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Issue 43, October 25, 2022

CDC Science Clips: Volume 14, Issue 43, October 25, 2022

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

This week, Science Clips is pleased to feature articles related to the new CDC Vital Signs on Inequities in Flu Vaccine Uptake: More Vaccination Needed for People from Some Racial/Ethnic Groups

Flu vaccination is the best way to protect against flu. Vaccination may not always prevent infection, but it can make symptoms less severe and reduce the risk of being hospitalized. Flu vaccination coverage has been consistently lower among Black, Hispanic, and AI/AN adults. There are many reasons for these inequities, including lack of access to health care and insurance, missed opportunities to vaccinate, and misinformation and distrust.

Increasing equitable vaccine uptake requires addressing the range of reasons why people do not get vaccinated. Over the past two years, CDC has begun two programs to address vaccination barriers and raise awareness about the importance of flu vaccination, specifically among people from racial and ethnic minority groups: the Partnering for Vaccine Equity (P4VE) program and a targeted flu vaccination campaign.


  1. CDC Vital Signs
    • Inequities in Flu Vaccine Uptake
      1. Flu activity & surveillance
        Atlanta, GA: US Department of Health and Human Services, CDC; 2022.

      2. Influenza (flu): flu vaccination coverage, United States, 2020–21 influenza season
        Atlanta, GA: US Department of Health and Human Services, CDC; 2021.

      3. The US Influenza Hospitalization Surveillance Network
        Chaves SS, Lynfield R, Lindegren ML, Bresee J, Finelli L.
        Emerg Infect Dis. 2015 Sep;21(9):1543-50.
        In 2003, surveillance for influenza in hospitalized persons was added to the Centers for Disease Control and Prevention Emerging Infections Program network. This surveillance enabled monitoring of the severity of influenza seasons and provided a platform for addressing priority questions associated with influenza. For enhanced surveillance capacity during the 2009 influenza pandemic, new sites were added to this platform. The combined surveillance platform is called the Influenza Hospitalization Surveillance Network (FluSurv-NET). FluSurv-NET has helped to determine the risk for influenza-associated illness in various segments of the US population, define the severity of influenza seasons and the 2009 pandemic, and guide recommendations for treatment and vaccination programs.

      4. Rates of Influenza-Associated Hospitalization, Intensive Care Unit Admission, and In-Hospital Death by Race and Ethnicity in the United States From 2009 to 2019
        O'Halloran AC, Holstein R, Cummings C, Daily Kirley P, Alden NB, Yousey-Hindes K, Anderson EJ, Ryan P, Kim S, Lynfield R, McMullen C, Bennett NM, Spina N, Billing LM, Sutton M, Schaffner W, Talbot HK, Price A, Fry AM, Reed C, Garg S.
        JAMA Netw Open. 2021 Aug 2;4(8):e2121880.
        IMPORTANCE: Racial and ethnic minority groups, such as Black, Hispanic, American Indian or Alaska Native, and Asian or Pacific Islander persons, often experience higher rates of severe influenza disease. OBJECTIVE: To describe rates of influenza-associated hospitalization, intensive care unit (ICU) admission, and in-hospital death by race and ethnicity over 10 influenza seasons. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data from the Influenza-Associated Hospitalization Surveillance Network (FluSurv-NET), which conducts population-based surveillance for laboratory-confirmed influenza-associated hospitalizations in selected counties, representing approximately 9% of the US population. Influenza hospitalizations from the 2009 to 2010 season to the 2018 to 2019 season were analyzed. Data were analyzed from October 2020 to July 2021. MAIN OUTCOMES AND MEASURES: The main outcomes were age-adjusted and age-stratified rates of influenza-associated hospitalization, ICU admission, and in-hospital death by race and ethnicity overall and by influenza season. RESULTS: Among 113 352 persons with an influenza-associated hospitalization (34 436 persons [32.0%] aged ≥75 years; 61 009 [53.8%] women), 70 225 persons (62.3%) were non-Hispanic White (White), 24 850 persons (21.6%) were non-Hispanic Black (Black), 11 903 persons (10.3%) were Hispanic, 5517 persons (5.1%) were non-Hispanic Asian or Pacific Islander, and 857 persons (0.7%) were non-Hispanic American Indian or Alaska Native. Among persons aged younger than 75 years and compared with White persons of the same ages, Black persons were more likely to be hospitalized (eg, age 50-64 years: rate ratio [RR], 2.50 95% CI, 2.43-2.57) and to be admitted to an ICU (eg, age 50-64 years: RR, 2.09; 95% CI, 1.96-2.23). Among persons aged younger than 50 years and compared with White persons of the same ages, American Indian or Alaska Native persons were more likely to be hospitalized (eg, age 18-49 years: RR, 1.72; 95% CI, 1.51-1.96) and to be admitted to an ICU (eg, age 18-49 years: RR, 1.84; 95% CI, 1.40-2.42). Among children aged 4 years or younger and compared with White children, hospitalization rates were higher in Black children (RR, 2.21; 95% CI, 2.10-2.33), Hispanic children (RR, 1.87; 95% CI, 1.77-1.97), American Indian or Alaska Native children (RR, 3.00; 95% CI, 2.55-3.53), and Asian or Pacific Islander children (RR, 1.26; 95% CI, 1.16-1.38), as were rates of ICU admission (Black children: RR, 2.74; 95% CI, 2.43-3.09; Hispanic children: RR, 1.96; 95% CI, 1.73-2.23; American Indian and Alaska Native children: RR, 3.51; 95% CI, 2.45-5.05). In this age group and compared with White children, in-hospital death rates were higher among Hispanic children (RR, 2.98; 95% CI, 1.23-7.19), Black children (RR, 3.39; 95% CI, 1.40-8.18), and Asian or Pacific Islander children (RR, 4.35; 95% CI, 1.55-12.22). Few differences were observed in rates of severe influenza-associated outcomes by race and ethnicity among adults aged 75 years or older. For example, in this age group, compared with White adults, hospitalization rates were slightly higher only among Black adults (RR, 1.05; 95% CI 1.02-1.09). Overall, Black persons had the highest age-adjusted hospitalization rate (68.8 [95% CI, 68.0-69.7] hospitalizations per 100 000 population) and ICU admission rate (11.6 [95% CI, 11.2-11.9] admissions per 100 000 population). CONCLUSIONS AND RELEVANCE: This cross-sectional study found racial and ethnic disparities in rates of severe influenza-associated disease. These data identified subgroups for whom improvements in influenza prevention efforts could be targeted.

      5. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices, United States, 2021-22 Influenza Season
        Grohskopf LA, Alyanak E, Ferdinands JM, Broder KR, Blanton LH, Talbot HK, Fry AM.
        MMWR Recomm Rep. 2021 Aug 27;70(5):1-28.
        This report updates the 2020-21 recommendations of the Advisory Committee on Immunization Practices (ACIP) regarding the use of seasonal influenza vaccines in the United States (MMWR Recomm Rep 2020;69[No. RR-8]). Routine annual influenza vaccination is recommended for all persons aged ≥6 months who do not have contraindications. For each recipient, a licensed and age-appropriate vaccine should be used. ACIP makes no preferential recommendation for a specific vaccine when more than one licensed, recommended, and age-appropriate vaccine is available. During the 2021-22 influenza season, the following types of vaccines are expected to be available: inactivated influenza vaccines (IIV4s), recombinant influenza vaccine (RIV4), and live attenuated influenza vaccine (LAIV4).The 2021-22 influenza season is expected to coincide with continued circulation of SARS-CoV-2, the virus that causes COVID-19. Influenza vaccination of persons aged ≥6 months to reduce prevalence of illness caused by influenza will reduce symptoms that might be confused with those of COVID-19. Prevention of and reduction in the severity of influenza illness and reduction of outpatient visits, hospitalizations, and intensive care unit admissions through influenza vaccination also could alleviate stress on the U.S. health care system. Guidance for vaccine planning during the pandemic is available at https://www.cdc.gov/vaccines/pandemic-guidance/index.html. Recommendations for the use of COVID-19 vaccines are available at https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/covid-19.html, and additional clinical guidance is available at https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html. Updates described in this report reflect discussions during public meetings of ACIP that were held on October 28, 2020; February 25, 2021; and June 24, 2021. Primary updates to this report include the following six items. First, all seasonal influenza vaccines available in the United States for the 2021-22 season are expected to be quadrivalent. Second, the composition of 2021-22 U.S. influenza vaccines includes updates to the influenza A(H1N1)pdm09 and influenza A(H3N2) components. U.S.-licensed influenza vaccines will contain hemagglutinin derived from an influenza A/Victoria/2570/2019 (H1N1)pdm09-like virus (for egg-based vaccines) or an influenza A/Wisconsin/588/2019 (H1N1)pdm09-like virus (for cell culture-based and recombinant vaccines), an influenza A/Cambodia/e0826360/2020 (H3N2)-like virus, an influenza B/Washington/02/2019 (Victoria lineage)-like virus, and an influenza B/Phuket/3073/2013 (Yamagata lineage)-like virus. Third, the approved age indication for the cell culture-based inactivated influenza vaccine, Flucelvax Quadrivalent (ccIIV4), has been expanded from ages ≥4 years to ages ≥2 years. Fourth, discussion of administration of influenza vaccines with other vaccines includes considerations for coadministration of influenza vaccines and COVID-19 vaccines. Providers should also consult current ACIP COVID-19 vaccine recommendations and CDC guidance concerning coadministration of these vaccines with influenza vaccines. Vaccines that are given at the same time should be administered in separate anatomic sites. Fifth, guidance concerning timing of influenza vaccination now states that vaccination soon after vaccine becomes available can be considered for pregnant women in the third trimester. As previously recommended, children who need 2 doses (children aged 6 months through 8 years who have never received influenza vaccine or who have not previously received a lifetime total of ≥2 doses) should receive their first dose as soon as possible after vaccine becomes available to allow the second dose (which must be administered ≥4 weeks later) to be received by the end of October. For nonpregnant adults, vaccination in July and August should be avoided unless there is concern that later vaccination might not be possible. Sixth, contraindications and precautions to the use of ccIIV4 and RIV4 have been modified, specifically with regard to persons with a history of severe allergic reaction (e.g., anaphylaxis) to an influenza vaccine. A history of a severe allergic reaction to a previous dose of any egg-based IIV, LAIV, or RIV of any valency is a precaution to use of ccIIV4. A history of a severe allergic reaction to a previous dose of any egg-based IIV, ccIIV, or LAIV of any valency is a precaution to use of RIV4. Use of ccIIV4 and RIV4 in such instances should occur in an inpatient or outpatient medical setting under supervision of a provider who can recognize and manage a severe allergic reaction; providers can also consider consulting with an allergist to help identify the vaccine component responsible for the reaction. For ccIIV4, history of a severe allergic reaction (e.g., anaphylaxis) to any ccIIV of any valency or any component of ccIIV4 is a contraindication to future use of ccIIV4. For RIV4, history of a severe allergic reaction (e.g., anaphylaxis) to any RIV of any valency or any component of RIV4 is a contraindication to future use of RIV4. This report focuses on recommendations for the use of vaccines for the prevention and control of seasonal influenza during the 2021-22 influenza season in the United States. A brief summary of the recommendations and a link to the most recent Background Document containing additional information are available at https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html. These recommendations apply to U.S.-licensed influenza vaccines used according to Food and Drug Administration-licensed indications. Updates and other information are available from CDC's influenza website (https://www.cdc.gov/flu); vaccination and health care providers should check this site periodically for additional information.

