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Issue 26, June 28, 2022

CDC Science Clips: Volume 14, Issue 26, June 28, 2022

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

  1. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Antimicrobial Resistance and Antibiotic Stewardship
      1. Continued increase of erythromycin- and clindamycin-nonsusceptibility among invasive group A streptococci driven by genomic clusters, USA, 2018-2019
        Li Y, Rivers J, Mathis S, Li Z, McGee L, Chochua S, Metcalf BJ, Fleming-Dutra KE, Nanduri SA, Beall B.
        Clin Infect Dis. 2022 Jun 10.
        We analyzed 9630 invasive Group A Streptococci (iGAS) surveillance isolates in the USA. From 2015-2017 to 2018-2019, significant increases in erythromycin-nonsusceptibility (18% vs. 25%) and clindamycin-nonsusceptibility (17% vs. 24%) occurred, driven mainly by rapid expansions of genomic subclones. Prevention and control of clustered infections appear key to containing antimicrobial resistance.

      2. Colonization with extended-spectrum cephalosporin-resistant enterobacterales (ESCrE) and carbapenem-resistant enterobacterales (CRE) in healthcare and community settings in Botswana: An Antibiotic Resistance In Communities And Hospitals (ARCH) Study
        Mannathoko N, Mospele M, Gross R, Smith RM, Alby K, Glaser L, Richard-Greenblatt M, Dumm R, Sharma A, Jaskowiak-Barr A, Cressman L, Sewawa K, Cowden L, Reesey E, Otukile D, Paganotti GM, Mokomane M, Lautenbach E.
        Int J Infect Dis. 2022 Jun 7.
        OBJECTIVES: Although extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) and carbapenem-resistant Enterobacterales (CRE) are a global challenge, data on these organisms in low- and middle-income countries are limited. We sought to characterize colonization data critical for larger antibiotic resistance surveillance efforts. METHODS: This study was conducted in three hospitals and six clinics in Botswana. We conducted ongoing surveillance of adult patients in hospitals and clinics as well as adults and children in the community. All participants had rectal swabs obtained for identification of ESCrE and CRE. RESULTS: Enrollment occurred from 1/15/20-9/4/20 but paused from 4/2/20-5/21/20 due to a countrywide COVID-19 lockdown. Of 5,088 individuals approached, 2,469 (49%) participated. ESCrE colonization prevalence was 30.7% overall (43% for hospital participants, 31% for clinic participants, 24% for adult community participants, and 26% for child community participants) (p<0.001). 42 (1.7%) participants were colonized with CRE. CRE colonization prevalence was 1.7% overall (6.8% for hospital participants, 0.7% for clinic participants, 0.2% for adult community participants, and 0.5% for child community participants) (p<0.001). ESCrE and CRE prevalence varied substantially across regions and was significantly higher pre-lockdown vs post-lockdown. CONCLUSIONS: ESCrE colonization was high in all settings in Botswana. CRE prevalence in hospitals was also considerable. Colonization prevalence varied by region and clinical setting and decreased following a countrywide lockdown.

      3. A multisite collaborative to decrease inappropriate antibiotics in urgent care centers
        Nedved A, Fung M, Bizune D, Liu CM, Obremskey J, Fleming-Dutra KE, Hamdy RF, Montalbano A.
        Pediatrics. 2022 Jun 15.
        BACKGROUND: Urgent care (UC; a convenient site to receive care for ambulatory-sensitive) centers conditions; however, UC clinicians showed the highest rate of inappropriate antibiotic prescriptions among outpatient settings according to national billing data. Antibiotic prescribing practices in pediatric-specific UC centers were not known but assumed to require improvement. The aim of this multisite quality improvement project was to reduce inappropriate antibiotic prescribing practices for 3 target diagnoses in pediatric UC centers by a relative 20% by December 1, 2019. METHODS: The Society of Pediatric Urgent Care invited pediatric UC clinicians to participate in a multisite quality improvement study from June 2019 to December 2019. The diagnoses included acute otitis media (AOM), otitis media with effusion, and pharyngitis. Algorithms based on published guidelines were used to identify inappropriate antibiotic prescriptions according to indication, agent, and duration. Sites completed multiple intervention cycles from a menu of publicly available antibiotic stewardship materials. Participants submitted data electronically. The outcome measure was the percentage of inappropriate antibiotic prescriptions for the target diagnoses. Process measures were use of delayed antibiotics for AOM and inappropriate testing in pharyngitis. RESULTS: From 20 UC centers, 157 providers submitted data from 3833 encounters during the intervention cycles. Overall inappropriate antibiotic prescription rates decreased by a relative 53.9%. Inappropriate antibiotic prescribing decreased from 57.0% to 36.6% for AOM, 54.6% to 48.4% for otitis media with effusion, and 66.9% to 11.7% for pharyngitis. CONCLUSIONS: Participating pediatric UC providers decreased inappropriate antibiotic prescriptions from 60.3% to 27.8% using publicly available interventions.

    • Chronic Diseases and Conditions
      1. Evaluating the sustainability of patient navigation programs in oncology by length of existence, funding, and payment model participation
        Garfield KM, Franklin EF, Battaglia TA, Dwyer AJ, Freund KM, Wightman PD, Rohan EA.
        Cancer. 2022 Jul 1;128 Suppl 13:2578-2589.
        BACKGROUND: For this study, the authors examined whether specific programmatic factors were associated with the sustainability of patient navigation programs. METHODS: This cross-sectional survey explored navigation programmatic factors associated with 3 measures of sustainability: 1) length of program existence, 2) reliance on sustainable funding, and 3) participation in alternative payment models. In total, 750 patient navigators or program administrators affiliated with oncology navigation programs in clinical-based and community-based settings completed the survey between April and July 2019. RESULTS: Associations were observed between both accreditation and work setting and measures of program sustainability. Accredited programs and larger, more resourced clinical institutions were particularly likely to exhibit multiple measures of sustainability. The results also identified significant gaps at the programmatic level in data collection and reporting among navigation programs, but no association was observed between programmatic data collection/reporting and sustainability. CONCLUSIONS: Navigation is not currently a reimbursable service and has historically been viewed as value-added in oncology settings. Therefore, factors associated with sustainability are critical to understand how to build a framework for successful navigation programs within the current system and also to develop the case for potential reimbursement in the future.

      2. Asthma-COPD overlap (ACO) is a respiratory condition with more severe respiratory symptoms, poorer quality of life, and increased hospital admissions compared with asthma or COPD alone.Objectives: Estimate asthma, chronic obstructive pulmonary disease (COPD), and ACO prevalence among workers by industry and occupation and assess physical and mental health status, healthcare utilization, among workers with ACO.Methods: The 2014-2018 National Health Interview Survey (NHIS) data for working adults aged ≥18 years employed (sample n = 99,424) in the 12 months prior to the survey were analyzed. Age-adjusted ACO, COPD and asthma prevalence and prevalence ratios adjusted for age, sex, race and smoking status were estimated.Results: During 2014-2018, of the estimated 166 million (annual average) US workers, age-adjusted asthma, COPD, and ACO prevalence was 6.9%, 4.0%, and 1.1%, respectively. ACO prevalence was highest among workers aged ≥65 years (2.0%), females (1.6%), current smokers (1.9%), those living below the federal poverty level (2.3%), and workers in the accommodation and food services (1.6%) industry and personal care and service (2.3%) occupations. Workers with ACO had more frequent (p < 0.05) physician office visits, emergency department visits; and were more likely to be in poorer mental health, obese, have more lost workdays, more bed days, and comorbidities compared to workers with asthma alone and workers with COPD alone.Conclusion: Higher ACO prevalence among worker groups and increased healthcare utilization underscores the need for early identification of asthma and COPD, assessment of potential workplace exposures, and implementation of tailored interventions to reduce ACO among working adults.

    • Communicable Diseases
      1. Factors associated with treatment outcomes among children and adolescents living with HIV receiving antiretroviral therapy in Central Kenya
        McLigeyo A, Wekesa P, Owuor K, Mwangi J, Isavwa L, Mutisya I.
        AIDS Res Hum Retroviruses. 2022 Jun;38(6):480-490.
        Expanded access to HIV treatment services has improved outcomes for children and adolescents living with HIV in Kenya. Minimal data are available on these outcomes. We describe temporal trends in outcomes for children and adolescents initiating antiretroviral therapy (ART) from 2004 to 2014 at sites supported by Centre for Health Solutions-Kenya, in central Kenya. We retrospectively analyzed data from children 0-9 years of age (n = 3,519) and adolescents 10-19 years of age (n = 1,663) living with HIV, who newly initiated ART at 47 health facilities in central Kenya. Year cohorts were analyzed from the Comprehensive Patient Application Database (CPAD) and International Quality Care (IQCare) electronic medical databases, including temporal trends in outcomes and associated factors using multivariable competing risk regression analysis. There were more girls (2,453 [52.7%]) than boys, with most enrolled at World Health Organization (WHO) stage II (1,813 [37.7%]) or III disease (1,694 [35.1%]). Most of the children and adolescents (4,431 [96.4%]) did not have tuberculosis (TB) symptoms. Cumulative lost to follow-up (LTFU) incidence at 6, 12, 24, and 36 months were 5.0%, 9.9%, 22.9%, and 33.1%, respectively. Cumulative mortality incidence at 6, 12, 24, and 36 months were 0.7%, 1.0%, 1.2%, and 1.5%, respectively. The incidence of LTFU was higher among female children and adolescents, those initiated on tenofovir-based regimens, and those with presumptive TB symptoms. Mortality risk was higher among those with WHO stage III or IV disease, and children and adolescents on TB treatment or who had presumptive TB. Enrollment occurred at a young age and pediatric-friendly ART regimens were initiated at earlier WHO stages implying effective early infant diagnosis and treatment for all strategies, resulting in improved treatment outcomes. The higher retention rates in recent years as well as the lower retention after many years of follow-up underscore the importance of implementing longitudinal follow-up strategies targeting this population.

      2. Population-weighted seroprevalence from SARS-CoV-2 infection, vaccination, and hybrid immunity among U.S. blood donations from January-December 2021
        Busch MP, Stramer SL, Stone M, Yu EA, Grebe E, Notari E, Saa P, Ferg R, Manrique IM, Weil N, Fink RV, Levy M, Green V, Cyrus S, Williamson PC, Haynes J, Groves J, Krysztof D, Custer B, Kleinman S, Biggerstaff BJ, Opsomer JD, Jones JM.
        Clin Infect Dis. 2022 Jun 10.
        BACKGROUND: Previous SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19) vaccination, independently and combined ("hybrid immunity"), result in partial protection from subsequent infection and strong protection from severe disease. Proportions of the U.S. population that have been infected, vaccinated, or with hybrid immunity remain unclear, posing a challenge for assessing effective pandemic mitigation strategies. METHODS: In this serial cross-sectional study, nationwide blood donor specimens collected during January-December 2021 were tested for spike and nucleocapsid antibodies, and donor COVID-19 vaccination history of ≥1 dose was collected. Monthly seroprevalence induced from SARS-CoV-2 infection, COVID-19 vaccination, or both, were estimated. Estimates were weighted to account for demographic differences from the general population, and were compared temporally and by demographic factors. RESULTS: Overall, 1,123,855 blood samples were assayed. From January to December 2021, the weighted percentage of donations with seropositivity due to: vaccination without previous infection increased from 3.5% (95% CI, 3.4%-3.7%) to 64.0%, (95% CI, 63.5%-64.5%); previous infection without vaccination decreased from 15.6% (95% CI, 15.2%-16.0%) to 11.7% (95% CI, 11.4%-12.0%); hybrid immunity increased from 0.7% (95% CI, 0.6%-0.7%) to 18.9% (95% CI, 18.5%-19.3%); and from infection, vaccination, or both increased from 19.8% (95% CI (19.3-20.2) to 94.5% (95% CI, 93.5%-94.0% 0.1%). Infection- and vaccination-induced antibody responses varied significantly by age, race-ethnicity, and region, but not by gender. CONCLUSIONS: Our results indicate substantial increases in population humoral immunity from SARS-CoV-2 infection, COVID-19 vaccination, and hybrid immunity during 2021. These findings are important to consider in future COVID-19 studies and long-term pandemic mitigation efforts.

