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Issue 19, May 10, 2022

CDC Science Clips: Volume 14, Issue 19, May 10, 2022

Welcome to CDC Science Clips, CDC’s weekly publications digest.

This week, Science Clips is pleased to feature articles related to the new CDC Vital Signs on Firearm Deaths Grow, Disparities Widen: Comprehensive Strategies Can Prevent Violence

Firearms were involved in 79% of all homicides and 53% of all suicides in 2020. Against the backdrop of the COVID-19 pandemic, there has been a historic increase of 35% in the firearm homicide rate, resulting in the highest firearm homicide rate in more than 25 years. This, along with increases in firearm suicide rates for some groups, has widened racial, ethnic, and other disparities, according to a new CDC Vital Signs analysis.

Firearm homicide rates are consistently highest among males, adolescents, young adults, and non-Hispanic Black and non-Hispanic American Indian and Alaska Native (AI/AN) people. In 2020, firearm homicide rates increased across all age groups, with the highest rates and increases observed among those 10–44 years old. Considering age, sex, and race/ethnicity simultaneously, the largest increases in firearm homicide rates were among non-Hispanic Black males 10–44 years old.

The overall firearm suicide rate remained nearly level between 2019 and 2020, with age-specific rate increases among persons 10–44 years old, partially offset by a decrease among those 45–64 years old. Considering age, sex, and race/ethnicity simultaneously, rates of firearm suicide increased most notably among non-Hispanic AI/AN males aged 10–44.

The Centers for Disease Control and Prevention (CDC) has developed technical packages to help states and communities prevent violence. A technical package is a select group of strategies based on the best available evidence to prevent or reduce public health problems, and improve the health and well-being of communities. (National Center for Injury Prevention and Control, Division of Violence Prevention, 2021)

  1. CDC Vital Signs
      1. Technical packages for violence prevention.
        CDC. 2021 [updated November 12, 2021; cited 2022 March 31, 2022].

      2. Pandemic, social unrest, and crime in US cities: 2020 year-end update.external icon
        Rosenfeld R AT, Lopez E.
        Washington, DC: Council on Criminal Justice, January 2021.

      3. Neighborhood racial and economic segregation and disparities in violence during the COVID-19 pandemicexternal icon
        Schleimer JP, Buggs SA, McCort CD, Pear VA, Biasi A, Tomsich E, Shev AB, Laqueur HS, Wintemute GJ.
        Am J Public Health. 2022 Jan;112(1):144-53.
        Objectives. To describe associations between neighborhood racial and economic segregation and violence during the COVID-19 pandemic. Methods. For 13 US cities, we obtained zip code-level data on 5 violence outcomes from March through July 2018 through 2020. Using negative binomial regressions and marginal contrasts, we estimated differences between quintiles of racial, economic, and racialized economic segregation using the Index of Concentration at the Extremes as a measure of neighborhood privilege (1) in 2020 and (2) relative to 2018 through 2019 (difference-in-differences). Results. In 2020, violence was higher in less-privileged neighborhoods than in the most privileged. For example, if all zip codes were in the least privileged versus most privileged quintile of racialized economic segregation, we estimated 146.2 additional aggravated assaults (95% confidence interval = 112.4, 205.8) per zip code on average across cities. Differences over time in less-privileged zip codes were greater than differences over time in the most privileged for firearm violence, aggravated assault, and homicide. Conclusions. Marginalized communities endure endemically high levels of violence. The events of 2020 exacerbated disparities in several forms of violence. Public Health Implications. To reduce violence and related disparities, immediate and long-term investments in low-income neighborhoods of color are warranted. (Am J Public Health. 2022;112(1):144-153. https://doi.org/10.2105/AJPH.2021.306540external icon).

      4. Domestic violence and substance abuse during COVID19: A systematic review.external icon
        Abdo C, Miranda EP, Santos CS, Júnior JB, Bernardo WM.
        Indian J Psychiatry. 2020 Sep;62(Suppl 3):S337-s42.
        INTRODUCTION: As COVID-19 develops around the world, numerous publications have described the psychiatric consequences of this pandemic. Although clinicians and healthcare systems are mainly focused on managing critically ill patients in an attempt to limit the number of casualties, psychiatric disease burden is increasing significantly. In this scenario, increased domestic violence and substance abuse have been recently reported. OBJECTIVE: The objective of this study is to perform a systematic review of the literature regarding the consequences of severe acute respiratory syndrome-CoV-2 infection in terms of domestic violence and substance abuse, and compare incidences found. MATERIALS AND METHODS: We conducted a literature search using the preferred reporting items for systematic reviews and meta-analyses guidelines. The keywords included "domestic violence," "substance abuse" AND "COVID-19," including multiple variants from December 2019 through June 2020. An extensive bibliographic search was carried out in different medical databases: Pubmed, EMBASE, LILACS, medRxiv, and bioRxiv. Titles and abstracts were reviewed according to the eligibility criteria. The risk of bias in the retrieved articles was assessed by the Joanna Briggs Institute's critical assessment instrument. RESULTS: A total of 1505 papers were initially retrieved after consulting the selected databases. After browsing through titles and abstracts, 94 articles were initially included considering the predefined eligibility criteria. After a more detailed analysis, only six scientific articles remained in our selection. Of these, three were evaluating domestic violence against children, while the other three were about substance abuse. CONCLUSION: There is not enough evidence to support the concept that COVID-19 has led to an increase in the rates of domestic violence and substance abuse. The initial decrease in violence reports might not translate into a real reduction in incidence but in accessibility. Apparently, there has been a slight increase in alcohol and tobacco abuse, especially by regular users, which also requires confirmatory studies. The inconsistency between expert opinon articles and the actual published data could be a result of the limited time since the beginnging of the crisis, the fact that psychitaric patients have been chronically exposed to stressful situatons, and a possible stimulated increase in demand for psychatric consultations.

      5. BACKGROUND: Multi-victim homicides are a persistent public health problem confronting the United States. Previous research shows that homicide rates in the U.S. are approximately seven times higher than those of other high-income countries, driven by firearm homicide rates that are 25 times higher; 31% of public mass shootings in the world also occur in the U.S.. The purpose of this analysis is to examine the characteristics of mass, multiple, and single homicides to help identify prevention points that may lead to a reduction in different types of homicides. METHODS: We used all available years (2003-2017) and U.S. states/jurisdictions (35 states, the District of Columbia, and Puerto Rico) included in CDC's National Violent Death Reporting System (NVDRS), a public health surveillance system which combines death certificate, coroner/medical examiner, and law enforcement reports into victim- and incident-level data on violent deaths. NVDRS includes up to 600 standard variables per incident; further information on types of mental illness among suspected perpetrators and incident resolution was qualitatively coded from case narratives. Data regarding number of persons nonfatally shot within incidents were cross-validated when possible with several other resources, including government reports and the Gun Violence Archive. Mass homicides (4+ victims), multiple homicides (2-3 victims) and single homicides were analyzed to assess group differences using Chi-square tests with Bonferroni-corrected post-hoc comparisons. RESULTS: Mass homicides more often had female, child, and non-Hispanic white victims than other homicide types. Compared with victims of other homicide types, victims of mass homicides were more often killed by strangers or someone else they did not know well, or by family members. More than a third were related to intimate partner violence. Approximately one-third of mass homicide perpetrators had suicidal thoughts/behaviors noted in the time leading up to the incident. Multi-victim homicides were more often perpetrated with semi-automatic firearms than single homicides. When accounting for nonfatally shot victims, over 4 times as many incidents could have resulted in mass homicide. CONCLUSIONS: These findings underscore the important interconnections among multiple forms of violence. Primary prevention strategies addressing shared risk and protective factors are key to reducing these incidents.

      6. Income inequality and firearm homicide in the US: a county-level cohort study.external icon
        Rowhani-Rahbar A, Quistberg DA, Morgan ER, Hajat A, Rivara FP.
        Inj Prev. 2019 Sep;25(Suppl 1):i25-i30.
        OBJECTIVE: Income inequality has been rising in the US and thought to be associated with violence especially homicide. About 75% of homicides involve firearms. We quantified the association between county-level income inequality and all-race/ethnicity and race/ethnicity-specific firearm homicide rates among individuals aged 14-39 years. METHODS: We conducted a cohort study of US counties to examine the association of Gini Index (ranging from 0 [perfect income equality] to 1.0 [perfect income inequality]) separately measured in 1990 and 2000 with all-race/ethnicity and race/ethnicity-specific firearm homicide rates in 2005-2015. Generalised linear mixed models with Poisson distribution including a random intercept for state provided IRRs and 95% CIs. Bayesian Poisson-lognormal hierarchical modelling with integrated nested Laplace approximations was used in exploratory spatial analyses. Models accounted for county-level age, sex and race/ethnicity composition, crime rate, deprivation, social capital, urbanicity, and firearm ownership. FINDINGS: The Gini Index was associated with firearm homicide rates among all races/ethnicities. After accounting for contextual determinants of firearm homicide, the association persisted among African-Americans. In this group, a 1 SD greater Gini Index in 1990 (IRR=1.09; 95% CI 1.02 to 1.16) and 2000 (IRR=1.09; 95% CI 1.01 to 1.17) was associated with greater firearm homicide rates in 2005-2015. Exploratory spatial analyses did not materially change the results. CONCLUSION: Policies addressing the gap between the rich and the poor deserve further considerations for reducing firearm homicide rates. Incorporating income inequality to refine measures of socioeconomic position may advance public health and clinical research and practice for firearm violence prevention.

      7. Association of county-level poverty and inequities with firearm-related mortality in US youth.external icon
        Barrett JT, Lee LK, Monuteaux MC, Farrell CA, Hoffmann JA, Fleegler EW.
        JAMA Pediatr. 2022 Feb 1;176(2):e214822.
        IMPORTANCE: Youth firearm-related deaths are a public health crisis in the US. The association between county-level poverty and the risk of firearm-related deaths among youth is unknown, however. OBJECTIVE: To examine the association between county-level poverty concentration and firearm-related mortality rates in US youth. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study analyzed US firearm fatalities in children and young adults aged 5 to 24 years that occurred between January 1, 2007, and December 31, 2016. Data were obtained from the Centers for Disease Control and Prevention's Compressed Mortality File, and annual intercensal county population data were obtained from the US Census Bureau. Data analyses were conducted between November 1, 2019, and June 30, 2020. EXPOSURES: County-level poverty was categorized into 5 groups: 0% to 4.9%, 5% to 9.9%, 10% to 14.9%, 15% to 19.9%, and ≥20% of the population living below the federal poverty level. MAIN OUTCOMES AND MEASURES: The main outcomes were firearm-related deaths in total and by specific intent (homicide, suicide, and unintentional) per 100 000 youths over the entire study period. Multivariable negative binomial regression models were used to analyze the association between firearm-related mortality rates and county poverty concentration, controlling for demographic variables, urbanicity, and statewide firearm prevalence. Adjusted incidence rate ratios (IRRs) were calculated, and statewide firearm prevalence was estimated. The population-attributable fraction (PAF) and years of potential life lost for each intent were calculated. RESULTS: A total of 67 905 firearm-related deaths among youth (predominantly composed of 60 164 male individuals [88.6%]) from 2007 to 2016 were analyzed. Of these deaths, 42 512 were homicides (62.6%), 23 034 were suicides (33.9%), and 1627 were unintentional (2.4%). Firearm-related mortality risk increased in a stepwise manner with increasing county poverty concentration. Compared with counties with the lowest poverty concentration, counties with the highest poverty concentration had an increased rate of total firearm-related deaths (adjusted IRR, 2.29; 95% CI, 1.96-2.67), homicides (adjusted IRR, 3.55; 95% CI, 2.80-4.51), suicides (adjusted IRR, 1.45; 95% CI, 1.20-1.75), and unintentional deaths (adjusted IRR, 9.32; 95% CI, 2.32-37.4). The PAF was 0.51 (95% CI, 0.43-0.57) for all firearm-related deaths, 0.66 (95% CI, 0.57-0.73) for homicides, 0.30 (95% CI, 0.17-0.42) for suicides, and 0.86 (95% CI, 0.46-0.97) for unintentional deaths. This calculation translated to 34 292 firearm-related deaths that would not have occurred if all counties had the same risk as counties with the lowest poverty concentration. A total of 3833 105 years of potential life lost was observed. CONCLUSIONS AND RELEVANCE: This study found an association between firearm-related mortality rates among youth and county-level poverty concentration. With more than half of firearm-related deaths and two-thirds of firearm-related homicides potentially associated with living in an area with a high concentration of poverty, a multidimensional strategy to reduce poverty and firearm-related deaths is urgently needed.

      8. Suicide mortality and coronavirus disease 2019-a perfect storm?external icon
        Reger MA, Stanley IH, Joiner TE.
        JAMA Psychiatry. 2020 Nov 1;77(11):1093-4.

      9. Structural racism and health inequities in the USA: evidence and interventions.external icon
        Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT.
        Lancet. 2017 Apr 8;389(10077):1453-63.
        Despite growing interest in understanding how social factors drive poor health outcomes, many academics, policy makers, scientists, elected officials, journalists, and others responsible for defining and responding to the public discourse remain reluctant to identify racism as a root cause of racial health inequities. In this conceptual report, the third in a Series on equity and equality in health in the USA, we use a contemporary and historical perspective to discuss research and interventions that grapple with the implications of what is known as structural racism on population health and health inequities. Structural racism refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice. These patterns and practices in turn reinforce discriminatory beliefs, values, and distribution of resources. We argue that a focus on structural racism offers a concrete, feasible, and promising approach towards advancing health equity and improving population health.

      10. Gun violence incidence during the COVID-19 pandemic is higher than before the pandemic in the United States.external icon
        Ssentongo P, Fronterre C, Ssentongo AE, Advani S, Heilbrunn ES, Hazelton JP, Oh JS, McCall-Hosenfeld JS, Chinchilli VM.
        Sci Rep. 2021 Oct 21;11(1):20654.
        During the coronavirus disease 2019 (COVID-19) pandemic, gun violence (GV) in the United States (U.S.) was postulated to increase strain on already taxed healthcare resources, such as blood products, intensive care beds, personal protective equipment, and even hospital staff. This report aims to estimate the relative risk of GV in the U.S. during the pandemic compared to before the pandemic. Daily police reports corresponding to gun-related injuries and deaths in the 50 states and the District of Columbia from February 1st, 2019, to March 31st, 2021 were obtained from the GV Archive. Generalized linear mixed-effects models in the form of Poisson regression analysis were utilized to estimate the state-specific rates of GV. Nationally, GV rates were 30% higher between March 01, 2020, and March 31, 2021 (during the pandemic), compared to the same period in 2019 (before the pandemic) [intensity ratio (IR) = 1.30; 95% CI 1.29, 1.32; p < 0.0001]. The risk of GV was significantly higher in 28 states and significantly lower in only one state. National and state-specific rates of GV were higher during the COVID-19 pandemic compared to the same timeframe 1 year prior. State-specific steps to mitigate violence, or at a minimum adequately prepare for its toll during the COVID-19 pandemic, should be taken.