      6. Surveillance of influenza vaccination coverage--United States, 2007-08 through 2011-12 influenza seasons
        Lu PJ, Santibanez TA, Williams WW, Zhang J, Ding H, Bryan L, O'Halloran A, Greby SM, Bridges CB, Graitcer SB, Kennedy ED, Lindley MC, Ahluwalia IB, LaVail K, Pabst LJ, Harris L, Vogt T, Town M, Singleton JA.
        MMWR Surveill Summ. 2013 Oct 25;62(ss04):1-29.
        PROBLEM/CONDITION: Substantial improvement in annual influenza vaccination of recommended groups is needed to reduce the health effects of influenza and reach Healthy People 2020 targets. No single data source provides season-specific estimates of influenza vaccination coverage and related information on place of influenza vaccination and concerns related to influenza and influenza vaccination. REPORTING PERIOD: 2007-08 through 2011-12 influenza seasons. DESCRIPTION OF SYSTEMS: CDC uses multiple data sources to obtain estimates of vaccination coverage and related data that can guide program and policy decisions to improve coverage. These data sources include the National Health Interview Survey (NHIS), the Behavioral Risk Factor Surveillance System (BRFSS), the National Flu Survey (NFS), the National Immunization Survey (NIS), the Immunization Information Systems (IIS) eight sentinel sites, Internet panel surveys of health-care personnel and pregnant women, and the Pregnancy Risk Assessment and Monitoring System (PRAMS). RESULTS: National influenza vaccination coverage among children aged 6 months-17 years increased from 31.1% during 2007-08 to 56.7% during the 2011-12 influenza season as measured by NHIS. Vaccination coverage among children aged 6 months-17 years varied by state as measured by NIS. Changes from season to season differed as measured by NIS and NHIS. According to IIS sentinel site data, full vaccination (having either one or two seasonal influenza vaccinations, as recommended by the Advisory Committee on Immunization Practices for each influenza season, based on the child's influenza vaccination history) with up to two recommended doses for the 2011-12 season was 27.1% among children aged 6 months-8 years and was 44.3% for the youngest children (aged 6-23 months). Influenza vaccination coverage among adults aged ≥18 years increased from 33.0% during 2007-08 to 38.3% during the 2011-12 influenza season as measured by NHIS. Vaccination coverage by age group for the 2011-12 season as measured by BRFSS was <5 percentage points different from NHIS estimates, whereas NFS estimates were 6-8 percentage points higher than BRFSS estimates. Vaccination coverage among persons aged ≥18 years varied by state as measured by BRFSS. For adults aged ≥18 years, a doctor's office was the most common place for receipt of influenza vaccination (38.4%, BRFSS; 32.5%, NFS) followed by a pharmacy (20.1%, BRFSS; 19.7%, NFS). Overall, 66.9% of health-care personnel (HCP) reported having been vaccinated during the 2011-12 season, as measured by an Internet panel survey of HCP, compared with 62.4%, as estimated through NHIS. Vaccination coverage among pregnant women was 47.0%, as measured by an Internet panel survey of women pregnant during the influenza season, and 43.0%, as measured by BRFSS during the 2011-12 influenza season. Overall, as measured by NFS, 86.8% of adults aged ≥18 years rated the influenza vaccine as very or somewhat effective, and 46.5% of adults aged ≥18 years believed their risk for getting sick with influenza if unvaccinated was high or somewhat high. INTERPRETATION: During the 2011-12 season, influenza vaccination coverage varied by state, age group, and selected populations (e.g., HCP and pregnant women), with coverage estimates well below the Healthy People 2020 goal of 70% for children aged 6 months-17 years, 70% for adults aged ≥18 years, and 90% for HCP. PUBLIC HEALTH ACTIONS: Continued efforts are needed to encourage health-care providers to offer influenza vaccination and to promote public health education efforts among various populations to improve vaccination coverage. Ongoing surveillance to obtain coverage estimates and information regarding other issues related to influenza vaccination (e.g., knowledge, attitudes, and beliefs) is needed to guide program and policy improvements to reduce morbidity and mortality associated with influenza by increasing vaccination rates. Ongoing comparisons of telephone and Internet panel surveys with in-person surveys such as NHIS are needed for appropriate interpretation of data and resulting public health actions. Examination of results from all data sources is necessary to fully assess the various components of influenza vaccination coverage among different populations in the United States.

      7. How Structural Racism Works - Racist Policies as a Root Cause of U.S. Racial Health Inequities
        Bailey ZD, Feldman JM, Bassett MT.
        N Engl J Med. 2021 Feb 25;384(8):768-773.

      8. Association of provider recommendation and offer and influenza vaccination among adults aged ≥18 years - United States
        Lu PJ, Srivastav A, Amaya A, Dever JA, Roycroft J, Kurtz MS, O'Halloran A, Williams WW.
        Vaccine. 2018 Feb 1;36(6):890-898.
        BACKGROUND: Influenza vaccination has been recommended for all persons aged ≥6 months since 2010. METHODS: Data from the 2016 National Internet Flu Survey were analyzed to assess provider vaccination recommendations and early influenza vaccination during the 2016-17 season among adults aged ≥18 years. Predictive marginals from a multivariable logistic regression model were used to identify factors independently associated with early vaccine uptake by provider vaccination recommendation status. RESULTS: Overall, 24.0% visited a provider who both recommended and offered influenza vaccination, 9.0% visited a provider who only recommended but did not offer, 25.1% visited a provider who neither recommended nor offered, and 41.9% did not visit a doctor from July 1 through date of interview. Adults who reported that a provider both recommended and offered vaccine had significantly higher vaccination coverage (66.6%) compared with those who reported that a provider only recommended but did not offer (48.4%), those who neither received recommendation nor offer (32.0%), and those who did not visit a doctor during the vaccination period (28.8%). Results of multivariable logistic regression indicated that having received a provider recommendation, with or without an offer for vaccination, was significantly associated with higher vaccination coverage after controlling for demographic and access-to-care factors. CONCLUSIONS: Provider recommendation was significantly associated with influenza vaccination. However, overall, 67.0% of adults did not visit a doctor during the vaccination period or did visit a doctor but did not receive a provider recommendation. Evidence-based strategies such as client reminder/recall, standing orders, provider reminders, or health systems interventions in combination should be undertaken to improve provider recommendation and influenza vaccination coverage. Other factors significantly associated with a higher level of influenza vaccination included age ≥50 years, being Hispanic, having a college or higher education, having a usual place for medical care, and having public health insurance.

      9. Improving adult immunization equity: Where do the published research literature and existing resources lead?
        Prins W, Butcher E, Hall LL, Puckrein G, Rosof B.
        Vaccine. 2017 May 25;35(23):3020-3025.
        Evidence suggests that disparities in adult immunization (AI) rates are growing. Providers need adequate patient resources and information about successful interventions to help them engage in effective practices to reduce AI disparities. The primary purposes of this paper were to review and summarize the evidence base regarding interventions to reduce AI disparities and to scan for relevant resources that could support providers in their AI efforts to specifically target disparities. First, building on a literature review conducted by the U.S. Centers for Disease Control and Prevention, we searched the peer-reviewed literature to identify articles that either discussed interventions to reduce AI disparities or provided reasons and associations for disparities. We scanned the articles and conducted an internet search to identify tools and resources to support efforts to improve AI rates. We limited both searches to resources that addressed influenza, pneumococcal, hepatitis B, Tdap, and/or herpes zoster vaccinations. We found that most articles characterized AI disparities, but several discussed strategies for reducing AI disparities, including practice-based changes, communication and health literacy approaches, and partnering with community-based organizations. The resources we identified were largely fact sheets and handouts for patients and journal articles for providers. Most resources pertain to influenza vaccination and Spanish was the most prevalent language after English. More evaluation is needed to assess the health literacy levels of the materials. We conclude that additional research is needed to identify effective ways to reduce AI disparities and more resources are needed to support providers in their efforts. We recommend identifying best practices of high performers, further reviewing the appropriateness and usefulness of available resources, and prioritizing which gaps should be addressed.

  2. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Antimicrobial Resistance and Antibiotic Stewardship
      1. Reference susceptibility testing and genomic surveillance of clostridioides difficile, United States, 2012-17
        Gargis AS, Karlsson M, Paulick AL, Anderson KF, Adamczyk M, Vlachos N, Kent AG, McAllister GA, McKay SL, Halpin AL, Albrecht V, Campbell D, Korhonen L, Elkins CA, Rasheed JK, Guh AY, McDonald LC, Lutgring JD.
        Clin Infect Dis. 2022 Oct 8.
        BACKGROUND: Antimicrobial susceptibility testing (AST) is not routinely performed for Clostridioides difficile and data evaluating minimum inhibitory concentrations (MICs) are limited. We performed AST and whole genome sequencing (WGS) for 593 C. difficile isolates collected between 2012-2017 through the Centers for Disease Control and Prevention's Emerging Infections Program. METHODS: MICs to six antimicrobial agents (ceftriaxone, clindamycin, meropenem, metronidazole, moxifloxacin, and vancomycin) were determined using the reference agar dilution method according to Clinical and Laboratory Standards Institute guidelines. WGS was performed on all isolates to detect the presence of genes or mutations previously associated with resistance. RESULTS: Among all isolates, 98.5% displayed a vancomycin MIC ≤ 2 μg/mL and 97.3% displayed a metronidazole MIC ≤ 2 μg/mL. Ribotype 027 (RT027) isolates displayed higher vancomycin MICs (MIC50: 2 μg/mL; MIC90: 2 μg/mL) than non-RT027 isolates (MIC50: 0.5 μg/mL; MIC90: 1 μg/mL) (P < 0.01). No vanA/B genes were detected. RT027 isolates also showed higher MICs to clindamycin and moxifloxacin and were more likely to harbor associated resistance genes or mutations. CONCLUSIONS: Elevated MICs to antibiotics used for treatment of C. difficile infection were rare and there was no increase in MICs over time. The lack of vanA/B genes or mutations consistently associated with elevated vancomycin MICs suggests there are multifactorial mechanisms of resistance. Ongoing surveillance of C. difficile using reference AST and WGS to monitor MIC trends and the presence of antibiotic resistance mechanisms is essential.

    • Chronic Diseases and Conditions
      1. Age-related association between multimorbidity and mortality in US veterans with incident chronic kidney disease
        Burrows NR, Koyama AK, Choudhury D, Yu W, Pavkov ME, Nee R, Cheung AK, Norris KC, Yan G.
        Am J Nephrol. 2022 Oct 7:1-11.
        INTRODUCTION: Mortality is an important long-term indicator of the public health impact of chronic kidney disease (CKD). We investigated the role of individual comorbidities and multimorbidity on age-specific mortality risk among US veterans with new-onset CKD. METHODS: The cohort included 892,005 veterans aged ≥18 years with incident CKD stage 3 between January 2004 and April 2018 in the US Veterans Health Administration (VHA) system and followed until death, December 2018, or up to 10 years. Incident CKD was defined as the first-time estimated glomerular filtration rate (eGFR) was <60 mL/min/1.73 m2 for >3 months. Comorbidities were ascertained using inpatient and outpatient clinical records in the VHA system and Medicare claims. We estimated death rates for any cardiovascular disease (CVD, a composite of 6 CVD conditions) and 15 non-CVD comorbidities, and adjusted risks of death (hazard ratio [HR], 95% confidence interval [CI]) overall and by age group at CKD incidence. RESULTS: At CKD incidence, the mean age was 72 years, and 97% were male; the mean eGFR was 52 mL/min/1.73 m2, and 95% had ≥2 comorbidities (median, 4) in addition to CKD. During a median follow-up of 4.5 years, among the 16 comorbidities, CVD was associated with the highest relative risk of death in younger veterans (HR 1.96 [95% CI: 1.61-2.37] in ages 18-44 years and HR 1.66 [1.63-1.70] in ages 45-64 years). Dementia was associated with the highest relative risk of death among older veterans (HR 1.71 [1.68-1.74] in ages 65-84 years and HR 1.69 [1.65-1.73] in ages 85-100 years). The additive effect of multimorbidity on risk of death was stronger in younger than older veterans. Compared to having 1 or no comorbidity at CKD onset, the risk of death with ≥5 comorbidities was >7-fold higher among veterans aged 18-44 years and >2-fold higher among veterans aged 85-100 years. CONCLUSION: The large burden of comorbidities in US veterans with newly identified CKD places them at the risk of premature death. Compared with older veterans, younger veterans with multiple comorbidities, particularly with CVD, at CKD onset are at an even higher relative risk of death.

