiene was implemented, including training and mentorship. Data were collected monthly between April 2018 and December 2019 in Thika and Kitale Hospitals. Healthcare workers trained on Infection Prevention and Control (IPC) observed and recorded HH opportunities and subsequent compliance among staff, including nurses, clinicians, and auxiliary staff, using the World Health Organization's "My Five Moments for Hand Hygiene" tool. Covariates were explored using mixed-effects logistic regression with random department-level intercepts. RESULTS: Hand hygiene compliance improved from 27% at baseline to 44% after 21 months. Indication/moment for HH was significantly associated with compliance. Adjusting for site, professional category and department, compliance was higher after a moment of body fluid exposure (aOR 1.43, 95% CI 1.17-1.74, p value < 0.001) and lower before an aseptic procedure (aOR 0.12, 95% CI 0.08-0.17, p value < 0.001) compared to after patient contact. Wearing of gloves often replaced proper HH in surgical departments, which although not significant, had lower compliance compared to departments for internal medicine (aOR 0.93, 95% CI 0.85-1.02). Adjusted HH compliance from all quarters improved from baseline, but comparing each quarter to the previous quarter, the improvement fluctuated over time. CONCLUSION: Training and mentorship on the importance of HH for all moments is needed to improve overall HH compliance. CQI with regular monitoring and feedback of HH performance can be an effective approach in improving HH compliance in public hospitals in Kenya.

      2. Qualitative evaluation of enabling factors and barriers to the success and sustainability of national public health institutes in Cambodia, Colombia, Liberia, Mozambique, Nigeria, Rwanda and Zambiaexternal icon
        Woldetsadik MA, Bratton S, Fitzpatrick K, Ravat F, Del Castillo L, McIntosh KJ, Jarvis D, Carnevale CR, Cassell CH, Chhea C, Prieto Alvarado F, MaCauley J, Jani I, Ilori E, Nsanzimana S, Mukonka VM, Baggett HC.
        BMJ Open. 2022 Apr 1;12(4):e056767.
        OBJECTIVES: The success of National Public Health Institutes (NPHIs) in low-income and middle-income countries (LMICs) is critical to countries' ability to deliver public health services to their populations and effectively respond to public health emergencies. However, empirical data are limited on factors that promote or are barriers to the sustainability of NPHIs. This evaluation explored stakeholders' perceptions about enabling factors and barriers to the success and sustainability of NPHIs in seven countries where the U.S. Centers for Disease Control and Prevention (CDC) has supported NPHI development and strengthening. DESIGN: Qualitative study. SETTING: Cambodia, Colombia, Liberia, Mozambique, Nigeria, Rwanda and Zambia. PARTICIPANTS: NPHI staff, non-NPHI government staff, and non-governmental and international organisation staff. METHODS: We conducted semistructured, in-person interviews at a location chosen by the participants in the seven countries. We analysed data using a directed content analysis approach. RESULTS: We interviewed 43 NPHI staff, 29 non-NPHI government staff and 24 staff from non-governmental and international organisations. Participants identified five enabling factors critical to the success and sustainability of NPHIs: (1) strong leadership, (2) financial autonomy, (3) political commitment and country ownership, (4) strengthening capacity of NPHI staff and (5) forming strategic partnerships. Three themes emerged related to major barriers or threats to the sustainability of NPHIs: (1) reliance on partner funding to maintain key activities, (2) changes in NPHI leadership and (3) staff attrition and turnover. CONCLUSIONS: Our findings contribute to the scant literature on sustainability of NPHIs in LMICs by identifying essential components of sustainability and types of support needed from various stakeholders. Integrating these components into each step of NPHI development and ensuring sufficient support will be critical to strengthening public health systems and safeguarding their continuity. Our findings offer potential approaches for country leadership to direct efforts to strengthen and sustain NPHIs.