  2. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Chronic Diseases and Conditions
      1. Cancer screening test use-U.S., 2019external icon
        Sabatino SA, Thompson TD, White MC, Shapiro JA, Clarke TC, Croswell JM, Richardson LC.
        Am J Prev Med. 2022 Apr 22.
        INTRODUCTION: The U.S. Preventive Services Task Force recommends breast, cervical, and colorectal cancer screening to reduce mortality from these cancers, but screening use has been below national targets. The purpose of this study is to examine the proportion of screening-eligible adults who are up to date with these screenings and how screening use compares with Healthy People 2020 targets. METHODS: Data from the 2019 National Health Interview Survey were used to examine the percentages of adults up to date with breast cancer screening among women aged 50‒74 years without previous breast cancer, cervical cancer screening among women aged 21‒65 years without previous cervical cancer or hysterectomy, and colorectal cancer screening among adults aged 50‒75 years without previous colorectal cancer. Estimates are presented by sociodemographic characteristics and healthcare access factors. Analyses were conducted in 2021. RESULTS: Percentages of adults up to date were 76.2% (95% CI= 75.0, 77.5) for breast cancer screening, 76.4% (95% CI= 75.2, 77.6) for cervical cancer screening, and 68.3% (95% CI= 67.3, 69.3) for colorectal cancer screening. Although some population subgroups met breast and colorectal cancer screening targets (81.1% and 70.5%, respectively), many did not, and cervical cancer screening was below the target for all examined subgroups. Lower education and income, nonmetropolitan county of residence (which included rural counties), no usual source of care or health insurance coverage, and Medicaid coverage were associated with lower screening test use. CONCLUSIONS: Estimated use of breast, cervical, and colorectal cancer screening tests based on the 2019 National Health Interview Survey were below national targets. Continued monitoring may allow for examination of screening trends, inform interventions, and track progress in eliminating disparities.

      2. Impact of HLA-B27 and disease status on the gut microbiome of the offspring of ankylosing spondylitis patientsexternal icon
        Stoll ML, DeQuattro K, Li Z, Sawhney H, Weiss PF, Nigrovic PA, Wright TB, Schikler K, Edelheit B, Morrow CD, Reveille JD, Brown MA, Gensler LS.
        Children (Basel). 2022 Apr 16;9(4).
        Multiple studies have shown the microbiota to be abnormal in patients with spondyloarthritis (SpA). The purpose of this study was to explore the genetic contributions of these microbiota abnormalities. We analyzed the impact of HLA-B27 on the microbiota of children at risk for SpA and compared the microbiota of HLA-B27+ pediatric offspring of ankylosing spondylitis (AS) patients with that of HLA-B27+ children with SpA. Human DNA was obtained from the offspring for determination of HLA-B27 status and polygenic risk score (PRS). Fecal specimens were collected from both groups for sequencing of the V4 region of the 16S ribosomal RNA gene. Among the offspring of AS patients, there was slight clustering by HLA-B27 status. After adjusting for multiple comparisons, five operational taxonomic units (OTUs) representing three unique taxa distinguished the HLA-B27+ from negative children: Blautia and Coprococcus were lower in the HLA-B27+ offspring, while Faecalibacterium prausnitzii was higher. HLA-B27+ offspring without arthritis were compared to children with treatment-naïve HLA-B27+ SpA. After adjustments, clustering by diagnosis was present. A total of 21 OTUs were significantly associated with diagnosis state, including Bacteroides (higher in SpA patients) and F. prausnitzii (higher in controls). Thus, our data confirmed associations with B. fragilis and F. prausnitzii with juvenile SpA, and also suggest that the mechanism by which HLA-B27 is associated with SpA may not involve alterations of the microbiota.

      3. Computable guidelines and clinical decision support for cervical cancer screening and management to improve outcomes and health equityexternal icon
        Saraiya M, Colbert J, Bhat GL, Almonte R, Winters DW, Sebastian S, O'Hanlon M, Meadows G, Nosal MR, Richards TB, Michaels M, Townsend JS, Miller JW, Perkins RB, Sawaya GF, Wentzensen N, White MC, Richardson LC.
        J Womens Health (Larchmt). 2022 Apr;31(4):462-468.
        Cervical cancer is highly preventable when precancerous lesions are detected early and appropriately managed. However, the complexity of and frequent updates to existing evidence-based clinical guidelines make it challenging for clinicians to stay abreast of the latest recommendations. In addition, limited availability and accessibility to information technology (IT) decision supports make it difficult for groups who are medically underserved to receive screening or receive the appropriate follow-up care. The Centers for Disease Control and Prevention (CDC), Division of Cancer Prevention and Control (DCPC), is leading a multiyear initiative to develop computer-interpretable ("computable") version of already existing evidence-based guidelines to support clinician awareness and adoption of the most up-to-date cervical cancer screening and management guidelines. DCPC is collaborating with the MITRE Corporation, leading scientists from the National Cancer Institute, and other CDC subject matter experts to translate existing narrative guidelines into computable format and develop clinical decision support tools for integration into health IT systems such as electronic health records with the ultimate goal of improving patient outcomes and decreasing disparities in cervical cancer outcomes among populations that are medically underserved. This initiative meets the challenges and opportunities highlighted by the President's Cancer Panel and the President's Cancer Moonshot 2.0 to nearly eliminate cervical cancer.

      4. Evaluation of the completeness of ALS case ascertainment in the US National ALS Registry: Application of the capture-recapture methodexternal icon
        Nelson LM, Topol B, Kaye W, Raymond J, Horton DK, Mehta P, Wagner T.
        Neuroepidemiology. 2022 ;56(2):104-114.
        INTRODUCTION: The Centers for Disease Control and Prevention (CDC) National Amyotrophic Lateral Sclerosis (ALS) Registry is the first national registry for a chronic neurologic disease in the USA and uses a combination of case-finding methods including administrative healthcare data and patient self-registration. METHODS: We applied capture-recapture methodology to estimate the completeness of the Registry for ascertaining patients with ALS for the first full year and the fourth year of the Registry (2011, 2014). The Registry uses the combination of two national administrative claims databases (Medicare and Veterans Affairs) with a self-register option at the registry portal. We conducted descriptive analyses of the demographic and clinical characteristics of the ALS cases identified by each of the sources and estimated the completeness of case ascertainment for each of the three ALS Registry sources individually, pairwise, and in all combinations. RESULTS: Case-finding completeness was 54% in 2011 and improved to 56% in 2014. A smaller proportion of ALS patients under age 65 were ascertained than those 65 or older, and ascertainment was also lower for nonwhite than white patients. The uncorrected ALS prevalence was 4.3/100,000 in 2011 (in 2014, 5.0/100,000), but after correction for underascertainment, annual prevalence in 2011 was 7.9/100,000 (95% CI: 7.6-8.2) (in 2014 was 8.9/100,000 [95% CI: 8.7-9.2]). DISCUSSION/CONCLUSION: Our findings indicate that administrative healthcare databases are a very efficient method for identifying the majority of ALS prevalent cases in the National ALS Registry and that the inclusion of a web registry portal for patients to self-register is important to ensure a more representative population for estimating ALS prevalence. Nonetheless, more than 40% of ALS cases were not ascertained by the Registry, with individuals younger than age 65 and people of color underrepresented. Recommendations are provided for additional methods that can be considered to improve the completeness of case ascertainment.

      5. Rates of severe influenza-associated outcomes among older adults living with diabetes-influenza hospitalization surveillance network (FluSurv-NET), 2012-2017external icon
        Owusu D, Rolfes MA, Arriola CS, Daily Kirley P, Alden NB, Meek J, Anderson EJ, Monroe ML, Kim S, Lynfield R, Angeles K, Spina N, Felsen CB, Billing L, Thomas A, Keipp Talbot H, Schaffner W, Chatelain R, Reed C, Garg S.
        Open Forum Infect Dis. 2022 May;9(5):ofac131.
        BACKGROUND: Diabetes mellitus (DM) is common among older adults hospitalized with influenza, yet data are limited on the impact of DM on risk of severe influenza-associated outcomes. METHODS: We included adults aged ≥65 years hospitalized with influenza during 2012-2013 through 2016-2017 from the Influenza Hospitalization Surveillance Network (FluSurv-NET), a population-based surveillance system for laboratory-confirmed influenza-associated hospitalizations conducted in defined counties within 13 states. We calculated population denominators using the Centers for Medicare and Medicaid Services county-specific DM prevalence estimates and National Center for Health Statistics population data. We present pooled rates and rate ratios (RRs) of intensive care unit (ICU) admission, pneumonia diagnosis, mechanical ventilation, and in-hospital death for persons with and without DM. We estimated RRs and 95% confidence intervals (CIs) using meta-analysis with site as a random effect in order to control for site differences in the estimates. RESULTS: Of 31 934 hospitalized adults included in the analysis, 34% had DM. Compared to those without DM, adults with DM had higher rates of influenza-associated hospitalization (RR, 1.57 [95% CI, 1.43-1.72]), ICU admission (RR, 1.84 [95% CI, 1.67-2.04]), pneumonia (RR, 1.57 [95% CI, 1.42-1.73]), mechanical ventilation (RR, 1.95 [95% CI, 1.74-2.20]), and in-hospital death (RR, 1.48 [95% CI, 1.23-1.80]). CONCLUSIONS: Older adults with DM have higher rates of severe influenza-associated outcomes compared to those without DM. These findings reinforce the importance of preventing influenza virus infections through annual vaccination, and early treatment of influenza illness with antivirals in older adults with DM.

      6. Cancer screening prevalence and associated factors among US adultsexternal icon
        Ma ZQ, Richardson LC.
        Prev Chronic Dis. 2022 Apr 21;19:E22.

      7. Adults who have never been screened for colorectal cancer, Behavioral Risk Factor Surveillance System, 2012 and 2020external icon
        Richardson LC, King JB, Thomas CC, Richards TB, Dowling NF, Coleman King S.
        Prev Chronic Dis. 2022 Apr 21;19:E21.

      8. The collection and evaluation of family health history in a clinical setting presents an opportunity to discuss cancer risk, tailor cancer screening recommendations, and identify people with an increased risk of carrying a pathogenic variant who may benefit from referral to genetic counseling and testing. National recommendations for breast and colorectal cancer screening indicate that men and women who have a first-degree relative affected with these types of cancers may benefit from talking to a healthcare provider about starting screening at an earlier age and other options for cancer prevention. The prevalence of reporting a first-degree relative who had cancer was assessed among adult respondents of the 2015 National Health Interview Survey who had never had cancer themselves (n = 27,999). We found 35.6% of adults reported having at least one first-degree relative with cancer at any site. Significant differences in reporting a family history of cancer were observed by sex, age, race/ethnicity, educational attainment, and census region. Nearly 5% of women under age 50 and 2.5% of adults under age 50 had at least one first-degree relative with breast cancer or colorectal cancer, respectively. We estimated that 5.8% of women had a family history of breast or ovarian cancer that may indicate increased genetic risk. A third of U.S. adults who have never had cancer report a family history of cancer in a first-degree relative. This finding underscores the importance of using family history to inform discussions about cancer risk and screening options between healthcare providers and their patients.

    • Communicable Diseases
      1. Corticosteroids and other treatments administered to children tested for SARS-CoV-2 infection in emergency departmentsexternal icon
        Freedman SB, Kuppermann N, Funk AL, Kim K, Xie J, Tancredi D, Dalziel SR, Neuman MI, Mintegi S, Plint AC, Gómez-Vargas J, Finkelstein Y, Ambroggio L, Klassen TP, Salvadori M, Malley R, Payne DC, Florin TA.
        Acad Pediatr. 2022 Apr 21.
        OBJECTIVE: We sought to determine if corticosteroids administration is associated with a SARS-CoV-2 nucleic acid test-positive result and to describe therapies administered to SARS-CoV-2 infected children. METHODS: We collected cross-sectional data from participants recruited in 41 pediatric emergency departments (ED) in 10 countries between March 2020 and June 2021. Participants were <18 years, had signs or symptoms of, or risk factors for acute SARS-CoV-2 infection, and had nucleic acid testing performed. We utilized a multivariable conditional logistic regression model matched by study site to compare treatments administered based on SARS-CoV-2 test and disposition status and determined if SARS-CoV-2 test status was independently associated with corticosteroid administration in all study participants, and in the subgroup of those hospitalized. RESULTS: 30.3% (3,121/10,315) of participants were SARS-CoV-2-positive. Although remdesivir was more commonly administered to SARS-CoV-2-positive children, use was infrequent [25/3120 (0.8%) vs. 1/7188 (0.01%); P=0.001]. Corticosteroid use was less common among SARS-CoV-2-positive children [219/3120 (7.0%) vs. 759/7190 (10.6%); P<0.001]. Among hospitalized children, there were also no differences in provision of inotropes, respiratory support, chest drainage or extracorporeal membrane oxygenation between groups. Corticosteroid administration was associated with age, history of asthma, wheezing, study month, hospitalization and intensive care unit admission; it was not associated with a positive SARS-CoV-2 test result overall (aOR: 0.91; 95%CI: 0.74, 1.12) or among the subgroup of those hospitalized (aOR: 1.04; 95%CI: 0.75, 1.44). CONCLUSIONS: Few disease-specific treatments are provided to SARS-CoV-2-positive children; clinical trials evaluating therapies in children are urgently needed.

      2. Diverse contexts and social factors among young cisgender men and transgender women who sell or trade sex in Bangkok and Pattaya, Thailand: formative research for a PrEP program implementation studyexternal icon
        Truong JM, Chemnasiri T, Wirtz AL, Mon SH, Varangrat A, Decker M, Janyam S, Linjongrat D, Sirivongrangson P, Hickey AC, Weir BW, Beyrer C.
        AIDS Care. 2022 Apr 26:1-9.
        HIV incidence is high and persistent among cisgender men who have sex with men (MSM) and transgender women (TGW) who have sex with men, particularly among those who sell or trade sex. In preparation for an open-label combination HIV pre-exposure prophylaxis (PrEP) program for these groups, we conducted formative research to explore the context of sex work/trade and factors that affect implementation of PrEP interventions. This study analyzed interviews with 20 young (aged 18-26 years) MSM and TGW who sell/trade sex and three sex work venue managers in Bangkok and Pattaya, Thailand. Participants described diverse contexts of sex work/trade, including in multiple informal and formal sex venues. Several participants reported mobility across provinces and out of the country, which led to intermittent sex work/trade. TGW sex workers reported challenges with access and cost of femininizing hormones and limited employment opportunities. Factors that could facilitate or challenge PrEP program implementation included HIV stigma, the role of venue management in sexual health practice, lack of PrEP knowledge, lower perceived HIV risk, and interest in personal health and wellbeing. Program implementers must consider myriad factors to successfully implement PrEP among young MSM and TGW engaged in sex work or trade in Thailand.