      3. Multisystem inflammatory syndrome in children (MIS-C) during SARS-CoV-2 Delta and Omicron variant circulation- United States, July 2021 - January 2022
        Miller AD, Yousaf AR, Bornstein E, Wu MJ, Lindsey K, Melgar M, Oster ME, Zambrano LD, Campbell AP.
        Clin Infect Dis. 2022 Jun 10.
        We describe 2,116 multisystem inflammatory syndrome in children (MIS-C) cases reported to CDC during Delta and Omicron circulation from July 2021-January 2022. Half of MIS-C patients were aged 5-11 years, 52% received ICU-level care, and 1.1% died. Only 3.0% of eligible patients were fully vaccinated prior to MIS-C onset.

      4. Association of trends in SARS-CoV-2 seroprevalence and state-issued nonpharmaceutical interventions- United States, August 1, 2020 - March 30, 2021
        Miller MJ, Himschoot A, Fitch N, Jawalkar S, Freeman D, Hilton C, Berney K, Guy GP, Benoit TJ, Clarke KE, Busch MP, Opsomer JD, Stramer SL, Hall AJ, Gundlapalli AV, MacNeil A, McCord R, Sunshine G, Howard-Williams M, Dunphy C, Jones JM.
        Clin Infect Dis. 2022 Jun 10.
        OBJECTIVES: To assess if state-issued nonpharmaceutical interventions (NPIs) are associated with reduced rates of SARS-CoV-2 infection as measured through anti-nucleocapsid (anti-N) seroprevalence, a proxy for cumulative prior infection that distinguishes seropositivity from vaccination). METHODS: Monthly anti-N seroprevalence during August 1, 2020 - March 30, 2021 was estimated using a nationwide blood donor serosurvey. Using multivariable logistic regression models, we measured the association of seropositivity and state-issued, county-specific NPIs for mask mandates, gathering bans, and bar closures. RESULTS: Compared with individuals living in a county with all three NPIs in place, the odds of having anti-N antibodies were 2.2 (95% CI: 2.0-2.3) times higher for people living in a county that did not have any of the three NPIs, 1.6 (95% CI: 1.5-1.7) times higher for people living in a county that only had a mask mandate and gathering ban policy, and 1.4 (95% CI: 1.3-1.5) times higher for people living in a county that had only a mask mandate. CONCLUSIONS: Consistent with studies assessing NPIs relative to COVID-19 incidence and mortality, the presence of NPIs were associated with lower SARS-CoV-2 seroprevalence indicating lower rates of cumulative infections. Multiple NPIs are likely more effective than single NPIs.

      5. Enteric illness outbreaks reported through the National Outbreak Reporting System-United States, 2009-2019
        Wikswo ME, Roberts V, Marsh Z, Manikonda K, Gleason B, Kambhampati A, Mattison C, Calderwood L, Balachandran N, Cardemil C, Hall AJ.
        Clin Infect Dis. 2022 Jun 10;74(11):1906-1913.
        BACKGROUND: The National Outbreak Reporting System (NORS) captures data on foodborne, waterborne, and enteric illness outbreaks in the United States. This study describes enteric illness outbreaks reported during 11 years of surveillance. METHODS: We extracted finalized reports from NORS for outbreaks occurring during 2009-2019. Outbreaks were included if caused by an enteric etiology or if any patients reported diarrhea, vomiting, bloody stools, or unspecified acute gastroenteritis. RESULTS: A total of 38 395 outbreaks met inclusion criteria, increasing from 1932 in 2009 to 3889 in 2019. Outbreaks were most commonly transmitted through person-to-person contact (n = 23 812; 62%) and contaminated food (n = 9234; 24%). Norovirus was the most commonly reported etiology, reported in 22 820 (59%) outbreaks, followed by Salmonella (n = 2449; 6%) and Shigella (n = 1171; 3%). Norovirus outbreaks were significantly larger, with a median of 22 illnesses per outbreak, than outbreaks caused by the other most common outbreak etiologies (P < .0001, all comparisons). Hospitalization rates were higher in outbreaks caused by Salmonella and Escherichia coli outbreaks (20.9% and 22.8%, respectively) than those caused by norovirus (2%). Case fatality rate was highest in E. coli outbreaks (0.5%) and lowest in Shigella and Campylobacter outbreaks (0.02%). CONCLUSIONS: Norovirus caused the most outbreaks and outbreak-associated illness, hospitalizations, and deaths. However, persons in E. coli and Salmonella outbreaks were more likely to be hospitalized or die. Outbreak surveillance through NORS provides the relative contributions of each mode of transmission and etiology for reported enteric illness outbreaks, which can guide targeted interventions.

      6. Enhanced federal collaborations in implementation science and research of HIV prevention and treatment
        Purcell DW, Namkung Lee A, Dempsey A, Gordon C.
        J Acquir Immune Defic Syndr. 2022 Jul 1;90(S1):S17-s22.
        Over the past decade, national initiatives in the United States (U.S.) have focused HIV prevention and care programs and research to optimize the delivery of HIV prevention and treatment through implementation research. Although existing biomedical and behavioral prevention tools could end HIV in the U.S., the implementation of these tools has been uneven because of many factors, including organizational capacity, insufficient uptake by key populations, lack of success with prioritizing by geography or population growth, and inadequate scaling. To address these challenges, the federal government has funded programs, research, and evaluation projects aimed at improving health outcomes among people with HIV and people vulnerable to HIV acquisition. Increasingly, several special federal efforts are being conducted under the umbrella of "implementation science and research" that are essential components to scaling up evidence-based HIV prevention and treatment interventions in the U.S. This paper describes federal collaborations that have supported this increased focus on implementation from the perspective of 3 agencies in the U.S. Department of Health and Human Services; the Centers for Disease Control and Prevention, the National Institutes of Health, and the Health Resources and Services Administration. These federal collaborations have resulted in improved communication and coordination of efforts in the shaping and alignment of priorities in research and service delivery, increased implementation research conducted in real-world community and clinical settings and provided a feedback loop to expedite action in response to emerging evidence from such projects.

      7. Updated US infection- and vaccine-induced SARS-CoV-2 seroprevalence estimates based on blood donations, July 2020-December 2021
        Jones JM, Opsomer JD, Stone M, Benoit T, Ferg RA, Stramer SL, Busch MP.
        Jama. 2022 Jun 13.

    • Community Health Services
      1. Comparison of the causes of death identified using automated verbal autopsy and complete autopsy among brought-in-dead cases at a tertiary hospital in Sub-Sahara Africa
        Yokobori Y, Matsuura J, Sugiura Y, Mutemba C, Julius P, Himwaze C, Nyahoda M, Mwango C, Kazhumbula L, Yuasa M, Munkombwe B, Mucheleng'anga L.
        Appl Clin Inform. 2022 May;13(3):583-591.
        BACKGROUND:  Over one-third of deaths recorded at health facilities in Zambia are brought in dead (BID) and the causes of death (CODs) are not fully analyzed. The use of automated verbal autopsy (VA) has reportedly determined the CODs of more BID cases than the death notification form issued by the hospital. However, the validity of automated VA is yet to be fully investigated. OBJECTIVES:  To compare the CODs identified by automated VA with those by complete autopsy to examine the validity of a VA tool. METHODS:  The study site was the tertiary hospital in the capital city of Zambia. From September 2019 to January 2020, all BID cases aged 13 years and older brought to the hospital during the daytime on weekdays were enrolled in this study. External COD cases were excluded. The deceased's relatives were interviewed using the 2016 World Health Organization VA questionnaire. The data were analyzed using InterVA, an automated VA tool, to determine the CODs, which were compared with the results of complete autopsies. RESULTS:  A total of 63 cases were included. The CODs of 50 BID cases were determined by both InterVA and complete autopsies. The positive predictive value of InterVA was 22%. InterVA determined the CODs correctly in 100% cases of maternal CODs, 27.5% cases of noncommunicable disease CODs, and 5.3% cases of communicable disease CODs. Using the three broader disease groups, 56.0% cases were classified in the same groups by both methods. CONCLUSION:  While the positive predictive value was low, more than half of the cases were categorized into the same broader categories. However, there are several limitations in this study, including small sample size. More research is required to investigate the factors leading to discrepancies between the CODs determined by both methods to optimize the use of automated VA in Zambia.

      2. Purpose: We examined the association of lesbian, gay, bisexual, transgender, and questioning (LGBTQ)-supportive school policies and practices with sexual health outcomes among LGB and heterosexual students. Methods: The 2014 and 2016 School Health Profiles data from principals and lead health educators from 117 high schools in 16 local education agencies across the United States assessed LGBTQ-supportive school policies and practices (e.g., having a gay/straight alliance or similar club). The 2015 and 2017 Youth Risk Behavior Survey data from 75,638 students from the same schools assessed sexual health outcomes (e.g., being currently sexually active). We conducted multilevel cross-sectional logistic regression analyses to examine the associations between school-level LGBTQ-supportive policies and practices with student-level sexual health outcomes, while controlling for sex, grade, race/ethnicity, and school priority status. Results: Several LGBTQ-supportive school policies and practices were significantly associated with lower odds of sexual risk behaviors (e.g., having four or more lifetime sexual partners) and ever being tested for human immunodeficiency virus (HIV) among both LGB and heterosexual students but not with using a condom during last sexual intercourse among sexually active gay, bisexual, or heterosexual male students. Having a greater number of LGBTQ-supportive school policies and practices was significantly associated with lower odds of ever having sex for LGB students and with sexual risk behaviors and ever being tested for HIV for heterosexual students. Conclusion: The study highlights the relationship between multifaceted LGBTQ-supportive school policies and practices and improving sexual health outcomes among both LGB and heterosexual students.

    • Disaster Preparedness and Emergency Services

    • Disease Reservoirs and Vectors
      1. The unreachable doorbells of South Texas: Community engagement in colonias on the US-Mexico border for mosquito control
        Juarez JG, Carbajal E, Dickinson KL, Garcia-Luna S, Vuong N, Mutebi JP, Hemme RR, Badillo-Vargas I, Hamer GL.
        BMC Public Health. 2022 Jun 13;22(1):1176.
        Mosquitoes and the diseases they transmit continue to place millions of people at risk of infection around the world. Novel methods of vector control are being developed to provide public health officials with the necessary tools to prevent disease transmission and reduce local mosquito populations. However, these methods will require public acceptance for a sustainable approach and evaluations at local settings. We present our efforts in community engagement carried out in colonias of the Lower Rio Grande Valley in south Texas for mosquito surveillance, control, and ecological projects. Along the US-Mexico border the term colonia refers to impoverished communities that are usually inhabited by families of Hispanic heritage. The different engagements were carried out from September 2016 to February 2019; during this time, we had three distinct phases for community engagement. In Phase 1 we show the initial approach to the colonias in which we assessed security and willingness to participate; in Phase 2 we carried out the first recruitment procedure involving community meetings and house-to-house recruitment; and in Phase 3 we conducted a modified recruitment procedure based on community members' input. Our findings show that incorporating community members in the development of communication materials and following their suggestions for engagement allowed us to generate culturally sensitive recruitment materials and to better understand the social relationships and power dynamics within these communities. We were able to effectively reach a larger portion of the community and decrease the dropout rate of participants. Progress gained with building trust in the communities allowed us to convey participant risks and benefits of collaborating with our research projects. Community engagement should be viewed as a key component of any local vector control program as well as for any scientific research project related to vector control. Even in the face of budgetary constraints, small efforts in community engagement go a long way.