      3. Characteristics of the audience reached by the National Network of Sexually Transmitted Disease Clinical Prevention Training Centers and correlation with sexually transmitted infection rates, 2015 to 2020external icon
        Hauschild BC, Burnside HC, Gray BA, Johnston C, Neu N, Park IU, Reno HE, Rompalo A, Van Wagoner N, Wendel KA, Coor A, Tromble E, Rietmeijer CA.
        Sex Transm Dis. 2022 Apr 1;49(4):313-317.
        BACKGROUND: The National Network of Sexually Transmitted Disease Clinical Prevention Training Centers (NNPTC) trains clinical providers to diagnose and treat sexually transmitted infections (STIs) in the United States. The purpose of this study was to examine the demographics of clinical providers and to correlate the number of training episodes with STI rates at the county level. METHODS: Registration data were collected between April 1, 2015, and March 31, 2020, in a custom Learning Management System from clinical providers taking NNPTC training. Using the 2018 STI surveillance data, counties were divided into quartiles based on reportable STI case rates and the number of county-level training events was compared per quartile. Univariate and multivariate analyses were conducted in IBM SPSS Statistics 23 (Armonk, NY) and SAS Enterprise Guide 7.1 (Cary, NC). RESULTS: From 2015 to 2020, the NNPTC trained 21,327 individuals, predominantly in the nursing professions and working in a public health environment. In multivariate analysis, the number of training events was significantly associated with higher STI rates at the county level (P < 0.0001) and the state where a prevention training center is located (P < 0001). CONCLUSIONS: The analysis suggests that NNPTC trainings are reaching the clinical providers working in geographic areas with higher STI rates.

    • Substance Use and Abuse
      1. Estimated number of injection-involved drug overdose deaths, United States, 2000 - 2018external icon
        Hall EW, Rosenberg ES, Jones CM, Asher A, Valverde E, Bradley H.
        Drug Alcohol Depend. 2022 Mar 26;234:109428.
        BACKGROUND: In the United States, drug overdose mortality has increased. Death records categorize overdose deaths by type of drug involved, but do not include information about the route of drug administration. METHODS: We utilized data from drug treatment admissions (Treatment Episodes Dataset, TEDS-A) and National Vital Statistics Systems to estimate the percentage of reported drug overdose deaths that were injection-involved from 2000 to 2018 in the U.S. Data on reported route of administration at admission were used to calculate the percent injecting each drug type, by demographic group (race/ethnicity, sex, age group) and year. Using the resulting probabilities, we estimated the number of overdose deaths that were injection-involved. Estimates were compared across drug types, demographic characteristics, and year. FINDINGS: The number of overdose deaths among adults increased more than 3-fold from 2000 (n = 17,196) to 2018 (n = 67,021). During that timeframe, the number of estimated injection-involved overdose deaths increased more than 8-fold from 2000 (n = 3467, 95% CI: 3449-3485) to 2018 (n = 28,257, 95% CI: 28,192-28,322). From 2000-2007, the percent of overdose deaths that were injection-involved remained stable around 20%. From 2007-2018, the percent of overdose deaths that were injection-involved increased from 18.4% (95% CI: 18.3-18.6%) to 42.2% (95% CI: 42.1-42.3%). In 2018, most estimated injection-involved overdose deaths were due to injecting heroin/synthetic opioids (n = 24,860, 95% CI: 24,800-24,919), which accounted for 88.0% of all injection-involved deaths. CONCLUSIONS: Much of the recent increase in overdose mortality is likely attributable to rising injection-involved overdose deaths.