      3. Attention to non-AIDS comorbidities is increasingly important in the HIV care and management in the United States. We sought to assess comorbidities before and after antiretroviral therapy (ART) initiation among persons with HIV (PWH). Using the 2008-2018 HIV Outpatient Study (HOPS) data, we assessed changes in prevalence of physical and psychiatric comorbidities, by sex, among participants initiating ART. Cox proportional hazards models were fit to investigate factors associated with the first documented occurrence of key comorbidities, adjusting for demographics and other covariates including insurance type, CD4+ cell count, ART regimen and smoking status. Among 1,236 participants who initiated ART (median age 36 years, CD4 cell count 375 cells/mm3), 79% were male, 66% non-white, 44% publicly-insured, 53% ever smoked, 33% had substance use history, and 22% had body mass index ≥ 30 kg/m2. Among females, the percentages with at least one condition were: at ART start, 72% had a physical and 42% a psychiatric comorbidity, and after a median of 6.1 years of follow-up, these were 87% and 63%, respectively. Among males, the percentages with at least one condition were: at ART start, 61% had a physical and 32% a psychiatric comorbidity, and after a median of 4.6 years of follow-up, these were 82% and 53%, respectively. In multivariable Cox proportional hazards analyses, increasing age and higher viral loads were associated with most physical comorbidities, and being a current/former smoker and higher viral loads were associated with all psychiatric comorbidities analyzed. HOPS participants already had a substantial burden of physical and psychiatric comorbidities at the time of ART initiation. With advancing age, PWH who initiate ART experience a clinically significant increase in the burden of chronic non-HIV comorbidities that warrants continued surveillance, prevention, and treatment.

      4. Respiratory viruses in hematopoietic cell transplant candidates: impact of preexisting lower tract disease on outcomesexternal icon
        Kim Y, Waghmare A, Xie H, Holmberg LA, Pergam SA, Jerome KR, Leisenring WM, Ogimi C, Campbell AP, Englund JA, Boeckh M.
        Blood Adv. 2022 Apr 21.
        Pretransplant respiratory virus infections (RVIs) have been shown to negatively impact hematopoietic cell transplantation (HCT) outcomes. The impact of and need for delay of HCT for pretransplant infection with human rhinovirus (HRV) or endemic human coronavirus (HCoV) (229E, OC43, NL63, and HKU1) remains controversial. We analyzed the impact of symptomatic RVI within <90 days prior to HCT on overall mortality, posttransplant lower respiratory tract disease (LRD), and days alive and out of hospital (DAOH) by day 100 post HCT in multivariable models. Among 1,643 adult HCT recipients (58% allogeneic recipients), 704 (43%) were tested for RVI before HCT and 307 (44%) tested positive. HRV was most commonly detected (56%). Forty-five (15%) of 307 HCT recipients had LRD with the same virus early after HCT. Pretransplant upper respiratory infection (URI) with influenza, respiratory syncytial virus, adenovirus, human metapneumovirus, parainfluenza virus, HRV or endemic HCoV was not associated with increased overall mortality or fewer DAOH. However, in allogeneic recipients who received myeloablative conditioning, LRD due to any respiratory virus, including HRV alone, was associated with increased overall mortality (adjusted hazard ratio 10.8 [95% CI 3.29, 35.1] for HRV and 3.21 [95% CI 1.15, 9.01] for all other viruses). HRV LRD was also associated with fewer DAOH. Thus, the presence of LRD due to common respiratory viruses, including HRV, before myeloablative allogeneic HCT was associated with increased mortality and hospitalization. Pretransplant URI due to HRV and endemic HCoV was not associated with these outcomes. Improved management strategies for pretransplant LRD are warranted.

      5. Characterizing HIV-preventive, plasma tenofovir concentrations. A pooled participant-level data analysis from HIV pre-exposure prophylaxis (PrEP) clinical trialsexternal icon
        Garcia-Cremades M, Vučićević K, Hendrix CW, Jayachandran P, Jarlsberg L, Grant R, Celum CL, Martin M, Baeten JM, Marrazzo J, Anderson P, Choopanya K, Vanichseni S, Glidden DV, Savic RM.
        Clin Infect Dis. 2022 Apr 26.
        BACKGROUND: Daily dosing of tenofovir disoproxil fumarate (TDF), with or without emtricitabine (FTC), has high efficacy in preventing HIV infection when individuals are adherent. The target protective plasma concentration of tenofovir (TFV), however, is not fully understood. The aim of this study is to estimate the protective TFV plasma concentration. METHODS: Participant data from TFV-based daily oral and topical active arms of phase III trials (iPrEx, VOICE and Partners PrEP) were pooled (n = 2,950). Individual specific risk scores (low and high risk) of acquiring HIV, based on an earlier placebo analysis, were created. Longitudinal TFV pharmacokinetics (PK), HIV outcome, individual risk scores and the effect of sex at birth data were integrated and analyzed using non-linear mixed effects models (NONMEM). RESULTS: Around 50% of the individuals were estimated to be adherent, which differed from self-reported adherence (∼90%) and large variation between longitudinal adherence patterns were identified. Following oral administration, the estimated protective TFV trough concentration was substantially higher in high risk females (45.8 ng/mL) compared to high risk males (16.1 ng/mL) and to low risk individuals (∼7.5 ng/mL). Dosing simulations indicated that high risk women require full adherence to maintain protective levels. CONCLUSIONS: Using the largest PK-HIV outcome database to date, we developed a population adherence-PK-risk-outcome model. Our results indicate that high risk females need higher levels of plasma TFV to achieve HIV protection compared to males. HIV protection exceeds 90% in all populations if daily adherence is achieved.

      6. SARS-CoV-2 seroprevalence after third wave of infections, South Africaexternal icon
        Kleynhans J, Tempia S, Wolter N, von Gottberg A, Bhiman JN, Buys A, Moyes J, McMorrow ML, Kahn K, Gómez-Olivé FX, Tollman S, Martinson NA, Wafawanaka F, Lebina L, du Toit JD, Jassat W, Neti M, Brauer M, Cohen C.
        Emerg Infect Dis. 2022 May;28(5):1055-1058.
        By November 2021, after the third wave of severe acute respiratory syndrome coronavirus 2 infections in South Africa, seroprevalence was 60% in a rural community and 70% in an urban community. High seroprevalence before the Omicron variant emerged may have contributed to reduced illness severity observed in the fourth wave.

      7. We analyzed a pharmacy dataset to assess the 20% decline in tuberculosis (TB) cases reported to the US National Tuberculosis Surveillance System (NTSS) during the coronavirus disease pandemic in 2020 compared with the 2016-2019 average. We examined the correlation between TB medication dispensing data to TB case counts in NTSS and used a seasonal autoregressive integrated moving average model to predict expected 2020 counts. Trends in the TB medication data were correlated with trends in NTSS data during 2006-2019. There were fewer prescriptions and cases in 2020 than would be expected on the basis of previous trends. This decrease was particularly large during April-May 2020. These data are consistent with NTSS data, suggesting that underreporting is not occurring but not ruling out underdiagnosis or actual decline. Understanding the mechanisms behind the 2020 decline in reported TB cases will help TB programs better prepare for postpandemic cases.

      8. Household Transmission and Symptomology of SARS-CoV-2 Alpha Variant Among Children-California and Colorado, 2021external icon
        Waltenburg MA, Whaley MJ, Chancey RJ, Donnelly MA, Chuey MR, Soto R, Schwartz NG, Chu VT, Sleweon S, McCormick DW, Uehara A, Retchless AC, Tong S, Folster JM, Petway M, Thornburg NJ, Drobeniuc J, Austin B, Hudziec MM, Stringer G, Albanese BA, Totten SE, Matzinger SR, Staples JE, Killerby ME, Hughes LJ, Matanock A, Beatty M, Tate JE, Kirking HL, Hsu CH.
        J Pediatr. 2022 Apr 18.
        OBJECTIVE: To assess the household secondary infection risk (SIR) of B.1.1.7 (Alpha) and non-Alpha lineages of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among children. STUDY DESIGN: During January-April 2021, we prospectively followed households with a SARS-CoV-2 infection. We collected questionnaires, serial nasopharyngeal swabs for RT-PCR testing and whole genome sequencing, and serial blood samples for serology testing. We calculated SIRs by primary case age (pediatric vs. adult), household contact age, and viral lineage. We evaluated risk factors associated with transmission and described symptom profiles among children. RESULTS: Among 36 households with pediatric primary cases, 21 (58%) had secondary infections. Among 91 households with adult primary cases, 51 (56%) had secondary infections. SIRs among pediatric and adult primary cases were 45% and 54%, respectively (OR: 0.79 [95% CI 0.41-1.54]). SIRs among pediatric primary cases with Alpha and non-Alpha lineage were 55% and 46%, respectively (OR: 1.52 [CI 0.51-4.53]). SIRs among pediatric and adult household contacts were 55% and 49%, respectively (OR: 1.01 [CI 0.68-1.50]). Among pediatric contacts, no significant differences in odds of acquiring infection by demographic or household characteristics were observed. CONCLUSIONS: Household transmission of SARS-CoV-2 from children and adult primary cases to household members was frequent. Risk of secondary infection was similar among child and adult household contacts. Among children, household transmission of SARS-CoV-2 and risk of secondary infection was not influenced by lineage. Continued mitigation strategies (e.g., masking, physical distancing, vaccination) are needed to protect at-risk groups regardless of virus lineage circulating in communities.

      9. Binding and neutralizing antibody responses to SARS-CoV-2 in very young children exceed those in adultsexternal icon
        Karron RA, Garcia Quesada M, Schappell EA, Schmidt SD, Deloria Knoll M, Hetrich MK, Veguilla V, Doria-Rose N, Dawood FS.
        JCI Insight. 2022 Apr 22;7(8).
        BackgroundSARS-CoV-2 infections are frequently milder in children than adults, suggesting that immune responses may vary with age. However, information is limited regarding SARS-CoV-2 immune responses in young children.MethodsWe compared receptor binding domain-binding antibody (RBDAb) titers and SARS-CoV-2-neutralizing antibody titers, measured by pseudovirus-neutralizing antibody assay in serum specimens obtained from children aged 0-4 years and 5-17 years and in adults aged 18-62 years at the time of enrollment in a prospective longitudinal household study of SARS-CoV-2 infection.ResultsAmong 56 seropositive participants at enrollment, children aged 0-4 years had more than 10-fold higher RBDAb titers than adults (416 vs. 31, P < 0.0001) and the highest RBDAb titers in 11 of 12 households with seropositive children and adults. Children aged 0-4 years had only 2-fold higher neutralizing antibody than adults, resulting in higher binding-to-neutralizing antibody ratios compared with adults (2.36 vs. 0.35 for ID50, P = 0.0004).ConclusionThese findings suggest that young children mount robust antibody responses to SARS-CoV-2 following community infections. Additionally, these results support using neutralizing antibody to measure the immunogenicity of COVID-19 vaccines in children aged 0-4 years.FundingCDC (award 75D30120C08737).

      10. Estimating COVID-19 hospitalizations in the United States with surveillance data using a Bayesian hierarchical model: A modeling studyexternal icon
        Couture A, Iuliano D, Chang H, Patel N, Gilmer M, Steele M, Havers F, Whitaker M, Reed C.
        JMIR Public Health Surveill. 2022 Apr 21.
        BACKGROUND: In the United States, COVID-19 is a nationally notifiable disease, meaning cases and hospitalizations are reported to the CDC by states. Identifying and reporting every case from every facility in the United States may not be feasible in the long term. Creating sustainable methods for estimating burden of COVID-19 from established sentinel surveillance systems is becoming more important. OBJECTIVE: We aimed to provide a method leveraging surveillance data to create a long-term solution to estimate monthly rates of hospitalizations for COVID-19. METHODS: We estimated monthly hospitalization rates for COVID-19 from May 2020 through April 2021 for the 50 states using surveillance data from COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) and a Bayesian hierarchical model for extrapolation. Hospitalization rates are calculated from patients hospitalized with a lab confirmed SARS-CoV-2 test during or within 14 days before admission. We created a model for six age groups (0-17, 18-49, 50-64, 65-74, 75-84, and ≥85 years), separately. We identified covariates from multiple data sources that varied by age, state, and/or month, and performed covariate selection for each age group based on two methods, Least Absolute Shrinkage and Selection Operator (LASSO) and Spike and Slab selection methods. We validated our method by checking sensitivity of model estimates to covariate selection and model extrapolation as well as comparing our results to external data. RESULTS: We estimated 3,583,100 (90% Credible Interval:3,250,500 - 3,945,400) hospitalizations for a cumulative incidence of 1,093.9 (992.4 - 1,204.6) hospitalizations per 100,000 population with COVID-19 in the United States from May 2020 through April 2021. Cumulative incidence varied from 359 - 1,856 per 100,000 between states. The age group with the highest cumulative incidence was aged ≥85 years (5,575.6; 5,066.4 - 6,133.7). The monthly hospitalization rate was highest in December (183.7; 154.3 - 217.4). Our monthly estimates by state showed variations in magnitudes of peak rates, number of peaks and timing of peaks between states. CONCLUSIONS: Our novel approach to estimate hospitalizations with COVID-19 has potential to provide sustainable estimates for monitoring COVID-19 burden, as well as a flexible framework leveraging surveillance data.

      11. Hospitalizations of children aged 5-11 years with laboratory-confirmed COVID-19 - COVID-NET, 14 states, March 2020-February 2022external icon
        Shi DS, Whitaker M, Marks KJ, Anglin O, Milucky J, Patel K, Pham H, Chai SJ, Kawasaki B, Meek J, Anderson EJ, Weigel A, Henderson J, Lynfield R, Ropp SL, Muse A, Bushey S, Billing LM, Sutton M, Talbot HK, Price A, Taylor CA, Havers FP.
        MMWR Morb Mortal Wkly Rep. 2022 Apr 22;71(16):574-581.
        On October 29, 2021, the Food and Drug Administration expanded the Emergency Use Authorization for Pfizer-BioNTech COVID-19 vaccine to children aged 5-11 years; CDC's Advisory Committee on Immunization Practices' recommendation followed on November 2, 2021.* In late December 2021, the B.1.1.529 (Omicron) variant of SARS-CoV-2 (the virus that causes COVID-19) became the predominant strain in the United States,(†) coinciding with a rapid increase in COVID-19-associated hospitalizations among all age groups, including children aged 5-11 years (1). COVID-19-Associated Hospitalization Surveillance Network (COVID-NET)(§) data were analyzed to describe characteristics of COVID-19-associated hospitalizations among 1,475 U.S. children aged 5-11 years throughout the pandemic, focusing on the period of early Omicron predominance (December 19, 2021-February 28, 2022). Among 397 children hospitalized during the Omicron-predominant period, 87% were unvaccinated, 30% had no underlying medical conditions, and 19% were admitted to an intensive care unit (ICU). The cumulative hospitalization rate during the Omicron-predominant period was 2.1 times as high among unvaccinated children (19.1 per 100,000 population) as among vaccinated(¶) children (9.2).** Non-Hispanic Black (Black) children accounted for the largest proportion of unvaccinated children (34%) and represented approximately one third of COVID-19-associated hospitalizations in this age group. Children with diabetes and obesity were more likely to experience severe COVID-19. The potential for serious illness among children aged 5-11 years, including those with no underlying health conditions, highlights the importance of vaccination among this age group. Increasing vaccination coverage among children, particularly among racial and ethnic minority groups disproportionately affected by COVID-19, is critical to preventing COVID-19-associated hospitalization and severe outcomes.

