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Issue 27, July 5, 2022

CDC Science Clips: Volume 14, Issue 27, July 5, 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. Point-prevalence survey of antibiotic use at three public referral hospitals in Kenya
        Omulo S, Oluka M, Achieng L, Osoro E, Kinuthia R, Guantai A, Opanga SA, Ongayo M, Ndegwa L, Verani JR, Wesangula E, Nyakiba J, Makori J, Sugut W, Kwobah C, Osuka H, Njenga MK, Call DR, Palmer GH, VanderEnde D, Luvsansharav UO.
        PLoS One. 2022 ;17(6):e0270048.
        Antimicrobial stewardship encourages appropriate antibiotic use, the specific activities of which will vary by institutional context. We investigated regional variation in antibiotic use by surveying three regional public hospitals in Kenya. Hospital-level data for antimicrobial stewardship activities, infection prevention and control, and laboratory diagnostic capacities were collected from hospital administrators, heads of infection prevention and control units, and laboratory directors, respectively. Patient-level antibiotic use data were abstracted from medical records using a modified World Health Organization point-prevalence survey form. Altogether, 1,071 consenting patients were surveyed at Kenyatta National Hospital (KNH, n = 579), Coast Provincial General Hospital (CPGH, n = 229) and Moi Teaching and Referral Hospital (MTRH, n = 263). The majority (67%, 722/1071) were ≥18 years and 53% (563/1071) were female. Forty-six percent (46%, 489/1071) were receiving at least one antibiotic. Antibiotic use was higher among children <5 years (70%, 150/224) than among other age groups (40%, 339/847; P < 0.001). Critical care (82%, 14/17 patients) and pediatric wards (59%, 155/265) had the highest proportion of antibiotic users. Amoxicillin/clavulanate was the most frequently used antibiotic at KNH (17%, 64/383 antibiotic doses), and ceftriaxone was most used at CPGH (29%, 55/189) and MTRH (31%, 57/184). Forty-three percent (326/756) of all antibiotic prescriptions had at least one missed dose recorded. Forty-six percent (204/489) of patients on antibiotics had a specific infectious disease diagnosis, of which 18% (37/204) had soft-tissue infections, 17% (35/204) had clinical sepsis, 15% (31/204) had pneumonia, 13% (27/204) had central nervous system infections and 10% (20/204) had obstetric or gynecological infections. Of these, 27% (56/204) had bacterial culture tests ordered, with culture results available for 68% (38/56) of tests. Missed antibiotic doses, low use of specimen cultures to guide therapy, high rates of antibiotic use, particularly in the pediatric and surgical population, and preference for broad-spectrum antibiotics suggest antibiotic use in these tertiary care hospitals is not optimal. Antimicrobial stewardship programs, policies, and guidelines should be tailored to address these areas.

    • Chronic Diseases and Conditions
      1. Use and impact of type 2 diabetes prevention interventions
        Campione JR, Ritchie ND, Fishbein HA, Mardon RE, Johnson MC, Pace W, Birch RJ, Seeholzer EL, Zhang X, Proia K, Siegel KR, McKeever Bullard K.
        Am J Prev Med. 2022 Jun 16.
        INTRODUCTION: RCTs have found that type 2 diabetes can be prevented among high-risk individuals by metformin medication and evidence-based lifestyle change programs. The purpose of this study is to estimate the use of interventions to prevent type 2 diabetes in real-world clinical practice settings and determine the impact on diabetes-related clinical outcomes. METHODS: The analysis performed in 2020 used 2010‒2018 electronic health record data from 69,434 patients aged ≥18 years at high risk for type 2 diabetes in 2 health systems. The use and impact of prescribed metformin, lifestyle change program, bariatric surgery, and combinations of the 3 were examined. A subanalysis was performed to examine uptake and retention among patients referred to the National Diabetes Prevention Program. RESULTS: Mean HbA1c values declined from before to after intervention for patients who were prescribed metformin (-0.067%; p<0.001) or had bariatric surgery (-0.318%; p<0.001). Among patients referred to the National Diabetes Prevention Program lifestyle change program, the type 2 diabetes postintervention incidence proportion was 14.0% for nonattendees, 12.8% for some attendance, and 7.5% for those who attended ≥4 sessions (p<0.001). Among referred patients to the National Diabetes Prevention Program lifestyle change program, uptake was low (13% for 1‒3 sessions, 15% for ≥4 sessions), especially among males and Hispanic patients. CONCLUSIONS: Findings suggest that metformin and bariatric surgery may improve HbA1c levels and that participation in the National Diabetes Prevention Program may reduce type 2 diabetes incidence. Efforts to increase the use of these interventions may have positive impacts on diabetes-related health outcomes.

      2. Estimating the number of people with Tourette syndrome and persistent tic disorder in the United States
        Tinker SC, Bitsko RH, Danielson ML, Newsome K, Kaminski JW.
        Psychiatry Res. 2022 Jun 14;314:114684.
        Estimates of the number of people in the U.S. with Tourette syndrome or other persistent tic disorders can inform service provision planning. Based on available prevalence estimates applied to 2020 population data from the U.S. Census, we estimated that 350,000-450,000 U.S. children and adults have Tourette syndrome and about one million have other persistent tic disorders. Variation across studies makes estimating the total number of people in the United States affected by these disorders challenging. More precise measurement could ensure that prevalence estimates accurately reflect all who are impacted by these disorders and who could benefit from evidence-based services.

    • Communicable Diseases
      1. Monkeypox: Avoiding the mistakes of past infectious disease epidemics
        Daskalakis D, McClung RP, Mena L, Mermin J.
        Ann Intern Med. 2022 Jun 16.

      2. Unmasking pneumococcal carriage in a high HIV prevalence population in two community cohorts with a high prevalence of HIV in South Africa, 2016-2018: the PHIRST study
        Carrim M, Tempia S, Thindwa D, Martinson NA, Kahn K, Flasche S, Hellferscee O, Treurnicht FK, McMorrow ML, Moyes J, Mkhencele T, Mathunjwa A, Kleynhans J, Lebina L, Mothlaoleng K, Wafawanaka F, Gómez-Olivé FX, Cohen C, Gottberg AV, Wolter N.
        Clin Infect Dis. 2022 Jun 19.
        INTRODUCTION: Longitudinal pneumococcus colonization data in high HIV prevalence settings following pneumococcal conjugate vaccine introduction are limited. METHODS: In 327 randomly selected households, 1,684 individuals were enrolled and followed-up for 6-10 months during 2016-2018 from two communities. Nasopharyngeal swabs were collected twice-weekly and tested for pneumococcus using quantitative lytA real-time PCR. A Markov model was fitted to the data to define the start and end of an episode of colonization. We assessed factors associated with colonization using logistic regression. RESULTS: During the study period, 98% (1,655/1,684) of participants were colonized with pneumococcus at least once. Younger age (<5 years: adjusted odds ratio (aOR) 14.1, 95% confidence (CI) 1.8-111.3 and 5-24 years: aOR 4.8, 95% CI 1.9-11.9, compared to 25-44 years) and HIV-infection (aOR 10.1; 95% CI 1.3-77.1) were associated with increased odds of colonization. Children aged <5 years had fewer colonization episodes (median 9) than individuals ≥5 years (median 18; P < 0.001) but had a longer episode duration (<5 years: 35.5 days (interquartile range (IQR): 17-88) vs. ≥5 years: 5.5 days (4-12)). High pneumococcal loads were associated with age (<1 year: aOR 25.4, 95% CI 7.4-87.6; 1-4 years: aOR 13.5, 95% CI 8.3-22.9; 5-14 years: aOR 3.1, 95% CI 2.1-4.4 vs. 45-65 year olds) and HIV infection (aOR 1.7; 95% CI 1.2-2.4). CONCLUSIONS: We observed high levels of pneumococcus colonization across all age groups. Children and people living with HIV were more likely to be colonized and had higher pneumococcal loads. Carriage duration decreased with age highlighting that children remain important in pneumococcal transmission.

      3. Increased deaths from fungal infections during the COVID-19 pandemic-National Vital Statistics System, United States, January 2020-December 2021
        Gold JA, Ahmad FB, Cisewski JA, Rossen LM, Montero AJ, Benedict K, Jackson BR, Toda M.
        Clin Infect Dis. 2022 Jun 19.
        BACKGROUND: COVID-19-associated fungal infections cause severe illness, but comprehensive data on disease burden are lacking. We analyzed US National Vital Statistics System (NVSS) data to characterize disease burden, temporal trends, and demographic characteristics of persons dying from fungal infections during the COVID-19 pandemic. METHODS: Using NVSS's January 2018-December 2021 Multiple Cause of Death Database, we examined numbers and age-adjusted rates (per 100,000 population) of fungal deaths by fungal pathogen, COVID-19 association, demographic characteristics, and year. RESULTS: Numbers and age-adjusted rates of fungal deaths increased from 2019 (n = 4,833, rate 1.2, 95% confidence interval [CI]    1.2-1.3) to 2021 (n = 7,199, rate: 1.8, 95% CI = 1.8-1.8); of 13,121 fungal deaths during 2020-2021, 2,868 (21.9%) were COVID-19-associated. Compared with non-COVID-19-associated fungal deaths (n = 10,253), COVID-19-associated fungal deaths more frequently involved Candida (n = 776 [27.1%] versus n = 2,432 [23.7%]) and Aspergillus (n = 668 [23.3%] versus n = 1,486 [14.5%]) and less frequently involved other specific fungal pathogens. Fungal death rates were generally highest in non-White and non-Asian populations. Death rates from Aspergillus infections were approximately two times higher in the Pacific US census division compared with most other divisions. CONCLUSIONS: Fungal deaths increased during 2020-2021 compared with previous years, primarily driven by COVID-19-associated fungal deaths, particularly those involving Aspergillus and Candida. Our findings may inform efforts to prevent, identify, and treat severe fungal infections in COVID-19 patients, especially in certain racial/ethnic groups and geographic areas.

      4. Life-threatening complications of influenza versus COVID-19 in U.S. Children
        Halasa NB, Spieker AJ, Young CC, Olson SM, Newhams MM, Amarin JZ, Moffitt KL, Nakamura MM, Levy ER, Soma VL, Talj R, Weiss SL, Fitzgerald JC, Mack EH, Maddux AB, Schuster JE, Coates BM, Hall MW, Schwartz SP, Schwarz AJ, Kong M, Spinella PC, Loftis LL, McLaughlin GE, Hobbs CV, Rowan CM, Bembea MM, Nofziger RA, Babbitt CJ, Bowens C, Flori HR, Gertz SJ, Zinter MS, Giuliano JS, Hume JR, Cvijanovich NZ, Singh AR, Crandall HA, Thomas NJ, Cullimore ML, Patel MM, Randolph AG.
        Clin Infect Dis. 2022 Jun 19.
        BACKGROUND: Clinical differences between critical illness from influenza infection versus coronavirus disease 2019 (COVID-19) have not been well characterized in pediatric patients. METHODS: We compared U.S. children (8 months to 17 years) admitted to the intensive care or high acuity unit with influenza (17 hospitals, 12/19/2019-3/9/2020) or COVID-19 (52 hospitals, 3/15/2020-12/31/2020). We compared demographics, underlying conditions, clinical presentation, severity, and outcomes. Using mixed-effects models, we assessed the odds of death or requiring life-support for influenza versus COVID-19 after adjustment for age, sex, race and Hispanic origin, and underlying conditions including obesity. RESULTS: Children with influenza (n = 179) were younger than those with COVID-19 (n = 381; median 5.2 vs. 13.8 years), less likely to be non-Hispanic black (14.5% vs. 27.6%) or Hispanic (24.0% vs. 36.2%), and less likely to have ≥1 underlying condition (66.4% vs. 78.5%) or be obese (21.4% vs. 42.2%). They were similarly likely to require invasive mechanical ventilation (both 30.2%), vasopressor support (19.6% and 19.9%), or extracorporeal membrane oxygenation (2.2% and 2.9%). Four children with influenza (2.2%) and 11 children with COVID-19 (2.9%) died. The odds of death or requiring life-support in children with influenza vs. COVID-19 were similar (adjusted odds ratio, 1.30 [95% CI: 0.78-2.15; P = 0.32]). Median duration of hospital stay was shorter for influenza than COVID-19 (5 versus 7 days). CONCLUSIONS: Despite differences in demographics and clinical characteristics of children with influenza or COVID-19, the frequency of life-threatening complications was similar. Our findings highlight the importance of implementing prevention measures to reduce transmission and disease severity of influenza and COVID-19.