      2. Trends in emergency department visits related to acute alcohol consumption before and during the COVID-19 pandemic in the United States, 2018-2020external icon
        Esser MB, Idaikkadar N, Kite-Powell A, Thomas C, Greenlund KJ.
        Drug Alcohol Depend Rep. 2022 Mar 27;3:100049.
        BACKGROUND: : Excessive drinking accounts for more than 95,000 deaths annually in the United States. Coronavirus disease 2019 (COVID-19) pandemic-related factors (e.g., social, economic, policy) may have affected alcohol consumption. Emergency department (ED) visits involving acute alcohol consumption (referred to as "alcohol-related") are a useful indicator for assessing changes in alcohol-related harms. METHODS: : The 2018-2020 National Syndromic Surveillance Program data, which include nonfatal ED visits from facilities in 49 states and Washington, DC, were analyzed. Trends in the number of alcohol-related ED visits among people ≥15 years, and weekly alcohol-related ED visit rates (per 10,000 total visits) overall, by demographic characteristics, and quarter (Q) were assessed. Quarterly rates for 2018 and 2019 were averaged to increase baseline data stability. RESULTS: : Alcohol-related visits accounted for 1.6% of 60,474,770 total visits (2018), 1.7% of 61,564,380 total visits (2019), and 1.8% of 52,174,507 total visits (2020). The number of alcohol-related ED visits generally increased during the first eight months of 2018 and 2019. However, it sharply declined at the onset of the COVID-19 pandemic in mid-March-mid-April 2020, before resuming pre-pandemic patterns. Alcohol-related ED visits per 10,000 were higher during quarters in 2020 than corresponding quarters in 2018-2019 (Q1: +7.3%, Q2: +23.8%, Q3: +9.7%, Q4: +6.5%). CONCLUSIONS: : Alcohol-related ED visit rates per 10,000 total visits increased during 2020 versus 2018-2019, with the greatest percentage difference in the second quarter. Fewer people sought ED care in 2020 than 2018-2019 but alcohol-related visits declined to a lesser extent than total visits.

      3. Estimating alcohol-attributable liver disease mortality: A comparison of methodsexternal icon
        Sherk A, Esser MB, Stockwell T, Naimi TS.
        Drug Alcohol Rev. 2022 Apr 1.
        INTRODUCTION: Alcohol is a leading contributor to liver disease, however, estimating the proportion of liver disease deaths attributable to alcohol use can be methodologically challenging. METHODS: We compared three approaches for estimating alcohol-attributable liver disease deaths (AALDD), using the USA as an example. One involved summing deaths from alcoholic liver disease and a proportion from unspecified cirrhosis (direct method); two used population attributable fraction (PAF) methodology, including one that adjusted for per capita alcohol sales. For PAFs, the 2011-2015 Behavioral Risk Factor Surveillance System and per capita sales from the Alcohol Epidemiologic Data System were used to derive alcohol consumption prevalence estimates at various levels (excessive alcohol use was defined by medium and high consumption levels). Prevalence estimates were used with relative risks from two meta-analyses, and PAFs were applied to the 2011-2015 average annual number of deaths from alcoholic cirrhosis and unspecified cirrhosis (using National Vital Statistics System data) to estimate AALDD. RESULTS: The number of AALDD was higher using the direct method (28 345 annually) than the PAF methods, but similar when alcohol prevalence was adjusted using per capita sales and all alcohol consumption levels were considered (e.g. 25 145 AALDD). Using the PAF method, disaggregating non-drinkers into lifetime abstainers and former drinkers to incorporate relative risks for former drinkers yielded higher AALDD estimates (e.g. 27 686) than methods with all non-drinkers combined. DISCUSSION AND CONCLUSIONS: Using PAF methods that adjust for per capita sales and model risks for former drinkers yield more complete and possibly more valid AALDD estimates.

      4. Exponential increases in drug overdose: Implications for epidemiology and researchexternal icon
        Compton WM, Einstein EB, Jones CM.
        Int J Drug Policy. 2022 Apr 2:103676.

      5. Tobacco use among HIV-positive and HIV-negative women and men in Zambia-Demographic and Health Survey, 2018external icon
        Kress AC, Stadnik C, Phiri MM, Goma FM, Twentyman E.
        Int J Environ Res Public Health. 2022 April-1;19(7) (no pagination).
        Country-specific estimates of tobacco use among people living with HIV (PLWH) are lacking for much of sub-Saharan Africa. We aim to evaluate the association between the HIV status and tobacco product use status, frequency, and intensity, using nationally representative data from Zambia. We analyzed data from the 2018 Demographic and Health Survey conducted in Zambia among women aged 15-49 years and men aged 15-59 years. We performed logistic regression to assess the associations of HIV status, selected sociodemographic, and other characteristics with indicators of tobacco use (i.e., status, frequency, and intensity). Among women, 14.3% tested positive for HIV and 2.7% reported current smoking or tobacco use; women living with HIV were more likely to report currently smoking or using tobacco than women living without HIV (4.4% vs. 2.4%; aPR: 1.46). Among men, 8.4% tested positive for HIV and 19.5% reported current smoking; men living with HIV were more likely than men living without HIV to report current smoking (27.8% vs. 18.7%; aPR: 1.22). Several sociodemographic characteristics were associated with tobacco use, including age, residence (urban/rural), education level, employment status, and wealth index. The frequency and intensity of smoking among men who currently smoked did not differ by HIV status. Tobacco use was more likely in PLWH than those without HIV in Zambia. Our findings highlight the need to encourage and support tobacco cessation among PLWH, possibly by offering cessation services at existing intersections with health care or integrating cessation support into mHealth and other alternative models of care. Copyright © 2022 by the authors. Licensee MDPI, Basel, Switzerland.