      12. Reduced spread of influenza and other respiratory viral infections during the COVID-19 pandemic in southern Puerto Ricoexternal icon
        Quandelacy TM, Adams LE, Munoz J, Santiago GA, Kada S, Johansson MA, Alvarado LI, Rivera-Amill V, Paz-Bailey G.
        PLoS One. 2022 ;17(4):e0266095.
        INTRODUCTION: Impacts of COVID-19 mitigation measures on seasonal respiratory viruses is unknown in sub-tropical climates. METHODS: We compared weekly testing and test-positivity of respiratory infections in the 2019-2020 respiratory season to the 2012-2018 seasons in southern Puerto Rico using Wilcoxon signed rank tests. RESULTS: Compared to the average for the 2012-2018 seasons, test-positivity was significantly lower for Influenza A (p<0.001) & B (p<0.001), respiratory syncytial virus (RSV) (p<0.01), respiratory adenovirus (AdV) (p<0.05), and other respiratory viruses (p<0.001) following March 2020 COVID-19 stay at home orders. CONCLUSIONS: Mitigation measures and behavioral social distancing choices may have reduced respiratory viral spread in southern Puerto Rico.

      13. Characteristics of people with and without laboratory-confirmed SARS-CoV-2 infection during pregnancy, Massachusetts, March 2020-March 2021external icon
        Shephard HM, Manning SE, Nestoridi E, Brown C, Yazdy MM.
        Public Health Rep. 2022 Apr 23:333549221084721.
        OBJECTIVES: Pregnant people infected with SARS-CoV-2, the virus that causes COVID-19, are at increased risk for severe illness and death compared with nonpregnant people. However, population-based information comparing characteristics of people with and without laboratory-confirmed SARS-CoV-2 infection during pregnancy is limited. We compared the characteristics of people with and without SARS-CoV-2 infection during pregnancy in Massachusetts. METHODS: We compared maternal demographic characteristics, pre-pregnancy conditions, and pregnancy complications of people with and without SARS-CoV-2 infection during pregnancy with completed pregnancies resulting in a live birth in Massachusetts during March 1, 2020-March 31, 2021. We tested for significant differences in the distribution of characteristics of pregnant people by SARS-CoV-2 infection status overall and stratified by race and ethnicity. We used modified Poisson regression analyses to examine the association between race and ethnicity and SARS-CoV-2 infection during pregnancy. RESULTS: Of 69 960 completed pregnancies identified during the study period, 3119 (4.5%) had laboratory-confirmed SARS-CoV-2 infection during pregnancy. Risk for SARS-CoV-2 infection was higher among Hispanic (adjusted risk ratio [aRR] = 2.3; 95% CI, 2.1-2.6) and non-Hispanic Black (aRR = 1.9; 95% CI, 1.7-2.1) pregnant people compared with non-Hispanic White pregnant people. CONCLUSIONS: This study demonstrates the disproportionate impact of SARS-CoV-2 infection on Hispanic and non-Hispanic Black pregnant people in Massachusetts, which may widen existent inequities in maternal morbidity and mortality. Future research is needed to elucidate the structural factors leading to these inequities.

      14. Characterizing tuberculosis transmission dynamics in high-burden urban and rural settingsexternal icon
        Smith JP, Oeltmann JE, Hill AN, Tobias JL, Boyd R, Click ES, Finlay A, Mondongo C, Zetola NM, Moonan PK.
        Sci Rep. 2022 Apr 26;12(1):6780.
        Mycobacterium tuberculosis transmission dynamics in high-burden settings are poorly understood. Growing evidence suggests transmission may be characterized by extensive individual heterogeneity in secondary cases (i.e., superspreading), yet the degree and influence of such heterogeneity is largely unknown and unmeasured in high burden-settings. We conducted a prospective, population-based molecular epidemiology study of TB transmission in both an urban and rural setting of Botswana, one of the highest TB burden countries in the world. We used these empirical data to fit two mathematical models (urban and rural) that jointly quantified both the effective reproductive number, [Formula: see text], and the propensity for superspreading in each population. We found both urban and rural populations were characterized by a high degree of individual heterogeneity, however such heterogeneity disproportionately impacted the rural population: 99% of secondary transmission was attributed to only 19% of infectious cases in the rural population compared to 60% in the urban population and the median number of incident cases until the first outbreak of 30 cases was only 32 for the rural model compared to 791 in the urban model. These findings suggest individual heterogeneity plays a critical role shaping local TB epidemiology within subpopulations.

      15. BACKGROUND: During the COVID-19 pandemic, disruptions were anticipated in the US health care system for routine preventive and other nonemergency care, including STI care. METHODS: Using a large national laboratory dataset, we assessed the impact of the COVID-19 pandemic on the weekly numbers and percent positivity of chlamydia and gonorrhea tests ordered from the 5th week of 2019 to the 52nd week of 2020 in the US. We compared weekly 2020 values for test volume, percent positive, and number of positives to the same week in 2019. We also examined the potential impact of stay-at-home orders for the month of April 2020. RESULTS: Immediately following the declaration of a national emergency for COVID-19 (week 11, 2020), the weekly number of gonorrhea and chlamydia tests steeply decreased. Tests then rebounded toward the 2019 pre-COVID-19 level beginning the 15th week of 2020. The weekly percent positive of chlamydia and gonorrhea remained consistently higher in 2020. In April 2020, the overall number of chlamydia tests were reduced by 53.0% (54.1% in states with stay-at-home orders versus 45.5% in states without stay-at-home orders), while the percent positive of chlamydia and gonorrhea tests increased by 23.5% and 79.1%, respectively. CONCLUSION: To limit the impact of the pandemic on control of chlamydia and gonorrhea, public health officials and healthcare providers can assess measures put in place during the pandemic and develop new interventions to enable care for STIs to be delivered under pandemic and other emergency conditions. The assessment like this study is continuously needed.

    • Disaster Preparedness and Emergency Services
      1. INTRODUCTION: There is limited literature on neonatal mortality in humanitarian emergencies. We estimated neonatal mortality and stillbirth rates; determined whether an association exists between proximity to a secondary health facility and neonatal mortality or stillbirth; and tested the correlation between the number of health facilities in a camp and neonatal mortality or stillbirth rates in Rohingya refugee camps in Bangladesh. METHODS: We conducted a prospective community-based mortality surveillance in 29 out of 34 Rohingya refugee camps between September 2017 and December 2018, covering approximately 811 543 Rohingya refugees with 19 477 estimated live births. We linked mortality surveillance data with publicly available information on camp population, number of functional health facilities and camp and health facility geospatial coordinates. Using descriptive statistics and spatial analyses, we estimated the mortality rate and tested for correlations. RESULTS: Overall, the estimated neonatal mortality rate was 27.0 (95% CI: 22.3 to 31.8) per 1000 live births, and the stillbirth rate was 15.2 (95% CI: 10.8 to 19.6) per 1000 total births. The majority of neonatal deaths (76.3%, n=405/531) and stillbirths (72.1%, n=202/280) occurred at home or in the community. A positive correlation existed between the camp population size and number of health facilities inside the camp (Spearman's rho=0.56, p value<0.01). No statistically significant correlation existed between the camp neonatal mortality rate or stillbirth rate and number of health facilities inside the camp. Camps that were located closer to a secondary health facility as compared with a labour room/sexual and reproductive health unit had a lower neonatal mortality rate (p value<0.01). CONCLUSIONS: The results provide insight into the neonatal mortality and stillbirth rates in Rohingya refugees camps in Bangladesh during 2017-2018. Prospective community-based mortality surveillance may be a feasible method to evaluate the effectiveness of humanitarian responses in improving neonatal survival and preventing stillbirths.

    • Environmental Health
      1. Public health response and medical management of internal contamination in past radiological or nuclear incidents: A narrative reviewexternal icon
        Li C, Alves Dos Reis A, Ansari A, Bertelli L, Carr Z, Dainiak N, Degteva M, Efimov A, Kalinich J, Kryuchkov V, Kukhta B, Kurihara O, Antonia Lopez M, Port M, Riddell T, Rump A, Sun Q, Tuo F, Youngman M, Zhang J.
        Environ Int. 2022 May;163:107222.
        Following a radiological or nuclear emergency, workers, responders and the public may be internally contaminated with radionuclides. Screening, monitoring and assessing any internal contamination and providing necessary medical treatment, especially when a large number of individuals are involved, is challenging. Experience gained and lessons learned from the management of previous incidents would help to identify gaps in knowledge and capabilities on preparedness for and response to radiation emergencies. In this paper, eight large-scale and five workplace radiological and nuclear incidents are reviewed cross 14 technical areas, under the broader topics of emergency preparedness, emergency response and recovery processes. The review findings suggest that 1) new strategies, algorithms and technologies are explored for rapid screening of large populations; 2) exposure assessment and dose estimation in emergency response and dose reconstruction in recovery process are supported by complementary sources of information, including 'citizen science'; 3) surge capacity for monitoring and dose assessment is coordinated through national and international laboratory networks; 4) evidence-based guidelines for medical management and follow-up of internal contamination are urgently needed; 5) mechanisms for international and regional access to medical countermeasures are investigated and implemented; 6) long-term health and medical follow up programs are designed and justified; and 7) capabilities and capacity developed for emergency response are sustained through adequate resource allocation, routine non-emergency use of technical skills in regular exercises, training, and continuous improvement.

      2. Gestational and childhood phthalate exposures and adolescent body composition: The HOME studyexternal icon
        Etzel TM, Braun JM, Kuiper JR, Calafat AM, Cecil KM, Chen A, Lanphear BP, Yolton K, Kalkwarf HJ, Buckley JP.
        Environ Res. 2022 Apr 21:113320.
        BACKGROUND: Early life phthalate exposures may disrupt metabolism but results from human studies are inconsistent and few have examined body composition during adolescence. We investigated associations of gestational and childhood urinary phthalate biomarker concentrations with body composition at age 12 years. METHODS: We used data from 206 mother-child pairs in a prospective pregnancy and birth cohort enrolled in Cincinnati, OH from 2003 to 2006. We measured nine phthalate metabolites in spot urine samples collected twice from mothers during pregnancy and up to seven times from children at 1, 2, 3, 4, 5, 8, and 12 years. At age 12 years, we assessed fat and lean mass of the whole body and android and gynoid subregions, and visceral fat area with dual x-ray absorptiometry, and calculated android to gynoid %fat ratio and age- and sex-standardized fat and lean mass index z-scores. Using a multiple informant model, we estimated covariate-adjusted associations between urinary phthalate biomarker concentrations at each time period and outcomes at age 12 years. We assessed effect measure modification by child sex using stratified models. RESULTS: Generally, urinary mono-benzyl phthalate (MBzP) concentrations were modestly associated with lower fat and lean mass. Each 10-fold increase in urinary MBzP concentrations during gestation and at ages 5 and 8 years was associated with a -0.34 (95%CI: -0.72, 0.05), -0.44 (95% CI: -0.83, -0.05), and -0.35 (95% CI: -0.71, 0.00) z-score difference in lean body mass index, respectively. Urinary monoethyl phthalate, mono-(3-carboxypropyl) phthalate, and summed di(2-ethylhexyl) phthalate metabolites were associated with greater lean mass at some exposure periods. Slightly weaker but similar patterns of association were found with other body composition measures; associations did not differ by child sex. CONCLUSION: While most associations were weak, exposure to certain phthalates during gestation and childhood may be associated with adolescent body composition, particularly lean mass.

    • Epidemiology and Surveillance
      1. Experiences and lessons learned in developing and implementing a population-based nutrition and health surveillance system in Guatemala 2011-2021external icon
        Palmieri M, Flores-Ayala R, Mesarina K, Mazariegos DI, Martínez C, López B, Santizo MC, Whitehead RD, Addo OY, Aponte J, Quiñónez EL, Sagastume MJ, Jefferds ME.
        Curr Dev Nutr. 2022 Apr;6(4):nzac027.
        BACKGROUND: Practice-based experiences documenting development and implementation of nutrition and health surveillance systems are needed. OBJECTIVES: To describe processes, methods, and lessons learned from developing and implementing a population-based household nutrition and health surveillance system in Guatemala. METHODS: The phases and methods for the design and implementation of the surveillance system are described. Efforts to institutionalize the system in government institutions are described, and illustrative examples describing different data uses, and lessons learned are provided. RESULTS: After initial assessments of data needs and consultations with officials in government institutions and partners in the country, a population-based nutrition surveillance system prototype with complex sampling was designed and tested in 5 Guatemalan Highland departments in 2011. After dissemination of the prototype, government and partners expanded the content, and multitopic nutrition and health surveillance cycles were collected in 2013, 2015, 2016, 2017/18, and 2018/19 providing nationally representative data for households, women of reproductive age (15-49 y), and children aged 0-59 mo. For each cycle, data were to be collected from 100 clusters, 30 households in each, and 1 woman and 1 child per household. Content covered ∼25 health and nutrition topics, including coverage of all large-scale nutrition-specific interventions; the micronutrient content of fortifiable sugar, salt, and bread samples; anthropometry; and biomarkers to assess annually, or at least once, ∼25 indicators of micronutrient status and chronic disease. Data were collected by 3-5 highly trained field teams. The design was flexible and revised each cycle allowing potential changes to questionnaires, population groups, biomarkers, survey design, or other changes. Data were used to change national guidelines for vitamin A and B-12 interventions, among others, and evaluate interventions. Barriers included frequent changes of high-level government officials and heavy dependence on US funding. CONCLUSIONS: This system provides high-quality data, fills critical data gaps, and can serve as a useful model for others.

      2. Electronic versus paper and pencil survey administration mode comparison: 2019 Youth Risk Behavior Surveyexternal icon
        Bryan LN, Smith-Grant J, Brener N, Kilmer G, Lo A, Queen B, Underwood JM.
        J Sch Health. 2022 Apr 21.
        BACKGROUND: Since the inception of the Youth Risk Behavior Surveillance System in 1991, all surveys have been conducted in schools, using paper and pencil instruments (PAPI). For the 2019 YRBSS, sites were offered the opportunity to conduct their surveys using electronic data collection. This study aimed to determine whether differences in select metrics existed between students who completed the survey electronically versus using PAPI. METHODS: Thirty risk behaviors were examined in this study. Data completeness, response rates and bivariate comparisons of risk behavior prevalence between administration modes were examined. RESULTS: Twenty-nine of 30 questions examined had more complete responses among students using electronic surveys. Small differences were found for student and school response rates between modes. Twenty-five of 30 adolescent risk behaviors showed no mode effect. CONCLUSIONS: Seven of 44 states and DC participated electronically. Because survey data were more complete; school and student response rates were consistent; and minor differences existed in risk behaviors between modes, the acceptability of collecting data electronically was demonstrated.