      5. SARS-CoV-2 transmission associated with an indoor music event that required proof of full vaccination against COVID-19 prior to entry-seattle, July 2021
        Roskosky M, Moni G, Kawakami V, Lambert J, Brostrom-Smith C, Whitney H, Phu A, Look J, Pallickaparambil A, Kay M, Duchin J.
        Clin Infect Dis. 2022 Jun 20.
        In July 2021, Public Health - Seattle and King County-investigated a COVID-19 outbreak at an indoor event intended for fully-vaccinated individuals, revealing unvaccinated staff, limited masking, poor ventilation, and overcrowding. Supporting businesses to develop and implement comprehensive COVID-19 prevention plans is essential for reducing spread in these settings. Word Count: 48/50.

      6. COVID-19 severity among women of reproductive age with symptomatic laboratory-confirmed SARS-CoV-2 by pregnancy status - United States, Jan 1, 2020 - Dec 25, 2021
        Strid P, Zapata LB, Tong VT, Zambrano LD, Woodworth KR, Riser AP, Galang RR, Gilboa SM, Ellington SR.
        Clin Infect Dis. 2022 Jun 19.
        BACKGROUND: Information on the severity of COVID-19 attributable to the Delta variant in the United States among pregnant people is limited. We assessed the risk for severe COVID-19 by pregnancy status in the period of Delta variant predominance compared with the pre-Delta period. METHODS: Laboratory-confirmed SARS-CoV-2 infections among symptomatic women of reproductive age (WRA) were assessed. We calculated adjusted risk ratios for severe disease including intensive care unit (ICU) admission, receipt of invasive ventilation or extracorporeal membrane oxygenation (ECMO), and death comparing the pre-Delta period (January 1, 2020 - June 26, 2021) and the Delta period (June 27, 2021 - December 25, 2021) for pregnant and nonpregnant WRA. RESULTS: Compared with the pre-Delta period, the risk of ICU admission during the Delta period was 41% higher (adjusted risk ratio [aRR] 1.41; 95% CI, 1.17-1.69) for pregnant WRA and 9% higher (aRR 1.09; 95% CI, 1.00-1.18) for nonpregnant WRA. The risk of invasive ventilation or ECMO was higher for pregnant (aRR 1.83; 95% CI, 1.26-2.65) and nonpregnant WRA (aRR 1.34; 95% CI, 1.17-1.54) in the Delta period. During the Delta period, the risk of death was 3.33 (95% CI, 2.48-4.46) times the risk in the pre-Delta period among pregnant WRA and 1.62 (95% CI, 1.49-1.77) among nonpregnant WRA. CONCLUSIONS: Compared with the pre-Delta period, pregnant and nonpregnant WRA were at increased risk for severe COVID-19 in the Delta period.

      7. Modeling the effectiveness of healthcare personnel reactive testing and screening for the SARS-CoV-2 Omicron variant within nursing homes
        Zipfel CM, Paul P, Gowler CD, Reddy SC, Stone ND, Jacobs Slifka K, Slayton RB.
        Clin Infect Dis. 2022 Jun 20.
        The SARS-CoV-2 Omicron variant has been hypothesized to exhibit faster clearance (time from peak viral concentration to clearance of acute infection), decreased sensitivity of antigen tests, and increased immune escape (the ability of the variant to evade immunity conferred by past infection or vaccination) compared to prior variants. These factors necessitate re-evaluation of prevention and control strategies-particularly in high-risk, congregate settings like nursing homes that have been heavily impacted by other COVID-19 variants. We used a simple model representing individual-level viral shedding dynamics to estimate the optimal strategy for testing nursing home healthcare personnel and quantify potential reduction in transmission of COVID-19. This provides a framework for prospectively evaluating testing strategies in emerging variant scenarios when data are limited. We find that case-initiated testing prevents 38% of transmission within a facility if implemented within a day of an index case testing positive, and screening testing strategies could prevent 30-78% of transmission within a facility if implemented daily, depending on test sensitivity.

      8. Projected resurgence of COVID-19 in the United States in July-December 2021 resulting from the increased transmissibility of the Delta variant and faltering vaccination
        Truelove S, Smith CP, Qin M, Mullany LC, Borchering RK, Lessler J, Shea K, Howerton E, Contamin L, Levander J, Salerno J, Hochheiser H, Kinsey M, Tallaksen K, Wilson S, Shin L, Rainwater-Lovett K, Lemairtre JC, Dent Hulse J, Kaminsky J, Lee EC, Perez-Saez J, Hill A, Karlen D, Chinazzi M, Davis JT, Mu K, Xiong X, Pastore YP, Vespignani A, Srivastava A, Porebski P, Venkatramanan S, Adiga A, Lewis B, Klahn B, Outten J, Orr M, Harrison G, Hurt B, Chen J, Vullikanti A, Marathe M, Hoops S, Bhattacharya P, Machi D, Chen S, Paul R, Janies D, Thill JC, Galanti M, Yamana TK, Pei S, Shaman JL, Healy JM, Slayton RB, Biggerstaff M, Johansson MA, Runge MC, Viboud C.
        Elife. 2022 Jun 21;11.
        In Spring 2021, the highly transmissible SARS-CoV-2 Delta variant began to cause increases in cases, hospitalizations, and deaths in parts of the United States. At the time, with slowed vaccination uptake, this novel variant was expected to increase the risk of pandemic resurgence in the US in summer and fall 2021. As part of the COVID-10 Scenario Modeling Hub, an ensemble of nine mechanistic models produced six-month scenario projections for July-December 2021 for the United States. These projections estimated substantial resurgences of COVID-19 across the US resulting from the more transmissible Delta variant, projected to occur across most of the US, coinciding with school and business reopening. The scenarios revealed that reaching higher vaccine coverage in July-December 2021 reduced the size and duration of the projected resurgence substantially, with the expected impacts was largely concentrated in a subset of states with lower vaccination coverage. Despite accurate projection of COVID-19 surges occurring and timing, the magnitude was substantially underestimated 2021 by the models compared with the of the reported cases, hospitalizations, and deaths occurring during July-December, highlighting the continued challenges to predict the evolving COVID-19 pandemic. Vaccination uptake remains critical to limiting transmission and disease, particularly in states with lower vaccination coverage. Higher vaccination goals at the onset of the surge of the new variant were estimated to avert over 1.5 million cases and 21,000 deaths, though may have had even greater impacts, considering the underestimated resurgence magnitude from the model.

      9. Seroprevalence of anti-SARS-CoV-2 antibodies in Senegal: a national population-based cross-sectional survey, between October and November 2020
        Talla C, Loucoubar C, Roka JL, Barry MA, Ndiaye S, Diarra M, Thiam MS, Faye O, Dia M, Diop M, Ndiaye O, Tall A, Faye R, Mbow AA, Diouf B, Diallo JP, Keita IM, Ndiaye M, Woudenberg T, White M, Ting J, Diagne CT, Pasi O, Diop B, Sall AA, Vigan-Womas I, Faye O.
        IJID Reg. 2022 Jun;3:117-125.
        OBJECTIVES: A nationwide cross-sectional epidemiological survey was conducted to capture the true extent of coronavirus disease 2019 (COVID-19) exposure in Senegal. METHODS: Multi-stage random cluster sampling of households was performed between October and November 2020, at the end of the first wave of COVID-19 transmission. Anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies were screened using three distinct ELISA assays. Adjusted prevalence rates for the survey design were calculated for each test separately, and thereafter combined. Crude and adjusted prevalence rates based on test performance were estimated to assess the seroprevalence. As some samples were collected in high malaria endemic areas, the relationship between SARS-CoV-2 seroreactivity and antimalarial humoral immunity was also investigated. RESULTS: Of the 1463 participants included in this study, 58.8% were female and 41.2% were male; their mean age was 29.2 years (range 0.20-84.8.0 years). The national seroprevalence was estimated at 28.4% (95% confidence interval 26.1-30.8%). There was substantial regional variability. All age groups were impacted, and the prevalence of SARS-CoV-2 was comparable in the symptomatic and asymptomatic groups. An estimated 4 744 392 (95% confidence interval 4 360 164-5 145 327) were potentially infected with SARS-CoV-2 in Senegal, while 16 089 COVID-19 RT-PCR laboratory-confirmed cases were reported by the national surveillance. No correlation was found between SARS-CoV-2 and Plasmodium seroreactivity. CONCLUSIONS: These results provide a better estimate of SARS-CoV-2 dissemination in the Senegalese population. Preventive and control measures need to be reinforced in the country and especially in the south border regions.

      10. Progress towards the elimination of hepatitis B in children in Colombia: a novel two-phase study approach
        Ríos-Hincapié CY, Murad-Rivera R, Tohme RA, Ropero AM, Gómez B, Cardona DL, Forest BN, Cuellar D, Cardenas I, Krow-Lucal E, Wannemuehler K, de la Hoz Restrepo F, Sánchez-Molano SM, Delgado CE, Rivillas-Garcia JC, Wasley A.
        J Viral Hepat. 2022 Jun 16.
        The World Health Organization (WHO) has established a target to eliminate mother-to-child-transmission (EMTCT) of hepatitis B virus (HBV), defined as a prevalence of hepatitis B surface antigen (HBsAg) of ≤0.1% among children, by 2030. Using nationally representative serosurveys to verify achievement of this target requires large sample sizes and significant resources. We assessed the feasibility of a potentially more efficient two-phase method to verify EMTCT of HBV in Colombia. In the first phase, we conducted a risk assessment to identify municipalities at the highest risk of ongoing HBV transmission. We ranked the 1,122 municipalities of Colombia based on reports of HBV infection in pregnant women per 1,000 population. Municipalities with ≥0.3 reports per 1,000 persons (equating to the top quartile) were further assessed based on health facility birth rates, coverage with three doses of hepatitis B vaccine (HepB3), and seroprevalence data. Hepatitis B risk was considered to be further increased for municipalities with HepB3 coverage or health facility birth rate <90%. In the second phase, we conducted a multistage household serosurvey of children aged 5-10 years in 36 municipalities with the highest assessed HBV risk. HBsAg was not detected in any of 3,203 children tested, yielding a 90% upper confidence bound of <0.1% prevalence. Coverage with HepB3 and hepatitis B birth dose was high at 97.5% and 95.6%, respectively. These results support the conclusion that Colombia has likely achieved EMTCT of HBV.

      11. Hepatitis C in pregnancy and the TiP-HepC registry
        Gupta N, Hiebert L, Armstrong PA, Wester C, Ward JW.
        Lancet Gastroenterol Hepatol. 2022 Jul;7(7):598-599.