    • Environmental Health
      1. Perceptions, knowledge, and communication preferences about indoor mold and its health implications among persons affected by Hurricane Harvey: A focus group analysis
        Gandhi P, Malone L, Williams S, Hall C, Short K, Benedict K, Toda M.
        BMC Public Health. 2022 Jun 15;22(1):1194.
        BACKGROUND: Among people affected by Hurricane Harvey, we assessed experiences and perceptions (e.g., knowledge, attitudes, and practices) regarding mold and its impact on health and elicited participants' opinions about how to improve public health messaging about indoor mold after a large flooding event. METHODS: Houston Health Department conducted four focus groups with 31 Houston metropolitan area residents during January to March 2020, using a semi-structured discussion guide and federal communication materials about indoor mold. Drawing from a theoretical framework analysis, transcripts were grouped into relevant themes using inductive and deductive coding. RESULTS: Hurricane Harvey had a large impact on participants' living standards, and widespread financial barriers to remediation led to long-term mold exposure for many participants. Knowledge about mold's impact on health and proper mold clean-up practices varied, and clean-up behaviors did not commonly align with federal guidance. Participants generally preferred traditional forms of outreach, such as in-person, radio, and television announcements, to communicate public health messaging. CONCLUSIONS: More strategic dissemination of expanded public health educational materials about proper mold clean-up practices and the health risks of mold exposure following flooding events is needed.

      2. Early-pregnancy plasma per- and polyfluoroalkyl substance (PFAS) concentrations and hypertensive disorders of pregnancy in the Project Viva cohort
        Preston EV, Hivert MF, Fleisch AF, Calafat AM, Sagiv SK, Perng W, Rifas-Shiman SL, Chavarro JE, Oken E, Zota AR, James-Todd T.
        Environ Int. 2022 Jun 6;165:107335.
        BACKGROUND: Hypertensive disorders of pregnancy (HDP), defined here as hypertensive disorders with onset in pregnancy (i.e., gestational hypertension, preeclampsia, and preeclampsia superimposed on chronic hypertension), affect up to 10% of pregnancies in the United States and are associated with substantial maternal and neonatal morbidity and mortality. Per- and polyfluoroalkyl substances (PFAS) are associated with adverse cardiometabolic outcomes during pregnancy, but associations between PFAS and HDP are inconsistent and joint effects of PFAS mixtures have not been evaluated. METHODS: We studied 1,558 pregnant individuals from the Project Viva cohort, recruited during 1999-2002. We quantified concentrations of eight PFAS in plasma samples (median 9.7 weeks of gestation). Using clinical records, we calculated trimester-specific mean systolic (SBP) and diastolic (DBP) blood pressure and categorized HDP status [no HDP (normotensive & chronic hypertension), gestational hypertension, preeclampsia]. We estimated associations of individual PFAS with HDP using multinomial logistic regression and estimated associations with blood pressure using linear regression. We used Bayesian kernel machine regression (BKMR) and quantile g-computation to assess joint effects of the PFAS mixture on HDP and blood pressure measures. RESULTS: Four percent of participants developed preeclampsia and 7% developed gestational hypertension. We observed higher odds of gestational hypertension, but not preeclampsia, per doubling of perfluorooctanoate (PFOA) [OR = 1.51 (95% confidence interval: 1.12, 2.03)], perfluorooctane sulfonate (PFOS) [OR = 1.38 (1.04, 1.82)], and perfluorohexane sulfonate [OR = 1.28 (1.06, 1.54)] concentrations. We observed higher mean DBP per doubling of PFOA [2nd trimester (T2): 0.39 mmHg (-0.01, 0.78); 3rd trimester (T3): 0.56 mmHg (0.14, 0.98)] and PFOS [T2: 0.46 mmHg (0.11, 0.82); T3: 0.43 mmHg (0.05, 0.80)]. The PFAS mixture was positively associated with odds of gestational hypertension [75th vs. 50th percentile: OR = 1.14 (95% credible interval:1.03, 1.25), BKMR] and mean DBP [T2 = 0.17 mmHg (-0.06, 0.40); T3 = 0.22 mmHg (-0.03, 0.48), BKMR]. CONCLUSIONS: These findings suggest that exposure to certain PFAS may increase the odds of gestational hypertension during pregnancy, with potential implications for subsequent maternal and child health outcomes.

      3. Passive in-line chlorination for drinking water disinfection: A critical review
        Lindmark M, Cherukumilli K, Crider YS, Marcenac P, Lozier M, Voth-Gaeddert L, Lantagne DS, Mihelcic JR, Zhang QM, Just C, Pickering AJ.
        Environ Sci Technol. 2022 Jun 14.
        The world is not on track to meet Sustainable Development Goal 6.1 to provide universal access to safely managed drinking water by 2030. Removal of priority microbial contaminants by disinfection is one aspect of ensuring water is safely managed. Passive chlorination (also called in-line chlorination) represents one approach to disinfecting drinking water before or at the point of collection (POC), without requiring daily user input or electricity. In contrast to manual household chlorination methods typically implemented at the point of use (POU), passive chlorinators can reduce the user burden for chlorine dosing and enable treatment at scales ranging from communities to small municipalities. In this review, we synthesized evidence from 27 evaluations of passive chlorinators (in 19 articles, 3 NGO reports, and 5 theses) conducted across 16 countries in communities, schools, health care facilities, and refugee camps. Of the 27 passive chlorinators we identified, the majority (22/27) were solid tablet or granular chlorine dosers, and the remaining devices were liquid chlorine dosers. We identified the following research priorities to address existing barriers to scaled deployment of passive chlorinators: (i) strengthening local chlorine supply chains through decentralized liquid chlorine production, (ii) validating context-specific business models and financial sustainability, (iii) leveraging remote monitoring and sensing tools to monitor real-time chlorine levels and potential system failures, and (iv) designing handpump-compatible passive chlorinators to serve the many communities reliant on handpumps as a primary drinking water source. We also propose a set of reporting indicators for future studies to facilitate standardized evaluations of the technical performance and financial sustainability of passive chlorinators. In addition, we discuss the limitations of chlorine-based disinfection and recognize the importance of addressing chemical contamination in drinking water supplies. Passive chlorinators deployed and managed at-scale have the potential to elevate the quality of existing accessible and available water services to meet "safely managed" requirements.

      4. Surface area matters: An evaluation of swabs and surface area for environmental surface sampling of healthcare pathogens
        West RM, Shams AM, Chan MY, Rose LJ, Noble-Wang JA.
        Infect Control Hosp Epidemiol. 2022 Jun 13:1-3.
        Flocked and foam swabs were used to sample five healthcare pathogens from three sizes of steel and plastic coupons; 26 cm(2), 323 cm(2), and 645 cm(2). As surface area increased, 1-2 log(10) decrease in recovered organisms (P < .05) was observed. Sampling 26-cm(2) yielded the optimal median percent of pathogens recovered.

      5. Ventilation improvement strategies among K-12 public schools - the National School COVID-19 Prevention Study, United States, February 14-March 27, 2022
        Pampati S, Rasberry CN, McConnell L, Timpe Z, Lee S, Spencer P, Moore S, Mead KR, Murray CC, Deng X, Iachan R, Tripathi T, Martin SB, Barrios LC.
        MMWR Morb Mortal Wkly Rep. 2022 Jun 10;71(23):770-775.
        Effective COVID-19 prevention in kindergarten through grade 12 (K-12) schools requires multicomponent prevention strategies in school buildings and school-based transportation, including improving ventilation (1). Improved ventilation can reduce the concentration of infectious aerosols and duration of potential exposures (2,3), is linked to lower COVID-19 incidence (4), and can offer other health-related benefits (e.g., better measures of respiratory health, such as reduced allergy symptoms) (5). Whereas ambient wind currents effectively dissipate SARS-CoV-2 (the virus that causes COVID-19) outdoors,* ventilation systems provide protective airflow and filtration indoors (6). CDC examined reported ventilation improvement strategies among a nationally representative sample of K-12 public schools in the United States using wave 4 (February 14-March 27, 2022) data from the National School COVID-19 Prevention Study (NSCPS) (420 schools), a web-based survey administered to school-level administrators beginning in summer 2021.(†) The most frequently reported ventilation improvement strategies were lower-cost strategies, including relocating activities outdoors (73.6%), inspecting and validating existing heating, ventilation and air conditioning (HVAC) systems (70.5%), and opening doors (67.3%) or windows (67.2%) when safe to do so. A smaller proportion of schools reported more resource-intensive strategies such as replacing or upgrading HVAC systems (38.5%) or using high-efficiency particulate air (HEPA) filtration systems in classrooms (28.2%) or eating areas (29.8%). Rural and mid-poverty-level schools were less likely to report several resource-intensive strategies. For example, rural schools were less likely to use portable HEPA filtration systems in classrooms (15.6%) than were city (37.7%) and suburban schools (32.9%), and mid-poverty-level schools were less likely than were high-poverty-level schools to have replaced or upgraded HVAC systems (32.4% versus 48.8%). Substantial federal resources to improve ventilation in schools are available.(§) Ensuring their use might reduce SARS-CoV-2 transmission in schools. Focusing support on schools least likely to have resource-intensive ventilation strategies might facilitate equitable implementation of ventilation improvements.

    • Epidemiology and Surveillance
      1. United States Centers for Disease Control and Prevention support for influenza surveillance, 2013-2021
        McCarron M, Kondor R, Zureick K, Griffin C, Fuster C, Hammond A, Lievre M, Vandemaele K, Bresee J, Xu X, Dugan VG, Weatherspoon V, Williams T, Vance A, Fry AM, Samaan M, Fitzner J, Zhang W, Moen A, Wentworth DE, Azziz-Baumgartner E.
        Bull World Health Organ. 2022 Jun 1;100(6):366-374.
        OBJECTIVE: To assess the stability of improvements in global respiratory virus surveillance in countries supported by the United States Centers for Disease Control and Prevention (CDC) after reductions in CDC funding and with the stress of the coronavirus disease 2019 (COVID-19) pandemic. METHODS: We assessed whether national influenza surveillance systems of CDC-funded countries: (i) continued to analyse as many specimens between 2013 and 2021; (ii) participated in activities of the World Health Organization's (WHO) Global Influenza Surveillance and Response System; (iii) tested enough specimens to detect rare events or signals of unusual activity; and (iv) demonstrated stability before and during the COVID-19 pandemic. We used CDC budget records and data from the WHO Global Influenza Surveillance and Response System. FINDINGS: While CDC reduced per-country influenza funding by about 75% over 10 years, the number of specimens tested annually remained stable (mean 2261). Reporting varied substantially by country and transmission zone. Countries funded by CDC accounted for 71% (range 61-75%) of specimens included in WHO consultations on the composition of influenza virus vaccines. In 2019, only eight of the 17 transmission zones sent enough specimens to WHO collaborating centres before the vaccine composition meeting to reliably identify antigenic variants. CONCLUSION: Great progress has been made in the global understanding of influenza trends and seasonality. To optimize surveillance to identify atypical influenza viruses, and to integrate molecular testing, sequencing and reporting of severe acute respiratory syndrome coronavirus 2 into existing systems, funding must continue to support these efforts.

      2. Enhancing surveillance protocols for acute hepatitis C virus infection, Utah, 2014-2019
        Lewis NM, Eason J, Barbeau B, Boulton R, Nakashima AK, Dunn AC.
        Public Health Rep. 2022 Jun 9:333549221101381.
        During 2014-2019, the Utah Department of Health (UDOH) enhanced its surveillance program for acute hepatitis C virus (HCV) infections by mandating electronic reporting of negative HCV test results in 2015 and liver function test results in 2016. UDOH also engaged with blood and plasma donation centers beginning in 2014 and syringe exchange programs in 2018 to encourage manual reporting of negative HCV test results from facilities without electronic reporting capabilities. UDOH hepatitis surveillance staff also provided training for case investigations in 2017. The number of cases detected increased 14-fold, from 9 during 2012 to 127 during 2019. In 2019, of 127 cases, 55% (n = 70) were detected through negative HCV test results reported electronically before positive test results (ie, recent seroconversions), 25% (n = 32) through positive HCV test results and elevated liver function test results, 18% (n = 23) through manually reported negative HCV test results, and 2% (n = 2) through positive HCV test results and clinical evidence. Challenges to surveillance included accessing patients for investigations and engaging donation centers in reporting negative test results. Utah's experience demonstrates practical considerations for improving surveillance of acute HCV infections.