    • Food Safety
      1. Use of whole genome sequencing by the federal interagency collaboration for genomics for food and feed safety in the United Statesexternal icon
        Stevens EL, Carleton HA, Beal J, Tillman GE, Lindsey RL, Lauer AC, Pightling A, Jarvis KG, Ottesen A, Ramachandran P, Hintz L, Katz LS, Folster JP, Whichard JM, Trees E, Timme RE, Mc D, Wolpert B, Bazaco M, Zhao S, Lindley S, Bruce BB, Griffin PM, Brown E, Allard M, Tallent S, Irvin K, Hoffmann M, Wise M, Tauxe R, Gerner-Smidt P, Simmons M, Kissler B, Defibaugh-Chavez S, Klimke W, Agarwala R, Lindsay J, Cook K, Austerman SR, Goldman D, McGarry S, Hale KR, Dessai U, Musser SM, Braden C.
        J Food Prot. 2022 May 1;85(5):755-772.
        ABSTRACT: This multiagency report developed by the Interagency Collaboration for Genomics for Food and Feed Safety provides an overview of the use of and transition to whole genome sequencing (WGS) technology for detection and characterization of pathogens transmitted commonly by food and for identification of their sources. We describe foodborne pathogen analysis, investigation, and harmonization efforts among the following federal agencies: National Institutes of Health; Department of Health and Human Services, Centers for Disease Control and Prevention (CDC) and U.S. Food and Drug Administration (FDA); and the U.S. Department of Agriculture, Food Safety and Inspection Service, Agricultural Research Service, and Animal and Plant Health Inspection Service. We describe single nucleotide polymorphism, core-genome, and whole genome multilocus sequence typing data analysis methods as used in the PulseNet (CDC) and GenomeTrakr (FDA) networks, underscoring the complementary nature of the results for linking genetically related foodborne pathogens during outbreak investigations while allowing flexibility to meet the specific needs of Interagency Collaboration partners. We highlight how we apply WGS to pathogen characterization (virulence and antimicrobial resistance profiles) and source attribution efforts and increase transparency by making the sequences and other data publicly available through the National Center for Biotechnology Information. We also highlight the impact of current trends in the use of culture-independent diagnostic tests for human diagnostic testing on analytical approaches related to food safety and what is next for the use of WGS in the area of food safety.

      2. Seroprevalence and associated risk factors of trichinellosis and T. Solium cysticercosis in indigenous pigs in Hoa Binh Province, Vietnamexternal icon
        Le TT, Vu-Thi N, Dang-Xuan S, Nguyen-Viet H, Pham-Duc P, Nguyen-Thanh L, Pham-Thi N, Noh J, Mayer-Scholl A, Baumann M, Meemken D, Unger F.
        Trop Med Infect Dis. 2022 Apr 7;7(4).
        Trichinellosis and cysticercosis remain challenges to human health and animal productivity worldwide, especially in developing countries. While information on the occurrence of both diseases is infrequent, they are endemic in parts of Vietnam and mainly related to indigenous pigs kept by ethnic minorities. This study aimed to determine the seroprevalence and risk factors of both diseases in indigenous pigs and explore the perception and awareness of both human and pig trichinellosis and cysticercosis of pig farmers. A total of 352 pig sera samples from 131 holdings were collected and analyzed using ELISA antibody tests in six communes in the Da Bac districts of Hoa Binh province, Vietnam. A survey was conducted with representatives from these households to understand the knowledge and perspective on food-borne parasitic diseases. Overall, the seroprevalence of trichinellosis and T. solium cysticercosis was 13.6% (95% CI 10.2-17.7) and 1.7% (95% CI 0.6-3.7), respectively. The seroprevalence of trichinellosis was significantly higher in female and older pigs. Risk perception and knowledge of interviewed people on both human and pig trichinellosis and cysticercosis of pig farmers was poor. Risky practices, including free roaming of pigs and eating undercooked or fermented pork, were observed. Educational and awareness campaigns aligned with further research on feasible practice changes are critical to addressing these issues.

    • Genetics and Genomics
      1. A genome-wide association study of obstructive heart defects among participants in the National Birth Defects Prevention Studyexternal icon
        Rashkin SR, Cleves M, Shaw GM, Nembhard WN, Nestoridi E, Jenkins MM, Romitti PA, Lou XY, Browne ML, Mitchell LE, Olshan AF, Lomangino K, Bhattacharyya S, Witte JS, Hobbs CA.
        Am J Med Genet A. 2022 Apr 22.
        Obstructive heart defects (OHDs) share common structural lesions in arteries and cardiac valves, accounting for ~25% of all congenital heart defects. OHDs are highly heritable, resulting from interplay among maternal exposures, genetic susceptibilities, and epigenetic phenomena. A genome-wide association study was conducted in National Birth Defects Prevention Study participants (N(discovery)  = 3978; N(replication)  = 2507), investigating the genetic architecture of OHDs using transmission/disequilibrium tests (TDT) in complete case-parental trios (N(discovery_TDT)  = 440; N(replication_TDT)  = 275) and case-control analyses separately in infants (N(discovery_CCI)  = 1635; N(replication_CCI)  = 990) and mothers (case status defined by infant; N(discovery_CCM)  = 1703; N(replication_CCM)  = 1078). In the TDT analysis, the SLC44A2 single nucleotide polymorphism (SNP) rs2360743 was significantly associated with OHD (p(discovery)  = 4.08 × 10(-9) ; p(replication)  = 2.44 × 10(-4) ). A CAPN11 SNP (rs55877192) was suggestively associated with OHD (p(discovery)  = 1.61 × 10(-7) ; p(replication)  = 0.0016). Two other SNPs were suggestively associated (p < 1 × 10(-6) ) with OHD in only the discovery sample. In the case-control analyses, no SNPs were genome-wide significant, and, even with relaxed thresholds ( × (discovery) < 1 × 10(-5) and p(replication) < 0.05), only one SNP (rs188255766) in the infant analysis was associated with OHDs (p(discovery)  = 1.42 × 10(-6) ; p(replication)  = 0.04). Additional SNPs with p(discovery) < 1 × 10(-5) were in loci supporting previous findings but did not replicate. Overall, there was modest evidence of an association between rs2360743 and rs55877192 and OHD and some evidence validating previously published findings.

      2. The scientific response to the COVID-19 pandemic has produced an abundance of publications, including peer-reviewed articles and preprints, across a wide array of disciplines, from microbiology to medicine and social sciences. Genomics and precision health (GPH) technologies have had a particularly prominent role in medical and public health investigations and response; however, these domains are not simply defined and it is difficult to search for relevant information using traditional strategies. To quantify and track the ongoing contributions of GPH to the COVID-19 response, the Office of Genomics and Precision Public Health at the Centers for Disease Control and Prevention created the COVID-19 Genomics and Precision Health database (COVID-19 GPH), an open access knowledge management system and publications database that is continuously updated through machine learning and manual curation. As of February 11, 2022, COVID-GPH contained 31,597 articles, mostly on pathogen and human genomics (72%). The database also includes articles describing applications of machine learning and artificial intelligence to the investigation and control of COVID-19 (28%). COVID-GPH represents about 10% (22983/221241) of the literature on COVID-19 on PubMed. This unique knowledge management database makes it easier to explore, describe, and track how the pandemic response is accelerating the applications of genomics and precision health technologies. COVID-19 GPH can be freely accessed via https://phgkb.cdc.gov/PHGKB/coVInfoStartPage.action .

    • Health Economics
      1. The Health Innovation Impact Checklist: a tool to improve the development and reporting of impact models for global health innovationsexternal icon
        Shahid M, Finnegan A, Kilburn K, Udayakumar K, Baumgartner JN.
        Glob Health Action. 2022 Dec 31;15(1):2056312.
        Donor financing is increasingly relying on performance-based measures that demonstrate impact. As new technologies and interventions enter the innovation space to address global health challenges, innovators often need to model their potential impact prior to obtaining solid effectiveness data. Diverse stakeholders rely on impact modeling data to make key funding and scaling decisions. With a lack of standardized methodology to model impact and various stakeholders using different modeling strategies, we propose that a universal innovation impact checklist be used to aid in transparent and aligned modeling efforts. This article describes a new Health Innovation Impact Checklist (HIIC) - a tool developed while evaluating the impact of health innovations funded under the Saving Lives at Birth (SL@B) program. SL@B, a global health Grand Challenge initiative, funded 116 unique maternal and newborn health innovations, four of which were selected for cost-effectiveness analyses (CEAs) within our evaluation. A key data source needed to complete a CEA was the lives saved estimate. HIIC was developed to help validate draft impact models from the SL@B donors and our own team's additional modeling efforts, to ensure the inclusion of standardized elements and to pressure test assumptions for modeling impact. This article describes the core components of HIIC including its strengths and limitations. It also serves as an open call for further reviewing and tailoring of this checklist for applicability across global efforts to model the impact of health innovations.

    • Health Equity and Health Disparities
      1. The influence of structural racism, pandemic stress, and SARS-CoV-2 infection during pregnancy with adverse birth outcomesexternal icon
        Janevic T, Lieb W, Ibroci E, Lynch J, Lieber M, Molenaar NM, Rommel AS, de Witte L, Ohrn S, Carreño JM, Krammer F, Zapata LB, Snead MC, Brody RI, Jessel RH, Sestito S, Adler A, Afzal O, Gigase F, Missall R, Carrión D, Stone J, Bergink V, Dolan SM, Howell EA.
        Am J Obstet Gynecol MFM. 2022 Apr 21:100649.
        BACKGROUND: Structural racism and pandemic-related stress from the COVID-19 pandemic may increase risk of adverse birth outcomes. OBJECTIVE: Our objective was to examine associations between neighborhood measures of structural racism and pandemic stress with three outcomes: SARS-CoV-2 infection, preterm birth (PTB) and delivering a newborn small-for-gestational-age (SGA). Our secondary objective was to investigate the joint associations of SARS-CoV-2 infection during pregnancy and neighborhood measures on PTB and SGA. STUDY DESIGN: We analyzed data for 967 patients from a prospective cohort of pregnant persons in New York City, comprised of 367 White persons (38%), 169 Black persons (17%), 293 Latina persons (30%), 87 Asian persons (9%), 41 persons of unknown race-ethnicity (4%), and 10 of unknown race-ethnicity (1%). We evaluated structural racism (social/built structural disadvantage, racial-economic segregation) and pandemic-related stress (community COVID-19 mortality, community unemployment rate increase) in quartiles by zip code. SARS-CoV-2 serologic enzyme-linked immunosorbent assay was performed on blood samples from pregnant persons. We ascertained preterm birth (PTB) and small-for-gestational age (SGA) from an electronic medical record database. We used log-binomial regression with robust standard error for clustering by zip code to estimate associations of each neighborhood measure separately with three outcomes: SARS-CoV-2 infection, PTB, and SGA. Covariates included maternal age, parity, insurance status, and BMI. Models with PTB and SGA as the dependent variables additionally adjusted for SARS-CoV-2 infection. RESULTS: 193 (20%) persons were SARS-CoV-2 seropositive, and the overall risk of PTB and SGA were 8.4% and 9.8%, respectively. Among birthing persons in neighborhoods in the highest quartile of structural disadvantage (n=190), 94% were non-White, 50% had public insurance, 41% were obese, 32% were seropositive, 11% delivered preterm, and 12% delivered an infant SGA. Among birthing persons in neighborhoods in the lowest quartile of structural disadvantage (n=360), 39% were non-White, 17% had public insurance, 15% were obese, 9% were seropositive, 6% delivered preterm, and 10% delivered an infant SGA. In adjusted analyses structural racism measures and community unemployment were associated with both SARS-CoV-2 infection and PTB, but not SGA. High vs. low structural disadvantage was associated with an adjusted relative risk (aRR) of 2.6 for infection (95% Confidence Interval (CI)=1.7, 3.9) and 1.7 for PTB (95%CI=1.0, 2.9); high vs. low racial-economic segregation was associated with aRR of 1.9 (95% CI=1.3, 2.8) for infection and 2.0 (95%CI=1.3, 3.2) for PTB; high vs. low community unemployment increase was associated with aRR of 1.7 (95% CI=1.2, 1.5) for infection and 1.6 (95%CI=1.0, 2.8) for PTB. COVID-19 mortality rate was associated with SARS-CoV-2 infection, but not PTB or SGA. SARS-CoV-2 infection was not independently associated with birth outcomes. We found no interaction between SARS-CoV-2 infection and neighborhood measures on PTB or SGA. CONCLUSIONS: Neighborhood measures of structural racism were associated with both SARS-CoV-2 infection and PTB, but these associations were independent and did not have a synergistic effect. Community unemployment rate increases were also associated with an increased risk of PTB independently of SARS-CoV-2 infection. Mitigating these factors might reduce the impact of the pandemic on pregnant people.

      2. Race, ethnicity, and disparities in risk of end-organ lupus manifestations following SLE diagnosis in a multiethnic cohortexternal icon
        Aguirre A, Izadi Z, Trupin L, Barbour KE, Greenlund KJ, Katz P, Lanata C, Criswell L, Dall'Era M, Yazdany J.
        Arthritis Care Res (Hoboken). 2022 Apr 22.
        OBJECTIVE: Data on onset of lupus manifestations across multiple organ domains and in diverse populations is limited. We analyzed racial and ethnic differences in risk of end-organ lupus manifestations following systemic lupus erythematosus (SLE) diagnosis in a multiethnic cohort. METHODS: The California Lupus Epidemiology Study (CLUES) is a longitudinal study of SLE. Data on major end-organ lupus manifestations were collected and categorized by organ system: renal, hematologic, neurologic, cardiovascular, and pulmonary. Multiorgan disease was defined as manifestations in ≥2 of these distinct organ systems. Kaplan-Meier curves assessed end-organ disease-free survival, and Cox proportional hazard regression estimated the rate of end-organ disease following SLE diagnosis adjusting for age at diagnosis, sex, and self-reported race and ethnicity (White, Hispanic, Black, and Asian). RESULTS: Of 326 participants, 89% were female and had a mean age and age at diagnosis of 45 and 29 years, respectively. Self-reported race and ethnicity was 30% White, 23% Hispanic, 11% Black, and 36% Asian. Multiorgan disease occurred in 29%. Compared to White participants, Hispanic and Asian participants had higher rates of renal (HR 2.9 [95% CI 1.8-4.7], HR 2.9 [95% CI 1.9-4.6]), hematologic (HR 2.7 [95% CI 1.3-5.7], HR 2.1 [95% CI 1.0-4.2]), and multiorgan disease (HR 3.3 [95% CI 1.8-5.9], HR 2.5 [95% CI 1.4-4.4]) following SLE diagnosis. CONCLUSION: We found heightened risks of developing renal, hematologic, and multiorgan disease following SLE diagnosis among Hispanic and Asian patients with SLE, as well as a high burden of multiorgan disease among CLUES participants.

      3. Disparities in first dose COVID-19 vaccination coverage among children 5-11 years of age, United Statesexternal icon
        Murthy NC, Zell E, Fast HE, Murthy BP, Meng L, Saelee R, Vogt T, Chatham-Stephens K, Ottis C, Shaw L, Gibbs-Scharf L, Harris L, Chorba T.
        Emerg Infect Dis. 2022 May;28(5):986-989.
        We analyzed first-dose coronavirus disease vaccination coverage among US children 5-11 years of age during November-December 2021. Pediatric vaccination coverage varied widely by jurisdiction, age group, and race/ethnicity, and lagged behind vaccination coverage for adolescents aged 12-15 years during the first 2 months of vaccine rollout.