      12. Incidence of typhoid and paratyphoid fever in Bangladesh, Nepal, and Pakistan: results of the Surveillance for Enteric Fever in Asia Project
        Garrett DO, Longley AT, Aiemjoy K, Yousafzai MT, Hemlock C, Yu AT, Vaidya K, Tamrakar D, Saha S, Bogoch , Date K, Saha S, Islam MS, Sayeed KM, Bern C, Shakoor S, Dehraj IF, Mehmood J, Sajib MS, Islam M, Thobani RS, Hotwani A, Rahman N, Irfan S, Naga SR, Memon AM, Pradhan S, Iqbal K, Shrestha R, Rahman H, Hasan MM, Qazi SH, Kazi AM, Saddal NS, Jamal R, Hunzai MJ, Hossain T, Marks F, Carter AS, Seidman JC, Qamar FN, Saha SK, Andrews JR, Luby SP.
        Lancet Glob Health. 2022 Jul;10(7):e978-e988.
        BACKGROUND: Precise enteric fever disease burden data are needed to inform prevention and control measures, including the use of newly available typhoid vaccines. We established the Surveillance for Enteric Fever in Asia Project (SEAP) to inform these strategies. METHODS: From September, 2016, to September, 2019, we conducted prospective clinical surveillance for Salmonella enterica serotype Typhi (S Typhi) and Paratyphi (S Paratyphi) A, B, and C at health facilities in predetermined catchment areas in Dhaka, Bangladesh; Kathmandu and Kavrepalanchok, Nepal; and Karachi, Pakistan. Patients eligible for inclusion were outpatients with 3 or more consecutive days of fever in the last 7 days; inpatients with suspected or confirmed enteric fever; patients with blood culture-confirmed enteric fever from the hospital laboratories not captured by inpatient or outpatient enrolment and cases from the laboratory network; and patients with non-traumatic ileal perforation under surgical care. We used a hybrid surveillance model, pairing facility-based blood culture surveillance with community surveys of health-care use. Blood cultures were performed for enrolled patients. We calculated overall and age-specific typhoid and paratyphoid incidence estimates for each study site. Adjusted estimates accounted for the sensitivity of blood culture, the proportion of eligible individuals who consented and provided blood, the probability of care-seeking at a study facility, and the influence of wealth and education on care-seeking. We additionally calculated incidence of hospitalisation due to typhoid and paratyphoid. FINDINGS: A total of 34 747 patients were enrolled across 23 facilitates (six tertiary hospitals, surgical wards of two additional hospitals, and 15 laboratory network sites) during the study period. Of the 34 303 blood cultures performed on enrolled patients, 8705 (26%) were positive for typhoidal Salmonella. Adjusted incidence rates of enteric fever considered patients in the six tertiary hospitals. Adjusted incidence of S Typhi, expressed per 100 000 person-years, was 913 (95% CI 765-1095) in Dhaka. In Nepal, the adjusted typhoid incidence rates were 330 (230-480) in Kathmandu and 268 (202-362) in Kavrepalanchok. In Pakistan, the adjusted incidence rates per hospital site were 176 (144-216) and 103 (85-126). The adjusted incidence rates of paratyphoid (of which all included cases were due to S Paratyphi A) were 128 (107-154) in Bangladesh, 46 (34-62) and 81 (56-118) in the Nepal sites, and 23 (19-29) and 1 (1-1) in the Pakistan sites. Adjusted incidence of hospitalisation was high across sites, and overall, 2804 (32%) of 8705 patients with blood culture-confirmed enteric fever were hospitalised. INTERPRETATION: Across diverse communities in three south Asian countries, adjusted incidence exceeded the threshold for "high burden" of enteric fever (100 per 100 000 person-years). Incidence was highest among children, although age patterns differed across sites. The substantial disease burden identified highlights the need for control measures, including improvements to water and sanitation infrastructure and the implementation of typhoid vaccines. FUNDING: Bill & Melinda Gates Foundation.

      13. Trends in acute hepatitis of unspecified etiology and adenovirus stool testing results in children - United States, 2017-2022
        Kambhampati AK, Burke RM, Dietz S, Sheppard M, Almendares O, Baker JM, Cates J, Stein Z, Johns D, Smith AR, Bull-Otterson L, Hofmeister MG, Cobb S, Dale SE, Soetebier KA, Potts CC, Adjemian J, Kite-Powell A, Hartnett KP, Kirking HL, Sugerman D, Parashar UD, Tate JE.
        MMWR Morb Mortal Wkly Rep. 2022 Jun 17;71(24):797-802.
        In November 2021, CDC was notified of a cluster of previously healthy children with hepatitis of unknown etiology evaluated at a single U.S. hospital (1). On April 21, 2022, following an investigation of this cluster and reports of similar cases in Europe (2,3), a health advisory* was issued requesting U.S. providers to report pediatric cases(†) of hepatitis of unknown etiology to public health authorities. In the United States and Europe, many of these patients have also received positive adenovirus test results (1,3). Typed specimens have indicated adenovirus type 41, which typically causes gastroenteritis (1,3). Although adenovirus hepatitis has been reported in immunocompromised persons, adenovirus is not a recognized cause of hepatitis in healthy children (4). Because neither acute hepatitis of unknown etiology nor adenovirus type 41 is reportable in the United States, it is unclear whether either has recently increased above historical levels. Data from four sources were analyzed to assess trends in hepatitis-associated emergency department (ED) visits and hospitalizations, liver transplants, and adenovirus stool testing results among children in the United States. Because of potential changes in health care-seeking behavior during 2020-2021, data from October 2021-March 2022 were compared with a pre-COVID-19 pandemic baseline. These data do not suggest an increase in pediatric hepatitis or adenovirus types 40/41 above baseline levels. Pediatric hepatitis is rare, and the relatively low weekly and monthly counts of associated outcomes limit the ability to interpret small changes in incidence. Ongoing assessment of trends, in addition to enhanced epidemiologic investigations, will help contextualize reported cases of acute hepatitis of unknown etiology in U.S. children.

      14. Notes from the field: Diagnosis and investigation of pneumonic plague during a respiratory disease pandemic - Wyoming, 2021
        Siu AW, Tillman C, Van Houten C, Busacker A, Harrist A.
        MMWR Morb Mortal Wkly Rep. 2022 Jun 17;71(24):806-807.

      15. Protocol for a sequential, prospective meta-analysis to describe coronavirus disease 2019 (COVID-19) in the pregnancy and postpartum periods
        Smith ER, Oakley E, He S, Zavala R, Ferguson K, Miller L, Grandner GW, Abejirinde IO, Afshar Y, Ahmadzia H, Aldrovandi G, Akelo V, Tippett Barr BA, Bevilacqua E, Brandt JS, Broutet N, Fernández Buhigas I, Carrillo J, Clifton R, Conry J, Cosmi E, Delgado-López C, Divakar H, Driscoll AJ, Favre G, Flaherman V, Gale C, Gil MM, Godwin C, Gottlieb S, Hernandez Bellolio O, Kara E, Khagayi S, Kim CR, Knight M, Kotloff K, Lanzone A, Le Doare K, Lees C, Litman E, Lokken EM, Laurita Longo V, Magee LA, Martinez-Portilla RJ, McClure E, Metz TD, Money D, Mullins E, Nachega JB, Panchaud A, Playle R, Poon LC, Raiten D, Regan L, Rukundo G, Sanin-Blair J, Temmerman M, Thorson A, Thwin S, Tolosa JE, Townson J, Valencia-Prado M, Visentin S, von Dadelszen P, Adams Waldorf K, Whitehead C, Yang H, Thorlund K, Tielsch JM.
        PLoS One. 2022 ;17(6):e0270150.
        We urgently need answers to basic epidemiological questions regarding SARS-CoV-2 infection in pregnant and postpartum women and its effect on their newborns. While many national registries, health facilities, and research groups are collecting relevant data, we need a collaborative and methodologically rigorous approach to better combine these data and address knowledge gaps, especially those related to rare outcomes. We propose that using a sequential, prospective meta-analysis (PMA) is the best approach to generate data for policy- and practice-oriented guidelines. As the pandemic evolves, additional studies identified retrospectively by the steering committee or through living systematic reviews will be invited to participate in this PMA. Investigators can contribute to the PMA by either submitting individual patient data or running standardized code to generate aggregate data estimates. For the primary analysis, we will pool data using two-stage meta-analysis methods. The meta-analyses will be updated as additional data accrue in each contributing study and as additional studies meet study-specific time or data accrual thresholds for sharing. At the time of publication, investigators of 25 studies, including more than 76,000 pregnancies, in 41 countries had agreed to share data for this analysis. Among the included studies, 12 have a contemporaneous comparison group of pregnancies without COVID-19, and four studies include a comparison group of non-pregnant women of reproductive age with COVID-19. Protocols and updates will be maintained publicly. Results will be shared with key stakeholders, including the World Health Organization (WHO) Maternal, Newborn, Child, and Adolescent Health (MNCAH) Research Working Group. Data contributors will share results with local stakeholders. Scientific publications will be published in open-access journals on an ongoing basis.

      16. BACKGROUND: Initial and follow-up sexually transmitted infection (STI) and HIV testing is recommended when taking HIV preexposure prophylaxis (PrEP). We assessed STI services before and after PrEP initiation among persons aged ≥18 years. METHODS: We conducted this retrospective cohort study at an US integrated healthcare delivery system. We measured HIV/STI testing rates, STI prevalence and treatment at 3 time points: (1) at PrEP initiation, (2) at 120 days, and (3) at 210 days. RESULTS: Of 685 PrEP initiators, 67.2% continued PrEP use at 120 days and 49.5% at 210 days. Of PrEP users, HIV and STI testing were > 85% and > 80%, respectively, at all 3 time points. Prevalence for any chlamydia, rectal chlamydia, and any gonorrhea, rectal gonorrhea, or pharyngeal gonorrhea was always high at the 120 days and 210 days (e.g, 6.9%, 10.5%, 6.7%, 5.0%, and 5.2%, respectively, at the 120-days for continuous PrEP users). Over 90% of all individuals who tested positive for chlamydia and/or gonorrhea received antibiotic pharmacy fills within seven days at 120 days and 210 days. Monthly PrEP-related pharmacy cost was about $2259-$2659. The proportion of the total medical cost that was PrEP-related pharmacy was about 82% for PrEP continuous users. CONCLUSIONS: Although HIV/STI testing rates were high, they can still be improved during HIV PrEP management. High STI prevalence after PrEP initiation in this study suggests that patients taking PrEP are at risk of acquiring an STI. Interventions to improve STI services during PrEP management are continuously needed.

    • Community Health Services
      1. Case investigation and contact tracing efforts from health departments in the United States, November 2020-December 2021
        Stargel A, Taylor MM, Zansky S, Spencer K, Hogben M, Shultz A.
        Clin Infect Dis. 2022 Jun 20.
        OBJECTIVES: Sixty-four state, local, and territorial health departments (HDs) in the United States (US) report monthly performance metrics on COVID-19 case investigation and contact tracing (CI/CT) activities. We describe national CI/CT efforts during October 25, 2020-December 24, 2021 which included three peaks in COVID-19 case reporting. METHODS: Standardized CI/CT data elements submitted by the 64 HDs were summarized as monthly performance metrics for each HD and the nation. These included measures of CI/CT completeness, timeliness, and workloads. We calculated contact tracing efficacy as the proportion of new cases that occurred in persons identified as contacts within the 14 days prior to being reported as a case. RESULTS: A total of 44,309,796 COVID-19 cases were reported to HDs, of which 18,153,353 (41%) completed HD interviews. Less than half of interviews yielded ≥1 contact. A total of 19,939,376 contacts were identified; 11,632,613 were notified (58%), with 3,618,846 undergoing SARS-CoV-2 testing within 14 days of notification. Of the total reported cases, 2,559,383 occurred in recently identified contacts. CONCLUSION: We document the resource-intense nationwide effort by US HDs to mitigate the impact of COVID-19 through CI/CT before and after vaccines became widely available. These results document the coverage and performance of CI/CT despite case surges and fluctuating workforce and workloads.

      2. Associations between sexual orientation, sex education curriculum, and exposure to affirming/disaffirming LGB content in two US-based cohorts of adolescents
        Tabaac AR, Johns MM, Zubizarreta D, Haneuse S, Tan AS, Austin SB, Potter J, Lindberg L, Charlton BM.
        Sex Educ. 2022 .
        Sexual health education experienced by lesbian, gay, and bisexual (LGB) youth varies widely in relevancy and representation. However, associations among sexual orientation, type of sex education, and exposure to affirming or disaffirming content have yet to be examined. Understanding these patterns can help to address gaps in LGB-sensitive sex education. Our goal in this study was to examine the prevalence and associations among abstinence-only until marriage (AOUM) and comprehensive sex education with LGB-affirming and -disaffirming content sought/received before age 18 (from 1999 to 2014) by sexual orientation (completely heterosexual with same-sex contact, completely heterosexual with no same-sex contact, mostly heterosexual, bisexual, gay/lesbian) in a sample of 12,876 US young adults from the Growing Up Today Study. Compared to completely heterosexual referents, LGB participants who received AOUM sex education were more likely to encounter LGB-disaffirming content, and this effect was largest among sexual minority participants. Conversely, exposure to comprehensive sex education was associated with receipt of LGB-affirming information. Overall, participants commonly reported receiving AOUM sex education, which may lead to deficits and potential harm to sexual minorities. © 2022 Informa UK Limited, trading as Taylor & Francis Group.