    • Global Health
      1. Early detection of SARS-CoV-2 variants using traveler-based genomic surveillance at four US airports, September 2021- January 2022
        Wegrzyn RD, Appiah GD, Morfino R, Milford SR, Walker AT, Ernst ET, Darrow WW, Li SL, Robison K, MacCannell D, Dai D, Girinathan BP, Hicks AL, Cosca B, Woronoff G, Plocik AM, Simen BB, Moriarty L, Guagliardo SA, Cetron MS, Friedman CR.
        Clin Infect Dis. 2022 Jun 10.
        We enrolled arriving international air travelers in SARS-CoV-2 genomic surveillance, using molecular testing of pooled nasal swabs, and sequencing positive samples for viral sublineage. Traveler-based genomic surveillance provided early warning variant detection; we reported the first U.S. Omicron BA.2 and first BA.3 in North America, weeks before next reported detection.

    • Health Economics
      1. Medicaid expansion and contraceptive use among female high-school students
        Kilmer G, Leon-Nguyen M, Smith-Grant J, Brittain AW, Rico A, Adkins SH, Lim C, Szucs LE.
        Am J Prev Med. 2022 Jun 7.
        INTRODUCTION: Access to effective contraception prevents unintended pregnancies among sexually active female youth. Potentially impacted by the Affordable Care Act's Medicaid-related policies, contraception use increased among sexually active high-school students from 2013 to 2019. METHODS: Analyses conducted in 2021 assessed state-level Youth Risk Behavior Survey data among female students in grades 9-12 who reported being sexually active. States that expanded Medicaid were compared with other states in 2013 (baseline) and 2019 (after expansion). Measured outcomes included self-reported use of moderately effective or highly effective, long-acting reversible contraception at last sex. Long-acting reversible contraception included intrauterine devices and implants. Moderately effective contraception included birth control pills, injectables, patches, or rings. Results were weighted and adjusted for age and race/ethnicity. RESULTS: Students in Medicaid expansion states (n=27,564) did not differ significantly from those in nonexpansion states (n=6,048) at baseline or after expansion with respect to age, age at first sex, or the number of sexual partners in the past 3 months; however, race/ethnicity population characteristics changed over time. Postexpansion increased use of intrauterine devices/implants was greater in Medicaid expansion states than in nonexpansion states (238.1% increase vs 120.0% increase, adjusted p=0.047). For those aged 16-17 years, Medicaid expansion states had a 283.3% increase in intrauterine device/implant use compared with an increase of 69.7% in nonexpansion states (adjusted p=0.004). CONCLUSIONS: Medicaid expansion was associated with a greater population-level increase in intrauterine device/implant use among sexually active female high-school students aged 16-17 years. These findings point to the possibility that the Affordable Care Act's Medicaid-related policies played a role in young women's use of intrauterine devices/implants.

      2. Estimation of the lifetime quality-adjusted life years (QALYS) lost due to syphilis acquired in the United States in 2018
        Lee K, You S, Li Y, Chesson H, Gift TL, Berruti AA, Hsu K, Yaesoubi R, Salomon JA, Rönn M.
        Clin Infect Dis. 2022 Jun 9.
        BACKGROUND: The purpose of this study was to estimate the health impact of syphilis in the United States in terms of the number of quality-adjusted life years (QALYs) lost attributable to infections in 2018. METHODS: We developed a Markov model which simulates the natural history and management of syphilis. The model was parameterized by sex and sexual orientation (women who have sex with men, men who have sex with women[MSW], and men who have sex with men[MSM]), and by age at primary infection. We developed a separate decision tree model to quantify health losses due to congenital syphilis. We estimated the average lifetime number of QALYs lost per infection, and the total expected lifetime number of QALYs lost due to syphilis acquired in 2018. RESULTS: We estimated the average number of discounted lifetime QALYs lost per infection as 0.09 [0.03-0.19 95% uncertainty interval (UI)]. The total expected number of QALYs lost due to syphilis acquired in 2018 was 13,349[5,071-31,360]. While per-case loss was the lowest among MSM(0.06), MSM accounted for 47.7% of the overall burden. For each case of congenital syphilis, we estimated 1.79[1.43-2.16] and 0.06[0.01-0.14] QALYs lost in the child and the mother, respectively. We projected 2,332[1,871-2,825] and 79[17-177] QALYs lost for children and mothers, respectively, due to congenital syphilis in 2018. CONCLUSIONS: Syphilis causes substantial health losses in adults and children. Quantifying these health losses in terms of QALYs can inform cost-effectiveness analyses and can facilitate comparisons of the burden of syphilis to that of other diseases.

    • Health Equity and Health Disparities
      1. Per- and polyfluoroalkyl substances and incident hypertension in multi-racial/ethnic women: The Study of Women's Health Across the Nation
        Ding N, Karvonen-Gutierrez CA, Mukherjee B, Calafat AM, Harlow SD, Park SK.
        Hypertension. 2022 Jun 13:101161hypertensionaha12118809.
        BACKGROUND: Perfluoroalkyl and polyfluoroalkyl substances (PFAS) are ubiquitous synthetic chemicals that may disrupt blood pressure controls; however, human evidence to support this hypothesis is scant. We examined the association between serum concentrations of PFAS and risks of developing hypertension. METHODS: This study included 1058 midlife women initially free of hypertension from the multiracial and multiethnic SWAN (Study of Women's Health Across the Nation) with annual follow-up visits between 1999 and 2017. Hypertension was defined as blood pressure ≥140 mm Hg systolic or ≥90 mm Hg diastolic or receiving antihypertensive treatment. Cox proportional hazards models were utilized to calculate hazard ratios and 95% CIs. Quantile g-computation was implemented to evaluate the joint effect of PFAS mixtures. RESULTS: During 11 722 person-years of follow-up, 470 participants developed incident hypertension (40.1 cases per 1000 person-years). Compared with the lowest tertile, women in the highest tertile of baseline serum concentrations had adjusted hazard ratios of 1.42 (95% CI, 1.19-1.68) for perfluorooctane sulfonate (P trend=0.01), 1.47 (95% CI, 1.24-1.75) for linear perfluorooctanoate (P trend=0.01), and 1.42 (95% CI, 1.19-1.70) for 2-(N-ethyl-perfluorooctane sulfonamido) acetate (P trend=0.01). No significant associations were observed for perfluorononanoate and perfluorohexane sulfonate. In the mixture analysis, women in the highest tertile of overall PFAS concentrations had a hazard ratio of 1.71 (95% CI, 1.15-2.54; P trend=0.008), compared with those in the lowest tertile. CONCLUSIONS: Several PFAS showed positive associations with incident hypertension. These findings suggest that PFAS might be an underappreciated contributing factor to women's cardiovascular disease risk.

      2. Increasing children's global access to COVID-19 vaccines
        Patel M, Patel M.
        Lancet. 2022 Jun 11;399(10342):2171-2173.

      3. COVID-19 vaccination coverage, by race and ethnicity - National Immunization Survey adult covid module, United States, December 2020-November 2021
        Kriss JL, Hung MC, Srivastav A, Black CL, Lindley MC, Lee JT, Koppaka R, Tsai Y, Lu PJ, Yankey D, Elam-Evans LD, Singleton JA.
        MMWR Morb Mortal Wkly Rep. 2022 Jun 10;71(23):757-763.
        Some racial and ethnic minority groups have experienced disproportionately higher rates of COVID-19-related illness and mortality (1,2). Vaccination is highly effective in preventing severe COVID-19 illness and death (3), and equitable vaccination can reduce COVID-19-related disparities. CDC analyzed data from the National Immunization Survey Adult COVID Module (NIS-ACM), a random-digit-dialed cellular telephone survey of adults aged ≥18 years, to assess disparities in COVID-19 vaccination coverage by race and ethnicity among U.S. adults during December 2020-November 2021. Asian and non-Hispanic White (White) adults had the highest ≥1-dose COVID-19 vaccination coverage by the end of April 2021 (69.6% and 59.0%, respectively); ≥1-dose coverage was lower among Hispanic (47.3%), non-Hispanic Black or African American (Black) (46.3%), Native Hawaiian or other Pacific Islander (NH/OPI) (45.9%), multiple or other race (42.6%), and American Indian or Alaska Native (AI/AN) (38.7%) adults. By the end of November 2021, national ≥1-dose COVID-19 vaccination coverage was similar for Black (78.2%), Hispanic (81.3%), NH/OPI (75.7%), and White adults (78.7%); however, coverage remained lower for AI/AN (61.8%) and multiple or other race (68.0%) adults. Booster doses of COVID-19 vaccine are now recommended for all adults (4), but disparities in booster dose coverage among the fully vaccinated have become apparent (5). Tailored efforts including community partnerships and trusted sources of information could be used to increase vaccination coverage among the groups with identified persistent disparities and can help achieve vaccination equity and prevent new disparities by race and ethnicity in booster dose coverage.

      4. Active surveillance with seroprevalence-based infection rates indicates racial disparities with pediatric SARS-CoV-2 requiring hospitalization in Mississippi, March 2020-February 2021
        Hobbs CV, Kim SS, Vemula P, Inagaki K, Harrison VA, Malloch L, Martin LM, Singh G, Agana U, Williams JM, Patterson K, Kittle T, Byers P, Palmer A, Santos RP, Dhanrajani A, Stephenson M, Hung L, Hankins P, Thornburg N, Drobeniuc J, Flannery B.
        Pediatr Infect Dis J. 2022 Jun 7.
        BACKGROUND: Racial disparities in SARS-CoV-2 infection, hospitalization, and multisystem inflammatory syndrome in children (MIS-C) have been reported. However, these reports have been based on incomplete data relying on passive reporting, unknown catchment populations, and unknown infection prevalence. We aimed to characterize population-based incidence of MIS-C and COVID-19 hospitalizations among non-Hispanic Black and White children using active surveillance based on seroprevalence-based cumulative incidence of pediatric SARS-CoV-2 infection in a defined catchment 16-county area of Mississippi. METHODS: Active, population-based surveillance for MIS-C and acute COVID-19 hospitalizations meeting clinical and laboratory criteria was conducted by adjudicating clinicians at the major pediatric referral hospital for Mississippi, University of Mississippi Medical Center, from March 2020, to February 2021. Race-stratified SARS-CoV-2 seroprevalence was estimated using convenience samples from persons <18 years to calculate cumulative SARS-CoV-2 infections in the population. RESULTS: Thirty-eight MIS-C cases and 74 pediatric acute COVID-19 hospitalizations were identified. Cumulative incidence of MIS-C was 4.7 times higher among Black compared with White children (40.7 versus 8.3 cases per 100,000 SARS-CoV-2 infections). Cumulative incidence of COVID-19 hospitalization was 62.3 among Black and 33.1 among White children per 100,000 SARS-CoV-2 infections. CONCLUSIONS: From the same catchment area, active surveillance, and cumulative incidence of infection estimated by seroprevalence, we show strikingly higher incidence of SARS-CoV-2-hospitalization and MIS-C in non-Hispanic Black children compared with White children before COVID-19 vaccination introduction in children. These disparities in SARS-CoV-2 manifestations cannot be accounted for by differences in exposure or testing. Targeted vaccine interventions will lessen disparities observed with SARS-CoV-2 manifestations in children.