      2. Survival and epidemiology of amyotrophic lateral sclerosis (ALS) cases in the Chicago and Detroit metropolitan cohort: incident cases 2009-2011 and survival through 2018
        Punjani R, Larson TC, Wagner L, Davis B, Horton DK, Kaye W.
        Amyotroph Lateral Scler Frontotemporal Degener. 2022 Oct 5:1-9.
        Amyotrophic lateral sclerosis (ALS) is a fatal, progressive neurodegenerative disorder. The National ALS Registry launched surveillance projects to understand the distribution of ALS in targeted geographic cohorts. Objective: To describe the demographics, incidence, and survival of persons with ALS (PALS) identified in the Chicago and Detroit area population-based cohort. Methods: Neurologists in the catchment area provided case reports for eligible ALS cases diagnosed and/or cared for from 1 January 2009 through 31 December 2011. Crude incidence rates were calculated for 2009-2011 and stratified by race and ethnicity. Using data from the National Death Index through 2018, we modeled the effect of patient covariates on mortality using the Cox proportional hazard regression. Results: Of the 574 cases, 372 (64.8%) were diagnosed from 2009 to 2011. The combined crude incidence rates for 2009, 2010, and 2011 were 1.44, 1.53, and 1.73 cases per 100,000 person-years, respectively. Of the 486 subjects with complete survival data, 81% were deceased at the end of follow-up. Median survival time was 2.2 years, with 30% and 9% of subjects surviving past 5 and 10 years after diagnosis, respectively. Additionally, female PALS and PALS with longer time between symptom onset and diagnosis experienced longer survival. Nonwhites also experienced longer survival than Whites, except for those cases diagnosed in the younger age categories. Conclusion: Understanding the survival of ALS patients can aid in understanding variable prognostic factors, which can potentially extend survival and improve disease management.

      3. Surveillance for sickle cell disease - sickle cell data collection program, two states, 2004-2018
        Snyder AB, Lakshmanan S, Hulihan MM, Paulukonis ST, Zhou M, Horiuchi SS, Abe K, Pope SN, Schieve LA.
        MMWR Surveill Summ. 2022 Oct 7;71(9):1-18.
        PROBLEM/CONDITION: Sickle cell disease (SCD), an inherited blood disorder affecting an estimated 100,000 persons in the United States, is associated with multiple complications and reduced life expectancy. Complications of SCD can include anemia, debilitating acute and chronic pain, infection, acute chest syndrome, stroke, and progressive organ damage, including decreased cognitive function and renal failure. Early diagnosis, screenings and preventive interventions, and access to specialist health care can decrease illness and death. Population-based public health surveillance is critical to understanding the course and outcomes of SCD as well as the health care use, unmet health care needs, and gaps in essential services of the population affected by SCD. PERIOD COVERED: 2004-2018. DESCRIPTION OF THE PROGRAM: In 2015, CDC established the Sickle Cell Data Collection (SCDC) program to characterize the epidemiology of SCD in two states (California and Georgia). Previously, surveillance for SCD was conducted by two short-term projects: Registry and Surveillance System for Hemoglobinopathies (RuSH), which was conducted during 2010-2012 and included 2004-2008 data, and Public Health Research, Epidemiology, and Surveillance for Hemoglobinopathies (PHRESH), which was conducted during 2012-2014 and included 2004-2008 data. Both California and Georgia participated in RuSH and PHRESH, which guided the development of the SCDC methods and case definitions. SCDC is a population-based tracking system that uses comprehensive data linkages in state health systems. These linkages serve to synthesize and disseminate population-based, longitudinal data for persons identified with SCD from multiple sources using selected International Classification of Diseases, Ninth Revision, Clinical Modification, and Tenth Revision codes and laboratory results confirmed through state newborn screening (NBS) programs or clinic case reporting. Administrative and clinical data sources include state Medicaid and Children's Health Insurance Program databases, death certificates, NBS programs, hospital discharge and emergency department records, and clinical records or case reports. Data from multiple sources and years are linked and deduplicated so that states can analyze and report on SCD population prevalence, demographic characteristics, health care access and use, and health outcomes. The SCD case definition is based on an algorithm that classifies cases with laboratory confirmation as confirmed cases and those with a reported clinical diagnosis or three or more diagnostic codes over a 5-year period from an administrative data source as probable cases. In 2019, nine states (Alabama, California, Georgia, Indiana, Michigan, Minnesota, North Carolina, Tennessee, and Virginia) were funded as part of an SCDC capacity-building initiative. The newly funded states developed strategies for SCD case identification and data linkage similar to those used by California and Georgia. As of 2021, the SCDC program had expanded to 11 states with the addition of Colorado and Wisconsin. RESULTS: During 2004-2018, the cumulative prevalence of confirmed and probable SCD cases identified in California and Georgia was 9,875 and 14,777 cases, respectively. The 2018 annual prevalence count was 6,027 cases for California and 9,141 for Georgia. Examination of prevalence counts by contributing data source during 2014-2018 revealed that each data source captured 16%-71% of cases in California and 17%-87% in Georgia; therefore, no individual source is sufficient to estimate statewide population prevalence. The proportion of pediatric SCD patients (children aged 0-18 years) was 27% in California and 40% in Georgia. The percentage of females with SCD in California and Georgia was 58% and 57%, respectively. Of the cases with SCD genotyping data available (n = 5,856), 63% of patients had sickle cell anemia. SCDC data have been used to directly apprise health care providers and policymakers about health care needs and gaps for patients with SCD. For example, an SCDC Georgia assessment indicated that 10% of babies born during 2004-2016 with SCD lived more than a 1-hour drive from any SCD specialty care option, and another 14% lived within a 1-hour drive of a periodic SCD specialty clinic only. Likewise, an SCDC California assessment indicated that during 2016-2018, most patients with SCD in Los Angeles County lived approximately 15-60 miles from hematologists experienced in SCD care. A surveillance capacity and performance assessment of all 11 SCDC states during 2020-2021 indicated that states differed in the availability of data sources used for SCD surveillance and the time frames for accessing each state data source. Nonetheless, methods for standardizing reporting were developed across all participating states. INTERPRETATION: This report is the first comprehensive description of CDC's efforts in collaboration with participating states to establish, maintain, and expand SCD surveillance through the SCDC program to improve health outcomes for persons living with SCD. Findings from California and Georgia analyses highlighted a need for additional SCD specialty clinics. Despite different approaches, expansion of SCDC to multiple states was possible using standardized, rigorous methods developed across all participating states for reporting on disease prevalence, health care needs and use, and deaths. PUBLIC HEALTH ACTION: Findings from surveillance can be used to improve and monitor care and outcomes for persons with SCD. These and other SCDC analyses have had a role in opening new SCD clinics, educating health care providers, developing state health care policies, and guiding new research initiatives. Public health officials can use this report as a guiding framework to plan or implement surveillance programs for persons with SCD. Both data-related activities (data sources; patient identifiers; and obtaining, transferring, and linking data) and the administrative considerations (stakeholder engagement, costs and resources, and long-term sustainability) are crucial to the success of these programs.

      4. INTRODUCTION: Family history is an established risk factor for both cardiovascular disease (CVD) and diabetes; however, no study has presented population-based prevalence estimates of family histories of CVD and diabetes and examined their joint impact on prevalence of diabetes, CVD, cardiometabolic risk factors, and mortality risk. METHODS: We analyzed data from a representative sample of the US adult population including 29,440 participants from the National Health and Nutrition Examination Survey (2007-2018) and assessed self-reported first-degree family history of diabetes and CVD (premature heart disease before age of 50 years) as well as meeting criteria and/or having risk factors for CVD and diabetes. RESULTS: Participants with joint family history exhibit 6.5 greater odds for having both diseases and are diagnosed with diabetes 6.6 years earlier than participants without family history. Healthy participants without prevalent CVD or diabetes but with joint family history exhibit a greater prevalence of diabetes risk factors compared to no family history counterparts. Joint family history is associated with an increase in all-cause mortality, but with no interactive effect. CONCLUSION: Over 44% of the US adult population has a family history of CVD and/or diabetes that is comparable in risk to common cardiometabolic risk factors. This wide presence of high-risk family history and its simplicity of ascertainment suggests that clinical and public health efforts should collect and act on joint family history of CVD and diabetes to improve population efforts in the prevention and early detection of these common chronic diseases.

    • Communicable Diseases
      1. Identification of small molecules with improved potency against orthopoxviruses from vaccinia to smallpox
        Brown LE, Seitz S, Kondas AV, Marcyk PT, Filone CM, Hossain MM, Schaus SE, Olson VA, Connor JH.
        Antimicrob Agents Chemother. 2022 Oct 12:e0084122.
        The genus Orthopoxvirus contains several human pathogens, including vaccinia, monkeypox, cowpox, and variola virus, the causative agent of smallpox. Although there are a few effective vaccines, widespread prophylactic vaccination has ceased and is unlikely to resume, making therapeutics increasingly important to treat poxvirus disease. Here, we described efforts to improve the potency of the anti-poxvirus small molecule CMLDBU6128. This class of small molecules, referred to as pyridopyrimidinones (PDPMs), showed a wide range of biological activities. Through the synthesis and testing of several exploratory chemical libraries based on this molecule, we identified several compounds that had increased potency from the micromolar into the nanomolar range. Two compounds, designated (12) and (16), showed inhibitory concentrations of 326 nM and 101 nM, respectively, which was more than a 10-fold increase in potency to CMLDBU6128 with an inhibitory concentration of around 6 μM. We also expanded our investigation of the breadth of action of these molecules and showed that they can inhibit the replication of variola virus, a related orthopoxvirus. Together, these findings highlighted the promise of this new class of antipoxviral agents as broad-spectrum small molecules with significant potential to be developed as antiviral therapy. This would add a small molecule option for therapy of spreading diseases, including monkeypox and cowpox viruses, that would also be expected to have efficacy against smallpox.

      2. Surveillance for acute respiratory illnesses in pediatric chronic care facilities
        Saiman L, Prill MM, Wilmont S, Neu N, Alba L, Hill-Ricciuti A, Larson E, Whitaker B, Lu X, Garg S, Gerber SI, Kim L.
        J Pediatric Infect Dis Soc. 2022 Oct 11.
        Overall, 119 (33%) of 364 pediatric chronic care facility residents experienced 182 acute respiratory illnesses (ARIs) that met the surveillance definition which led to 31 (17%) emergency room visits, 34 (19%) acute care hospitalizations, and/or 25 (14%) ICU admissions. Continued PCR-positivity was observed in 35% of ARIs during follow-up testing.