    • Disease Reservoirs and Vectors
      1. Range expansion of native and invasive ticks, a looming public health threat
        Molaei G, Eisen LM, Price KJ, Eisen RJ.
        J Infect Dis. 2022 Jun 23.
        Native and invasive tick species pose a serious public health concern in the United States. Range expansion of several medically important tick species has resulted in an increasing number of communities at risk for exposure to ticks and tickborne pathogens.

    • Environmental Health
      1. Extreme heat exposure: Access and barriers to cooling centers - Maricopa and Yuma Counties, Arizona, 2010-2020
        Mallen E, Roach M, Fox L, Gillespie E, Watkins L, Hondula DM, Vaidyanathan A, Manangan A, Perkins AN, Schramm PJ.
        MMWR Morb Mortal Wkly Rep. 2022 Jun 17;71(24):781-785.
        Extreme heat exposure increases the risk for heat-related illnesses (HRIs) and deaths, and comprehensive strategies to prevent HRIs are increasingly important in a warming climate (1). An estimated 702 HRI-associated deaths and 67,512 HRI-associated emergency department visits occur in the United States each year (2,3). In 2020, Phoenix and Yuma, Arizona, experienced a record 145 and 148 days, respectively, of temperatures >100°F (37.8°C), and a record 522 heat-related deaths occurred in the state. HRIs are preventable through individual and community-based strategies*(,)(†); cooling centers,(§) typically air-conditioned or cooled buildings designated as sites to provide respite and safety during extreme heat, have been established in Maricopa and Yuma counties to reduce HRIs among at-risk populations, such as older adults. This analysis examined trends in HRIs by age during 2010-2020 for Maricopa and Yuma counties and data from a survey of older adults related to cooling center availability and use in Yuma County during 2018-2019. Data from CDC's Social Vulnerability Index (SVI) were also used to overlay cooling center locations with SVI scores. During 2010-2020, heat days, defined as days with an excessive heat warning issued by the National Weather Service Phoenix Office,(¶) for any part of Maricopa and Yuma counties (4), increased in both Maricopa County (1.18 days per year) and Yuma County (1.71 days per year) on average. Adults aged ≥65 years had higher rates of HRI hospitalization compared with those aged <65 years. In a survey of 39 adults aged ≥65 years in Yuma County, 44% reported recent HRI symptoms, and 18% reported electricity cost always or sometimes constrained their use of air conditioning. Barriers to cooling center access among older adults include awareness of location and transportation. Collaboration among diverse community sectors and health profession education programs is important to better prepare for rising heat exposure and HRIs. States and communities can implement adaptation and evaluation strategies to mitigate and assess heat risk, such as the use of cooling centers to protect communities disproportionately affected by HRI during periods of high temperatures.

    • Food Safety
      1. Multistate outbreak of Salmonella mbandaka infections linked to sweetened puffed wheat cereal-United States, 2018
        Keaton AA, Schwensohn CA, Brandenburg JM, Pereira E, Adcock B, Tecle S, Hinnenkamp R, Havens J, Bailey K, Applegate B, Whitney P, Gibson D, Manion K, Griffin M, Ritter J, Biskupiak C, Ajileye K, Golwalkar M, Gosciminski M, Viveiros B, Caron G, McCullough L, Smith L, Vidyaprakash E, Doyle M, Hardy C, Elliot EL, Gieraltowski LB.
        Epidemiol Infect. 2022 Jun 20:1-14.

      2. Inadequate refrigeration of some commercial foods is a continued cause of foodborne botulism in the United States, 1994-2021
        Edmunds S, Vugia DJ, Rosen HE, Wong KK, Dykes JK, Griffin PM, Chatham-Stephens K.
        Foodborne Pathog Dis. 2022 Jun;19(6):417-422.
        Foodborne botulism is a rapidly progressive potentially fatal paralyzing illness caused by the consumption of botulinum neurotoxin, which is most commonly produced by Clostridium botulinum. Refrigeration is the primary barrier to botulinum neurotoxin production in many processed foods. C. botulinum toxin production has occurred and caused botulism in the United States when foods that were not processed to destroy spores of C. botulinum were stored in an anaerobic environment and not properly refrigerated. We identified 37 cases, including 4 deaths, that occurred during 1994-2021 in the United States from 13 events associated with inadequate refrigeration of commercially produced products. In 11 events, the patient stored the product unrefrigerated at home; in 2 events, a product was kept unrefrigerated at the store before the consumer purchased it. In three events, refrigeration instructions were inadequate or not easily accessible (one label printed on outer but not inner packaging, one label not clearly visible, and one label was not in English). The number of people affected per event ranged from 1 to 16. Using enhanced cost estimates for foodborne botulism cases from a published economic model, these events were estimated to cost >$79M. Potential solutions to this recurring problem include the addition of a secondary barrier, such as an acidifier, to prevent botulinum toxin production, and better labeling to convey risks of refrigerated foods that have not been processed to destroy spores of C. botulinum and to decrease the occurrence of improper storage and handling.

    • Genetics and Genomics
      1. Exome sequencing identifies genetic variants in anophthalmia and microphthalmia
        Li J, Yang W, Wang YJ, Ma C, Curry CJ, McGoldrick D, Nickerson DA, Chong JX, Blue EE, Mullikin JC, Reefhuis J, Nembhard WN, Romitti PA, Werler MM, Browne ML, Olshan AF, Finnell RH, Feldkamp ML, Pangilinan F, Almli LM, Bamshad MJ, Brody LC, Jenkins MM, Shaw GM.
        Am J Med Genet A. 2022 Jun 18.
        Anophthalmia and microphthalmia (A/M) are rare birth defects affecting up to 2 per 10,000 live births. These conditions are manifested by the absence of an eye or reduced eye volumes within the orbit leading to vision loss. Although clinical case series suggest a strong genetic component in A/M, few systematic investigations have been conducted on potential genetic contributions owing to low population prevalence. To overcome this challenge, we utilized DNA samples and data collected as part of the National Birth Defects Prevention Study (NBDPS). The NBDPS employed multi-center ascertainment of infants affected by A/M. We performed exome sequencing on 67 family trios and identified numerous genes affected by rare deleterious nonsense and missense variants in this cohort, including de novo variants. We identified 9 nonsense changes and 86 missense variants that are absent from the reference human population (Genome Aggregation Database), and we suggest that these are high priority candidate genes for A/M. We also performed literature curation, single cell transcriptome comparisons, and molecular pathway analysis on the candidate genes and performed protein structure modeling to determine the potential pathogenic variant consequences on PAX6 in this disease.

      2. Five complete Salmonella enterica serotype reading genomes recovered from patients in the United States
        Webb HE, Tagg KA, Kim JY, Miller EA, Johnson TJ, Peñil-Celis A, de la Cruz F, Folster JP.
        Microbiol Resour Announc. 2022 Jun 21:e0038822.
        Between 2018 and 2019, Salmonella enterica serotype Reading caused a large, multistate outbreak linked to contact with raw turkey products in the United States. Here, we provide five Salmonella Reading reference genomes collected from US patients between 2016 and 2018.

    • Health Behavior and Risk
      1. Self-reported mask use among persons with or without SARS CoV-2 vaccination -United States, December 2020-August 2021
        Calamari LE, Tjaden AH, Edelstein SL, Weintraub WS, Santos R, Gibbs M, Ward J, Santacatterina M, Bertoni AG, Ward LM, Saydah S, Plumb ID, Runyon MS.
        Prev Med Rep. 2022 Aug;28:101857.
        Wearing a facemask can help to decrease the transmission of COVID-19. We investigated self-reported mask use among subjects aged 18 years and older participating in the COVID-19 Community Research Partnership (CRP), a prospective longitudinal COVID-19 surveillance study in the mid-Atlantic and southeastern United States. We included those participants who completed ≥5 daily surveys each month from December 1, 2020 through August 31, 2021. Mask use was defined as self-reported use of a face mask or face covering on every interaction with others outside the household within a distance of less than 6 feet. Participants were considered vaccinated if they reported receiving ≥1 COVID-19 vaccine dose. Participants (n = 17,522) were 91% non-Hispanic White, 68% female, median age 57 years, 26% healthcare workers, with 95% self-reported receiving ≥1 COVID-19 vaccine dose through August 2021; mean daily survey response was 85%. Mask use was higher among vaccinated than unvaccinated participants across the study period, regardless of the month of the first dose. Mask use remained relatively stable from December 2020 through April (range 71-80% unvaccinated; 86-93% vaccinated) and declined in both groups beginning in mid-May 2021 to 34% and 42% respectively in June 2021; mask use increased again since July 2021. Mask use by all was lower during weekends and on Christmas and Easter, regardless of vaccination status. Independent predictors of higher mask use were vaccination, age ≥65 years, female sex, racial or ethnic minority group, and healthcare worker occupation, whereas a history of self-reported prior COVID-19 illness was associated with lower use.

      2. Partner seeking and sexual behavior in the United States during the COVID-19 pandemic, March 2020 to March 2021
        Rushmore J, Copen CE, Schneider J, Lamuda PS, Taylor BG, Kirkcaldy RD, Bernstein KT.
        Sex Transm Dis. 2022 Apr 1;49(4):e57-e60.
        We examined partner seeking and sexual behaviors among a representative sample of US adults (n = 1161) during the first year of the COVID-19 pandemic. Approximately 10% of survey respondents sought a new partner, with age and sexual identity being associated with partner seeking behavior. Approximately 7% of respondents had sex with a new partner, which marks a decrease as compared with a prepandemic estimate from 2015 to 2016 in which 16% of US adults reported having sex with a new partner during the past year. Among respondents who had in-person sex with a new partner during the first year of the pandemic, public health guidelines for in-person sexual activity were infrequently followed.

    • Health Economics
      1. Economic burden of reported lyme disease in high-incidence areas, United States, 2014-2016
        Hook SA, Jeon S, Niesobecki SA, Hansen AP, Meek JI, Bjork JK, Dorr FM, Rutz HJ, Feldman KA, White JL, Backenson PB, Shankar MB, Meltzer MI, Hinckley AF.
        Emerg Infect Dis. 2022 Jun;28(6):1170-1179.
        Approximately 476,000 cases of Lyme disease are diagnosed in the United States annually, yet comprehensive economic evaluations are lacking. In a prospective study among reported cases in Lyme disease-endemic states, we estimated the total patient cost and total societal cost of the disease. In addition, we evaluated disease and demographic factors associated with total societal cost. Participants had a mean patient cost of ≈$1,200 (median $240) and a mean societal cost of ≈$2,000 (median $700). Patients with confirmed disseminated disease or probable disease had approximately double the societal cost of those with confirmed localized disease. The annual, aggregate cost of diagnosed Lyme disease could be $345-968 million (2016 US dollars) to US society. Our findings emphasize the importance of effective prevention and early diagnosis to reduce illness and associated costs. These results can be used in cost-effectiveness analyses of current and future prevention methods, such as a vaccine.