    • Healthcare Associated Infections
      1. Impact of COVID-19 pandemic on central-line-associated bloodstream infections during the early months of 2020, National Healthcare Safety Network
        Patel PR, Weiner-Lastinger LM, Dudeck MA, Fike LV, Kuhar DT, Edwards JR, Pollock D, Benin A.
        Infect Control Hosp Epidemiol. 2022 Jun;43(6):790-793.
        Data reported to the Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC NHSN) were analyzed to understand the potential impact of the COVID-19 pandemic on central-line-associated bloodstream infections (CLABSIs) in acute-care hospitals. Descriptive analysis of the standardized infection ratio (SIR) was conducted by location, location type, geographic area, and bed size.

    • Immunity and Immunization
      1. Association of E484K spike protein mutation with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in vaccinated persons: Maryland, January-May 2021
        Feder KA, Patel A, Vepachedu VR, Dominguez C, Keller EN, Klein L, Kim C, Blood T, Hyun J, Williams TW, Feldman KA, Mostafa HH, Morris CP, Ravel J, Duwell M, Blythe D, Myers R.
        Clin Infect Dis. 2022 Jun 10;74(11):2053-2056.
        Among 9048 people infected with SARS-CoV-2 between January and May 2021 in Maryland, in regression-adjusted analysis, SARS-CoV-2 viruses carrying the spike protein mutation E484K were disproportionately prevalent among persons infected after full vaccination against COVID-19 compared with infected persons who were not fully vaccinated (aOR, 1.96; 95% CI: 1.36-2.83).

      2. Multiplex detection of antibody landscapes to SARS-CoV-2/influenza/common human coronaviruses following vaccination or infection with SARS-CoV-2 and influenza
        Li ZN, Liu F, Jefferson S, Horner L, Carney P, Johnson MD, King JP, Martin ET, Zimmerman RK, Wernli K, Gaglani M, Thompson M, Flannery B, Stevens J, Tumpey T, Levine MZ.
        Clin Infect Dis. 2022 Jun 10.
        BACKGROUND: SARS-CoV-2 and influenza viruses continue to co-circulate, representing two major public health threats from respiratory infections with similar clinical presentations. SARS-CoV-2 and influenza vaccines can also now be co-administered. However, data on antibody responses to SARS-CoV-2 and influenza co-infection, and vaccine co-administration remains limited. METHODS: We developed a 41-plex antibody immunity assay that can simultaneously characterize antibody landscapes to SARS-CoV-2/influenza/common human coronaviruses. We analyzed sera from 840 individuals (11-93 years), including sera from reverse transcription polymerase chain reaction (RT-PCR) confirmed SARS-CoV-2 positive (n = 218) and negative (n = 120) cases, paired sera from SARS-CoV-2 vaccination (n = 29) and infection (n = 11), and paired sera from influenza vaccination (n = 56) and RT-PCR confirmed influenza infection (n = 158) cases. Lastly, we analyzed sera collected from 377 individual that exhibited acute respiratory illness (ARI) in 2020. RESULTS: This 41-plex assay has high sensitivity and specificity in detecting SARS-CoV-2 infections. It differentiated SARS-CoV-2 vaccination (antibody responses only to spike protein) from infection (antibody responses to both spike and nucleoprotein). No cross-reactive antibodies were detected to SARS-CoV-2 from influenza vaccination and infection, and vice versa, suggesting no interaction between SARS-CoV-2 and influenza antibody responses. However, cross-reactive antibodies were detected between spike proteins of SARS-CoV-2 and common human coronaviruses that were removed by serum adsorption. Among 377 individual who exhibited ARI in 2020, 129 were influenza positive, none had serological evidence of SARS-CoV-2/influenza co-infections. CONCLUSIONS: Multiplex detection of antibody landscapes can provide in-depth analysis of the antibody protective immunity to SARS-CoV-2 in the context of other respiratory viruses including influenza.

      3. Exposure outcomes in fully vaccinated healthcare personnel with known SARS-CoV-2 exposure-Minnesota, January-August 2021
        Ruhland A, Fell A, Holzbauer SM, D'Heilly P, Curtis K, Wick H, Friedman B, Mumm E, Ireland M, Estey-Dix C, Betts-Roelike M, Beaudoin A.
        Clin Infect Dis. 2022 Jun 10.
        Healthcare personnel (HCP) are at potential risk for SARS-CoV-2 infection in occupational and non-occupational settings, even when fully vaccinated. This risk has increased during Delta variant circulation. SARS-CoV-2 testing of fully vaccinated HCP working in the 14 days after exposure is important to prevent virus introduction into healthcare settings.

      4. Determinants of COVID-19 vaccine acceptance and uptake in a transborder population at the Mexico-Guatemala border, September-November 2021
        Bojorquez I, Leyva-Flores R, Rodríguez-Chávez C, Hernández-Campos C, Arévalo M, Cortés-Alcalá R, Rodríguez-Elizondo G, Ward S, Merrill R, Rodriguez-Lainz A, Escotto D, Bustamante N.
        Int J Environ Res Public Health. 2022 Jun 6;19(11).
        Assessing COVID-19 vaccination uptake of transborder populations is critical for informing public health policies. We conducted a probability (time-venue) survey of adults crossing from Mexico into Guatemala from September to November 2021, with the objective of describing COVID-19 vaccination status, willingness to get vaccinated, and associated factors. The main outcomes were receipt of ≥1 dose of a COVID-19 vaccine, being fully vaccinated, and willingness to get vaccinated. We assessed the association of outcomes with sociodemographic characteristics using logistic regressions. Of 6518 participants, 50.6% (95%CI 48.3,53.0) were vaccinated (at least one dose); 23.3% (95%CI 21.4,25.2) were unvaccinated but willing to get vaccinated, and 26.1% (95%CI 24.1,28.3) were unvaccinated and unwilling to get vaccinated. Those living in Mexico, independent of country of birth, had the highest proportion vaccinated. The main reason for unwillingness was fear of side effects of COVID-19 vaccines (47.7%, 95%CI 43.6,51.9). Education level was positively associated with the odds of partial and full vaccination as well as willingness to get vaccinated. People identified as Catholic had higher odds of getting vaccinated and being fully vaccinated than members of other religious groups or the non-religious. Further studies should explore barriers to vaccination among those willing to get vaccinated and the motives of the unwilling.

      5. Major changes in spatiotemporal trends of US rotavirus laboratory detections after rotavirus vaccine introduction-2009-2021
        Burnett E, Parashar UD, Winn A, Curns AT, Tate JE.
        Pediatr Infect Dis J. 2022 Jun 1.
        For the 15 years before rotavirus vaccine introduction in 2006, annual rotavirus activity in the United States showed a distinct spatiotemporal pattern, peaking first in the Southwest and last in the Northeast. We modeled spatiotemporal trends in rotavirus laboratory detections from 2009 to 2021. Laboratories reporting to the National Respiratory and Enteric Virus Surveillance System were eligible for inclusion in a given surveillance year (July to June) if ≥1 polymerase chain reaction or enzyme immunoassay rotavirus test per week was reported during ≥26 weeks and totaling ≥100 annual tests. For each laboratory, the season peak was the week with the highest 7-week moving average of the number of rotavirus positive tests during the national season, defined as the period with a 3-week moving average of >10% rotavirus positivity lasting ≥2 consecutive weeks. We input peak week as a continuous variable and the geospatial coordinates of each laboratory into a spherical variogram model for Kriging spatial interpolation. We also created a state-level bivariate choropleth map using tertiles of the 2010-2019 average birth rates and rotavirus vaccine coverage. Following the established biennial trend, the 2010-2011, 2012-2013, 2014-2015, 2016-2017, and 2018-2019 surveillance years had >10% rotavirus positivity for ≥2 weeks and were included in the geospatial analysis. During all 5 seasons included in the geospatial analysis, the earliest peak week occurred in Oklahoma, Arkansas, and the western Gulf coast, a pattern markedly different from prevaccine seasons. These states also had the average lowest rotavirus vaccine coverage and highest birth rate, suggesting that more rapid accumulation of susceptible children drives annual rotavirus season activity. Increasing vaccine coverage remains a key tool in reducing rotavirus burden.

      6. An evaluation of adverse events following an immunization campaign with the live, attenuated SA14-14-2 Japanese encephalitis vaccine in Cambodia
        Hills SL, Soeung SC, Sarath S, Morn C, Dara C, Fischer M, Thigpen MC.
        PLoS One. 2022 ;17(6):e0269480.
        INTRODUCTION: Japanese encephalitis (JE) virus is the most common cause of vaccine-preventable encephalitis in Asia. The SA14-14-2 JE vaccine manufactured by Chengdu Institute of Biological Products has been shown to be safe and effective in clinical trials and childhood routine immunization programs. However, there are few published reports describing results of surveillance for adverse events following immunization (AEFI) when the vaccine is used in mass campaigns. We describe the results of AEFI surveillance following a 2013 vaccination campaign among almost 310,000 children aged 9 months-12 years in Battambang Province, Cambodia. METHODS: Routine AEFI surveillance was strengthened by staff training and supplemented by active hospital surveillance. An AEFI was defined as any sign, symptom, or disease temporally associated (i.e., within 4 weeks) with receipt of the vaccine, irrespective of whether it was considered related to immunization. Data were collected on standardized forms and causality assessments were conducted for serious AEFI. RESULTS: Passive and active surveillance detected 28 AEFI for an overall incidence of 9.0 AEFI per 100,000 doses administered. The most frequent events were vasovagal episodes (n = 7, 25%) and rash (n = 6, 21%), and most other events were common childhood conditions such as fever and vomiting. Three AEFI were classified as serious, including one hypersensitivity reaction and two meningoencephalitis cases. Of these, the hypersensitivity event was the only serious AEFI classified as being consistent with a causal association to immunization. CONCLUSIONS: Most reported adverse events were conditions that commonly occur after other childhood vaccinations or independently of vaccination, and in the context of careful monitoring for serious AEFI only one serious event consistent with a causal association with immunization was identified. These results support the good safety profile of the SA14-14-2 JE vaccine, and provide reassuring data as the vaccine's use expands.

      7. COVID-19 vaccination and intent among pregnant women, United States, April 2021
        Razzaghi H, Kahn KE, Masalovich S, Black CL, Nguyen KH, Barfield WD, Galang RR, Singleton JA.
        Public Health Rep. 2022 Jun 14:333549221099244.
        OBJECTIVES: National data on COVID-19 vaccination coverage among pregnant women are limited. We assessed COVID-19 vaccination coverage and intent, factors associated with COVID-19 vaccination, reasons for nonvaccination, and knowledge, attitudes, and beliefs related to COVID-19 illness and vaccination among pregnant women in the United States. METHODS: Data from an opt-in internet panel survey of pregnant women conducted March 31-April 16, 2021, assessed receipt of ≥1 dose of any COVID-19 vaccine during pregnancy. The sample included 1516 women pregnant any time during December 1, 2020-April 16, 2021, who were not fully vaccinated before pregnancy. We used multivariable logistic regression to determine variables independently associated with receipt of COVID-19 vaccine. RESULTS: As of April 16, 2021, 21.7% of pregnant women had received ≥1 dose of COVID-19 vaccine during pregnancy, 24.0% intended to receive a vaccine, 17.2% were unsure, and 37.1% did not intend to receive a vaccine. Pregnant women with (vs without) a health care provider recommendation (adjusted prevalence ratio [aPR] = 4.86), those who lived (vs not) with someone with a condition that could increase risk for serious medical complications of COVID-19 (aPR = 2.11), and those who had received (vs not) an influenza vaccination (aPR = 2.35) were more likely to receive a COVID-19 vaccine. Common reasons for nonvaccination included concerns about safety risk to baby (37.2%) or self (34.6%) and about rapid vaccine development (29.7%) and approval (30.9%). CONCLUSIONS: Our findings indicate a continued need to emphasize the benefits of COVID-19 vaccination during pregnancy and to widely disseminate the recommendations of the Centers for Disease Control and Prevention and other clinical professional societies for all pregnant women to be vaccinated.