      3. Seroprevalence studies can estimate proportions of the population that have been infected or vaccinated, including infections that were not reported because of the lack of symptoms or testing. Based on information from studies in the United States from mid-summer 2020 through the end of 2021, we describe proportions of the population with antibodies to SARS-CoV-2 as functions of age and time. Slices through these surfaces at arbitrary times provide initial and target conditions for simulation modeling. They also provide the information needed to calculate age-specific forces of infection, attack rates, and - together with contact rates - age-specific probabilities of infection on contact between susceptible and infectious people. We modified the familiar Susceptible-Exposed-Infectious-Removed (SEIR) model to include features of the biology of COVID-19 that might affect transmission of SARS-CoV-2 and stratified by age and location. We consulted the primary literature or subject matter experts for contact rates and other parameter values. Using time-varying Oxford COVID-19 Government Response Tracker assessments of US state and DC efforts to mitigate the pandemic and compliance with non-pharmaceutical interventions (NPIs) from a YouGov survey fielded in the US during 2020, we estimate that the efficacy of social-distancing when possible and mask-wearing otherwise at reducing susceptibility or infectiousness was 31% during the fall of 2020. Initialized from seroprevalence among people having commercial laboratory tests for purposes other than SARS-CoV-2 infection assessments on 7 September 2020, our age- and location-stratified SEIR population model reproduces seroprevalence among members of the same population on 25 December 2020 quite well. Introducing vaccination mid-December 2020, first of healthcare and other essential workers, followed by older adults, people who were otherwise immunocompromised, and then progressively younger people, our metapopulation model reproduces seroprevalence among blood donors on 4 April 2021 less well, but we believe that the discrepancy is due to vaccinations being under-reported or blood donors being disproportionately vaccinated, if not both. As experimenting with reliable transmission models is the best way to assess the indirect effects of mitigation measures, we determined the impact of vaccination, conditional on NPIs. Results indicate that, during this period, vaccination substantially reduced infections, hospitalizations and deaths. This manuscript was submitted as part of a theme issue on "Modelling COVID-19 and Preparedness for Future Pandemics."

      4. Epidemiological and clinical characteristics of patients with monkeypox in the GeoSentinel Network: a cross-sectional study
        Angelo KM, Smith T, Camprubí-Ferrer D, Balerdi-Sarasola L, Díaz Menéndez M, Servera-Negre G, Barkati S, Duvignaud A, Huber KL, Chakravarti A, Bottieau E, Greenaway C, Grobusch MP, Mendes Pedro D, Asgeirsson H, Popescu CP, Martin C, Licitra C, de Frey A, Schwartz E, Beadsworth M, Lloveras S, Larsen CS, Guagliardo SA, Whitehill F, Huits R, Hamer DH, Kozarsky P, Libman M.
        Lancet Infect Dis. 2022 Oct 7.
        BACKGROUND: The early epidemiology of the 2022 monkeypox epidemic in non-endemic countries differs substantially from the epidemiology previously reported from endemic countries. We aimed to describe the epidemiological and clinical characteristics among individuals with confirmed cases of monkeypox infection. METHODS: We descriptively analysed data for patients with confirmed monkeypox who were included in the GeoSentinel global clinical-care-based surveillance system between May 1 and July 1 2022, across 71 clinical sites in 29 countries. Data collected included demographics, travel history including mass gathering attendance, smallpox vaccination history, social history, sexual history, monkeypox exposure history, medical history, clinical presentation, physical examination, testing results, treatment, and outcomes. We did descriptive analyses of epidemiology and subanalyses of patients with and without HIV, patients with CD4 counts of less than 500 cells per mm(3) or 500 cells per mm(3) and higher, patients with one sexual partner or ten or more sexual partners, and patients with or without a previous smallpox vaccination. FINDINGS: 226 cases were reported at 18 sites in 15 countries. Of 211 men for whom data were available, 208 (99%) were gay, bisexual, or men who have sex with men (MSM) with a median age of 37 years (range 18-68; IQR 32-43). Of 209 patients for whom HIV status was known, 92 (44%) men had HIV infection with a median CD4 count of 713 cells per mm(3) (range 36-1659; IQR 500-885). Of 219 patients for whom data were available, 216 (99%) reported sexual or close intimate contact in the 21 days before symptom onset; MSM reported a median of three partners (IQR 1-8). Of 195 patients for whom data were available, 78 (40%) reported close contact with someone who had confirmed monkeypox. Overall, 30 (13%) of 226 patients were admitted to hospital; 16 (53%) of whom had severe illness, defined as hospital admission for clinical care rather than infection control. No deaths were reported. Compared with patients without HIV, patients with HIV were more likely to have diarrhoea (p=0·002), perianal rash or lesions (p=0·03), and a higher rash burden (median rash burden score 9 [IQR 6-21] for patients with HIV vs median rash burden score 6 [IQR 3-14] for patients without HIV; p<0·0001), but no differences were identified in the proportion of men who had severe illness by HIV status. INTERPRETATION: Clinical manifestations of monkeypox infection differed by HIV status. Recommendations should be expanded to include pre-exposure monkeypox vaccination of groups at high risk of infection who plan to engage in sexual or close intimate contact. FUNDING: US Centers for Disease Control and Prevention, International Society of Travel Medicine.

      5. Standardized enhanced adherence counseling for improved HIV viral suppression among children and adolescents in Homa Bay and Turkana Counties, Kenya
        Masaba RO, Woelk G, Herrera N, Siamba S, Simiyu R, Ochanda B, Okomo G, Odionyi J, Audo M, Mwangi E.
        Medicine (Baltimore). 2022 Oct 7;101(40):e30624.
        Viral suppression is suboptimal among children and adolescents on antiretroviral therapy (ART) in Kenya. We implemented and evaluated a standardized enhanced adherence counseling (SEAC) package to improve viral suppression in children and adolescents with suspected treatment failure in Homa Bay and Turkana. The SEAC package, implemented from February 2019 to September 2020, included: standard procedures operationalizing the enhanced adherence counseling (EAC) process; provider training on psychosocial support and communication skills for children living with HIV and their caregivers; mentorship to providers and peer educators on EAC processes; and individualized case management. We enrolled children and adolescents aged 0 to 19 years with suspected treatment failure (viral load [VL] >1000 copies/mL) who received EAC before standardization as well as those who received SEAC in a pre-post evaluation of the SEAC package conducted in 6 high-volume facilities. Pre-post standardization comparisons were performed using Wilcoxon-Mann-Whitney and Pearson's chi-square tests at a 5% level of significance. Multivariate logistic regression was performed to identify factors associated with viral resuppression. The study enrolled 741 participants, 595 pre- and 146 post-SEAC implementation. All post-SEAC participants attended at least 1 EAC session, while 17% (n = 98) of pre-SEAC clients had no record of EAC attendance. Time to EAC following the detection of high VL was reduced by a median of 8 days, from 49 (interquartile range [IQR]: 23.0-102.5) to 41 (IQR: 20.0-67.0) days pre- versus post-SEAC (P = .006). Time to completion of at least 3 sessions was reduced by a median of 12 days, from 59.0 (IQR: 36.0-91.0) to 47.5 (IQR: 33.0-63.0) days pre- versus post-SEAC (P = .002). A greater percentage of clients completed the recommended minimum 3 EAC sessions at post-SEAC, 88.4% (n = 129) versus 61.1% (n = 363) pre-SEAC, P < .001. Among participants with a repeat VL within 3 months following the high VL, SEAC increased viral suppression from 34.6% (n = 76) to 52.5% (n = 45), P = .004. Implementation of the SEAC package significantly reduced the time to initiate EAC and time to completion of at least 3 EAC sessions, and was significantly associated with viral suppression in children and adolescents with suspected treatment failure.

      6. Monkeypox case investigation - Cook County Jail, Chicago, Illinois, July-August 2022
        Hagan LM, Beeson A, Hughes S, Hassan R, Tietje L, Meehan AA, Spencer H, Turner J, Richardson M, Howard J, Schultz A, Ali S, Butler MM, Arce Garza D, Morgan CN, Kling C, Baird N, Townsend MB, Carson WC, Lowe D, Wynn NT, Black SR, Kerins JL, Rafinski J, Defuniak A, Auguston P, Mosites E, Ghinai I, Zawitz C.
        MMWR Morb Mortal Wkly Rep. 2022 Oct 7;71(40):1271-1277.
        Knowledge about monkeypox transmission risk in congregate settings is limited. In July 2022, the Chicago Department of Public Health (CDPH) confirmed a case of monkeypox in a person detained in Cook County Jail (CCJ) in Chicago, Illinois. This case was the first identified in a correctional setting in the United States and reported to CDC during the 2022 multinational monkeypox outbreak. CDPH collaborated with CCJ, the Illinois Department of Public Health (IDPH), and CDC to evaluate transmission risk within the facility. Fifty-seven residents were classified as having intermediate-risk exposures to the patient with monkeypox during the 7-day interval between the patient's symptom onset and his isolation. (Intermediate-risk exposure was defined as potentially being within 6 ft of the patient with monkeypox for a total of ≥3 hours cumulatively, without wearing a surgical mask or respirator, or potentially having contact between their own intact skin or clothing and the skin lesions or body fluids from the patient or with materials that were in contact with the patient's skin lesions or body fluids.) No secondary cases were identified among a subset of 62% of these potentially exposed residents who received symptom monitoring, serologic testing, or both. Thirteen residents accepted postexposure prophylaxis (PEP), with higher acceptance among those who were offered counseling individually or in small groups than among those who were offered PEP together in a large group. Monkeypox virus (MPXV) DNA, but no viable virus, was detected on one surface in a dormitory where the patient had been housed with other residents before he was isolated. Although monkeypox transmission might be limited in similar congregate settings in the absence of higher-risk exposures, congregate facilities should maintain recommended infection control practices in response to monkeypox cases, including placing the person with monkeypox in medical isolation and promptly and thoroughly cleaning and disinfecting spaces where the person has spent time. In addition, officials should provide information to residents and staff members about monkeypox symptoms and transmission modes, facilitate confidential monkeypox risk and symptom disclosure and prompt medical evaluation for symptoms that are reported, and provide PEP counseling in a private setting.