      2. COVID-19 cases and hospitalizations among Medicare beneficiaries with and without disabilities - United States, January 1, 2020-November 20, 2021
        Yuan Y, Thierry JM, Bull-Otterson L, Yeargin-Allsopp M, Clark KE, Rice C, Ritchey M, Ryerson AB.
        MMWR Morb Mortal Wkly Rep. 2022 Jun 17;71(24):791-796.
        Approximately 27% of adults in the United States live with a disability,* some of whom qualify for Medicare benefits. Persons with disabilities are at increased risk for severe COVID-19-associated outcomes compared with the general population (1); however, existing studies have limited generalizability(†) or only pertain to a specific disability (e.g., intellectual) (2). Older age is also associated with COVID-19-associated hospitalization and death, but the extent to which age might contribute to increased risk for severe COVID-19-associated outcomes among persons with disabilities is unknown (3). To describe the impact of COVID-19 on persons with disabilities and whether and how age contributes to disease rates, CDC assessed COVID-19 cases and hospitalizations during January 2020-November 2021, among Centers for Medicare & Medicaid Services (CMS) Medicare beneficiaries aged ≥18 years who were either eligible because of a disability (disability-eligible(§)) or only eligible because of age ≥65 years (age-eligible). COVID-19 incidence and hospitalization rates were higher in the disability-eligible group (10,978 and 3,148 per 100,000 population, respectively) throughout the study period compared with the age-eligible group (8,102 and 2,129 per 100,000 population, respectively). Both COVID-19 incidence and hospitalization rates increased with age in both disability- and age-eligible beneficiaries. American Indian or Alaska Native (AI/AN) persons had the highest disability-eligible (4,962 per 100,000) and age-eligible (5,024 per 100,000) hospitalization rates. Among all other racial and ethnic groups, hospitalization rates were higher among disability-eligible than among age-eligible patients. COVID-19 incidence and hospitalization rates among disability-eligible Medicare beneficiaries were disproportionally higher than rates among age-eligible beneficiaries. Collection of disability status as a core demographic variable in public health surveillance data and identification, as well as the addition of disability questions in other existing data sources can guide research and development of interventions for persons with disabilities. Efforts to increase access to and use of COVID-19 prevention and treatment strategies, including activities that support equitable vaccine access regardless of the substantial challenges that older adults and persons with disability face, are critical to reducing severe COVID-19-associated outcomes among these groups.

      3. Inpatient care cost, duration, and acute complications associated with BMI in children and adults hospitalized for COVID-19
        Kompaniyets L, Goodman AB, Wiltz JL, Shrestha SS, Grosse SD, Boehmer T, Blanck HM.
        Obesity (Silver Spring). 2022 Jun 22.
        OBJECTIVE: To assess the association of body mass index (BMI) with inpatient care cost, duration, and acute complications among patients hospitalized for COVID-19 at 273 U.S. hospitals. METHODS: Children (2-17 years) and adults (≥18 years) hospitalized for COVID-19 during March 2020-July 2021 and measured BMI in a large electronic administrative healthcare database were included. We used generalized linear models to assess the association of BMI categories with the cost and duration of inpatient care. RESULTS: Among 108,986 adults and 409 children hospitalized for COVID-19, obesity prevalence was 53.4% and 45.0%, respectively. Among adults, overweight and obesity were associated with higher costs of care, and obesity was associated with longer hospital stays. Children with severe obesity had a higher cost of care, but not significantly longer hospital stays, compared to those with healthy weights. Children with severe obesity were 3.7 times (95% CI: 1.5 to 9.5) as likely to have invasive mechanical ventilation and 62% more likely to have an acute complication (95% CI, 39-90), compared to children with healthy weight. CONCLUSIONS: These findings show that patients with high BMIs experience significant healthcare burden during inpatient COVID-19 care. This article is protected by copyright. All rights reserved.

    • Healthcare Associated Infections
      1. Investigation of a cluster of rapidly growing mycobacteria infections associated with joint replacement surgery in a Kentucky Hospital, 2013-2014 with 8-year Follow-up
        Groenewold MR, Flinchum A, Pillai A, Konkle S, Meissner HM, Tosh PK, Thoroughman DA.
        Am J Infect Control. 2022 Jun 19.
        BACKGROUND: We describe the investigation of a nosocomial outbreak of rapidly growing mycobacteria (RGM) infections and the results of mitigation efforts after 8 years. METHODS: A cluster of RGM cases in a Kentucky hospital in 2013 prompted an investigation into RGM surgical site infections following joint replacement surgery. A case-control study was conducted to identify risk factors. RESULTS: Eight cases were identified, five caused by M. wolinskyi and three by M. goodii. The case-control study showed the presence of a particular nurse in the operating room was significantly associated with infection. Environmental sampling at the nurse's home identified an outdoor hot tub as the likely source of M. wolinskyi, confirmed by pulsed-field gel electrophoresis and whole genome sequencing. The hot tub reservoir was eliminated, and hospital policies were revised to correct infection control lapses. No new cases of RGM infections have been identified as of 2021. DISCUSSION: Breaches in infection control practices at multiple levels may have led to a chain of infection from a nurse's hot tub to surgical sites via indirect person-to-person transmission from a colonized health care worker (HCW). CONCLUSION: The multifactorial nature of the outbreak's cause highlights the importance of overlapping or redundant layers of protection preventing patient harm. Future investigations of RGM outbreaks should consider the potential role of colonized HCWs as a transmission vector.

    • Immunity and Immunization
      1. Vaccine effectiveness of CanSino (Adv5-nCoV) COVID-19 vaccine among childcare workers - Mexico, March-December 2021
        Richardson VL, Franco MA, Márquez AB, Valdez LM, Ceronio LE, Cruz VC, Gharpure R, Lafond KE, Yau TS, Azziz-Baumgartner E, Ávila MH.
        Clin Infect Dis. 2022 Jun 19.
        BACKGROUND: Beginning in March 2021, Mexico vaccinated childcare workers with a single-dose CanSino Biologics (Adv5-nCoV) COVID-19 vaccine. Although CanSino is currently approved for use in 10 Latin American, Asian, and European countries, little information is available about its vaccine effectiveness (VE). METHODS: We evaluated CanSino VE within a childcare worker cohort that included 1,408 childcare facilities. Participants were followed during March-December 2021 and tested through SARS-CoV-2 RT-PCR or rapid antigen test if they developed any symptom compatible with COVID-19. Vaccination status was obtained through worker registries. VE was calculated as 100% × (1-hazard ratio for SARS-CoV-2 infection in fully vaccinated vs. unvaccinated participants), using an Andersen-Gill model adjusted for age, sex, state, and local viral circulation. RESULTS: The cohort included 43,925 persons who were mostly (96%) female with a median age of 32 years; 37,646 (86%) were vaccinated with CanSino. During March-December 2021, 2,250 (5%) participants had laboratory-confirmed COVID-19, of whom 25 were hospitalized and 6 died. Adjusted VE was 20% (95% CI = 10-29%) against illness, 76% (42-90%) against hospitalization, and 94% (66-99%) against death. VE against illness declined from 48% (95% CI = 33-61) after 14-60 days following full vaccination to 20% (95% CI = 9-31) after 61-120 days. CONCLUSIONS: CanSino vaccine was effective at preventing COVID-19 illness and highly effective at preventing hospitalization and death. It will be useful to further evaluate duration of protection and assess the value of booster doses to prevent COVID-19 and severe outcomes.

      2. Recent mumps outbreaks among highly vaccinated populations, including college students, have called into question the vaccine effectiveness (VE) of routine two-dose measles, mumps, and rubella (MMR2) immunization. We aimed to estimate the VE required for a novel vaccination strategy (e.g., MMR booster dose, novel vaccine) to prevent large mumps outbreaks on college campuses. Using mumps college outbreak data reported to the U.S. Centers for Disease Control and Prevention during 2016-2017, we estimated current MMR2 VE using the screening method and implemented a compartmental model of mumps transmission. We performed 2000 outbreak simulations, following introduction of an infectious person to a population of 10,000, over ranges of MMR2 vaccine coverage (VC) and VE (30.0-99.0%). We compared the impact of varying VC and VE on mumps and mumps orchitis case counts and determined VE thresholds that ensured < 5.0% and < 2.0% of the outbreak simulations exceeded 20 and 100 mumps cases. Median estimated MMR2 VE in reported mumps outbreaks was 60.5% and median reported MMR2 VC was 97.5%. Simulated mumps case count was more sensitive to changes in VE than in VC. The opposite was true for simulated mumps orchitis case count, though orchitis case count was small (mean <10 cases across simulations for VE near 60.5% and VC near 97.5%). At 97.5% VC, 73.1% and 78.2% VE were required for < 5.0% and < 2.0% of outbreaks, respectively, to exceed 100 mumps cases. Maintaining 97.5% VC, 82.4% and 85.9% VE were required for < 5.0% and < 2.0% of outbreaks, respectively, to exceed 20 cases. We conclude that maintaining current levels of MMR2 VC, a novel vaccination strategy aimed at reducing mumps transmission must achieve at least 73.1-85.9% VE among young adults to prevent large mumps outbreaks on college campuses.

      3. Case report: Rubella virus-induced cutaneous granulomas in two pediatric patients with DNA double strand breakage repair disorders - outcome after hematopoietic stem cell transplantation
        Baumann U, Schulte JH, Groß JP, Beier R, Ludwig M, Wahn V, Hofmann J, Maecker-Kolhoff B, Sauer M, Kaiser-Labusch P, Karimian N, Blume-Peytavi U, Ghoreschi F, Ott H, Perelygina L, Klemann C, Blankenstein O, von Bernuth H, Krüger R.
        Front Immunol. 2022 ;13:886540.
        We report two patients with DNA repair disorders (Artemis deficiency, Ataxia telangiectasia) with destructive skin granulomas, presumably triggered by live-attenuated rubella vaccinations. Both patients showed reduced naïve T cells. Rapid resolution of skin lesions was observed following hematopoietic stem cell transplantation. However, the patient with AT died due to complications of severe hepatic veno-occlusive disease 6 month after HSCT. Dried blood spots obtained after birth were available from this patient and showed absent T-cell receptor excision circles (TRECs). Therefore, newborn screening may help to prevent patients with moderate T-cell deficiency from receiving live-attenuated rubella vaccine potentially causing granulomas.

      4. Genetic characterization of novel oral polio vaccine type 2 viruses during initial use phase under emergency use listing - worldwide, March-October 2021
        Martin J, Burns CC, Jorba J, Shulman LM, Macadam A, Klapsa D, Majumdar M, Bullows J, Frolov A, Mate R, Bujaki E, Castro CJ, Bullard K, Konz J, Hawes K, Gauld J, Blake IM, Mercer LD, Kurji F, Voorman A, Diop OM, Oberste MS, Modlin J, Macklin G, Eisenhawer M, Bandyopadhyay AS, Zipursky S.
        MMWR Morb Mortal Wkly Rep. 2022 Jun 17;71(24):786-790.
        The emergence and international spread of neurovirulent circulating vaccine-derived polioviruses (cVDPVs) across multiple countries in Africa and Asia in recent years pose a major challenge to the goal of eradicating all forms of polioviruses. Approximately 90% of all cVDPV outbreaks are caused by the type 2 strain of the Sabin vaccine, an oral live, attenuated vaccine; cVDPV outbreaks typically occur in areas of persistently low immunization coverage (1). A novel type 2 oral poliovirus vaccine (nOPV2), produced by genetic modification of the type 2 Sabin vaccine virus genome (2), was developed and evaluated through phase I and phase II clinical trials during 2017-2019. nOPV2 was demonstrated to be safe and well-tolerated, have noninferior immunogenicity, and have superior genetic stability compared with Sabin monovalent type 2 (as measured by preservation of the primary attenuation site [domain V in the 5' noncoding region] and significantly lower neurovirulence of fecally shed vaccine virus in transgenic mice) (3-5). These findings indicate that nOPV2 could be an important tool in reducing the risk for generating vaccine-derived polioviruses (VDPVs) and the risk for vaccine-associated paralytic poliomyelitis cases. Based on the favorable preclinical and clinical data, and the public health emergency of international concern generated by ongoing endemic wild poliovirus transmission and cVDPV type 2 outbreaks, the World Health Organization authorized nOPV2 for use under the Emergency Use Listing (EUL) pathway in November 2020, allowing for its first use for outbreak response in March 2021 (6). As required by the EUL process, among other EUL obligations, an extensive plan was developed and deployed for obtaining and monitoring nOPV2 isolates detected during acute flaccid paralysis (AFP) surveillance, environmental surveillance, adverse events after immunization surveillance, and targeted surveillance for adverse events of special interest (i.e., prespecified events that have the potential to be causally associated with the vaccine product), during outbreak response, as well as through planned field studies. Under this monitoring framework, data generated from whole-genome sequencing of nOPV2 isolates, alongside other virologic data for isolates from AFP and environmental surveillance systems, are reviewed by the genetic characterization subgroup of an nOPV working group of the Global Polio Eradication Initiative. Global nOPV2 genomic surveillance during March-October 2021 confirmed genetic stability of the primary attenuating site. Sequence data generated through this unprecedented global effort confirm the genetic stability of nOPV2 relative to Sabin 2 and suggest that nOPV2 will be an important tool in the eradication of poliomyelitis. nOPV2 surveillance should continue for the duration of the EUL.