    • Injury and Violence
      1. Stakeholder-engaged development of a theory-driven, feasible, and acceptable approach to concussion education
        Kroshus E, Chrisman SP, Hunt T, Hays R, Garrett K, Peterson A, Rivara FP, Chiampas G, Ramshaw Ba D, Glang A.
        Health Educ Behav. 2022 Jun 15:10901981221099886.
        Concussion education is widely mandated and largely ineffective. Recent consensus guidance on concussion education asserts the importance of (1) theory-driven programming that targets the team as a system and (2) working with end users throughout the development process, and considering issues such as feasibility, acceptability, and sustainability. Consistent with this guidance, and in collaboration with youth sport stakeholders in two regions of the United States, we developed a novel approach to concussion education: Pre-game safety huddles. Safety huddles have the following two core components: (1) athletes, coaches, and other stakeholders come together before the start of each game and (2) opinion leaders (coaches, referees) affirm the importance of care seeking for suspected concussion. The aim of this article is to provide an overview of the collaborative process through which we refined the safety huddle concept into an acceptable and feasible intervention with potential for sustainable implementation in diverse youth sports settings with minimal resource demands. In describing our process and discussing challenges and opportunities, we hope to provide an example for others seeking to develop and implement injury prevention interventions in youth sports settings.

      2. Interpersonal violence victimization experiences of middle school youth: An exploration by gender and sexual/romantic attraction
        Ray CM, Norris AL, Liu GS, Bogen KW, Pearlman DN, Reidy DE, Estefan LF, Orchowski LM.
        J Homosex. 2022 Jun 14:1-24.
        Sexual minority youth (SMY) are at increased risk for interpersonal violence victimization compared to heterosexual youth. The current study examined how self-reported victimization (i.e., bullying, sexual harassment and dating violence) among middle school youth varied as a function of sexual/romantic attraction as well as gender identity. Cross-sectional data were gathered from students at seven middle schools in New England (n = 2245). Mean comparisons with post-hoc Tukey tests determined differences in rates of past 6-month and lifetime interpersonal violence victimization by sexual/romantic attraction and the intersection of gender and attraction. As hypothesized, interpersonal violence victimization among middle school youth differed as a function of sexual/romantic attraction as well as gender. To date, most research has focused on older samples, particularly high-school youth and young adults. These data are consistent with these prior studies documenting increased risk for interpersonal violence victimization among youth who indicate same-gender attraction but add to the literature in demonstrating the expansive forms of peer victimization that same-gender-attracted youth already experience by early adolescence. Given that victimization is associated acutely and longitudinally with many deleterious outcomes, including poorer mental health and increased risk for subsequent victimization, greater structural supports are needed for early adolescent SMY.

      3. Challenges and opportunities in diagnosing and managing mild traumatic brain injury in rural settings
        Daugherty J, Waltzman D, Popat S, Horn Groenendaal A, Cherney M, Knudson A.
        Rural Remote Health. 2022 Jun;22(2):7241.
        INTRODUCTION: There is some evidence to suggest that Americans living in rural areas are at increased risk for sustaining a traumatic brain injury (TBI) compared to those living in urban areas. In addition, once a TBI has been sustained, rural residents have worse outcomes, including a higher risk of death. Individuals living in rural areas tend to live farther from hospitals and have less access to TBI specialists. Aside from these factors, little is known what challenges healthcare providers practicing in rural areas face in diagnosing and managing TBI in their patients and what can be done to overcome these challenges. METHODS: Seven focus groups and one individual interview were conducted with a total of 18 healthcare providers who mostly practiced in primary care or emergency department settings in rural areas. Providers were asked about common mechanisms of TBI in patients that they treat, challenges they face in initial and follow-up care, and opportunities for improvement in their practice. RESULTS: The rural healthcare providers reported that common mechanisms of injury included sports-related injuries for their pediatric and adolescent patients and work-related accidents, motor vehicle crashes, and falls among their adult patients. Most providers felt prepared to diagnose and manage their patients with TBI, but acknowledged a series of challenges they face, including pushback from parents, athletes, and coaches and lack of specialists to whom they could refer. They also noted that patients had their own barriers to overcome for timely and adequate care, including lack of access to transportation, difficulties with cost and insurance, and denial about the seriousness of the injury. Despite these challenges, the focus group participants also outlined benefits to practicing in a rural area and several ways that their practice could improve with support. CONCLUSION: Rural healthcare providers may be comfortable diagnosing, treating, and managing their patients who present with a suspected TBI, but they also face many challenges in their practice. In this study it was continually noted that there was lack of resources and a lack of awareness, or recognition of the seriousness of TBI, among the providers' patient populations. Education about common symptoms and the need for evaluation after an injury is needed. The use of telemedicine, an increasingly common technology, may help close some gaps in access to services. People living in rural areas may be at increased risk for TBI. Healthcare providers who work in these areas face many challenges but have found ways to successfully manage the treatment of this injury in their patients.

    • Laboratory Sciences
      1. Pathogens detected using a syndromic molecular diagnostic platform in patients hospitalized with severe respiratory illness in South Africa in 2017
        Moleleki M, du Plessis M, Ndlangisa K, Reddy C, Hellferscee O, Mekgoe O, McMorrow M, Walaza S, Cohen C, Tempia S, von Gottberg A, Wolter N.
        Int J Infect Dis. 2022 Jun 11.
        OBJECTIVES: We describe the use of a multi-pathogen platform, TaqMan array card (TAC) real-time PCR, for the detection of pathogens in patients hospitalized with severe respiratory illness (SRI). METHODS: Prospective hospital-based syndromic surveillance for acute and chronic SRI was carried out at two sentinel sites in South Africa between January and December 2017. We tested respiratory specimens for 21 respiratory pathogens and blood samples for nine bacteria using TAC. Pathogen detection was compared by age group and HIV status using the chi-squared test. RESULTS: During 2017, 956 patients of all ages were enrolled in the SRI surveillance, and of these, 637 (67%) patients were included in this study (637 blood, 487 naso- and oro-pharyngeal swabs and 411 sputum specimens tested). At least one pathogen was detected in 83% (527/637) of patients. Common pathogens detected included H. influenzae (225/637; 35%), S. pneumoniae (224/637; 35%), rhinovirus (144/637; 23%), S. aureus (129/637; 20%), K. pneumoniae (85/637; 13%), M. tuberculosis (75/637; 12%), and respiratory syncytial virus (57/637; 9%). Multiple pathogens (≥2) were co-detected in 57% (364/637) of patients. CONCLUSION: While use of a multi-pathogen platform improved pathogen yield, pathogen co-detections were common and would need clinical assessment for usefulness in individual-level treatment and management decisions.

      2. Performance of Xpert MTB/RIF and mycobacterial culture on multiple specimen types for diagnosis of tuberculosis disease in young children and clinical characterization according to standardized research case definitions
        Click ES, Song R, Smith JP, McHembere W, Fajans M, Hariri P, Okeyo E, McCarthy KD, Gethi D, Odeny L, Musau S, Okumu A, Orwa J, Perez-Velez CM, Wright CA, Andres MM, Marais BJ, Schaaf HS, Graham SM, Cruz AT, Cain KP.
        Pediatr Infect Dis J. 2022 May 31.
        BACKGROUND: Tuberculosis (TB) is a leading cause of illness and death in children globally. Improved bacteriologic and clinical diagnostic approaches in children are urgently needed. METHODS: In a prospective cohort study, a consecutive series of young (<5 years) children presenting with symptoms suggestive of TB and parenchymal abnormality on chest radiograph in inpatient and outpatient settings in Kisumu County, Kenya from October 2013 to August 2015 were evaluated at baseline and over 6 months. Up to 14 specimens per child were tested for the Mycobacterium tuberculosis complex by fluorescence microscopy, Xpert MTB/RIF and mycobacterial culture. Using detailed clinical characterization, cases were retrospectively classified according to standardized research case definitions and the sensitivity and specificity of microbiological tests on different specimen types were determined. RESULTS: Among 300 young children enrolled, 266 had sufficient information to be classified according to the research clinical case definition. Of these, 36% (96/266) had TB disease; 32% (31/96) with bacteriologically confirmed intrathoracic TB. Compared to culture, the sensitivity of a single Xpert test ranged from 60 to 67% and specificity from 97.5 to 100% for different specimen types. CONCLUSIONS: Despite extensive specimen collection and laboratory testing, TB could not be bacteriologically confirmed in almost two-thirds of children with intrathoracic TB classified by research clinical case definitions. Improved diagnostic tests are needed to identify children with TB and to exclude other potential causes of illness.

      3. Evaluation of Whatman FTA cards for the preservation of yellow fever virus RNA for use in molecular diagnostics
        Davis EH, Velez JO, Russell BJ, Basile AJ, Brault AC, Hughes HR.
        PLoS Negl Trop Dis. 2022 Jun;16(6):e0010487.
        Yellow fever virus (YFV) is a flavivirus that frequently causes outbreaks of hemorrhagic fever in Africa and South America and is considered a reemerging public health threat. Accurate diagnosis of yellow fever (YF) disease is critical as one confirmed case constitutes an outbreak and may trigger a mass vaccination campaign. Highly sensitive and specific molecular diagnostics have been developed; however, these assays require maintenance of cold-chain during transport of specimens to prevent the degradation of viral RNA prior to testing. Such cold-chain requirements are difficult to meet in some regions. In this study, we investigated Whatman FTA cards as an alternative stabilization method of YFV RNA for use in molecular diagnosis. Using contrived specimens, linear regression analysis showed that RNA detection from a single 6mm FTA card punch was significantly less sensitive than traditional RNA extraction; however, pooling RNA extracted from two FTA punches significantly lowered the limit of detection to be equal to that of the traditional RNA extraction gold standard. In experiments addressing the ability of FTA card methodology to stabilize YFV RNA at variable temperature, RNA could be detected for more than two weeks following storage at 25°C. Even more promising, YFV RNA was detectable on cards held at 37°C from two days to over two weeks depending on viral input. FTA cards were also shown to stabilize YFV RNA at high humidity if cards were desiccated prior to inoculation. These results support that FTA cards could be cost effective and easy to use in molecular diagnosis of YF, preserving viral RNA to allow for positive diagnoses in situations where maintaining cold-chain is not feasible.

    • Occupational Safety and Health
      1. Laboratory assessment of bacterial contamination of a sterile environment when using respirators not traditionally used in a sterile field environment
        Myers W, Ajewole S, Xu S, Yorio P, Hornbeck A, Zhuang Z.
        Infect Control Hosp Epidemiol. 2022 Jun 15:1-6.
        OBJECTIVE: During infectious disease outbreaks or pandemics, an increased demand for surgical N95s that create shortages and necessitate the use of alternative National Institute for Occupational Safety and Health (NIOSH)-approved respirators that do not meet the Food and Drug Administration (FDA) additional requirements. The objective of this research was to quantify the level of bacterial contamination resulting from wearing NIOSH-approved respirators lacking the additional protections afforded by surgical N95s. METHODS: Participants performed simulated healthcare tasks while wearing 5 different respirators approved by the NIOSH. Sterile field contamination resulting from use of a surgical mask cleared by the FDA served as a baseline for comparison with the NIOSH-approved respirators. RESULTS: The bacterial contamination produced by participants wearing the N95 filtering facepiece respirators (FFRs) without an exhalation valve, the powered air-purifying respirators (PAPRs) with an assigned protection factor of 25 or 1,000 was not significantly different compared to the contamination resulting from wearing the surgical mask. The bacterial contamination resulting from wearing the N95 FFR with an exhalation valve and elastomeric half-mask respirator (EHMR) with an exhalation valve was found to be statistically significantly higher than the bacterial contamination resulting from wearing the surgical mask. CONCLUSIONS: Overall, NIOSH-approved respirators without exhalation valves maintain a sterile field as well as a surgical mask. These findings inform respiratory guidance on the selection of respirators where sterile fields are needed during shortages of surgical N95 FFRs.