      4. A growing literature has pointed out disparities in teleworking among different racial and ethnic (hereafter racial) workers. This study estimated racial disparities in teleworking due to the COVID-19 pandemic and the extent to which these disparities were mediated by four-year college education and occupation in the United States. The data source for this study was the Current Population Survey, May 2020 through July 2021. The results showed that in the reduced model, the odds for Black and Hispanic workers to telework were 35% and 55% lower, respectively, and for Asian workers 44% higher than for White workers, controlling for covariates. When four-year college education and occupation were included as mediator variables in the model, the odds for Black and Hispanic workers to telework were reduced to 7% and 16%, respectively. Overall, disparities in four-year college education and occupation explained 83% and 78% of the variation in the odds of teleworking for Black and Hispanic workers, respectively. Between the mediators, occupation explained more than 60% of the total effect. The results of this study could not rule out the possibility of racial discrimination in teleworking. Ultimately, reducing racial disparities in four-year college education and in different occupations might be a long-term solution for reducing racial disparities in teleworking.

    • Immunity and Immunization
      1. American College of Rheumatology Guidance for COVID-19 vaccination in patients with rheumatic and musculoskeletal diseases: Version 4external icon
        Curtis JR, Johnson SR, Anthony DD, Arasaratnam RJ, Baden LR, Bass AR, Calabrese C, Gravallese EM, Harpaz R, Kroger A, Sadun RE, Turner AS, Williams EA, Mikuls TR.
        Arthritis Rheumatol. 2022 May;74(5):e21-e36.
        OBJECTIVE: To provide guidance to rheumatology providers on the use of COVID-19 vaccines for patients with rheumatic and musculoskeletal diseases (RMDs). METHODS: A task force was assembled that included 9 rheumatologists/immunologists, 2 infectious disease specialists, and 2 public health physicians. After agreeing on scoping questions, an evidence report was created that summarized the published literature and publicly available data regarding COVID-19 vaccine efficacy and safety, as well as literature for other vaccines in RMD patients. Task force members rated their agreement with draft consensus statements on a 9-point numerical scoring system, using a modified Delphi process and the RAND/University of California Los Angeles Appropriateness Method, with refinement and iteration over 2 sessions. Consensus was determined based on the distribution of ratings. RESULTS: Despite a paucity of direct evidence, statements were developed by the task force and agreed upon with consensus to provide guidance for use of the COVID-19 vaccines, including supplemental/booster dosing, in RMD patients and to offer recommendations regarding the use and timing of immunomodulatory therapies around the time of vaccination. CONCLUSION: These guidance statements are intended to provide direction to rheumatology health care providers on how to best use COVID-19 vaccines and to facilitate implementation of vaccination strategies for RMD patients.

      2. Projected risks and health benefits of vaccination against herpes zoster and related complications in US adultsexternal icon
        Janusz CB, Anderson TC, Leidner AJ, Lee GM, Dooling K, Prosser LA.
        Hum Vaccin Immunother. 2022 Apr 27:1-5.
        The Advisory Committee on Immunization Practices (ACIP) recommends recombinant zoster vaccine (RZV) to prevent against herpes zoster (HZ) and related complications in immunocompetent adults ≥50 y and immunocompromised adults ≥19 y. In 2019, a statistical safety signal for Guillain-Barré syndrome (GBS) following RZV was identified using data from the Vaccine Safety Datalink (VSD). Subsequently, the U.S. Food and Drug Administration (FDA), the Centers for Disease Control and Prevention (CDC), and collaborators undertook additional analyses using Centers for Medicare & Medicaid Services (CMS) Medicare data to further investigate the potential risk of GBS following RZV. Concurrently, epidemiologic data suggested a potentially elevated risk of GBS following HZ in U.S. adults. Using data from these sources and a published simulation model, this study evaluated the health benefits and risks associated with vaccinating immunocompetent adults ≥50 y with RZV compared to no vaccination. In the base case analysis, RZV vaccination averted 43,000-63,000 cases of HZ, including GBS complications, per million vaccinated per 10-y age cohort compared to 3-6 additional cases of GBS projected following RZV per million vaccinated in the same population. This analysis highlights the projected health benefits of RZV vaccination compared to the relatively low potential risk of GBS following RZV.

      3. Measles immunity gap among reproductive-age women participating in a simulated HIV vaccine efficacy trial in Zambiaexternal icon
        Malama K, Tichacek A, Kelly H, Parker R, Inambao M, Sharkey T, Wall KM, Kilembe W, Price MA, Fast P, Priddy F, Allen S.
        Hum Vaccin Immunother. 2022 Apr 21:1-5.
        Measles is a vaccine-preventable viral disease whose vaccination coverage remains low in Zambia, where the target group for vaccination is children aged 9 to 18 months. In addition to inadequate measles vaccination coverage among children, few studies address potential resultant immunity gaps among adults. We analyzed data from a simulated HIV vaccine efficacy trial (SiVET) conducted from 2015-2017 among adult Zambian women of childbearing age to determine measles antibody seroprevalence before and after vaccination with the measles, mumps and rubella (MMR) vaccine. We used MMR vaccine as a substitute for an experimental HIV vaccine as part of a simulation exercise to prepare for an HIV vaccine efficacy trial. We found that 75% of women had measles antibodies prior to receiving MMR, which increased to 98% after vaccination. In contrast, mumps and rubella antibody prevalence was high before (93% and 97%, respectively) and after (99% and 100%, respectively) vaccination. The low baseline measles seropositivity suggests an immunity gap among women of childbearing age. We recommend that measles vaccination programs target women of childbearing age, who can pass antibodies on to neonates. Moreover, administering the MMR vaccine to clinical trial candidates could prevent measles, mumps or rubella-related adverse events during actual trials.

      4. Receipt of COVID-19 booster dose among fully vaccinated pregnant individuals aged 18 to 49 years by key demographicsexternal icon
        Razzaghi H, Meghani M, Crane B, Ellington S, Naleway AL, Irving SA, Patel SA.
        Jama. 2022 Apr 22.

      5. Incidence of Guillain-Barré Syndrome after COVID-19 vaccination in the vaccine safety datalinkexternal icon
        Hanson KE, Goddard K, Lewis N, Fireman B, Myers TR, Bakshi N, Weintraub E, Donahue JG, Nelson JC, Xu S, Glanz JM, Williams JT, Alpern JD, Klein NP.
        JAMA Netw Open. 2022 Apr 1;5(4):e228879.
        IMPORTANCE: Postauthorization monitoring of vaccines in a large population may detect rare adverse events not identified in clinical trials such as Guillain-Barré syndrome (GBS), which has a background rate of 1 to 2 per 100 000 person-years. OBJECTIVE: To describe cases and incidence of GBS following COVID-19 vaccination and assess the risk of GBS after vaccination for Ad.26.COV2.S (Janssen) and mRNA vaccines. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used surveillance data from the Vaccine Safety Datalink at 8 participating integrated health care systems in the United States. There were 10 158 003 participants aged at least 12 years. Data analysis was performed from November 2021 to February 2022. EXPOSURES: Ad.26.COV2.S, BNT162b2 (Pfizer-BioNTech), or mRNA-1273 (Moderna) COVID-19 vaccine, including mRNA vaccine doses 1 and 2, December 13, 2020, to November 13, 2021. MAIN OUTCOMES AND MEASURES: GBS with symptom onset in the 1 to 84 days after vaccination, confirmed by medical record review and adjudication. Descriptive characteristics of confirmed cases, GBS incidence rates during postvaccination risk intervals after each type of vaccine compared with the background rate, rate ratios (RRs) comparing GBS incidence in the 1 to 21 vs 22 to 42 days postvaccination, and RRs directly comparing risk of GBS after Ad.26.COV2.S vs mRNA vaccination, using Poisson regression adjusted for age, sex, race and ethnicity, site, and calendar day. RESULTS: From December 13, 2020, through November 13, 2021, 15 120 073 doses of COVID-19 vaccines were administered to 7 894 989 individuals (mean [SE] age, 46.5 [0.02] years; 8 138 318 doses received [53.8%] by female individuals; 3 671 199 doses received [24.3%] by Hispanic or Latino individuals, 2 215 064 doses received [14.7%] by Asian individuals, 6 266 424 doses received [41.4%] by White individuals), including 483 053 Ad.26.COV2.S doses, 8 806 595 BNT162b2 doses, and 5 830 425 mRNA-1273 doses. Eleven cases of GBS after Ad.26.COV2.S were confirmed. The unadjusted incidence rate of GBS per 100 000 person-years in the 1 to 21 days after Ad.26.COV2.S was 32.4 (95% CI, 14.8-61.5), significantly higher than the background rate, and the adjusted RR in the 1 to 21 vs 22 to 42 days following Ad.26.COV2.S was 6.03 (95% CI, 0.79-147.79). Thirty-six cases of GBS after mRNA vaccines were confirmed. The unadjusted incidence rate per 100 000 person-years in the 1 to 21 days after mRNA vaccines was 1.3 (95% CI, 0.7-2.4) and the adjusted RR in the 1 to 21 vs 22 to 42 days following mRNA vaccines was 0.56 (95% CI, 0.21-1.48). In a head-to-head comparison of Ad.26.COV2.S vs mRNA vaccines, the adjusted RR was 20.56 (95% CI, 6.94-64.66). CONCLUSIONS AND RELEVANCE: In this cohort study of COVID-19 vaccines, the incidence of GBS was elevated after receiving the Ad.26.COV2.S vaccine. Surveillance is ongoing.

      6. Vaccination coverage with selected vaccines and exemption rates among children in kindergarten - United States, 2020-21 School Yearexternal icon
        Seither R, Laury J, Mugerwa-Kasujja A, Knighton CL, Black CL.
        MMWR Morb Mortal Wkly Rep. 2022 Apr 22;71(16):561-568.
        State and local school vaccination requirements serve to protect students against vaccine-preventable diseases (1). This report summarizes data collected for the 2020-21 school year by state and local immunization programs* on vaccination coverage among children in kindergarten in 47 states and the District of Columbia (DC), exemptions for kindergartners in 48 states and DC, and provisional enrollment or grace period status for kindergartners in 28 states. Vaccination coverage(†) nationally was 93.9% for 2 doses of measles, mumps, and rubella vaccine (MMR); 93.6% for the state-required number of doses of diphtheria, tetanus, and acellular pertussis vaccine (DTaP); and 93.6% for the state-required doses of varicella vaccine. Compared with the 2019-20 school year, vaccination coverage decreased by approximately one percentage point for all vaccines. Although 2.2% of kindergartners had an exemption from at least one vaccine,(§) an additional 3.9% who did not have a vaccine exemption were not up to date for MMR. The COVID-19 pandemic affected schools' vaccination requirement and provisional enrollment policies, documentation, and assessment activities. As schools continue to return to in-person learning, enforcement of vaccination policies and follow-up with undervaccinated students are important to improve vaccination coverage.

      7. Changes in incidence rates of outcomes of interest in vaccine safety studies during the COVID-19 pandemicexternal icon
        Xu S, Hong V, Sy LS, Glenn SC, Ryan DS, Morrissette KL, Nelson JC, Hambidge SJ, Crane B, Zerbo O, DeSilva MB, Glanz JM, Donahue JG, Liles E, Duffy J, Qian L.
        Vaccine. 2022 Apr 18.
        BACKGROUND: The COVID-19 pandemic caused an abrupt drop in in-person health care (inpatient, Emergency Department, outpatient) and an increase in telehealth care, which poses challenges in vaccine safety studies that identify outcomes from in-person encounters. We examined the changes in incidence rates of selected encounter-based outcomes during the COVID-19 pandemic. METHODS: We assembled a cohort of members from 8 Vaccine Safety Datalink sites from January 1, 2017 through December 31, 2020. Using ICD-10 diagnosis codes or laboratory criteria, we identified 21 incident outcomes in traditional in-person settings and all settings. We defined 4 periods in 2020: January-February (pre-pandemic), April-June (early pandemic), July-September (middle pandemic), and October-December (late pandemic). We defined four corresponding periods in each year during 2017-2019. We calculated incidence rates, conducted difference in difference (DiD) analyses, and reported ratios of incidence rate ratios (RRR) to examine changes in rates from pre-pandemic to early, middle, and late pandemic in 2020, after adjusting for changes across similar periods in 2017-2019. RESULTS: Among > 10 million members, regardless of setting and after adjusting for changes during 2017-2019, we found that incidence rates of acute disseminated encephalomyelitis, encephalitis/myelitis/encephalomyelitis/meningoencephalitis, and thrombotic thrombocytopenic purpura did not significantly change from the pre-pandemic to early, middle or late pandemic periods (p-values ≥ 0.05). Incidence rates decreased from the pre-pandemic to early pandemic period during 2020 for acute myocardial infarction, anaphylaxis, appendicitis, Bell's palsy, convulsions/seizures, Guillain-Barré syndrome, immune thrombocytopenia (ITP), narcolepsy/cataplexy, hemorrhagic stroke, ischemic stroke, and venous thromboembolism (p-values < 0.05). Incidence rates of Bell's palsy, ITP, and narcolepsy/cataplexy were higher in all settings than in traditional in-person settings during the three pandemic periods (p-values < 0.05). CONCLUSION: Rates of some clinical outcomes during the pandemic changed and should not be used as historical background rates in vaccine safety studies. Inclusion of telehealth visits should be considered for vaccine studies involving Bell's palsy, ITP, and narcolepsy/cataplexy.

    • Informatics
      1. BACKGROUND: Population size estimates (PSE) provide critical information in determining resource allocation for HIV services geared toward those at high risk of HIV, including female sex workers, men who have sex with men, and people who inject drugs. Capture-recapture (CRC) is often used to estimate the size of these often-hidden populations. Compared with the commonly used 2-source CRC, CRC relying on 3 (or more) samples (3S-CRC) can provide more robust PSE but involve far more complex statistical analysis. OBJECTIVE: This study aims to design and describe the Shiny application (shinyrecap), a user-friendly interface that can be used by field epidemiologists to produce PSE. METHODS: shinyrecap is built on the Shiny web application framework for R. This allows it to seamlessly integrate with the sophisticated CRC statistical packages (eg, Rcapture, dga, LCMCR). Additionally, the application may be accessed online or run locally on the user's machine. RESULTS: The application enables users to engage in sample size calculation based on a simulation framework. It assists in the proper formatting of collected data by providing a tool to convert commonly used formats to that used by the analysis software. A wide variety of methodologies are supported by the analysis tool, including log-linear, Bayesian model averaging, and Bayesian latent class models. For each methodology, diagnostics and model checking interfaces are provided. CONCLUSIONS: Through a use case, we demonstrated the broad utility of this powerful tool with 3S-CRC data to produce PSE for female sex workers in a subnational unit of a country in sub-Saharan Africa.

    • Injury and Violence
      1. ABSTRACTIntimate partner violence (IPV) can increase a person's risk of HIV and other sexually transmitted infections (STIs), and may affect access to sexual health services. We assessed the prevalence of HIV screening and IPV among heterosexually-active persons using data from the 2016 National HIV Behavioral Surveillance. Participants were eligible if they were 18-60 years old, could complete the interview in English or Spanish, and reported having sex with an opposite sex partner in the previous 12 months. People who reported neither injection drug use within the past 12 months nor prior HIV diagnosis, and persons with valid responses to questions regarding HIV screening and physical/sexual IPV within the past 12 months were included (N = 7,777). Overall, 17% reported IPV in the previous 12 months and 19% had never had HIV screening. Abused persons were more likely to have been screened for HIV and to report high risk behaviors than non-abused persons. There was no difference in the proportion being offered HIV screening by their health care provider in the previous year. Findings suggest an integrated approach to violence prevention and sexual health may help increase awareness about clinical best practices and reduce risk for HIV/STIs among at-risk communities.