      5. Evaluation of acute adverse events after COVID-19 vaccination during pregnancy
        DeSilva M, Haapala J, Vazquez-Benitez G, Vesco KK, Daley MF, Getahun D, Zerbo O, Naleway A, Nelson JC, Williams JT, Hambidge SJ, Boyce TG, Fuller CC, Lipkind HS, Weintraub E, McNeil MM, Kharbanda EO.
        N Engl J Med. 2022 Jun 22.

      6. Maternal vaccination and risk of hospitalization for COVID-19 among infants
        Halasa NB, Olson SM, Staat MA, Newhams MM, Price AM, Pannaraj PS, Boom JA, Sahni LC, Chiotos K, Cameron MA, Bline KE, Hobbs CV, Maddux AB, Coates BM, Michelson KN, Heidemann SM, Irby K, Nofziger RA, Mack EH, Smallcomb L, Schwartz SP, Walker TC, Gertz SJ, Schuster JE, Kamidani S, Tarquinio KM, Bhumbra SS, Maamari M, Hume JR, Crandall H, Levy ER, Zinter MS, Bradford TT, Flori HR, Cullimore ML, Kong M, Cvijanovich NZ, Gilboa SM, Polen KN, Campbell AP, Randolph AG, Patel MM.
        N Engl J Med. 2022 Jun 22.
        BACKGROUND: Infants younger than 6 months of age are at high risk for complications of coronavirus disease 2019 (Covid-19) and are not eligible for vaccination. Transplacental transfer of antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) after maternal Covid-19 vaccination may confer protection against Covid-19 in infants. METHODS: We used a case-control test-negative design to assess the effectiveness of maternal vaccination during pregnancy against hospitalization for Covid-19 among infants younger than 6 months of age. Between July 1, 2021, and March 8, 2022, we enrolled infants hospitalized for Covid-19 (case infants) and infants hospitalized without Covid-19 (control infants) at 30 hospitals in 22 states. We estimated vaccine effectiveness by comparing the odds of full maternal vaccination (two doses of mRNA vaccine) among case infants and control infants during circulation of the B.1.617.2 (delta) variant (July 1, 2021, to December 18, 2021) and the B.1.1.259 (omicron) variant (December 19, 2021, to March 8, 2022). RESULTS: A total of 537 case infants (181 of whom had been admitted to a hospital during the delta period and 356 during the omicron period; median age, 2 months) and 512 control infants were enrolled and included in the analyses; 16% of the case infants and 29% of the control infants had been born to mothers who had been fully vaccinated against Covid-19 during pregnancy. Among the case infants, 113 (21%) received intensive care (64 [12%] received mechanical ventilation or vasoactive infusions). Two case infants died from Covid-19; neither infant's mother had been vaccinated during pregnancy. The effectiveness of maternal vaccination against hospitalization for Covid-19 among infants was 52% (95% confidence interval [CI], 33 to 65) overall, 80% (95% CI, 60 to 90) during the delta period, and 38% (95% CI, 8 to 58) during the omicron period. Effectiveness was 69% (95% CI, 50 to 80) when maternal vaccination occurred after 20 weeks of pregnancy and 38% (95% CI, 3 to 60) during the first 20 weeks of pregnancy. CONCLUSIONS: Maternal vaccination with two doses of mRNA vaccine was associated with a reduced risk of hospitalization for Covid-19, including for critical illness, among infants younger than 6 months of age. (Funded by the Centers for Disease Control and Prevention.).

      7. Human papillomavirus vaccination trends among adolescents: 2015 to 2020
        Lu PJ, Yankey D, Fredua B, Hung MC, Sterrett N, Markowitz LE, Elam-Evans LD.
        Pediatrics. 2022 Jun 22.
        OBJECTIVE: To assess trends in recent human papillomavirus (HPV) vaccination initiation and factors associated with vaccination among adolescents. METHODS: The 2015 to 2020 National Immunization Survey-Teen data were used to assess vaccination trends. Multivariable logistic regression analysis were conducted to assess factors associated with vaccination. RESULTS: Overall, HPV vaccination coverage (≥1 dose) among adolescents significantly increased from 56.1% in 2015 to 75.4% in 2020. There were larger increases in coverage among males (4.7 percentage points annually) than females (2.7 percentage points annually) and coverage differences between males and females decreased in 2015 through 2020. Coverage in 2020 was 75.4% for adolescents aged 13 to 17 years; 73.7% for males and 76.8% for females (P < .05); 80.7% for those with a provider recommendation and 51.7% for those without (P < .05); and 80.3% for those with a well child visit at age 11 to 12 years, and 64.8% for those without (P < .05). Multivariable logistic regression results showed that main characteristics independently associated with a higher likelihood of vaccination included: a provider recommendation, age 16 to 17 years, non-Hispanic Black, Hispanic, or American Indian or Alaskan Native, Medicaid insurance, ≥2 provider contacts in the past 12 months, a well-child visit at age 11 to 12 years and having 1 or 2 vaccine providers (P < .05). CONCLUSIONS: Overall, HPV vaccination coverage among adolescents increased during 2015 to 2020. Coverage increased faster among males than females and differences by sex narrowed during this time. Receiving a provider recommendation vaccination was important to increase vaccination coverage.

      8. Vaccine-associated attenuation of subjective severity among outpatients with influenza
        Chung JR, Kim SS, Flannery B, Smith ME, Dunnigan K, Raiyani C, Murthy K, Gaglani M, Jackson ML, Jackson LA, Bear T, Moehling Geffel K, Nowalk MP, Zimmerman RK, Martin ET, Lamerato L, McLean HQ, King JP, Belongia EA, Thompson MG, Patel M.
        Vaccine. 2022 Jun 14.
        Influenza vaccines can mitigate illness severity, including reduced risk of ICU admission and death, in people with breakthrough infection. Less is known about vaccine attenuation of mild/moderate influenza illness. We compared subjective severity scores in vaccinated and unvaccinated persons with medically attended illness and laboratory-confirmed influenza. Participants were prospectively recruited when presenting for care at five US sites over nine seasons. Participants aged ≥ 16 years completed the EQ-5D-5L visual analog scale (VAS) at enrollment. After controlling for potential confounders in a multivariable model, including age and general health status, VAS scores were significantly higher among 2,830 vaccinated participants compared with 3,459 unvaccinated participants, indicating vaccinated participants felt better at the time of presentation for care. No differences in VAS scores were observed by the type of vaccine received among persons aged ≥ 65 years. Our findings suggest vaccine-associated attenuation of milder influenza illness is possible.

      9. COVID-19 vaccination coverage and intent among women aged 18-49 years by pregnancy status, United States, April-November 2021
        Razzaghi H, Yankey D, Vashist K, Lu PJ, Kriss JL, Nguyen KH, Lee J, Ellington S, Polen K, Bonner K, Jatlaoui TC, Wilhelm E, Meaney-Delman D, Singleton JA.
        Vaccine. 2022 Jun 13.
        BACKGROUND: Pregnant and postpartum women are at increased risk for severe illness from COVID-19. We assessed COVID-19 vaccination coverage, intent, and attitudes among women of reproductive age overall and by pregnancy status in the United States. METHODS: Data from the National Immunization Survey Adult COVID Module collected during April 22-November 27, 2021, were analyzed to assess COVID-19 vaccination (receipt of ≥1 dose), intent for vaccination, and attitudes towards vaccination among women aged 18-49 years overall and by pregnancy status (trying to get pregnant, currently pregnant, breastfeeding, and not trying to get pregnant or currently pregnant or breastfeeding). Logistic regression and predictive marginals were used to generate unadjusted and adjusted prevalence ratios (PRs and aPRs). Trend analyses were conducted to assess monthly changes in vaccination and intent. RESULTS: Our analyses included 110,925 women aged 18-49 years. COVID-19 vaccination coverage (≥1 dose) was 63.2% overall (range from 53.3% in HHS Region 4 to 76.5% in HHS Region 1). Vaccination coverage was lowest among pregnant women (45.1%), followed by women who were trying to get pregnant (49.5%), women who were breastfeeding (51.5%), and all other women (64.9%). Non-Hispanic (NH) Black women who were pregnant or breastfeeding had significantly lower vaccination coverage (aPR: 0.74 and 0.66, respectively) than NH White women. DISCUSSION: Our findings are consistent with other studies showing lower vaccination coverage among pregnant individuals, with substantially lower vaccination coverage among NH Black women who are pregnant or breastfeeding. Given the overlapping and disproportionate risks of COVID-19 and maternal mortality among Black women, it is critical that COVID-19 vaccination be strongly recommended for these populations and all women of reproductive age. Healthcare and public health providers may take advantage of every opportunity to encourage vaccination and enlist the assistance of community leaders, particularly in communities with low vaccination coverage.

    • Informatics
      1. PLACES: Local data for better health
        Greenlund KJ, Lu H, Wang Y, Matthews KA, LeClercq JM, Lee B, Carlson SA.
        Prev Chronic Dis. 2022 Jun 16;19:E31.
        Local-level data on the health of populations are important to inform and drive effective and efficient actions to improve health, but such data are often expensive to collect and thus rare. Population Level Analysis and Community EStimates (PLACES) (www.cdc.gov/places/), a collaboration between the Centers for Disease Control and Prevention (CDC), the Robert Wood Johnson Foundation, and the CDC Foundation, provides model-based estimates for 29 measures among all counties and most incorporated and census-designated places, census tracts, and ZIP Code tabulation areas across the US. PLACES allows local health departments and others to better understand the burden and geographic distribution of chronic disease-related outcomes in their areas regardless of population size and urban-rural status and assists them in planning public health interventions. Online resources allow users to visually explore health estimates geographically, compare estimates, and download data for further use and exploration. By understanding the PLACES overall approach and using the easy-to-use PLACES applications, practitioners, policy makers, and others can enhance their efforts to improve public health, including informing prevention activities, programs, and policies; identifying priority health risk behaviors for action; prioritizing investments to areas with the biggest gaps or inequities; and establishing key health objectives to achieve community health and health equity.

    • Injury and Violence
      1. Associations between school absence and school violence by sexual identity
        Lowry R, Kennedy K, Johns MM, Harper CR, Wilkins NJ.
        Am J Prev Med. 2022 Jun 14.
        INTRODUCTION: Sexual minority youth are disproportionately exposed to school violence compared with their heterosexual peers. It is unknown whether the associations between school absence and exposure to school violence vary by sexual identity. METHODS: In 2021, data were combined from the 2015, 2017, and 2019 national Youth Risk Behavior Surveys to produce nationally representative samples of U.S. high-school students who identified as gay/lesbian (n=1,061), identified as bisexual (n=3,210), were not sure of their sexual identity (n=1,696), or identified as heterosexual (n=35,819). Associations were examined between 3 school violence exposures (being threatened/injured with a weapon at school, being bullied at school, and being in a physical fight at school) and school absence due to safety concerns. In each sample, multivariable logistic regression models were used to calculate adjusted prevalence ratios adjusted for sex, race/ethnicity, grade, current substance use, being offered/sold drugs at school, feeling sad/hopeless, and suicidal thoughts. Adjusted prevalence ratios were considered statistically significant if 95% CIs did not include 1.0. RESULTS: Exposure to school violence and school absence due to safety concerns were more prevalent among sexual minority students than among heterosexual students. Associations between exposure to school violence and school absence due to safety concerns were similar across sexual identity groups. For example, school absence was associated with being threatened/injured with a weapon at school among gay/lesbian (adjusted prevalence ratio=3.00), bisexual (adjusted prevalence ratio=3.66), those not sure (adjusted prevalence ratio=4.56), and heterosexual (adjusted prevalence ratio=3.75) students. CONCLUSIONS: Associations between school absenteeism and school violence exist in each sexual identity group. Therefore, programs providing safe and supportive school environments may result in reduced absenteeism among all students.