      6. Awareness and use of heated tobacco products among middle school and high school students, United States, 2019-2020external icon
        Puvanesarajah S, Wang T, Alexander DS, Gomez Y, Head SK, Alexandridis AA, Jamal A, Trivers K.
        Nicotine Tob Res. 2022 Mar 11.
        PURPOSE: Heated tobacco products (HTP) heat-processed tobacco leaf into an aerosol inhaled by the user. This study assessed prevalence and correlates of HTP awareness, ever use, and current use among US middle and high school students. METHODS: Data came from the 2019 and 2020 National Youth Tobacco Survey, a cross-sectional survey of US public and private, middle and high school students. HTP awareness, ever use, and current (past 30-day) use were assessed. Weighted prevalence estimates and adjusted prevalence ratios (aPR) were assessed overall and by sex, school level, race/ethnicity, and current other tobacco product use. RESULTS: In 2019, 12.8% (3.44 million) of all students reported HTP awareness, increasing to 19.3% (5.29 million) in 2020 (p < .01). Ever [2019: 2.6% (630 000); 2020: 2.4% (620 000)] and current [2019: 1.6% (420 000); 2020: 1.4% (370 000)] HTP use did not significantly change from 2019 to 2020. Current e-cigarette users were more likely to report ever (2020 aPR = 1.79, 95% CI:1.23, 2.62) or current HTP use (2019 aPR = 5.16, 95% CI: 3.48, 7.67; 2020 aPR = 3.39, 95% CI: 2.10, 5.47) than nonusers. In both years, ever and current HTP use was more likely among current combustible (aPR range = 3.59-8.17) and smokeless tobacco product (aPR range = 2.99-4.09) users than nonusers. CONCLUSIONS: HTP awareness increased 51% among US students during 2019-2020; however, HTP use did not significantly change during this period. Students who used other tobacco products were more likely to currently use HTPs. Estimates of HTP awareness and use provided serve as a baseline as future monitoring of these products is warranted. IMPLICATIONS: Awareness of heated tobacco products (HTPs) increased among US youth from 2019 to 2020; however, HTP use did not change. These estimates of HTP awareness and use serve as a baseline for future surveillance of these products as their availability in the US increases.

    • Zoonotic and Vectorborne Diseases
      1. Prevalence of Crimean-Congo hemorrhagic fever virus among livestock and ticks in Zhambyl Region, Kazakhstan, 2017external icon
        Bryant-Genevier J, Bumburidi Y, Kazazian L, Seffren V, Head JR, Berezovskiy D, Zhakipbayeva B, Salyer SJ, Knust B, Klena JD, Chiang CF, Mirzabekova G, Rakhimov K, Koekeev J, Kartabayev K, Mamadaliyev S, Guerra M, Blanton C, Shoemaker T, Singer D, Moffett DB.
        Am J Trop Med Hyg. 2022 Apr 4.
        Crimean-Congo hemorrhagic fever (CCHF) is a highly fatal zoonotic disease endemic to Kazakhstan. Previous work estimated the seroprevalence of CCHF virus (CCHFV) among livestock owners in the Zhambyl region of southern Kazakhstan at 1.2%. To estimate CCHFV seroprevalence among cattle and sheep, we selected 15 villages with known history of CCHFV circulation (endemic) and 15 villages without known circulation (nonendemic) by cluster sampling with probability proportional to livestock population size. We collected whole blood samples from 521 sheep and 454 cattle from randomly selected households within each village and collected ticks found on the animals. We tested livestock blood for CCHFV-specific IgG antibodies by ELISA; ticks were screened for CCHFV RNA by real-time reverse transcription polymerase chain reaction and CCHFV antigen by antigen-capture ELISA. We administered questionnaires covering animal demographics and livestock herd characteristics to an adult in each selected household. Overall weighted seroprevalence was 5.7% (95% CI: 3.1, 10.3) among sheep and 22.5% (95% CI: 15.8, 31.2) among cattle. CCHFV-positive tick pools were found on two sheep (2.4%, 95% CI: 0.6, 9.5) and three cattle (3.8%, 95% CI: 1.2, 11.5); three CCHFV-positive tick pools were found in nonendemic villages. Endemic villages reported higher seroprevalence among sheep (15.5% versus 2.8%, P < 0.001) but not cattle (25.9% versus 20.1%, P = 0.42). Findings suggest that the current village classification scheme may not reflect the geographic distribution of CCHFV in Zhambyl and underscore that public health measures must address the risk of CCHF even in areas without a known history of circulation.