      7. Increase in acute respiratory illnesses among children and adolescents associated with rhinoviruses and enteroviruses, including enterovirus D68 - United States, July-September 2022
        Ma KC, Winn A, Moline HL, Scobie HM, Midgley CM, Kirking HL, Adjemian J, Hartnett KP, Johns D, Jones JM, Lopez A, Lu X, Perez A, Perrine CG, Rzucidlo AE, McMorrow ML, Silk BJ, Stein Z, Vega E, Hall AJ.
        MMWR Morb Mortal Wkly Rep. 2022 Oct 7;71(40):1265-1270.
        Increases in severe respiratory illness and acute flaccid myelitis (AFM) among children and adolescents resulting from enterovirus D68 (EV-D68) infections occurred biennially in the United States during 2014, 2016, and 2018, primarily in late summer and fall. Although EV-D68 annual trends are not fully understood, EV-D68 levels were lower than expected in 2020, potentially because of implementation of COVID-19 mitigation measures (e.g., wearing face masks, enhanced hand hygiene, and physical distancing) (1). In August 2022, clinicians in several geographic areas notified CDC of an increase in hospitalizations of pediatric patients with severe respiratory illness and positive rhinovirus/enterovirus (RV/EV) test results.* Surveillance data were analyzed from multiple national data sources to characterize reported trends in acute respiratory illness (ARI), asthma/reactive airway disease (RAD) exacerbations, and the percentage of positive RV/EV and EV-D68 test results during 2022 compared with previous years. These data demonstrated an increase in emergency department (ED) visits by children and adolescents with ARI and asthma/RAD in late summer 2022. The percentage of positive RV/EV test results in national laboratory-based surveillance and the percentage of positive EV-D68 test results in pediatric sentinel surveillance also increased during this time. Previous increases in EV-D68 respiratory illness have led to substantial resource demands in some hospitals and have also coincided with increases in cases of AFM (2), a rare but serious neurologic disease affecting the spinal cord. Therefore, clinicians should consider AFM in patients with acute flaccid limb weakness, especially after respiratory illness or fever, and ensure prompt hospitalization and referral to specialty care for such cases. Clinicians should also test for poliovirus infection in patients suspected of having AFM because of the clinical similarity to acute flaccid paralysis caused by poliovirus. Ongoing surveillance for EV-D68 is critical to ensuring preparedness for possible future increases in ARI and AFM.

      8. Respiratory virus surveillance among children with acute respiratory illnesses - New Vaccine Surveillance Network, United States, 2016-2021
        Perez A, Lively JY, Curns A, Weinberg GA, Halasa NB, Staat MA, Szilagyi PG, Stewart LS, McNeal MM, Clopper B, Zhou Y, Whitaker BL, LeMasters E, Harker E, Englund JA, Klein EJ, Selvarangan R, Harrison CJ, Boom JA, Sahni LC, Michaels MG, Williams JV, Langley GE, Gerber SI, Campbell A, Hall AJ, Rha B, McMorrow M.
        MMWR Morb Mortal Wkly Rep. 2022 Oct 7;71(40):1253-1259.
        The New Vaccine Surveillance Network (NVSN) is a prospective, active, population-based surveillance platform that enrolls children with acute respiratory illnesses (ARIs) at seven pediatric medical centers. ARIs are caused by respiratory viruses including influenza virus, respiratory syncytial virus (RSV), human metapneumovirus (HMPV), human parainfluenza viruses (HPIVs), and most recently SARS-CoV-2 (the virus that causes COVID-19), which result in morbidity among infants and young children (1-6). NVSN estimates the incidence of pathogen-specific pediatric ARIs and collects clinical data (e.g., underlying medical conditions and vaccination status) to assess risk factors for severe disease and calculate influenza and COVID-19 vaccine effectiveness. Current NVSN inpatient (i.e., hospital) surveillance began in 2015, expanded to emergency departments (EDs) in 2016, and to outpatient clinics in 2018. This report describes demographic characteristics of enrolled children who received care in these settings, and yearly circulation of influenza, RSV, HMPV, HPIV1-3, adenovirus, human rhinovirus and enterovirus (RV/EV),* and SARS-CoV-2 during December 2016-August 2021. Among 90,085 eligible infants, children, and adolescents (children) aged <18 years(†) with ARI, 51,441 (57%) were enrolled, nearly 75% of whom were aged <5 years; 43% were hospitalized. Infants aged <1 year accounted for the largest proportion (38%) of those hospitalized. The most common pathogens detected were RV/EV and RSV. Before the emergence of SARS-CoV-2, detected respiratory viruses followed previously described seasonal trends, with annual peaks of influenza and RSV in late fall and winter (7,8). After the emergence of SARS-CoV-2 and implementation of associated pandemic nonpharmaceutical interventions and community mitigation measures, many respiratory viruses circulated at lower-than-expected levels during April 2020-May 2021. Beginning in summer 2021, NVSN detected higher than anticipated enrollment of hospitalized children as well as atypical interseasonal circulation of RSV. Further analyses of NVSN data and continued surveillance are vital in highlighting risk factors for severe disease and health disparities, measuring the effectiveness of vaccines and monoclonal antibody-based prophylactics, and guiding policies to protect young children from pathogens such as SARS-CoV-2, influenza, and RSV.

      9. Medically attended influenza during pregnancy in the 2019-2020 and 2020-2021 influenza seasons
        Irving SA, Shuster E, Henderson JT, Li DK, Ferber J, Odouli R, Munoz FM, Nicholson E, Hadden L, Juergens M, Newes-Adeyi G, Reichle L, Arriola CS, Dawood FS, Daugherty M, Wielgosz K, Naleway AL.
        Obstet Gynecol. 2022 Oct 6.
        Influenza testing and case-confirmation rates in pregnant populations have not been reported during the coronavirus disease 2019 (COVID-19) pandemic. Using electronic medical record data from a cohort of nearly 20,000 pregnancies in the United States, this retrospective cohort study examines the frequency of acute respiratory or febrile illness encounters, influenza testing, and influenza positivity during the 2020-2021 influenza season, which occurred during the COVID-19 pandemic, compared with the 2019-2020 influenza season, which largely did not. The ratios of influenza tests to acute respiratory or febrile illness visits were similar in the 2019-2020 and 2020-2021 influenza seasons (approximately 1:8 and 1:9, respectively) but were low and varied by study site. Although influenza testing in pregnant patients continued in the 2020-2021 season, when severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) circulation was widespread in the United States, no cases of influenza were identified in our study cohort.

      10. Investigation of a COVID-19 outbreak at a regional prison, Northern Uganda, September 2020
        Migisha R, Morukileng J, Biribawa C, Kadobera D, Kisambu J, Bulage L, Ndyabakira A, Katana E, Mills LA, Ario AR, Harris JR.
        Pan Afri Med J. 2022 ;43.
        Despite implementing measures to prevent introduction of COVID-19 in prisons, a COVID-19 outbreak occurred at Moroto Prison, northern Uganda in September 2020. We investigated factors associated with the introduction and spread of COVID-19 in the prison. A case was PCR-confirmed SARS-CoV-2 infection in a prisoner/staff at Moroto Prison during August-September 2020. We reviewed prison medical records to identify case-patients and interviewed prison and hospital staff to understand possible infection mechanisms for the index case-patient and opportunities for spread. In a retrospective cohort study, we interviewed all prisoners and available staff to identify risk factors. Data were analyzed using log-binomial regression. On September 1, 2020, a recently-hospitalized prisoner with unrecognized SARS-CoV-2 infection was admitted to Moroto Prison quarantine. He had become infected while sharing a hospital ward with a subsequently-diagnosed COVID-19 patient. A sample taken from the hospitalized prisoner on August 20 tested positive on September 3. Mass reactive testing at the prison on September 6, 14, and 15 revealed infection among 202/692 prisoners and 8/90 staff (overall attack rate=27%). One prison staff and one prisoner who cared for the sick prisoner while at the hospital re-entered the main prison without quarantining. Both tested positive on September 6. Food and cleaning service providers also regularly transited between quarantine and unrestricted prison areas. Using facemasks >50% of the time (adjusted risk ratio [aRR]=0.26; 95%CI: 0.13-0.54), or in combination with handwashing after touching surfaces (aRR=0.25; 95%CI: 0.14-0.46) were protective. Prisoners recently transferred from other facilities to Moroto Prison had an increased risk of infection (aRR=1.50; 95%CI: 1.02-2.22). COVID-19 was likely introduced into Moroto Prison quarantine by a prisoner with hospital-acquired infection and delayed test results, and/or by caretakers who were not quarantined after hospital exposures. The outbreak may have amplified via shared food/cleaning service providers who transited between quarantined and non-quarantined prisoners. Facemasks and handwashing were protective. Reduced test turnaround time for the hospitalized prisoner could have averted this outbreak. Testing incoming prisoners for SARS-CoV-2 before quarantine, providing unrestricted soap/water for handwashing, and universal facemask use in prisons could mitigate risk of future outbreaks. © Richard Migisha et al.

      11. Tuberculosis surveillance in Dushanbe: A way forward to strengthening
        Sidzhotkhonov AA, Tilloeva ZK, Pirmakhmadzoda BP, Dzhafarov ND, Amirzoda AA, Nabirova D.
        Tuberc Lung Dis. 2022 ;100(3):33-38.
        The objective: to evaluate the current tuberculosis surveillance system in Dushanbe for each of the following parameters: simplicity, flexibility, acceptability, sensitivity, and promptness of response; to provide recommendations to improve the system. Methods. The tuberculosis surveillance system was evaluated in the city of Dushanbe in April-May 2021 using updated guidelines of the Center for Disease Control and Prevention for evaluating public health surveillance systems, 2006. Result: The system fulfills its goals and objectives, but has gaps in promptness of response, acceptability and representativeness. Conclusions. The tuberculosis surveillance system needs to be improved and requires professional development training of family medicine workers, TB specialists, and epidemiologists. © 2022 New Terra Publishing House. All rights reserved.

    • Disaster Preparedness and Emergency Services
      1. Time motion studies for conduct of population monitoring during functional radiological exercises at community reception centers
        Finklea L, Salame-Alfie A, Ansari A.
        Disaster Med Public Health Prep. 2022 Oct 10:1-8.
        OBJECTIVE: The objectives of this study were to: validate current capacity estimates for radiological emergency response by collecting time motion observations from stations that would be used for screening and decontaminating populations, and use collected times to evaluate potential impact on current throughput calculations. METHODS: Time observations were collected at 11 functional radiation exercises across the country and aggregated for analysis for population monitoring activities, including contamination screening, decontamination, and registration. Collected times were compared to published estimates in current planning guidance, and evaluated to determine the suitability of using exercise observations to estimate throughput capacity. RESULTS: 2532-time observations were collected from 11 functional exercises. Of those, 2380 were validated and used for analysis. Contamination screening times varied greatly from current guidance, ranging from 19% below to 267% above existing estimates. Measurements indicate that capacity to perform contamination screening is significantly overestimated when using current estimates of service times and calculations when compared to observed aggregate service times. CONCLUSION: Aggregate service time data presented in this study can be used to yield a more realistic estimate of capacity to respond to a radiation event.

      2. Public health readiness for citizen science: Health department experiences
        Siddiqi SM, Uscher-Pines L, Leinhos M, Dekker D, Chari R.
        J Public Health Manag Pract. 2022 Oct 9.
        OBJECTIVE: The aim of this study was to examine the experiences of US health departments with citizen science. DESIGN: In 2019, we conducted a national survey of 272 local health department (LHD) representatives about knowledge and attitudes, readiness, experiences, and barriers related to citizen science (response rate = 45%). SETTING: LHDs in the United States in 2019. PARTICIPANTS: LHD representatives. MAIN OUTCOME MEASURES: Knowledge and attitudes, readiness, experiences, and barriers related to citizen science. RESULTS: Sixty-two percent of respondents reported LHD experience with citizen science in areas such as health promotion, emergency preparedness, and environmental health. LHDs in large jurisdictions (78%) were more likely to report staff familiarity with citizen science than small (51%) and medium (59%) jurisdictions (P = .01). Although 64% reported readiness for citizen science, only 32% reported readiness for community-led activities. We found that LHDs use citizen science more for community engagement activities, such as public education, than data collection activities. Respondents indicated that staff education and training in citizen science methods, funding, and partners with relevant expertise were priority needs. CONCLUSION: LHDs have leveraged citizen science for community engagement, but barriers to technical uses remain.