    • Laboratory Sciences
      1. Baseline assessment findings of the Africa Society for Blood Transfusion Step-Wise Accreditation Programme in 10 sub-Saharan African countries, 2016-2018
        Kanagasabai U, Qualls M, Shiraishi RW, Eno L, Zungu I, Bust L, Drammeh B, Selenic D.
        Vox Sang. 2022 Jun;117(6):839-846.
        BACKGROUND AND OBJECTIVES: The accreditation of blood services promotes continuous quality improvement in blood and transfusion services. The Africa Society for Blood Transfusion (AfSBT) conducted 20 baseline assessments of National Blood Transfusion Services (NBTS) or blood banks as part of the Step-Wise Accreditation Programme (SWAP) in 10 sub-Saharan African (SSA) countries from 2016 to 2018. This paper aims to elucidate the process and findings of the baseline assessments. MATERIALS AND METHODS: This is a descriptive study of 20 baseline assessments of NBTS. Eleven sections of the AfSBT assessment were reviewed, and 48 out of 68 standards and 356 out of 466 criteria were assessed. Each standard was assigned a value of 1 if it was fully achieved, 0.5 if partially achieved and 0 if not achieved. We defined average section scores >75% as having 'met AfSBT Standards', ≤25% as not meeting standards, 26%-50% as needs major improvement, and 51%-75% as needs some improvement and >75% as meets standards. RESULTS: The AfSBT SWAP standards were met in 4 out of the 11 sections: donor management, blood collection, component production and compatibility testing. Three sections were determined to need some improvement (quality system; handling, transport and storage and testing of donated blood), and three sections were determined to need major improvement (haemovigilance, blood administration and national blood service accreditation). One section (receipt, ordering, and issuing of blood) did not meet standards. CONCLUSION: Despite improvements in the quality of blood services in SSA over the past two decades, governments may consider the importance of prioritizing investments in NBTS, ensuring these institutions meet international accreditation standards that are aligned with safe blood transfusion services.

    • Maternal and Child Health
      1. The impact of maternal human immunodeficiency virus infection on the burden of respiratory syncytial virus among pregnant women and their infants, Western Kenya
        Nyawanda BO, Otieno NA, Otieno MO, Emukule GO, Bigogo G, Onyango CO, Lidechi S, Nyaundi J, Langley GE, Widdowson MA, Chaves SS.
        J Infect Dis. 2022 Jun 15;225(12):2097-2105.
        BACKGROUND: Respiratory syncytial virus (RSV) is an important cause of respiratory illness worldwide; however, burden data on mother-infant pairs remain sparse in sub-Saharan Africa, where human immunodeficiency virus (HIV) is prevalent. We evaluated the impact of maternal HIV infection on the burden of RSV among mothers and their infants in western Kenya. METHODS: We enrolled pregnant women (≤20 weeks' gestation) and followed them and their newborns weekly for up to 3-6 months postpartum, to document cases of acute respiratory illness (ARI). Nasal/oropharyngeal swabs were collected and tested for RSV using polymerase chain reaction. Analyses were stratified by maternal HIV status and incidence was computed per 1000 person-months. RESULTS: Compared to RSV-negative ARI cases, RSV-positive cases were associated with cough, apnea, and hospitalization among infants. RSV incidence per 1000 person-months among mothers was 4.0 (95% confidence interval [CI], 3.2-4.4), and was twice that among the HIV-infected mothers (8.4 [95% CI, 5.7-12.0]) compared to the HIV-uninfected mothers (3.1 [95% CI, 2.3-4.0]). Among infants, incidence per 1000 person-months was 15.4 (95% CI, 12.5-18.8); incidence did not differ by HIV exposure or prematurity. CONCLUSIONS: HIV infection may increase the risk of RSV illness among pregnant women. Future maternal RSV vaccines may have added benefit in areas with high HIV prevalence.

    • Occupational Safety and Health
      1. Working hours, sleep, and fatigue in the public safety sector: A scoping review of the research
        Allison P, Tiesman HM, Wong IS, Bernzweig D, James L, James SM, Navarro KM, Patterson PD.
        Am J Ind Med. 2022 Jun 16.
        BACKGROUND: The public safety sector includes law enforcement officers (LEO), corrections officers (CO), firefighter service (FF), wildland firefighting (WFF), and emergency medical services (EMS), as defined in the National Occupational Research Agenda (NORA) of the National Institute for Occupational Safety and Health (NIOSH). Across these occupations, shiftwork, long-duration shifts, and excessive overtime are common. Our objective was to identify research gaps related to working hours, sleep, and fatigue among these workers. METHODS: We used a scoping review study design that included searches of MEDLINE, Embase, CAB Abstracts, Global Health, PsychInfo, CINAHL, Scopus, Academic Search Complete, Agricultural and Environmental Science Collection, ProQuest Central, Cochrane Library, Safety Lit, Homeland Security Digital Library, and Sociological Abstracts using a range of occupational search terms and terms related to working hours, sleep, and fatigue. RESULTS: Out of 3415 articles returned from our database search, 202 met all inclusion criteria. Six common outcomes related to working hours, sleep, and fatigue emerged: sleep, fatigue, work performance, injury, psychosocial stress, and chronic disease. Nearly two-thirds (59%, n = 120) of the studies were observational, of which 64% (n = 77) were cross sectional and 9% were (n = 11) longitudinal; 14% (n = 30) of the studies were reviews; and 19% (n = 39) were experimental or quasi-experimental studies. Only 25 of the 202 articles described mitigation strategies or interventions. FFs, LEOs, EMS, and WFFs were the most studied, followed by COs. CONCLUSIONS: In general, more longitudinal and experimental studies are needed to enrich the knowledge base on the consequences of long working hours, poor sleep, and fatigue in the public safety sector. Few experimental studies have tested novel approaches to fatigue mitigation in diverse sectors of public safety. This gap in research limits the decisions that may be made by employers to address fatigue as a threat to public-safety worker health and safety.

      2. NIOSH risk-based model to resume field research and public health service in 2020 during the COVID-19 pandemic
        Johns DO, Yeoman KM, Harney JM, Howard J, Poplin GS.
        Am J Public Health. 2022 Jun 16:e1-e4.
        In the early months of the COVID-19 pandemic, field research and public health service work conducted by the National Institute for Occupational Safety and Health (NIOSH) was put on hold. During this time, NIOSH developed a risk-based model to resume fieldwork, balancing the public health benefit of such fieldwork with the risks of severe acute respiratory syndrome coronavirus 2 exposure and transmission. We describe our experiences with this model, along with the broader public health significance of the methods used to inform risk management decisions. (Am J Public Health. Published online ahead of print June 16, 2022:e1-e4. https://doi.org/10.2105/AJPH.2022.306882).

      3. In the ever-expanding complexities of the modern-day mining workplace, the continual monitoring of a safe and healthy work environment is a growing challenge. One specific workplace exposure concern is the inhalation of dust containing respirable crystalline silica (RCS) which can lead to silicosis, a potentially fatal lung disease. This is a recognized and regulated health hazard, commonly found in mining. The current methodologies to monitor this type of exposure involve distributed sample collection followed by costly and relatively lengthy follow-up laboratory analysis. To address this concern, we have investigated a data-driven predictive modeling pipeline to predict the amount of silica deposition quickly and accurately on a filter within minutes of sample collection completion. This field-based silica monitoring technique involves the use of small, and easily deployable, Fourier transform infrared (FTIR) spectrometers used for data collection followed by multivariate regression methodologies including Principal Component Analysis (PCA) and Partial Least Squares (PLS). Given the complex nature of respirable dust mixtures, there is an increasing need to account for multiple variables quickly and efficiently during analysis. This analysis consists of several quality control steps including data normalization, PCA and PLS outlier detection, as well as applying correction factors based on the sampler and cassette used for sample collection. While outside the scope of this article to test, these quality control steps will allow for the acceptance of data from many different FTIR instruments and sampling types, thus increasing the overall useability of this method. Additionally, any sample analyzed through the model and validated using a secondary method can be incorporated into the training dataset creating an ever-growing, more robust predictive model. Multivariant predictive modeling has far-reaching implications given its speed, cost, and scalability compared to conventional approaches. This contribution presents the application of PCA and PLS as part of a computational pipeline approach to predict the amount of a deposited mineral of interest using FTIR data. For this specific application, we have developed the model to analyze RCS, although this process can be implemented in the analysis of any IR-active mineral, and this pipeline applied to any FTIR data.

      4. Reported exposures among in-person workers with SARS-CoV-2 infection in 6 states, September 2020-June 2021
        Free H, Luckhaupt SE, Billock RM, Groenewold MR, Burrer S, Sweeney MH, Wong J, Gibb K, Rodriguez A, Vergara X, Cummings K, Lavender A, Argueta G, Crawford HL, Erukunuapor K, Karlsson ND, Armenti K, Thomas H, Gaetz K, Dang G, Harduar-Morano L, Modji K.
        Clin Infect Dis. 2022 Jun 19.
        BACKGROUND: Surveillance systems lack detailed occupational exposure information from workers with SARS-CoV-2 infection. The National Institute for Occupational Safety and Health partnered with six states to collect information from adults diagnosed with SARS-CoV-2 infection (either COVID-19 or asymptomatic infection) who worked in person (outside the home) in non-healthcare settings during the two weeks prior to illness onset. METHODS: The survey captured demographic, medical, occupational characteristics, and work- and non-work-related risk factors for SARS-CoV-2 infection. Reported close contact with a person known or suspected to have COVID-19 was categorized by setting as: exposure at work, exposure outside of work only, or no known exposure/didn't know if they had exposures. Frequencies and percentages of exposure types are compared by respondent characteristics and risk factors for SARS-CoV-2 infection. RESULTS: Of 1,111 qualified respondents, 19.4% reported exposure at work, 23.4% reported exposure outside of work only, and 57.2% reported no known exposure/didn't know if they had exposures. Workers in protective service occupations (48.8%) and public administration industries (35.6%) reported exposure at work most often. Over a third (33.7%) of respondents who experienced close contact with ≥10 coworkers per day and 28.8% of respondents who experienced close contact with ≥10 customers/clients per day reported exposures at work. CONCLUSIONS: Exposure to SARS-CoV-2 at work was common among respondents. Examining differences in exposures among different groups of workers can help identify populations with the greatest need for prevention interventions. The benefits of recording employment characteristics as standard demographic information will remain relevant as new and reemerging public health issues occur.

      5. Lung toxicity profile of inhaled copper-nickel welding fume in A/J mice
        Zeidler-Erdely PC, Erdely A, Kodali V, Andrews R, Antonini J, Trainor-DeArmitt T, Salmen R, Battelli L, Grose L, Kashon M, Service S, McKinney W, Stone S, Falcone L.
        Inhal Toxicol. 2022 Jun 20:1-12.
        Objective: Stainless steel welding creates fumes rich in carcinogenic metals such as chromium (Cr). Welding consumables devoid of Cr are being produced in an attempt to limit worker exposures to toxic and carcinogenic metals. The study objective was to characterize a copper-nickel (Cu-Ni) fume generated using gas metal arc welding (GMAW) and determine the pulmonary deposition and toxicity of the fume in mice exposed by inhalation. Materials and Methods: Male A/J mice (6-8 weeks of age) were exposed to air or Cu-Ni welding fumes for 2 (low deposition) or 4 (high deposition) hours/day for 10 days. Mice were sacrificed, and bronchoalveolar lavage (BAL), macrophage function, and histopathological analyses were performed at different timepoints post-exposure to evaluate resolution. Results and Discussion: Characterization of the fume indicated that most of the particles were between 0.1 and 1 µm in diameter, with a mass median aerodynamic diameter of 0.43 µm. Metal content of the fume was Cu (∼76%) and Ni (∼12%). Post-exposure, BAL macrophages had a reduced ability to phagocytose E. coli, and lung cytotoxicity was evident and significant (>12%-19% fold change). Loss of body weight was also significant at the early timepoints. Lung inflammation, the predominant finding identified by histopathology, was observed as a subacute response early that progressively resolved by 28 days with only macrophage aggregates remaining late (84 days). Conclusions: Overall, there was high acute lung toxicity with a resolution of the response in mice which suggests that the Cu-Ni fume may not be ideal for reducing toxic and inflammatory lung effects.