    • Laboratory Sciences
      1. A novel loop-mediated isothermal amplification assay for rapid detection of Yersinia pestisexternal icon
        Bai Y, Rizzo MR, Parise C, Maes S, Eisen RJ.
        Front Microbiol. 2022 ;13:863142.
        Rapid detection of Yersinia pestis, the causative agent of plague, is essential during field investigations to enable prompt control measures for prevention of the spread of the disease. Affordable, efficient, reliable, and simple detection assays are extremely useful, particularly in plague-endemic regions with limited resources. We developed a loop-mediated isothermal amplification (LAMP) assay that detects Y. pestis within 30 min by simply incubating at 65°C on a dry bath heater. The assay targeted the caf1A gene that is situated on the pMT1 plasmid using six specific primers. Y. pestis presence is visually detected based on the color change in the reactions. For comparison of the assay performance, a real-time LAMP with fluorescent dye detection was conducted on a real-time PCR instrument using the same six primers. Sensitivity assessment showed that the limit of detection (LOD) was 0.2 and 0.03 pg when performed on the dry bath heater and on the real-time PCR instrument, respectively. The assay was 100% specific, having no cross-reactivity with closely related Yersinia spp. and other bacterial species. We tested the LAMP assay on field-collected fleas and showed that it successfully detected Y. pestis with identical results to that of a previously published pentaplex real-time PCR assay. These findings suggest that the relatively inexpensive and simpler LAMP assay could be used to support field investigations, yielding comparable results to more expensive and complex PCR assays.

      2. Current state of pediatric reference intervals and the importance of correctly describing the biochemistry of child development: A reviewexternal icon
        Lyle AN, Pokuah F, Dietzen DJ, Wong EC, Pyle-Eilola AL, Fuqua JS, Woodworth A, Jones PM, Akinbami LJ, Garibaldi LR, Vesper HW.
        JAMA Pediatr. 2022 Apr 25.
        IMPORTANCE: Appropriately established pediatric reference intervals are critical to the clinical decision-making process and should reflect the physiologic changes that occur during healthy child development. Reference intervals used in pediatric care today remain highly inconsistent across a broad range of common clinical biomarkers. OBSERVATIONS: This narrative review assesses biomarker-specific pediatric reference intervals and their clinical utility with respect to the underlying biological changes occurring during development. Pediatric reference intervals from PubMed-indexed articles published from January 2015 to April 2021, commercial laboratory websites, study cohorts, and pediatric reference interval books were all examined. Although large numbers of pediatric reference intervals are published for some biomarkers, very few are used by clinical and commercial laboratories. The patterns, extent, and timing of biomarker changes are highly variable, particularly during developmental stages with rapid physiologic changes. However, many pediatric reference intervals do not capture these changes and thus do not accurately reflect the underlying biochemistry of development, resulting in significant inconsistencies between reference intervals. CONCLUSIONS AND RELEVANCE: There is a need to correctly describe the biochemistry of child development as well as to identify strategies to develop accurate and consistent pediatric reference intervals for improved pediatric care.

    • Maternal and Child Health
      1. Child marriage among displaced populations - a 2019 study in Kurdistan Region of Iraqexternal icon
        Goers M, Hunersen K, Karim LS, Jeffery A, Zedan A, Robinson C, Metzler J.
        BMC Public Health. 2022 Apr 21;22(1):796.
        BACKGROUND: Many of the factors that increase risk of child marriage are common among refugees and internally displaced persons (IDPs). We sought to address the gaps in knowledge surrounding child marriage in displaced and host populations in the Kurdistan Region of Iraq (KRI). METHODS: A multistage cluster sample design was employed collecting data of KRI host communities, Iraqi IDPs, and Syrian refugees. Interviews were conducted in eligible households, requiring at least one adult female and one female adolescent present, addressing views of marriage, demographics and socioeconomic factors. Household rosters were completed to assess WHO indicators, related to child marriage including completed child marriage in females 10-19 and completed risk of previously conducted child marriages in females 20-24. RESULTS: Interviews were completed in 617 hosts, 664 IDPs, and 580 refugee households, obtaining information on 10,281 household members and 1,970 adolescent females. Overall, 10.4% of girls age 10-19 were married. IDPs had the highest percentage of married 10-19-year-old females (12.9%), compared to the host community (9.8%) and refugees (8.1%). Heads of households with lower overall education had higher percentages of child marriage in their homes; this difference in prevalence was most notable in IDPs and refugees. When the head of the household was unemployed, 14.5% of households had child marriage present compared to 8.0% in those with employed heads of household. Refugees and IDPs had larger percentages of child marriage when heads of households were unemployed (refugees 13.1%, IDPs 16.9%) compared to hosts (11.9%). When asked about factors influencing marriage decisions, respondents predominately cited family tradition (52.5%), family honor (15.7%), money/resources (9.6%), or religion (8.0%). Over a third of those interviewed (38.9%) reported a change in influencing factors on marriage after displacement (or after the arrival of refugees in the area for hosts). CONCLUSIONS: Being an IDP in Iraq, unemployment and lower education were associated with an increase in risk for child marriage. Refugees had similar percentages of child marriage as hosts, though the risk of child marriage among refugees was higher in situations of low education and unemployment. Ultimately, child marriage remains a persistent practice worldwide, requiring continued efforts to understand and address sociocultural norms in low socioeconomic and humanitarian settings.

      2. Newborn screen for X-Linked adrenoleukodystrophy using flow injection tandem mass spectrometry in negative ion modeexternal icon
        Teber TA, Conti BJ, Haynes CA, Hietala A, Baker MW.
        Int J Neonatal Screen. 2022 Apr 14;8(2).
        X-linked adrenoleukodystrophy (X-ALD) is a genetic disorder caused by pathogenic variants in the ATP-binding cassette subfamily D member 1 gene (ABCD1) that encodes the adrenoleukodystrophy protein (ALDP). Defects in ALDP result in elevated cerotic acid, and lead to C26:0-lysophosphatidylcholine (C26:0-LPC) accumulation, which is the primary biomarker used in newborn screening (NBS) for X-ALD. C26:0-LPC levels were measured in dried blood spot (DBS) NBS specimens using a flow injection analysis (FIA) coupled with electrospray ionization (ESI) tandem mass spectrometry (MS/MS) performed in negative ion mode. The method was validated by assessing and confirming linearity, accuracy, and precision. We have also established C26:0-LPC cutoff values that identify newborns at risk for X-ALD. The mean concentration of C26:0-LPC in 5881 de-identified residual routine NBS specimens was 0.07 ± 0.02 µM (mean + 1 standard deviation (SD)). All tested true X-ALD positive and negative samples were correctly identified based on C26:0-LPC cutoff concentrations for borderline between 0.15 µM and 0.22 µM (mean + 4 SD) and presumptive screening positive at ≥0.23 µM (mean + 8 SD). The presented FIA method shortens analysis run-time to 1.7 min, while maintaining the previously established advantage of utilizing negative mode MS to eliminate isobaric interferences that could lead to screening false positives.

    • Occupational Safety and Health
      1. Estimated N95 respirator needs for nonhealthcare essential workers in the United States during communicable respiratory infectious disease pandemicsexternal icon
        Fechter-Leggett ED, Fedan KB, Cox-Ganser JM, Meltzer MI, Adhikari BB, Dowell CH.
        Health Secur. 2022 Mar-Apr;20(2):127-136.
        Early in the COVID-19 pandemic, demand for N95 respirators far exceeded the supply, leading to widespread shortages. Initially, the US Centers for Disease Control and Prevention did not recommend N95 respirators in nonhealthcare settings, in order to reserve them for healthcare workers. As N95s became more available, the recommendations were updated in May 2021 to include N95 respirators for nonhealthcare settings. In this study, we estimated the numbers of N95s needed for nonhealthcare essential workers in the United States. This information is valuable for crisis preparedness and planning for future large-scale communicable respiratory infectious disease epidemics or pandemics. We adapted a spreadsheet-based tool originally built to estimate the potential demand for N95 respirators during an influenza pandemic. We defined nonhealthcare essential occupations according to the 2020 US Department of Homeland Security guidance and used US Bureau of Labor Statistics employment numbers and Occupational Information Network data as model parameters. We modeled minimum, intermediate, and maximum N95 provision scenarios (as 1, 2, and 5 N95 respirators, respectively) per week per worker, for pandemic durations of 15 and 40 weeks. For 85.15 million nonhealthcare essential workers during a 15-week pandemic, an estimated 1.3 billion N95 respirators would be needed under minimum provision scenarios, 2.6 billion for intermediate provision, and 6.4 billion for maximum provision. During a 40-week pandemic, these estimates increased to 3.4 billion, 6.8 billion, and 17 billion. Public health authorities and policymakers can use these estimates when considering workplace respirator-wearing practices, including prioritization of allocation, for nonhealthcare essential workers. Our novel spreadsheet-based tool can also be used to quickly generate estimates of other preparedness and response equipment.

      2. Exposure assessment of polycyclic aromatic hydrocarbons in refined coal tar sealant applicationsexternal icon
        McCormick S, Snawder JE, Chen IC, Slone J, Calafat AM, Wang Y, Meng L, Alexander-Scott M, Breitenstein M, Johnson B, Meadows J, Fairfield Estill C.
        Int J Hyg Environ Health. 2022 Apr 23;242:113971.
        BACKGROUND: Refined coal tar sealant (RCTS) emulsions are used to seal the surface of asphalt pavement. Nine of the 22 polycyclic aromatic hydrocarbons (PAHs) evaluated in this study are classified as known, probable, or possible human carcinogens. Exposure assessment research for RCTS workers has not been published previously. OBJECTIVES: The overall objective of this study was to develop a representative occupational exposure assessment of PAH exposure for RCTS workers based on worksite surveys. The specific aims were to: 1) quantify full-shift airborne occupational exposures to PAHs among RCTS workers; 2) quantify workers' dermal exposures to PAHs; 3) quantify biomarkers of PAH exposure in workers' urine; 4) identify specific job titles associated with RCTS exposure; and 5) apply these results to a biological exposure index to assess risk of potential genotoxicity from occupational exposures. METHODS: A total of twenty-one RCTS workers were recruited from three companies. Personal and area air samples were collected using a modification of NIOSH Method 5515. Dermal exposure was assessed by hand and neck wipes before and after shifts. Twenty-two PAHs were quantified via gas chromatography-mass spectrometry selected ion monitoring. Internal dose was estimated by quantifying select PAH metabolites in pre- and post-shift urine samples using on-line solid phase extraction-high performance liquid chromatography-tandem mass spectrometry. RESULTS: PAH levels in the worker breathing zones were highest for naphthalene, acenaphthene, and phenanthrene, with geometric means of 52.1, 11.4, and 9.8 μg/m(3), respectively. Hand wipe levels of phenanthrene, fluoranthene and pyrene were the highest among the 22 PAHs with geometric means of 7.9, 7.7, and 5.5 μg/cm(2), respectively. Urinary PAH biomarkers for naphthalene, fluorene, phenanthrene, and pyrene were detected in all workers and were higher for post-shift samples than those collected pre-shift. Urinary concentrations of the metabolite 1-hydroxypyrene were greater than the American Conference of Governmental Industrial Hygienists (ACGIH) Biological Exposure Index (BEI) for this metabolite in 89 percent of post-shift samples collected on the final day of the work week or field survey. Statistically significances were found between concentrations of fluorene, naphthalene, and phenanthrene in the breathing zone of workers and their corresponding urinary PAH biomarkers. Workers were placed in two work place exposure groups: applicators and non-applicators. Applicators had higher total PAH concentrations in personal breathing zone (PBZ) air samples than non-applicators and were more likely to have post-shift hand wipe concentrations significantly higher than pre-shift concentrations. Concentrations of post-shift urinary biomarkers were higher, albeit not significantly, for applicators than non-applicators. CONCLUSIONS: The exposure results from RCTS worker samples cannot be explained by proximal factors such as nearby restaurants or construction. Air and skin concentration levels were substantially higher for RCTS workers than previously published levels among asphalt workers for all PAHs. PAH profiles on skin wipes were more consistent with RCTS sealant product than air samples. Last day post-shift urinary concentrations of 1-hydroxypyrene greatly exceeded the ACGIH BEI benchmark of 2.5 μg/L in 25 of 26 samples, which suggests occupational exposure and risk of genotoxicity. When pyrene and benzo[a]pyrene were both detected, concentration ratios from personal exposure samples were used to calculate the adjusted BEI. Concentrations of 1-hydroxypyrene exceeded the adjusted BEIs for air, hand wipes, and neck wipes in most cases. These results indicate the need to increase safety controls and exposure mitigation for RCTS workers.

      3. OBJECTIVE: To analyze health behaviors and conditions among maritime workers using Behavioral Risk Factor Surveillance System (BRSS). METHODS: BRFSS data from 2014 to 2018 were used to calculate weighted prevalence estimates and adjusted prevalence ratios (aPRs) for 10 health behaviors and conditions. Logistic regression was used to compare aPRs between maritime workers and all other US workers. RESULTS: Compared with other workers, maritime workers had higher weighted prevalence estimates for six of 10 health behaviors and conditions: binge drinking, smoking, obese/overweight, diabetes, cancer, and chronic obstructive pulmonary disease. Maritime workers had significantly higher aPRs for binge drinking (aPR = 1.28) and smoking cigarettes (aPR = 1.39) compared with all other US workers. CONCLUSIONS: This study uses BRFSS data to estimate the prevalence of adverse health conditions across maritime industries. This study can serve as the foundation for additional follow-on research.

      4. While Bacillus cereus typically causes opportunistic infections in humans, within the last three decades, severe and fatal infections caused by isolates of the B. cereus group harboring anthrax toxin genes have been reported in the United States. From 1994 to 2020, seven cases of anthrax-like illness resulting from these isolates have been identified. With one exception, the cases have occurred in the Gulf States region of the United States among metalworkers. We aimed to develop an ecological niche model (ENM) to estimate a spatial area conducive to the survival of these organisms based on the presence of known human infections and environmental variables. The estimated ecological niche for B. cereus was modeled with the maximum entropy algorithm (Maxent). Environmental variables contributing most to the model were soil characteristics (cation exchange capacity, carbon content, soil pH), temperature, enhanced vegetation index (EVI), and land surface temperature (LST). Much of the suitable environments were located throughout the Gulf Coast Plain, Texas Backland Prairies, East Central Texas Plains, Edwards Plateau, Cross Timbers, Mississippi Alluvial Plain, and Central Great Plains. These findings may provide additional guidance to narrow potential risk areas to efficiently communicate messages to metalworkers and potentially identify individuals who may benefit from the anthrax vaccine.