    • Environmental Health
      1. Early exposure to flame retardants is prospectively associated with anxiety symptoms in adolescents: A prospective birth cohort study
        Strawn JR, Xu Y, Cecil KM, Khoury J, Altaye M, Braun JM, Lanphear BP, Sjodin A, Chen A, Yolton K.
        Depress Anxiety. 2022 Oct 11.
        BACKGROUND: Anxiety disorders emerge during childhood and adolescence and are frequently preceded by subsyndromal anxiety symptoms. Environmental toxicants, including gestational polybrominated diphenyl ether (PBDE) exposure, are associated with neuropsychiatric sequelae; however, the role of PBDEs as risk factors for anxiety in adolescence is unclear. METHODS: Using data from the Health Outcomes and Measures of the Environment (HOME) Study, a prospective pregnancy and birth cohort enrolled from 2003 to 2006, we investigated the relationship between gestational serum PBDE concentrations and anxiety symptoms in adolescents (N = 236). We measured five PBDE congeners (PBDE-28, -47, -99, -100, and -153) at 16 ± 3 weeks of gestation and calculated their sum (∑PBDE). We assessed self-reported anxiety symptoms using the Screen for Child Anxiety Related Emotional Disorders (SCARED) and depressive symptoms using the Children's Depression Inventory (CDI-2) at age 12 years. We estimated the associations of maternal PBDE concentrations with child anxiety and depressive symptoms using multivariable linear regression and modified Poisson regression. Covariates included child sex, maternal race, maternal age at delivery, maternal marital status, maternal education, and household income at the 12-year study visit as well as maternal depressive and anxiety symptoms. Sensitivity analyses were performed to control for maternal lead and mercury at delivery. RESULTS: After adjusting for predetermined covariates, each doubling in maternal PBDE concentrations was associated with increased SCARED scores (e.g., for ∑PBDE, SCARED total score, β = 1.6 95% confidence interval [CI]: 0.3-2.9, p = .019) and a nonsignificant increase in depressive symptoms (e.g., for CDI total score, β = .8, 95% CI: -0.2-1.8, p = .11). CONCLUSIONS: Gestational serum PBDE concentrations just before mid-pregnancy and during a period of active cortical and limbic neurogenesis, synaptogenesis and myelogenesis may be a risk factor for developing anxiety symptoms in early adolescence.

      2. Household characteristics associated with surface contamination of SARS-CoV-2 and frequency of RT-PCR and viral culture positivity-California and Colorado, 2021
        Shragai T, Pratt C, Castro Georgi J, Donnelly MA, Schwartz NG, Soto R, Chuey M, Chu VT, Marcenac P, Park GW, Ahmad A, Albanese B, Totten SE, Austin B, Bunkley P, Cherney B, Dietrich EA, Figueroa E, Folster JM, Godino C, Herzegh O, Lindell K, Relja B, Sheldon SW, Tong S, Vinjé J, Thornburg NJ, Matanock AM, Hughes LJ, Stringer G, Hudziec M, Beatty ME, Tate JE, Kirking HL, Hsu CH.
        PLoS One. 2022 ;17(10):e0274946.
        While risk of fomite transmission of SARS-CoV-2 is considered low, there is limited environmental data within households. This January-April 2021 investigation describes frequency and types of surfaces positive for SARS-CoV-2 by real-time reverse transcription polymerase chain reaction (RT-PCR) among residences with ≥1 SARS-CoV-2 infection, and associations of household characteristics with surface RT-PCR and viable virus positivity. Of 1232 samples from 124 households, 27.8% (n = 342) were RT-PCR positive with nightstands (44.1%) and pillows (40.9%) most frequently positive. SARS-CoV-2 lineage, documented household transmission, greater number of infected persons, shorter interval between illness onset and sampling, total household symptoms, proportion of infected persons ≤12 years old, and persons exhibiting upper respiratory symptoms or diarrhea were associated with more positive surfaces. Viable virus was isolated from 0.2% (n = 3 samples from one household) of all samples. This investigation suggests that while SARS-CoV-2 on surfaces is common, fomite transmission risk in households is low.

      3. Gestational exposure to organophosphate esters and infant anthropometric measures in the first 4 weeks after birth
        Yang W, Braun JM, Vuong AM, Percy Z, Xu Y, Xie C, Deka R, Calafat AM, Ospina M, Burris HH, Yolton K, Cecil KM, Lanphear BP, Chen A.
        Sci Total Environ. 2022 Oct 8:159322.
        BACKGROUND: Few studies have examined whether gestational exposure to organophosphate esters (OPEs), widely used chemicals with potential endocrine-disrupting potency and developmental toxicity, is associated with impaired infant growth. METHODS: We analyzed data from 329 mother-infant pairs in the Health Outcomes and Measures of the Environment (HOME) Study (2003-2006, Cincinnati, Ohio, USA). We quantified concentrations of four OPE metabolites in maternal urine collected at 16 and 26 weeks of gestation, and at delivery. We calculated z-scores using 2006 World Health Organization (WHO) child growth standards for the 4-week anthropometric measures (weight, length, and head circumference), the ponderal index, and weekly growth rates. We used multiple informant models to examine window-specific associations between individual OPE metabolites and anthropometric outcomes. We further modeled OPEs as a mixture for window-specific associations with 4-week anthropometric outcomes using mean field variational Bayesian inference procedure for lagged kernel machine regression (MFVB-LKMR). We stratified the models by infant sex. RESULTS: Diphenyl phosphate (DPHP) in mothers at 16 weeks, and bis(2-chloroethyl) phosphate (BCEP) and bis(1,3-dichloro-2-propyl) phosphate (BDCIPP) at delivery were positively associated with z-scores of weight, length, and head circumference in all infants at 4 weeks of age. After stratifying by infant sex, positive associations were only observed in males for DPHP at 16 weeks and BCEP at delivery and in females for BDCIPP at delivery. Negative associations not present in all infants were observed in males for di-n-butyl phosphate (DNBP) at 26 weeks of gestation with weight z-score and DPHP at delivery with head circumference z-score. Results were generally similar using MFVB-LKMR models with more conservative 95 % credible intervals. We did not identify consistent associations of gestational OPE metabolite concentrations with the ponderal index and weekly growth rates. CONCLUSION: In this cohort, exposure to OPEs during gestation was associated with altered infant anthropometry at 4 weeks after birth.

    • Food Safety
      1. Preliminary incidence and trends of infections caused by pathogens transmitted commonly through food - Foodborne Diseases Active Surveillance Network, 10 U.S. Sites, 2016-2021
        Collins JP, Shah HJ, Weller DL, Ray LC, Smith K, McGuire S, Trevejo RT, Jervis RH, Vugia DJ, Rissman T, Garman KN, Lathrop S, LaClair B, Boyle MM, Harris S, Kufel JZ, Tauxe RV, Bruce BB, Rose EB, Griffin PM, Payne DC.
        MMWR Morb Mortal Wkly Rep. 2022 Oct 7;71(40):1260-1264.
        To evaluate progress toward prevention of enteric infections in the United States, the Foodborne Diseases Active Surveillance Network (FoodNet) conducts active population-based surveillance for laboratory-diagnosed infections caused by Campylobacter, Cyclospora, Listeria, Salmonella, Shiga toxin-producing Escherichia coli (STEC), Shigella, Vibrio, and Yersinia at 10 U.S. sites. This report summarizes preliminary 2021 data and describes changes in annual incidence compared with the average annual incidence for 2016-2018, the reference period for the U.S. Department of Health and Human Services' (HHS) Healthy People 2030 goals for some pathogens (1). During 2021, the incidence of infections caused by Salmonella decreased, incidence of infections caused by Cyclospora, Yersinia, and Vibrio increased, and incidence of infections caused by other pathogens did not change. As in 2020, behavioral modifications and public health interventions implemented to control the COVID-19 pandemic might have decreased transmission of enteric infections (2). Other factors (e.g., increased use of telemedicine and continued increase in use of culture-independent diagnostic tests [CIDTs]) might have altered their detection or reporting (2). Much work remains to achieve HHS Healthy People 2030 goals, particularly for Salmonella infections, which are frequently attributed to poultry products and produce, and Campylobacter infections, which are frequently attributed to chicken products (3).

    • Genetics and Genomics
      1. Inhibition of vaccinia virus L1 N-myristoylation by the host N-myristoyltransferase inhibitor IMP-1088 generates non-infectious virions defective in cell entry
        Priyamvada L, Kallemeijn WW, Faronato M, Wilkins K, Goldsmith CS, Cotter CA, Ojeda S, Solari R, Moss B, Tate EW, Satheshkumar PS.
        PLoS Pathog. 2022 Oct 10;18(10):e1010662.
        We have recently shown that the replication of rhinovirus, poliovirus and foot-and-mouth disease virus requires the co-translational N-myristoylation of viral proteins by human host cell N-myristoyltransferases (NMTs), and is inhibited by treatment with IMP-1088, an ultrapotent small molecule NMT inhibitor. Here, we examine the importance of N-myristoylation during vaccinia virus (VACV) infection in primate cells and demonstrate the anti-poxviral effects of IMP-1088. N-myristoylated proteins from VACV and the host were metabolically labelled with myristic acid alkyne during infection using quantitative chemical proteomics. We identified VACV proteins A16, G9 and L1 to be N-myristoylated. Treatment with NMT inhibitor IMP-1088 potently abrogated VACV infection, while VACV gene expression, DNA replication, morphogenesis and EV formation remained unaffected. Importantly, we observed that loss of N-myristoylation resulted in greatly reduced infectivity of assembled mature virus particles, characterized by significantly reduced host cell entry and a decline in membrane fusion activity of progeny virus. While the N-myristoylation of VACV entry proteins L1, A16 and G9 was inhibited by IMP-1088, mutational and genetic studies demonstrated that the N-myristoylation of L1 was the most critical for VACV entry. Given the significant genetic identity between VACV, monkeypox virus and variola virus L1 homologs, our data provides a basis for further investigating the role of N-myristoylation in poxviral infections as well as the potential of selective NMT inhibitors like IMP-1088 as broad-spectrum poxvirus inhibitors.

    • Health Communication and Education
      1. Communicating effectively with people experiencing homelessness to prevent infectious diseases
        Allen EM, Smither B, Barranco L, Reynolds J, Bursey K, Mattson K, Mosites E.
        J Infect Dis. 2022 Oct 7;226(Supplement_3):S340-s345.
        BACKGROUND: People experiencing homelessness (PEH) are disproportionately affected by many infectious diseases, including coronavirus disease 2019 (COVID-19). However, communication efforts during public health emergencies like the COVID-19 pandemic often do not consider the unique needs of PEH. We examined how PEH seek and receive health information and how traditional health communication methods resonate with them. METHODS: We conducted in-person focus groups with PEH in 4 jurisdictions (Cincinnati, Ohio; Denver, Colorado; Sacramento, California; and the Bronx, New York) during July 2021. RESULTS: Findings from 15 focus groups with PEH (n = 53) revealed the need for trusted messengers and consistent messaging across local organizations, as PEH seek to verify information they receive from multiple sources. PEH overwhelmingly preferred to receive health information through face-to-face conversations, especially with healthcare providers with whom they had an established relationship, but they also cited news media, the internet, and social media as their main sources for obtaining health information. PEH reported that effective communication products pair a recommended action with instructions and resources about how to take that action within their community. CONCLUSIONS: These findings support healthcare providers collaborating with public health agencies to ensure that infectious disease prevention messages for PEH are provided by trusted messengers, multimodal, paired with resources, and consistent.