      2. Characteristics associated with healthcare worker knowledge and confidence in elastomeric half-mask respirator use
        Thurman P, Zhuang E, Chen HH, McClain C, Sietsema M, Fernando R, McDiarmid MA, Hines SE.
        J Occup Environ Med. 2022 Jun 14.
        OBJECTIVE: This study evaluated healthcare workers' (HCW) knowledge and confidence in using elastomeric half-mask respirator (EHMR) attributes known to influence usage. METHODS: HCW were surveyed regarding their EHMR donning and doffing experience. Respondents were categorized into competency categories based on their scores. Category differences were analyzed using chi square and multiple logistic regression. RESULTS: 72% showed high levels of EHMR donning and doffing knowledge and confidence (mastery); however, 21% had greater confidence than knowledge (misinformed). Respiratory therapists had greater odds of mastery than other HCW (p < .05), while those working in medical/surgical and pediatric units had greater odds of doubt than other HCW (p < .01). CONCLUSION: While most HCW show high knowledge and confidence with EHMR use strategies to confirm respirator use competency may ensure greater HCW protection.

    • Occupational Safety and Health - Mining
      1. Identifying longwall-induced fracture zone height through core drilling
        Van Dyke MA, Zhang P, Dougherty H, Su D, Kim BH.
        Min Metall Explor. 2022 .
        The National Institute for Occupational Safety and Health (NIOSH) has been evaluating longwall mining-induced strata fractures and their impacts on casing stability of Marcellus shale gas wells located in longwall pillars. To understand the extent of overburden fractures after longwall mining, NIOSH researchers drilled a post-mining corehole into the fractured strata above the Pittsburgh coal seam longwall gob. Knowing the extent of the fracture zone height will help gas operators minimize the hazards of drilling into longwall gobs. The core was retrieved from the surface down to the top of the gob void. Various fractures were encountered varying from 35 to 64°, depending on lithologic type and relative closeness to the gob. The longwall panel dimension was 457-m wide and 3657-m long, in which the total fracture zone height was found to be at 141 m and the hydraulic connected fracture zone at 87.7 m above the top of the Pittsburgh seam. In addition to core drilling through the gob, FLAC3D modeling was also used to simulate the formation of fracture zone and the orientations of longwall-induced fractures. This study provides much-needed evidence on the fracture zone of Pittsburgh seam longwall gobs to help gas operators avoid potential hazards associated with drilling through highly fractured zones in longwall gobs. © 2022, This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.

      2. A reliable and stable ventilation system is essential to the safe operation of underground mines. The stability of a mine ventilation system becomes extremely critical while responding to a fire incident since an unstable ventilation system will pose a risk of airflow reversal. The reversed airflow could bring the fire contaminants such as toxic gases and smoke unexpectedly to working areas. In the past few years, there has been a growing interest in the study of ventilation network stability using the concept of resistance sensitivity, which is described as an indicator of how the airflow in an airway is reacting to a resistance change of other airways. Several methods of calculating the resistance sensitivity in a mine ventilation network have been carried out by researchers and scholars around the world. However, the proposed methods heavily rely on a vast amount of mine ventilation simulations, which are very time consuming and computer-power intensive, especially for a large-scale mine ventilation network. In this paper, a derivative method calculating the resistance sensitivities with a single mine ventilation simulation has been developed and implemented into a mine fire simulation software, MFIRE. The results from the derivative method were verified against the results from a traditional method. The derivative method has been proven to be reliable and accurate. © 2022, This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.

    • Parasitic Diseases
      1. STARTER checklist for antimalarial therapeutic efficacy reporting
        Plucinski MM, Ashley EA, Bassat Q, Venkatesan M, Rosenthal PJ, Halsey ES.
        Malar J. 2022 Jun 13;21(1):187.

    • Public Health Leadership and Management
      1. Answering the call: The response of Centers For Disease Control And Prevention's federal public health nursing workforce to the COVID-19 pandemic
        Zauche LH, Pomeroy M, Demeke HB, Mettee Zarecki SL, Williams JL, Newsome K, Hill L, Dooyema CA.
        Am J Public Health. 2022 Jun;112(S3):S226-s230.

      2. Epidemic Intelligence Service alumni in public health leadership roles
        So M, Winquist A, Fisher S, Eaton D, Carroll D, Simone P, Pevzner E, Arvelo W.
        Int J Environ Res Public Health. 2022 May 30;19(11).
        Since 1951, the Epidemic Intelligence Service (EIS) of the U.S. Centers for Disease Control and Prevention (CDC) has trained physicians, nurses, scientists, veterinarians, and other allied health professionals in applied epidemiology. To understand the program's effect on graduates' leadership outcomes, we examined the EIS alumni representation in five select leadership positions. These positions were staffed by 353 individuals, of which 185 (52%) were EIS alumni. Among 12 CDC directors, four (33%) were EIS alumni. EIS alumni accounted for 29 (58%) of the 50 CDC center directors, 61 (35%) of the 175 state epidemiologists, 27 (56%) of the 48 Field Epidemiology Training Program resident advisors, and 70 (90%) of the 78 Career Epidemiology Field Officers. Of the 185 EIS alumni in leadership positions, 136 (74%) were physicians, 22 (12%) were scientists, 21 (11%) were veterinarians, 6 (3%) were nurses, and 94 (51%) were assigned to a state or local health department. Among the 61 EIS alumni who served as state epidemiologists, 40 (66%) of them were assigned to a state or local health department during EIS. Our evaluation suggests that epidemiology training programs can serve as a vital resource for the public health workforce, particularly given the capacity strains brought to light by the COVID-19 pandemic.

    • Reproductive Health
      1. Male circumcision uptake during the Botswana Combination Prevention Project
        Marukutira T, Ussery F, Kadima E, Mills LA, Moore J, Block L, Bachanas P, Davis S, Schissler T, Mosha R, Komotere O, Diswai T, Ntsuape C, Lebelonyane R, Bock N.
        PLoS One. 2022 ;17(6):e0269178.
        INTRODUCTION: Voluntary medical male circumcision (VMMC) uptake has been slow in some countries, including Botswana. To inform demand creation efforts, we examined sociodemographic characteristics and referral procedures associated with VMMC uptake in the Botswana Combination Prevention Project (BCPP) and examined the effectiveness of referral of men to MC services from HIV testing venues. DESIGN: BCPP was a community-randomized trial evaluating the impact of a combination HIV prevention package which included VMMC on community HIV incidence. We conducted a sub-analysis of VMMC uptake in intervention communities. METHODS: During the initial VMMC campaign in 15 intervention communities, baseline male circumcision (MC) status was assessed among men eligible for HIV testing. Uncircumcised male community residents aged 16-49 years with negative/unknown HIV status were mobilized and linked to study VMMC services. Outcomes included MC baseline status and uptake through study services. Univariate and multivariate logistic regressions were performed to identify factors associated with MC uptake. RESULTS: Of 12,864 men eligible for testing, 50% (n = 6,448) were already circumcised. Among the uncircumcised men (n = 6,416), 10% (n = 635) underwent MC. Of the 5,071 men identified as eligible for MC through HIV testing services, 78% declined referral and less than 1% of those were circumcised. Of those accepting referral (n = 1,107), 16% were circumcised. Younger (16-24 years) (aOR: 1.51; 95%CI:1.22,1.85), unemployed men (aOR:1.34; 95%CI: 1.06,1.69), and those undergoing HIV testing at mobile venues (aOR: 1.88; 95%CI: 1.53,2.31) were more likely to get circumcised. Fear of pain was the most prevalent (27%) reason given for not being circumcised. CONCLUSION: Younger, unemployed men seeking HIV testing at mobile sites in Botswana were more likely to get VMMC. Addressing unique barriers for employed and older men may be necessary. Given the simplicity of VMMC as an intervention, the HIV testing programs offer a platform for identifying uncircumcised men and offering information and encouragement to access services.

    • Substance Use and Abuse
      1. Persons who inject drugs (PWID) engaging in receptive syringe sharing with their sex partner (dual partnership) may have different behavior patterns than people who have only sex or syringe sharing partnerships. PWID from 23 US cities were recruited for the National HIV Behavioral Surveillance in 2018 using respondent-driven sampling, interviewed, and tested for HIV. Log-linked Poisson regression was conducted to examine the associations between injecting and sexual behaviors and dual partnership. A total of 3435 PWID reported receptive syringe sharing and 42% engaged in dual partnership with their last sharing injecting partner. PWID who reported condomless vaginal or anal sex at last sex were more likely to engage in dual partnership (aPR = 1.85, 95% CI = 1.65-2.08). PWID who reported having two or more sex partners (aPR = 0.67, 95% CI = 0.62-0.72) or two or more sharing injecting partners (aPR = 0.54, 95% CI = 0.50-0.59) were less likely to engage in dual partnership. Findings suggest opportunities for tailored prevention intervention, including couple-based HIV testing, pre-exposure prophylaxis, and access to syringe services programs coupled with safer injection education to help reduce HIV risk.

      2. Patterns in nonopioid pain medication prescribing after the release of the 2016 Guideline for Prescribing Opioids for Chronic Pain
        Goldstick JE, Guy GP, Losby JL, Baldwin GT, Myers MG, Bohnert AS.
        JAMA Netw Open. 2022 Jun 1;5(6):e2216475.
        IMPORTANCE: In 2016, the Centers for Disease Control and Prevention (CDC) released the evidence-based Guideline for Prescribing Opioids for Chronic Pain. How the release of this guideline coincided with changes in nonopioid pain medication prescribing rates remains unknown. OBJECTIVE: To evaluate changes in nonopioid pain medication prescribing after the 2016 CDC guideline release and to assess the heterogeneity in these changes as a function of patient demographic and clinical characteristics. DESIGN, SETTING, AND PARTICIPANTS: This cohort study constructed 7 (4 preguideline and 3 postguideline) annual cohorts using claims data from the national Optum Clinformatics Data Mart Database for the period January 1, 2011, through December 31, 2018. The cohorts included adults with commercial insurance, no cancer or palliative care claims, and 2 years of continuous insurance enrollment. Individuals could qualify for inclusion in multiple cohorts. Each cohort covered a 2-year period, with year 1 as the baseline period used to calculate opioid exposure and other clinical characteristics and year 2 as the follow-up period used to calculate prescribing outcomes. Data were analyzed in March 2022. EXPOSURES: The CDC guideline, which was released in March 2016. MAIN OUTCOMES AND MEASURES: The primary outcome was receipt of any nonopioid pain medication prescriptions (analgesics or antipyretics, anticonvulsants, antidepressants, and nonsteroidal anti-inflammatory drugs) during the follow-up period. This postguideline prescribing pattern was compared with estimates based on the preguideline prescribing pattern, and then the differences were stratified by patient clinical characteristics (chronic pain, recent opioid exposure, substance use disorder, anxiety disorder, and mood disorder). RESULTS: A total of 15 879 241 individuals (2015 mean [SD] age, 50.2 [18.6] years; 8 298 271 female patients [52.3%]) qualified for inclusion in 1 or more cohorts. Logistic regression models showed that nonopioid pain medication prescribing odds were higher by 3.0% (95% CI, 2.6%-3.3%) in postguideline year 1, by 8.7% (95% CI, 8.3%-9.2%) in postguideline year 2, and by 9.7% (95% CI, 9.2%-10.3%) in postguideline year 3 than the preguideline pattern-based estimates. The magnitude of the postguideline departures from the preguideline pattern varied by several clinical characteristics (chronic pain, recent opioid exposure, anxiety disorder, and mood disorder). The largest departure was found among those with chronic pain, with postguideline prescribing being higher than estimated in postguideline year 2 (13.6%; 95% CI, 12.7%-14.6%) and postguideline year 3 (14.9%; 95% CI, 13.8%-16.0%). CONCLUSIONS AND RELEVANCE: Results of this study showed increases in nonopioid pain medication prescribing after the release of the 2016 CDC guideline, suggesting that the guideline may be associated with an increase in guideline-concordant care, but additional studies are needed to understand the role of other secular changes in the opioid policy landscape and other sources of nonopioid medication use.