      2. SARS-CoV-2 Outbreak among Malayan tigers and humans, Tennessee, USA, 2020external icon
        Grome HN, Meyer B, Read E, Buchanan M, Cushing A, Sawatzki K, Levinson KJ, Thomas LS, Perry Z, Uehara A, Tao Y, Queen K, Tong S, Ghai R, Fill MM, Jones TF, Schaffner W, Dunn J.
        Emerg Infect Dis. 2022 Apr;28(4):833-836.
        We report an outbreak of severe acute respiratory syndrome coronavirus 2 involving 3 Malayan tigers (Panthera tigris jacksoni) at a zoo in Tennessee, USA. Investigation identified naturally occurring tiger-to-tiger transmission; genetic sequence change occurred with viral passage. We provide epidemiologic, environmental, and genomic sequencing data for animal and human infections.

      3. Personal protection measures to prevent human tick encounters from resulting in bites are widely recommended as the first line of defense against health impacts associated with ticks. This includes using repellents, wearing untreated or permethrin-treated protective clothing, and conducting tick checks after coming inside, aided by removing outdoor clothing articles and running them in a dryer on high heat (to kill undetected ticks) and taking a shower/bath (to aid in detecting ticks on the skin). These measures have the benefit of incurring no or low cost, but they need to be used consistently to be most effective. In this paper, I review the level of use (acceptability combined with behavior) of the above-mentioned personal protection measures and their effectiveness to prevent tick bites and tick-borne disease. Studies on the level of use of personal protection measures to prevent tick bites have used different recruitment strategies, focused on different types of respondent populations, employed variable phrasings of survey questions relating to a given personal protection measure, and presented results based on variable frequencies of taking action. This complicates the synthesis of the findings, but the studies collectively indicate that members of the public commonly take action to prevent tick bites, most frequently by wearing untreated protective clothing or conducting tick checks (done routinely by 30 to 70% of respondents in most studies of the public), followed by showering/bathing after being outdoors or using repellents on skin/clothing (15 to 40% range), and with permethrin-treated clothing being the least frequently used tick bite prevention method (<5 to 20% range). A suite of experimental studies have shown that applying repellents or permethrin to coveralls or uniform-style clothing can result in decreased numbers of tick bites, but similar studies are lacking for members of the public wearing summer-weight clothing during normal daily activities. Moreover, a set of case-control and cross-sectional studies have explored associations between use of different personal protection measures to prevent tick bites and Lyme disease or other tick-borne infections. The results are mixed for each personal protection measure, with some studies indicating that regular use of the measure is associated with a reduction in tick-borne disease while other studies found no similar protective effect. One possible interpretation is that these personal protection measures can protect against tick-borne infection but the information gathered to date has not been sufficiently detailed to clarify the circumstances under which protection is achieved, especially with regards to frequency of use, parts of the body being protected, and use of combinations of two or more potentially protective measures. In conclusion, personal protection measures to prevent tick bites are used by the public and merit further study to better understand how they need to be used to have the greatest public health impact.

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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