    • Health Economics
      1. Evaluating the cost-effectiveness of hepatitis B vaccination strategies in high-impact settings for adults
        Hall EW, Gounder P, Angles J, Nelson NP, Rosenberg ES, Weng MK.
        J Viral Hepat. 2022 Oct 6.
        Adults at increased risk for hepatitis B virus (HBV) infection are recommended to receive vaccination. We conducted a cost utility analysis to evaluate approaches for implementing that recommendation in selected high-risk settings: community outreach events with a large proportion of immigrants, syringe service programs, substance use treatment centers, sexually transmitted infection (STI) clinics, tuberculosis (TB) clinics, and jails. We utilized a decision tree framework with a Markov disease progression model to compare quality adjusted life-years and cost in 2021 United States dollars from four strategies: a 3-dose vaccination regimen with prevaccination screening and testing (PVST; baseline comparison); PVST at the initial encounter followed by a 2-dose series (Intervention 1); PVST with the first dose of a 2-dose vaccination series at the initial encounter (Intervention 2); and a 2-dose vaccination series without PVST (Intervention 3). In all settings, Intervention 1 resulted in worse health outcomes compared to the baseline strategy. Intervention 2 averted incident chronic HBV infections in all settings (range -9.4% in TB clinics, -14.8% in syringe service programs) and was a cost-saving approach in settings with higher risk of infection (i.e. jails, -$266 per person; syringe service programs, -$597; substance use treatment centers, -$130). Providing a 2-dose vaccination series without any screening (Intervention 3) averted incident HBV infections and was cost-saving in all settings, but resulted in more HBV-related deaths in settings with higher HBV prevalence. These results demonstrate a 2-dose vaccine series is a cost-effective approach in these high impact settings, even if prevaccination testing is not possible.

    • Health Equity and Health Disparities
      1. BACKGROUND: The Centers for Disease Control and Prevention launched the Colorectal Cancer Control Program to increase colorectal cancer screening among groups with low screening uptake. This engagement has enabled the health systems participating in the program to enhance infrastructure, systems, and process to implement interventions for colorectal cancer screening. These improvements have enabled other health promotion innovations such as the delivery of integrated interventions and supporting activities (referred to as integrated approaches) for multiple cancers. Using implementation science frameworks, the program evaluation team has examined these integrated approaches to capture the experiences of the awardees, health systems, and clinics. METHODS AND RESULTS: The findings from this comprehensive evaluation are presented in a series of 3 manuscripts. The first manuscript provides a conceptual framework for integrated approaches for cancer screening to support comprehensive evaluations and offers recommendations for future research. The second manuscript presents findings on key factors that support readiness for implementing integrated approaches based on qualitative interviews guided by implementation science constructs. The final manuscript reports on the challenges and benefits of integrated approaches to increase cancer screening in primary care facilities based on lessons learned from three real-world implementation case studies. CONCLUSION: Integrated models for implementing cancer screening could offer cost-effective approaches to reduce healthcare disparities. Additional implementation science-based systematic evaluations are needed to ensure integrated approaches are optimized, and cost-efficient models are scaled up.

      2. Changes in racial and ethnic disparities of HIV diagnoses among adolescents and young adults aged 13-24 years, 2015-2019
        Gabriel MG, Eppink ST, Henny KD, Chesson H, McCree DH.
        J Adolesc Health. 2022 Oct 8.
        PURPOSE: We examined changes in racial/ethnic disparities in HIV diagnoses among adolescents and young adults aged 13-24 years from 2015 through 2019. METHODS: We used national surveillance data for 2015-2019 from AtlasPlus to calculate 12 absolute and relative disparity measures for 7 racial/ethnic groups to understand HIV diagnosis trends over time. We calculated four absolute measures (Black-to-White rate difference, Hispanic-to-White rate difference, Absolute Index of Disparity [ID], population-weighted Absolute ID) and eight relative measures (Black-to-White rate ratio, Hispanic-to-White rate ratio, ID, population-weighted ID, population attributable proportion, Gini coefficient, Theil index, and mean log deviation). RESULTS: HIV diagnosis rates decreased by 15.9% across all racial/ethnic groups combined. All the absolute disparity measures we examined indicated substantial reductions (13.5%-18.5%) in absolute disparities. Most of the relative disparity measures (eight of eight population-unadjusted measures and five of eight population-adjusted measures) declined as well, but the change was relatively modest and ranged from a 3.3% decrease to a 2.1% increase across the measures. DISCUSSION: Despite progress, racial/ethnic disparities in HIV diagnoses among adolescents and young adults remain. Programs and services that are culturally relevant and tailored for this population may assist with continued progress toward reducing racial/ethnic disparities.

      3. Historically black college and university (HBCU) COVID-19 return-to-campus policies and prevention measures-Fall 2021
        Gazmararian JA, Liu Z, McLeod E, Cavallo M, Jiwani S, Paniagua U, Guest JL, Thomas ES, Good MK.
        J Am Coll Health. 2022 Oct 6:1-8.
        Objectives: Examine publicly accessible HBCU COVID-19 policies and associations with community COVID-19 infection and vaccination rates, and utilization of a dashboard. Participants: Excluding unaccredited or closed programs (n = 5) and those without COVID-19 information on website (n= 18), 76 HBCUs were included. Methods: Data on vaccine requirements, masking, and other policies were collected. Student enrollment and demographics and community infection and vaccination rates were obtained from websites. Results: Between August 15 and September 6, 2021, 36% of HBCU websites indicated vaccination requirements for students, with differences by private (57%) and public (17%). Masking requirements were more prevalent in HBCUs in areas with >50% community vaccination coverage vs those with <25%. Private institutions were more likely than public to require faculty/staff testing (34% vs 19%). HBCUs in areas with low/moderate COVID-19 rates were twice as likely to require vaccinations than HBCUs with higher rates. Conclusions: Easily accessible COVID-19 policies may help guide community prevention measures.

      4. Homelessness and infectious diseases: Understanding the gaps and defining a public health approach: Introduction
        Mosites E, Hughes L, Butler JC.
        J Infect Dis. 2022 Oct 7;226(Supplement_3):S301-s303.

      5. Public health and homelessness: A framework
        Mosites E, Lobelo EE, Hughes L, Butler JC.
        J Infect Dis. 2022 Oct 7;226(Supplement_3):S372-s374.

      6. Relative risks of COVID-19-associated hospitalizations and clinical outcomes by age and race/ethnicity-March 2020-March 2021
        Bozio CH, Butterfield K, Irving SA, Vazquez-Benitez G, Ong TC, Zheng K, Ball SW, Naleway AL, Barron M, Reed C.
        Open Forum Infect Dis. 2022 Oct;9(10):ofac376.
        BACKGROUND: Limited data exist on population-based risks and risk ratios (RRs) of coronavirus disease 2019 (COVID-19)-associated hospitalizations and clinical outcomes stratified by age and race/ethnicity. METHODS: Using data from electronic health records and claims from 4 US health systems for the period March 2020-March 2021, we calculated risk and RR by age and race/ethnicity for COVID-19-associated hospitalizations and clinical outcomes among adults (≥18 years). COVID-19-associated hospitalizations were defined based on COVID-19 discharge codes or a positive severe acute respiratory syndrome coronavirus 2 result. Proportions of acute exacerbations of underlying conditions were estimated among hospitalized patients with select underlying conditions, stratified by age and race/ethnicity. RESULTS: Among 2.6 million adults included in the patient cohort, 6879 had COVID-19-associated hospitalizations during March 2020-March 2021 (risk: 264 per 100 000 population). Compared with younger, non-Hispanic White adults, non-Hispanic Black and Hispanic adults aged ≥65 years had the highest hospitalization risk ratios (RR, 8.6; 95% CI, 7.6-9.9; and RR, 9.3; 95% CI, 8.5-10.3, respectively). Among hospitalized adults with COVID-19 and renal disease or cardiovascular disease, the highest proportion of acute renal failure (55.5%) or congestive heart failure (43.9%) occurred in older, non-Hispanic Black patients. Among hospitalized adults with chronic lung disease or asthma, the highest proportion of respiratory failure (62.9%) or asthma exacerbation (66.7%) occurred in older, Hispanic patients. CONCLUSIONS: During the first year of the US COVID-19 pandemic in this cohort, older non-Hispanic Black and Hispanic adults had the highest relative risks of COVID-19-associated hospitalization and adverse outcomes and, among those with select underlying conditions, the highest occurrences of acute exacerbations of underlying conditions.

      7. Duration of behavioral policy interventions and incidence of COVID-19 by social vulnerability of US counties, April-December 2020
        Kao SZ, Sharpe JD, Lane RI, Njai R, McCord RF, Ajiboye AS, Ladva CN, Vo L, Ekwueme DU.
        Public Health Rep. 2022 Oct 6:333549221125202.
        OBJECTIVE: State-issued behavioral policy interventions (BPIs) can limit community spread of COVID-19, but their effects on COVID-19 transmission may vary by level of social vulnerability in the community. We examined the association between the duration of BPIs and the incidence of COVID-19 across levels of social vulnerability in US counties. METHODS: We used COVID-19 case counts from USAFacts and policy data on BPIs (face mask mandates, stay-at-home orders, gathering bans) in place from April through December 2020 and the 2018 Social Vulnerability Index (SVI) from the Centers for Disease Control and Prevention. We conducted multilevel linear regression to estimate the associations between duration of each BPI and monthly incidence of COVID-19 (cases per 100 000 population) by SVI quartiles (grouped as low, moderate low, moderate high, and high social vulnerability) for 3141 US counties. RESULTS: Having a BPI in place for longer durations (ie, ≥2 months) was associated with lower incidence of COVID-19 compared with having a BPI in place for <1 month. Compared with having no BPI in place or a BPI in place for <1 month, differences in marginal mean monthly incidence of COVID-19 per 100 000 population for a BPI in place for ≥2 months ranged from -4 cases in counties with low SVI to -401 cases in counties with high SVI for face mask mandates, from -31 cases in counties with low SVI to -208 cases in counties with high SVI for stay-at-home orders, and from -227 cases in counties with low SVI to -628 cases in counties with high SVI for gathering bans. CONCLUSIONS: Establishing COVID-19 prevention measures for longer durations may help reduce COVID-19 transmission, especially in communities with high levels of social vulnerability.

      8. It's not just the Southeast - geographically pervasive racial disparities in Neisseria gonorrhoeae between Non-Hispanic Black and White US females
        Rowlinson E, Stenger MR, Valentine JA, Hughes JP, Khosropour CM, Golden MR.
        Sex Transm Dis. 2022 Oct 11.
        BACKGROUND: Spatial analyses of gonorrhea morbidity among females often highlight the southeastern US but may not provide information on geographic variation in the magnitude of racial disparities; such maps also focus on geographic space, obscuring underlying population characteristics. We created a series of visualizations depicting both county-level racial disparities in female gonorrhea diagnoses and variations in population size. METHODS: We calculated county- and region-level race-specific relative rates (RelR) and between-race rate differences (RD) and rate ratios (RR) comparing gonorrhea case rates in non-Hispanic Black (NHB) vs non-Hispanic White (NHW) females. We then created proportional symbol maps with color representing counties' RelR/RD/RR category and symbol size representing counties' female population. RESULTS: Gonorrhea rates among NHB females were highest in the Midwest (718.7/100,000) and West (504.8), rates among NHW females were highest in the West (74.1) and Southeast (72.1). RDs were highest in the Midwest (654.6 excess cases/100,000) and West (430.7), while RRs were highest in the Northeast (12.4) and Midwest (11.2). Nearly all US counties had NHB female rates ≥3x those in NHW females, with NHB females in most highly populated counties experiencing ≥9-fold difference in gonorrhea rates. CONCLUSIONS: Racial disparities in gonorrhea were not confined to the Southeast; both relative and absolute disparities were equivalent or larger in magnitude in areas of the Northeast, Midwest, and West. Our findings help counter damaging regional stereotypes, provide evidence to refocus prevention efforts to areas of highest disparities, and suggest a useful template for monitoring racial disparities as an actionable public health metric.