      3. Characteristics of adults aged ≥18 years evaluated for substance use and treatment planning - United States, 2019
        Kacha-Ochana A, Jones CM, Green JL, Dunphy C, Govoni TD, Robbins RS, Guy GP.
        MMWR Morb Mortal Wkly Rep. 2022 Jun 10;71(23):749-756.
        In 2019, 65.8 million U.S. adults reported past-month binge drinking and 35.8 million reported illicit drug use or prescription pain reliever misuse during the past month; 20.4 million met diagnostic criteria for a substance use disorder during the past year (1). Approximately 81,000 persons died of a drug overdose* during May 2019-May 2020; excessive alcohol use contributes to an estimated 95,000 deaths per year (2). Persons with a substance use disorder are at elevated risk for overdose and associated harms (3). To examine the prevalence of past 30-day substance use patterns and the severity of problems experienced across seven biopsychosocial domains (alcohol, drug, employment, family, legal, medical, and psychiatric), CDC used 2019 data from the National Addictions Vigilance Intervention and Prevention Program (NAVIPPRO) Addiction Severity Index-Multimedia Version (ASI-MV) tool (4); these data are collected from adults aged ≥18 years who seek substance use treatment in the United States. Alcohol was the most commonly reported substance used during the past 30 days (35.8%), followed by cannabis (24.9%), prescription opioids (misuse) (18.5%), illicit stimulants (14.0%), heroin (10.2%), prescription sedatives or tranquilizers (misuse) (8.5%), cocaine (7.4%), illicit fentanyl (4.9%), and prescription stimulants (misuse) (1.8%).(†) Polysubstance use (use of two or more substances) during the past 30 days was reported by 32.6% of respondents. Among the biopsychosocial domains measured, 45.4% of assessments reported more severe problems with drugs; others reported psychiatric (35.2%), legal (28.8%), medical (27.4%), employment (25.0%), alcohol (24.2%), and family problems (22.8%). These findings highlight the complex nature of substance use in the United States, the interplay between substance use and mental illness, and the complex challenges that persons with substance use disorder face when seeking treatment. Actions to enhance comprehensive substance use programs that incorporate polysubstance use and co-occurring mental health problems into strategies for prevention, treatment, and response are needed, as is expanded linkage to services. CDC provides data and resources to equip and inform states, territories, and local jurisdictions to help improve opioid prescribing practices, improve linkage to care for the treatment of opioid use disorder, and prevent and reverse overdoses.(§).

    • Telehealth and Telemedicine
      1. Assessing progress toward the vision of a comprehensive, shared electronic care plan: Scoping review
        Norton JM, Ip A, Ruggiano N, Abidogun T, Camara DS, Fu H, Hose BZ, Miran S, Hsiao CJ, Wang J, Bierman AS.
        J Med Internet Res. 2022 Jun 10;24(6):e36569.
        BACKGROUND: Care plans are central to effective care delivery for people with multiple chronic conditions. But existing care plans-which typically are difficult to share across care settings and care team members-poorly serve people with multiple chronic conditions, who often receive care from numerous clinicians in multiple care settings. Comprehensive, shared electronic care (e-care) plans are dynamic electronic tools that facilitate care coordination and address the totality of health and social needs across care contexts. They have emerged as a potential way to improve care for individuals with multiple chronic conditions. OBJECTIVE: To review the landscape of e-care plans and care plan-related initiatives that could allow the creation of a comprehensive, shared e-care plan and inform a joint initiative by the National Institutes of Health and the Agency for Healthcare Research and Quality to develop e-care planning tools for people with multiple chronic conditions. METHODS: We conducted a scoping review, searching literature from 2015 to June 2020 using Scopus, Clinical Key, and PubMed; we also searched the gray literature. To identify initiatives potentially missing from this search, we interviewed expert informants. Relevant data were then identified and extracted in a structured format for data synthesis and analysis using an expanded typology of care plans adapted to our study context. The extracted data included (1) the perspective of the initiatives; (2) their scope, (3) network, and (4) context; (5) their use of open syntax standards; and (6) their use of open semantic standards. RESULTS: We identified 7 projects for e-care plans and 3 projects for health care data standards. Each project provided critical infrastructure that could be leveraged to promote the vision of a comprehensive, shared e-care plan. All the e-care plan projects supported both broad goals and specific behaviors; 1 project supported a network of professionals across clinical, community, and home-based networks; 4 projects included social determinants of health. Most projects specified an open syntax standard, but only 3 specified open semantic standards. CONCLUSIONS: A comprehensive, shared, interoperable e-care plan has the potential to greatly improve the coordination of care for individuals with multiple chronic conditions across multiple care settings. The need for such a plan is heightened in the wake of the ongoing COVID-19 pandemic. While none of the existing care plan projects meet all the criteria for an optimal e-care plan, they all provide critical infrastructure that can be leveraged as we advance toward the vision of a comprehensive, shared e-care plan. However, critical gaps must be addressed in order to achieve this vision.

      2. BACKGROUND: The novel coronavirus disease COVID-19 caused by SARS-CoV-2 threatens to disrupt global progress toward HIV epidemic control. Opportunities exist to leverage ongoing public health responses to mitigate the impacts of COVID-19 on HIV services, and novel approaches to care provision might help address both epidemics. OBJECTIVE: As the COVID-19 pandemic continues, novel approaches to maintain comprehensive HIV prevention service delivery are needed. The aim of this study was to summarize the related literature to highlight adaptations that could address potential COVID-19-related service interruptions. METHODS: We performed a systematic review and searched six databases, OVID/Medline, Scopus, Cochrane Library, CINAHL, PsycINFO, and Embase, for studies published between January 1, 2010, and October 26, 2021, related to recent technology-based interventions for virtual service delivery. Search terms included "telemedicine," "telehealth," "mobile health," "eHealth," "mHealth," "telecommunication," "social media," "mobile device," and "internet," among others. Of the 6685 abstracts identified, 1259 focused on HIV virtual service delivery, 120 of which were relevant for HIV prevention efforts; 48 pertained to pre-exposure prophylaxis (PrEP) and 19 of these focused on evaluations of interventions for the virtual service delivery of PrEP. Of the 16 systematic reviews identified, three were specific to PrEP. All 35 papers were reviewed for outcomes of efficacy, feasibility, and/or acceptability. Limitations included heterogeneity of the studies' methodological approaches and outcomes; thus, a meta-analysis was not performed. We considered the evidence-based interventions found in our review and developed a virtual service delivery model for HIV prevention interventions. We also considered how this platform could be leveraged for COVID-19 prevention and care. RESULTS: We summarize 19 studies of virtual service delivery of PrEP and 16 relevant reviews. Examples of technology-based interventions that were effective, feasible, and/or acceptable for PrEP service delivery include: use of SMS, internet, and smartphone apps such as iText (50% [95% CI 16%-71%] reduction in discontinuation of PrEP) and PrEPmate (OR 2.62, 95% CI 1.24-5.5.4); telehealth and eHealth platforms for virtual visits such as PrEPTECH and IowaTelePrEP; and platforms for training of health care workers such as Extension for Community Healthcare Outcomes (ECHO). We suggest a virtual service delivery model for PrEP that can be leveraged for COVID-19 using the internet and social media for demand creation, community-based self-testing, telehealth platforms for risk assessment and follow-up, applications for support groups and adherence/appointment reminders, and applications for monitoring. CONCLUSIONS: Innovations in the virtual service provision of PrEP occurred before COVID-19 but have new relevance during the COVID-19 pandemic. The innovations we describe might strengthen HIV prevention service delivery during the COVID-19 pandemic and in the long run by engaging traditionally hard-to-reach populations, reducing stigma, and creating a more accessible health care platform. These virtual service delivery platforms can mitigate the impacts of the COVID-19 pandemic on HIV services, which can be leveraged to facilitate COVID-19 pandemic control now and for future responses.

    • Zoonotic and Vectorborne Diseases
      1. Assessment of knowledge, attitudes, and practices toward ticks and tickborne disease among healthcare professionals working in schools in New York and Maryland
        Howard K, Beck A, Kaufman A, Rutz H, Hutson J, Crum D, Rowe A, Marx G, Hinckley A, White J.
        J Sch Nurs. 2022 Jun 1:10598405221099484.
        Healthcare Professionals Working in Schools (HPWS) are responsible for providing health services to students and play a role in providing education to prevent illnesses, including tickborne diseases (TBD). Providing TBD education to children has been shown to increase prevention behaviors and knowledge of TBD symptoms, but little is known regarding the current state of TBD awareness among HPWS. In spring 2019 we conducted a cross-sectional knowledge, attitudes, and practices (KAP) survey of HPWS in two states with a high incidence of Lyme disease (LD) to inform design of TBD prevention programs. The survey queried general knowledge of TBDs, school practices regarding TBDs, and availability of TBD resources. Overall, higher confidence, experience, risk perception, prior training on TBD, and more years employed as a HPWS were independently associated with knowledge of LD transmission, symptoms, and correct tick removal practices. State and local health departments should consider prioritizing engagement with HPWS to provide educational opportunities about tickborne diseases.

      2. Risk factors for infection with chikungunya and Zika viruses in southern Puerto Rico: A community-based cross-sectional seroprevalence survey
        Adams LE, Sánchez-González L, Rodriguez DM, Ryff K, Major C, Lorenzi O, Delorey M, Medina FA, Muñoz-Jordán JL, Brown G, Ortiz M, Waterman SH, Rivera-Amill V, Paz-Bailey G.
        PLoS Negl Trop Dis. 2022 Jun;16(6):e0010416.
        Chikungunya virus (CHIKV) caused a large outbreak in Puerto Rico in 2014, followed by a Zika virus (ZIKV) outbreak in 2016. Communities Organized for the Prevention of Arboviruses (COPA) is a cohort study in southern Puerto Rico, initiated in 2018 to measure arboviral disease risk and provide a platform to evaluate interventions. To identify risk factors for infection, we assessed prevalence of previous CHIKV infection and recent ZIKV and DENV infection in a cross-sectional study among COPA participants. Participants aged 1-50 years (y) were recruited from randomly selected households in study clusters. Each participant completed an interview and provided a blood specimen, which was tested by anti-CHIKV IgG ELISA assay and anti-ZIKV and anti-DENV IgM MAC-ELISA assays. We assessed individual, household, and community factors associated with a positive result for CHIKV or ZIKV after adjusting for confounders. During 2018-2019, 4,090 participants were enrolled; 61% were female and median age was 28y (interquartile range [IQR]: 16-41). Among 4,035 participants tested for CHIKV, 1,268 (31.4%) had evidence of previous infection. CHIKV infection prevalence was lower among children 1-10 years old compared to people 11 and older (adjusted odds ratio [aOR] 2.30; 95% CI 1.71-3.08). Lower CHIKV infection prevalence was associated with home screens (aOR 0.51; 95% CI 0.42-0.61) and air conditioning (aOR 0.64; 95% CI 0.54-0.77). CHIKV infection prevalence also varied by study cluster of residence and insurance type. Few participants (16; 0.4%) had evidence of recent DENV infection by IgM. Among 4,035 participants tested for ZIKV, 651 (16%) had evidence of recent infection. Infection prevalence increased with older age, from 7% among 1-10y olds up to 19% among 41-50y olds (aOR 3.23; 95% CI 2.16-4.84). Males had an increased risk of Zika infection prevalence compared with females (aOR 1.31; 95% CI 1.09-1.57). ZIKV infection prevalence also decreased with the presence of home screens (aOR 0.66; 95% CI 0.54-0.82) and air conditioning (aOR 0.69; 95% CI 0.57-0.84). Similar infection patterns were observed for recent ZIKV infection prevalence and previous CHIKV infection prevalence by age, and the presence of screens and air conditioners in the home decreased infection risk from both viruses by as much as 50%.

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