      5. Objective: A limited focus on dissemination and implementation (D&I) science has hindered the uptake of evidence-based interventions (EBIs) that reduce workplace morbidity and mortality. D&I science methods can be used in the occupational safety and health (OSH) field to advance the adoption, implementation, and sustainment of EBIs for complex workplaces. These approaches should be responsive to contextual factors, including the needs of partners and beneficiaries (such as employers, employees, and intermediaries). Method(s): By synthesizing seminal literature and texts and leveraging our collective knowledge as D&I science and/or OSH researchers, we developed a D&I science primer for OSH. First, we provide an overview of common D&I terminology and concepts. Second, we describe several key and evolving issues in D&I science: balancing adaptation with intervention fidelity and specifying implementation outcomes and strategies. Next, we review D&I theories, models, and frameworks and offer examples for applying these to OSH research. We also discuss widely used D&I research designs, methods, and measures. Finally, we discuss future directions for D&I science application to OSH and provide resources for further exploration. Result(s): We compiled a D&I science primer for OSH appropriate for practitioners and evaluators, especially those newer to the field. Conclusion(s): This article fills a gap in the OSH research by providing an overview of D&I science to enhance understanding of key concepts, issues, models, designs, methods and measures for the translation into practice of effective OSH interventions to advance the safety, health and well-being of workers. Copyright © 2022

    • Parasitic Diseases
      1. Efficacy of single-dose primaquine with artemisinin combination therapy on plasmodium falciparum gametocytes and transmission: An individual patient meta-analysisexternal icon
        Stepniewska K, Humphreys GS, Gonçalves BP, Craig E, Gosling R, Guerin PJ, Price RN, Barnes KI, Raman J, Smit MR, D'Alessandro U, Stone WJ, Bjorkman A, Samuels AM, Arroyo-Arroyo MI, Bastiaens GJ, Brown JM, Dicko A, El-Sayed BB, Elzaki SG, Eziefula AC, Kariuki S, Kwambai TK, Maestre AE, Martensson A, Mosha D, Mwaiswelo RO, Ngasala BE, Okebe J, Roh ME, Sawa P, Tiono AB, Chen I, Drakeley CJ, Bousema T.
        J Infect Dis. 2022 Apr 1;225(7):1215-1226.
        BACKGROUND: Since the World Health Organization recommended single low-dose (0.25 mg/kg) primaquine (PQ) in combination with artemisinin-based combination therapies (ACTs) in areas of low transmission or artemisinin-resistant Plasmodium falciparum, several single-site studies have been conducted to assess efficacy. METHODS: An individual patient meta-analysis to assess gametocytocidal and transmission-blocking efficacy of PQ in combination with different ACTs was conducted. Random effects logistic regression was used to quantify PQ effect on (1) gametocyte carriage in the first 2 weeks post treatment; and (2) the probability of infecting at least 1 mosquito or of a mosquito becoming infected. RESULTS: In 2574 participants from 14 studies, PQ reduced PCR-determined gametocyte carriage on days 7 and 14, most apparently in patients presenting with gametocytemia on day 0 (odds ratio [OR], 0.22; 95% confidence interval [CI], .17-.28 and OR, 0.12; 95% CI, .08-.16, respectively). Rate of decline in gametocyte carriage was faster when PQ was combined with artemether-lumefantrine (AL) compared to dihydroartemisinin-piperaquine (DP) (P = .010 for day 7). Addition of 0.25 mg/kg PQ was associated with near complete prevention of transmission to mosquitoes. CONCLUSIONS: Transmission blocking is achieved with 0.25 mg/kg PQ. Gametocyte persistence and infectivity are lower when PQ is combined with AL compared to DP.

    • Substance Use and Abuse
      1. BACKGROUND: The majority of drug overdose deaths in the United States involve opioids, and synthetic opioid-involved overdose death rates are increasing. Naloxone is a key prevention strategy yet estimates of its administration are limited. METHODS: We analyzed 2019 data from 37 states and the District of Columbia in CDC's State Unintentional Drug Overdose Reporting System to estimate the percentage of decedents, by sociodemographic subgroup, who experienced a fatal opioid-involved overdose and had no evidence of naloxone administration. RESULTS: A total of 77.3% of 33,084 opioid-involved overdose deaths had no evidence of naloxone administration. Statistically significant subgroup differences were observed for all sociodemographic groups examined except housing status. The highest percentages of decedents lacking evidence of naloxone administration were those with highest educational attainment (doctorate or professional degree, 87.0%), oldest (55-64 years, 83.4%; ≥65 years, 87.3%) and youngest ages (<15 years, 87.5%), and single marital status (84.5%). The lowest percentages of no evidence of naloxone administration were observed for non-Hispanic American Indian/Alaskan Native persons (66.2%) and those ages 15-24 years (70.8%). CONCLUSIONS: More than three-quarters of opioid-involved overdose deaths had no evidence of naloxone administration, underscoring the need to ensure sufficient naloxone access and capacity for utilization. While fatal overdose data cannot fully characterize sociodemographic disparities in naloxone administration, naloxone education and access efforts can be informed by apparent inequities. Public health partners can assist persons who use drugs (PWUD) by maintaining naloxone supply and amplifying messages about the high risk of using drugs alone among PWUD and their social networks.

      2. The quantitation of squalene and squalane in bronchoalveolar lavage fluid using gas chromatography mass spectrometryexternal icon
        Cowan EA, Tran H, Watson CH, Blount BC, Valentín-Blasini L.
        Front Chem. 2022 ;10:874373.
        Chemicals of unknown inhalational toxicity are present in electronic cigarette and vaping products. E-cigarettes typically contain nicotine and other relatively hydrophilic chemicals while vaping products typically contain cannabinoids and other hydrophobic chemicals. For example, vaping products can include hydrophobic terpenes such as squalane (SQA) and squalene (SQE). However, little is known about the SQA and SQE transmission from liquid to aerosol. SQA and SQE are used in commercial products that are applied dermally and ingested orally, but limited information is available on their inhalational exposure and toxicity. We developed and validated a quantitative method to measure SQE and SQA in bronchoalveolar lavage fluid to assess if these chemicals accumulate in lung epithelial lining fluid after inhalation. Calibration curves spanned a range of 0.50-30.0 µg analyte per mL bronchoalveolar lavage fluid. Recoveries were found to be 97-105% for SQE and 81-106% for SQA. Limits of detection were 0.50 μg/ml for both SQE and SQA. The method was applied to bronchoalveolar lavage fluid samples of patients from the 2019 outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) and a comparison group. Neither SQA nor SQE was detected above the method LOD for any samples analyzed; conversely, SQA or SQE were reproducibly measured in spiked quality control BAL fluids (relative standards deviations <15% for both analytes). Further applications of this method may help to evaluate the potential toxicity of SQA and SQE chronically inhaled from EVPs.

      3. Lead poisoning among asymptomatic individuals with a long-term history of opiate use in Golestan Cohort Studyexternal icon
        Etemadi A, Hariri S, Hassanian-Moghaddam H, Poustchi H, Roshandel G, Shayanrad A, Kamangar F, Boffetta P, Brennan P, Dargan PI, Dawsey SM, Jones RL, Freedman ND, Malekzadeh R, Abnet CC.
        Int J Drug Policy. 2022 Apr 23;104:103695.
        BACKGROUND: Recent reports of lead poisoning suggest that people who use opium may be exposed to high amounts of lead. Here, we investigate the association between opium use and blood lead levels (BLL) in a population-based cohort study. METHODS: In 2017, we studied a random sample of 410 people who currently (both within the past year and the past month) used opium and 104 who did not from participants of the Golestan Cohort Study in northeast Iran. Participants were stratified by sex and tobacco use history, completed a comprehensive opiate and tobacco use questionnaire and provided blood. BLL was measured by Lead Care® II Blood Lead Test Kit, validated by inductively coupled plasma triple quadrupole mass spectrometry. BLL was categorized as "<5 µg/dL", "elevated" (5-10 µg/dL), "high" (10-50 µg/dL), and "very high" (above 50 µg/dL). To assess the association between BLL categories and opiate use, route of consumption and weekly use, we used ordered logistic regression models, and report OR (odds ratio) and 95% CI (confidence interval) adjusted for age, sex, place of residence, education, occupation, household fuel type, and tobacco use. RESULTS: In the cohort, participants used only raw (teriak) or refined (shireh) opium, which were smoked (45%, n = 184), taken orally (46%, n = 189), or both (9%, n = 37), for a mean duration of 24.2 (standard deviation: 11.6) years. The median BLL was significantly higher in people who currently used opium (11.4 µg/dL; IQR: 5.2-23.4) compared with those who did not (2.3 µg/dL; IQR: 2.3-4.2), and the highest median BLL was seen in oral use (21.7 µg/dL; IQR: 12.1-34.1). The BLL was <5 µg/dL among 79.8% of people with no opiate use, compared with only 22.7% in those using opium. BLL was elevated in 21.7%, high in 50.5% and very high in 5.1% of people using opium. About 95% of those with oral (180/189) or dual use (35/37) and 55% (102/184) of those who smoked opium had levels of blood lead above 5 µg/dL. The OR for the association between any opium use and each unit of increase in BLL category was 10.5 (95%CI: 5.8-19.1), and oral use of opium was a very strong predictor of increasing BLL category (OR=74.1; 95%CI: 35.1-156.3). This odds ratio was 38.8 (95%CI: 15.9-95.1) for dual use and 4.9 (95%CI: 2.6-9.1) for opium smoking. There was an independent dose-response association between average weekly dose and BLL among people using opium, overall and when stratified by route of use. CONCLUSION: Our results indicate that regular use of lead-adulterated opium can expose individuals to high levels of lead, which may contribute to mortality and cancer risks associated with long-term opium use.

      4. As policies legalizing adult cannabis use increase in the United States, understanding and characterizing the proportion of individuals consuming cannabis for medical and nonmedical purposes is important to inform targeted health education efforts. Data came from 7672 adults (> = 18 years) with past month cannabis use who responded to questions about reason for cannabis use on the 2018 Behavioral Risk Factor Surveillance System survey in 14 states. State and aggregated data were analyzed using weighted frequencies for descriptive analyses, and prevalence ratios were computed to identify demographic and substance use characteristics associated with medical only use or use for both medical and nonmedical reasons (vs. nonmedical use). Overall, 28.6% (95% CI: 26.7, 30.4) of adults who use cannabis reported using cannabis medically, 34.2% (95% CI: 32.3, 36.2) nonmedically, and 37.2% (95% CI: 35.2, 39.2) both medically and nonmedically. Characteristics associated with medical only use (compared with nonmedical only use) included being female; aged > 45 years; out of work, a homemaker, or unable to work; having daily or near daily cannabis use; having past month cigarette use; having no past month alcohol use; self-reporting poor health; and ever having been diagnosed with certain chronic diseases. Medical only use of cannabis is the least prevalent reason for use; use for both medical and nonmedical reasons is the most prevalent. Monitoring reasons for cannabis use can aid states in understanding differences between medical and nonmedical cannabis users, providing context to use patterns, and targeting health education messages to appropriate audiences.

    • Zoonotic and Vectorborne Diseases
      1. Effects of tick-control interventions on tick abundance, human encounters with ticks, and incidence of tickborne diseases in residential neighborhoods, New York, USAexternal icon
        Keesing F, Mowry S, Bremer W, Duerr S, Evans AS, Fischhoff IR, Hinckley AF, Hook SA, Keating F, Pendleton J, Pfister A, Teator M, Ostfeld RS.
        Emerg Infect Dis. 2022 May;28(5):957-966.
        Tickborne diseases (TBDs) such as Lyme disease result in ≈500,000 diagnoses annually in the United States. Various methods can reduce the abundance of ticks at small spatial scales, but whether these methods lower incidence of TBDs is poorly understood. We conducted a randomized, replicated, fully crossed, placebo-controlled, masked experiment to test whether 2 environmentally safe interventions, the Tick Control System (TCS) and Met52 fungal spray, used separately or together, affected risk for and incidence of TBDs in humans and pets in 24 residential neighborhoods. All participating properties in a neighborhood received the same treatment. TCS was associated with fewer questing ticks and fewer ticks feeding on rodents. The interventions did not result in a significant difference in incidence of human TBDs but did significantly reduce incidence in pets. Our study is consistent with previous evidence suggesting that reducing tick abundance in residential areas might not reduce incidence of TBDs in humans.

      2. Detection and isolation of rickettsia tillamookensis (rickettsiales: Rickettsiaceae) from ixodes pacificus (acari: Ixodidae) from multiple regions of Californiaexternal icon
        Paddock CD, Slater K, Swei A, Zambrano ML, Kleinjan JE, Padgett KA, Saunders ME, Andrews ES, Trent E, Zhong J, Sambado S, Goldsmith CS, Pascoe EL, Foley J, Lane RS, Karpathy SE.
        J Med Entomol. 2022 Apr 25.
        The western black-legged tick (Ixodes pacificus) is the most frequently identified human-biting tick species in the western United States and the principal vector of at least three recognized bacterial pathogens of humans. A potentially pathogenic Rickettsia species, first described in 1978 and recently characterized as a novel transitional group agent designated as Rickettsia tillamookensis, also exists among populations of I. pacificus, although the distribution and frequency of this agent are poorly known. We evaluated DNA extracts from 348 host-seeking I. pacificus nymphs collected from 9 locations in five California counties, and from 916 I. pacificus adults collected from 24 locations in 13 counties, by using a real-time PCR designed specifically to detect DNA of R. tillamookensis. DNA of R. tillamookensis was detected in 10 (2.9%) nymphs (95% CI: 1.6-5.2%) and 17 (1.9%) adults (95% CI: 1.2-3.0%) from 11 counties of northern California. Although site-specific infection rates varied greatly, frequencies of infection remained consistently low when aggregated by stage, sex, habitat type, or geographical region. Four novel isolates of R. tillamookensis were cultivated in Vero E6 cells from individual adult ticks collected from Alameda, Nevada, and Yolo counties. Four historical isolates, serotyped previously as 'Tillamook-like' strains over 40 yr ago, were revived from long-term storage in liquid nitrogen and confirmed subsequently by molecular methods as isolates of R. tillamookensis. The potential public health impact of R. tillamookensis requires further investigation.

      3. Epidemiological and clinical characteristics of acute dengue virus infections detected through acute febrile illness surveillance, Belize 2020external icon
        Ly AN, Manzanero R, Maliga A, Gunter SM, Ronca SE, Zielinski-Gutierrez E, Morey F, Bautista K, Espinosa-Bode A, López B, Cadena L, Fuentes RC, Erickson TA, Munoz FM, Mackey J, Morazán G, Murray KO.
        Viruses. 2022 Apr 7;14(4).
        The Acute Febrile Illness (AFI) Surveillance Network in Belize is a country-wide active surveillance program aimed at diagnosing vector-borne, respiratory, and enteric pathogens among patients presenting to 11 participating hospitals and clinics with new onset fever. This study describes the epidemiology of dengue virus (DENV) infections in Belize diagnosed through AFI surveillance in 2020. Of the 894 patients enrolled and PCR-tested for DENV in this period, 44 DENV-positive cases (5%) were identified. All four DENV serotypes were detected, with two cases testing positive for DENV serotype 4, which is the first report of this serotype in Belize since 2004. The majority of DENV cases (66%) were diagnosed in the Belize District, which contains the largest urban center in the country (Belize City). Positive cases were detected between January 2020 and September 2020, with the majority (89%) diagnosed during the dry season between January and April, unlike years prior when cases were more often diagnosed during the wet season. Clinical signs and symptoms varied slightly between DENV serotypes. Active surveillance of DENV among AFI cases provides insight into the epidemiologic and clinical characteristics of DENV in Belize. This information is important for informing public health interventions to mitigate DENV transmission.

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

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