      6. A method for measuring peracetic acid vapors in air using impinger sampling and field-portable colorimetric analysis is presented. The capture efficiency of aqueous media in glass and plastic impingers was evaluated when used for peracetic acid vapor sampling. Measurement of peracetic acid was done using an N,N-diethyl-p-phenylenediamine colorimetric method with a field portable spectrometer. The linearity of the N,N-diethyl-p-phenylenediamine method was determined for peracetic acid both in-solution and captured from vapor phase using glass or plastic impingers. The Limits of Detection for the glass and plastic impingers were 0.24 mg/m(3) and 0.28 mg/m(3), respectively, for a 15 L air sample. The Limits of Quantitation were 0.79 mg/m(3) and 0.92 mg/m(3) for the glass and plastic impingers, respectively. Both metrics were below the American Conference of Governmental Industrial Hygienists Threshold Limit Value Short-Term Exposure Limit of 1.24 mg/m(3) (0.4 ppmv) during a 15-minute period. This impinger sampling method presented herein allows for an easy to use and rapid in-field measurement that can be used for evaluating occupational exposure to peracetic acid.

      7. Association between the metabolic syndrome and retinal microvascular diameters among police officers
        Gu JK, Charles LE, Allison P, Violanti JM, Andrew ME.
        J Occup Environ Med. 2022 Jun 16.
        OBJECTIVES: We examined associations of the metabolic syndrome severity score (MSSS) and the metabolic syndrome (MetSyn) components with central retinal arteriolar equivalent (CRAE) and central retinal venular equivalent (CRVE). METHODS: Participants in this cross-sectional study were 253 officers from the Buffalo Cardio-Metabolic Occupational Police Stress study (2011-2014). The MSSS is a z-score that represents the severity of MetSyn and was estimated using a sex-race-specific equation and the five MetSyn components. Associations of MSSS and the MetSyn with CRAE/CRVE were obtained using linear regression models or Analysis of Covariance. RESULTS: For every 1-standard deviation of MSSS, CRAE decreased by 2.3 μm (SE = 1.2, p = 0.0262) and CRVE increased by 3.4 μm (SE = 1.6, p = 0.0308) after adjusting for confounders. CONCLUSIONS: Officers with higher MSSS had narrower (i.e., worse) arteriolar diameters and wider (i.e., worse) venular diameters.

      8. Roof stability and support strategies associated with longwall-induced horizontal stress changes in belt entries
        Zhang P, Esterhuizen G, Sears M, Trackemas J, Minoski T, Tulu B.
        Min Metall Explor. 2022 .
        Longwall mining is a highly productive and efficient coal mining method used in the USA. During longwall retreating, the belt entry must be maintained stable, and any roof fall in the belt entry would jeopardize mine safety and substantially interrupt the continuous production of coal in the longwall face. Past experience of longwall mining has shown that belt entry stability was the greatest challenge in longwall ground control, and the occurrence of roof falls in belt entries was largely associated with high horizontal stress. To properly support the roof in the belt entry, it is important to understand how longwall-induced horizontal stress changes affect roof stability in belt entries and to strategically install supplementary support to prevent any potential roof falls. Researchers from the National Institute for Occupational Safety and Health (NIOSH) performed horizontal stress measurements in the immediate roof of the belt entries for two Pittsburgh seam longwall panels oriented unfavorably to high horizontal stress. Hollow inclusion cells (HICells) were installed in the immediate roof at the intersection in each of the belt entries, and stress changes were monitored as the longwall face was approaching and passing the intersection. Numerical models were set up to calculate the longwall-induced horizontal stress changes in the roof at the monitoring sites. With the verified model, investigations were made of how horizontal stress is concentrated and relieved in the belt entry roof near the face under different panel orientations. Both measurements and modeling results showed that high horizontal stress is concentrated in the roof in the belt entry within about 15 m outby the face when a longwall panel is unfavorably oriented to the major horizontal stress. The study demonstrated that longwall-induced differential horizontal stress can be used as an indication of the degree of horizontal stress concentration. Roof support strategies are discussed on how to maintain the stability of belt entry under high horizontal stress concentration. © 2022, This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.

      9. Progressive massive fibrosis: An overview of the recent literature
        Weissman DN.
        Pharmacol Ther. 2022 Jun 19:108232.
        This review provides an overview of literature addressing progressive massive fibrosis (PMF) from September 2009 to the present. Advances are described in understanding its pathophysiology, epidemiology of the occurrence of PMF and related conditions, the impact of PMF on pulmonary function, advances in imaging of PMF, and factors affecting progression of pneumoconiosis in dust-exposed workers to PMF. Basic advances in understanding the etiology of PMF are impeded by the lack of a well-accepted animal model for human PMF. Recent studies evaluating lung tissue samples and epidemiologic investigations support an important role for the silica component of coal mine dust in causing coal workers' pneumoconiosis and PMF in contemporary coal miners in the United States and for silica in causing silicosis and PMF in artificial stone workers throughout the world. Development of PMF is associated with substantial decline in pulmonary function relative to no disease or small opacity pneumoconiosis. In recent reports, computed tomography has had greater sensitivity for detecting PMF than chest x-ray. Magnetic resonance imaging shows promise in differentiating between PMF and lung cancer. Although PMF develops in dust-exposed workers without previously identified small opacity pneumoconiosis, the presence of small opacity pneumoconiosis increases the risk for progression to PMF, as does heavier dust exposure. Recent literature does not document any effective new treatments for PMF and new therapies to prevent and treat PMF are an important need.

    • Parasitic Diseases
      1. Factors associated with human IgG antibody response to Anopheles albimanus salivary gland extract: Artibonite Department, Haiti, 2017
        Jaramillo-Underwood A, Impoinvil D, Sutcliff A, Hamre KE, Joseph V, Hoogen LV, Frantz Lemoine J, Ashton RA, Chang MA, Existe A, Boncy J, Drakeley C, Stresman G, Druetz T, Eisele T, Rogier E.
        J Infect Dis. 2022 Jun 17.
        Serological data can provide estimates of human exposure to both malaria vector and parasite based on antibody responses. A multiplex bead-based assay was developed to simultaneously detect IgG to Anopheles albimanus salivary gland extract (SGE) and 23 Plasmodium falciparum antigens among 4,185 participants enrolled in Artibonite department, Haiti in 2017. Logistic regression adjusted for participant- and site-level covariates and found children under 5 years and 6-15 years old had 3.7- and 5.4-fold increase in odds, respectively, of high anti-SGE IgG compared to participants >15 years. Seropositivity to P. falciparum CSP, Rh2_2030, and SEA-1 antigens was significantly associated with high IgG response against SGE, and participant enrollment at elevations under 200m was associated with higher anti-SGE IgG levels. The ability to approximate population exposure to malaria vectors through SGE serology data is very dependent by age categories, and SGE antigens can be easily integrated into a multiplex serological assay.

      2. A cluster randomized trial of delivery of intermittent preventive treatment of malaria in pregnancy at the community level in Malawi
        Rubenstein BL, Chinkhumba J, Chilima E, Kwizombe C, Malpass A, Cash S, Wright K, Troell P, Nsona H, Kachale F, Ali D, Kaunda E, Lankhulani S, Kayange M, Mathanga DP, Munthali J, Gutman JR.
        Malar J. 2022 Jun 21;21(1):195.
        BACKGROUND: Malaria in pregnancy doubles the risk of low birthweight; up to 11% of all neonatal deaths in sub-Saharan Africa are associated with malaria in pregnancy. To prevent these and other adverse health consequences, the World Health Organization recommends administering intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine for all pregnant women at each antenatal care (ANC) visit, starting as early as possible in the second trimester. The target is for countries to administer a minimum of three doses (IPTp3+) to at least 85% of pregnant women. METHODS: A cluster randomized, controlled trial was conducted to assess the effect of delivery of IPTp by community health workers on the coverage of IPTp3 + and ANC visits in Malawi. Community delivery of IPTp was implemented within two districts in Malawi over a 21-month period, from November 2018 to July 2020. In control sites, IPTp was delivered at health facilities. Representative samples of women who delivered in the prior 12 months were surveyed at baseline (n = 370, December 2017) and endline (n = 687, August 2020). A difference in differences analysis was conducted to assess the change in coverage of IPTp and ANC over time, accounting for clustering at the health facility level. RESULTS: Overall IPTp coverage increased over the study period. At baseline, women received a mean of 2.3 IPTp doses (range 0-5 doses) across both arms, and at endline, women received a mean of 2.8 doses (range 0-9 doses). Despite overall increases, the change in IPTp3 + coverage was not significantly different between intervention and control groups (6.9%, 95% CI: -5.9%, 19.6%). ANC4 + coverage increased significantly in the intervention group compared with the control group, with a difference-in-differences of 25.3% points (95% CI: 1.3%, 49.3%). CONCLUSIONS: In order to reduce the burden of malaria in pregnancy, new strategies are needed to improve uptake of effective interventions such as IPTp. While community health workers' delivery of IPTp did not increase uptake in this study, they may be effective in other settings or circumstances. Further research can help identify the health systems characteristics that are conducive to community delivery of IPTp and the operational requirements for effective implementation. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03376217. Registered December 6, 2017, https://clinicaltrials.gov/ct2/show/NCT03376217 .

    • Reproductive Health
      1. A mixed-methods pilot evaluation of Manhood 2.0, a program to reduce unintended pregnancy among young men
        Manlove J, Parekh J, Whitfield B, Griffith I, Garg A, Fasula AM.
        Am J Mens Health. 2022 May-Jun;16(3):15579883221104895.
        One promising though understudied approach to addressing race/ethnic disparities in teen pregnancy rates is through sexual and reproductive health (SRH) programming for young men. This pilot study assessed the feasibility, quality, and preliminary efficacy of Manhood 2.0-a group-based, after-school SRH program for young Black and Latino men, which examines gender norms. This mixed-methods study describes program attendance and quality; participant experiences and engagement in the program; and changes in participant gender norms, knowledge, attitudes, self-efficacy, and social support. Quantitative data from baseline and post-intervention surveys (n = 51) were analyzed using paired t-tests and McNemar's tests. Qualitative data from five post-intervention focus groups (n = 27) were transcribed, coded, and analyzed for themes. At baseline, participants were ages 15 to18 years (M = 16.4 years), 30% were Latino, 66% were Black, 34% ever had sex, and 44% of sexually active participants had sex without any contraceptive method or condom. Quality ratings by program observers were high. The majority of participants (61%) attended at least 75% of sessions, and 96% rated Manhood 2.0 as "very good" or "excellent." Pre-post comparisons showed increases in receipt of SRH information; contraception knowledge; positive attitudes about supporting partners in pregnancy prevention; self-efficacy in partner communication about sex; discussing program content with friends and family; and social competence and support. Focus group participants described benefits from the Manhood 2.0 content (i.e., full range of contraceptive methods, sexual consent, gender norms) and delivery (i.e., reflective discussion, nonjudgmental facilitators). Findings suggest that Manhood 2.0 is a promising SRH program for young men.

    • Zoonotic and Vectorborne Diseases
      1. A review of zoonotic disease threats to pet owners: A compendium of measures to prevent zoonotic diseases associated with non-traditional pets: Rodents and other small mammals, reptiles, amphibians, backyard poultry, and other selected animals
        Varela K, Brown JA, Lipton B, Dunn J, Stanek D, Behravesh CB, Chapman H, Conger TH, Vanover T, Edling T, Holzbauer S, Lennox AM, Lindquist S, Loerzel S, Mehlenbacher S, Mitchell M, Murphy M, Olsen CW, Yager CM.
        Vector Borne Zoonotic Dis. 2022 Jun;22(6):303-360.

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