    • Immunity and Immunization
      1. COVID-19 Vaccine uptake and factors affecting hesitancy among US nurses, March-June 2021
        Rich-Edwards JW, Rocheleau CM, Ding M, Hankins JA, Katuska LM, Kumph X, Steege AL, Boiano JM, Lawson CC.
        Am J Public Health. 2022 Nov;112(11):1620-1629.
        Objectives. To characterize COVID-19 vaccine uptake and hesitancy among US nurses. Methods. We surveyed nurses in 3 national cohorts during spring 2021. Participants who indicated that they did not plan to receive or were unsure whether they planned to receive the vaccine were considered vaccine hesitant. Results. Among 32 426 female current and former nurses, 93% had been or planned to be vaccinated. After adjustment for age, race/ethnicity, and occupational variables, vaccine hesitancy was associated with lower education, living in the South, and working in a group care or home health setting. Those who experienced COVID-19 deaths and those reporting personal or household vulnerability to COVID-19 were less likely to be hesitant. Having contracted COVID-19 doubled the risk of vaccine hesitancy (95% confidence interval [CI] = 1.85, 2.53). Reasons for hesitancy that were common among nurses who did not plan to receive the vaccine were religion/ethics, belief that the vaccine was ineffective, and lack of concern about COVID-19; those who were unsure often cited concerns regarding side effects or medical reasons or reported that they had had COVID-19. Conclusions. Vaccine hesitancy was unusual and stemmed from specific concerns. Public Health Implications. Targeted messaging and outreach might reduce vaccine hesitancy. (Am J Public Health. 2022;112(11):1620-1629. https://doi.org/10.2105/AJPH.2022.307050).

      2. Characteristics associated with a previous COVID-19 diagnosis, vaccine uptake, and intention to be vaccinated among essential workers in the US Household Pulse Survey
        Steege AL, Luckhaupt SE, Guerin RJ, Okun AH, Hung MC, Syamlal G, Lu PJ, Santibanez TA, Groenewold MR, Billock R, Singleton JA, Sweeney MH.
        Am J Public Health. 2022 Nov;112(11):1599-1610.
        Objectives. To explore previous COVID-19 diagnosis and COVID-19 vaccination status among US essential worker groups. Methods. We analyzed the US Census Household Pulse Survey (May 26-July 5, 2021), a nationally representative sample of adults aged 18 years and older. We compared currently employed essential workers working outside the home with those working at home using adjusted prevalence ratios. We calculated proportion vaccinated and intention to be vaccinated, stratifying by essential worker and demographic groups for those who worked or volunteered outside the home since January 1, 2021. Results. The proportion of workers with previous COVID-19 diagnosis was highest among first responders (24.9%) working outside the home compared with workers who did not (13.3%). Workers in agriculture, forestry, fishing, and hunting had the lowest vaccination rates (67.5%) compared with all workers (77.8%). Those without health insurance were much less likely to be vaccinated across all worker groups. Conclusions. This study underscores the importance of improving surveillance to monitor COVID-19 and other infectious diseases among workers and identify and implement tailored risk mitigation strategies, including vaccination campaigns, for workplaces. (Am J Public Health. 2022;112(11):1599-1610. https://doi.org/10.2105/AJPH.2022.307010).

      3. Vaccine effectiveness of primary series and booster doses against covid-19 associated hospital admissions in the United States: living test negative design study
        Adams K, Rhoads JP, Surie D, Gaglani M, Ginde AA, McNeal T, Talbot HK, Casey JD, Zepeski A, Shapiro NI, Gibbs KW, Files DC, Hager DN, Frosch AE, Exline MC, Mohamed A, Johnson NJ, Steingrub JS, Peltan ID, Brown SM, Martin ET, Lauring AS, Khan A, Busse LW, Duggal A, Wilson JG, Chang SY, Mallow C, Kwon JH, Chappell JD, Halasa N, Grijalva CG, Lindsell CJ, Lester SN, Thornburg NJ, Park S, McMorrow ML, Patel MM, Tenforde MW, Self WH.
        Bmj. 2022 Oct 11;379:e072065.
        OBJECTIVE: To compare the effectiveness of a primary covid-19 vaccine series plus booster doses with a primary series alone for the prevention of hospital admission with omicron related covid-19 in the United States. DESIGN: Multicenter observational case-control study with a test negative design. SETTING: Hospitals in 18 US states. PARTICIPANTS: 4760 adults admitted to one of 21 hospitals with acute respiratory symptoms between 26 December 2021 and 30 June 2022, a period when the omicron variant was dominant. Participants included 2385 (50.1%) patients with laboratory confirmed covid-19 (cases) and 2375 (49.9%) patients who tested negative for SARS-CoV-2 (controls). MAIN OUTCOME MEASURES: The main outcome was vaccine effectiveness against hospital admission with covid-19 for a primary series plus booster doses and a primary series alone by comparing the odds of being vaccinated with each of these regimens versus being unvaccinated among cases versus controls. Vaccine effectiveness analyses were stratified by immunosuppression status (immunocompetent, immunocompromised). The primary analysis evaluated all covid-19 vaccine types combined, and secondary analyses evaluated specific vaccine products. RESULTS: Overall, median age of participants was 64 years (interquartile range 52-75 years), 994 (20.8%) were immunocompromised, 85 (1.8%) were vaccinated with a primary series plus two boosters, 1367 (28.7%) with a primary series plus one booster, and 1875 (39.3%) with a primary series alone, and 1433 (30.1%) were unvaccinated. Among immunocompetent participants, vaccine effectiveness for prevention of hospital admission with omicron related covid-19 for a primary series plus two boosters was 63% (95% confidence interval 37% to 78%), a primary series plus one booster was 65% (58% to 71%), and for a primary series alone was 37% (25% to 47%) (P<0.001 for the pooled boosted regimens compared with a primary series alone). Vaccine effectiveness was higher for a boosted regimen than for a primary series alone for both mRNA vaccines (BNT162b2 (Pfizer-BioNTech): 73% (44% to 87%) for primary series plus two boosters, 64% (55% to 72%) for primary series plus one booster, and 36% (21% to 48%) for primary series alone (P<0.001); mRNA-1273 (Moderna): 68% (17% to 88%) for primary series plus two boosters, 65% (55% to 73%) for primary series plus one booster, and 41% (25% to 54%) for primary series alone (P=0.001)). Among immunocompromised patients, vaccine effectiveness for a primary series plus one booster was 69% (31% to 86%) and for a primary series alone was 49% (30% to 63%) (P=0.04). CONCLUSION: During the first six months of 2022 in the US, booster doses of a covid-19 vaccine provided additional benefit beyond a primary vaccine series alone for preventing hospital admissions with omicron related covid-19. READERS' NOTE: This article is a living test negative design study that will be updated to reflect emerging evidence. Updates may occur for up to two years from the date of original publication.

      4. Severity of influenza illness by seasonal influenza vaccination status among hospitalised patients in four South American countries, 2013-19: a surveillance-based cohort study
        Regan AK, Arriola CS, Couto P, Duca L, Loayza S, Nogareda F, de Almeida WA, Antman J, Araya S, Avendaño Vigueras MA, Battaglia Paredes SC, Brstilo IF, Bustos P, Fandiño ME, Fasce R, Giovacchini CM, González Caro CI, von Horoch M, Del Valle Juarez M, Katz N, Olivares MF, da Silva DA, da Silva ET, Sotomayor V, Vergara N, Azziz-Baumgartner E, Ropero AM.
        Lancet Infect Dis. 2022 Oct 4.
        BACKGROUND: Although several studies have reported attenuated influenza illness following influenza vaccination, results have been inconsistent and have focused predominantly on adults in the USA. This study aimed to evaluate the severity of influenza illness by vaccination status in a broad range of influenza vaccine target groups across multiple South American countries. METHODS: We analysed data from four South American countries (Argentina, Brazil, Chile, and Paraguay) participating in REVELAC-i, a multicentre, test-negative design, vaccine effectiveness network including 41 sentinel hospitals. Individuals hospitalised at one of these centres with severe acute respiratory infection were tested for influenza by real-time RT-PCR, and were included in the analysis if they had complete information about their vaccination status and outcomes of their hospital stay. We used multivariable logistic regression weighted by inverse probability of vaccination and adjusted for antiviral use, duration of illness before admission, and calendar week, to calculate the adjusted odds ratios (aORs) of intensive care unit (ICU) admission and in-hospital death (and combinations of these outcomes) among influenza-positive patients by vaccination status for three target groups: young children (aged 6-24 months), adults (aged 18-64 years) with pre-existing health conditions, and older adults (aged ≥65 years). Survival curves were used to compare length of hospital stay by vaccination status in each target group. FINDINGS: 2747 patients hospitalised with PCR-confirmed influenza virus infection between Jan 1, 2013, and Dec 8, 2019, were included in the study: 649 children (70 [10·8%] fully vaccinated, 193 [29·7%] partially vaccinated) of whom 87 (13·4%) were admitted to ICU and 12 (1·8%) died in hospital; 520 adults with pre-existing medical conditions (118 [22·7%] vaccinated), of whom 139 (26·7%) were admitted to ICU and 55 (10·6%) died in hospital; and 1578 older adults (609 [38·6%] vaccinated), of whom 271 (17·2%) were admitted to ICU and 220 (13·9%) died in hospital. We observed earlier discharge among partially vaccinated children (adjusted hazard ratio 1·14 [95% CI 1·01-1·29]), fully vaccinated children (1·24 [1·04-1·47]), and vaccinated adults with pre-existing medical conditions (1·78 [1·18-2·69]) compared with their unvaccinated counterparts, but not among vaccinated older adults (0·82 [0·65-1·04]). Compared with unvaccinated individuals, lower odds of ICU admission were found for partially vaccinated children (aOR 0·64 [95% CI 0·44-0·92]) and fully vaccinated children (0·52 [0·28-0·98]), but not for adults with pre-existing conditions (1·25 [0·93-1·67]) or older adults (0·88 [0·72-1·08]). Lower odds of in-hospital death (0·62 [0·50-0·78]) were found in vaccinated versus unvaccinated older adults, with or without ICU admission, but did not differ significantly in partially vaccinated (1·35 [0·57-3·20]) or fully vaccinated young children (0·88 [0·16-4·82]) or adults with pre-existing medical conditions (1·09 [0·73-1·63]) compared with the respective unvaccinated patient groups. INTERPRETATION: Influenza vaccination was associated with illness attenuation among those hospitalised with influenza, although results differed by vaccine target group. These findings might suggest that attenuation of disease severity might be specific to certain target groups, seasons, or settings. FUNDING: US Centers for Disease Control and Prevention. TRANSLATIONS: For the Spanish and Portuguese translations of the abstract see Supplementary Materials section.

      5. Incidence of monkeypox among unvaccinated persons compared with persons receiving ≥1 JYNNEOS vaccine vose - 32 U.S. jurisdictions, July 31-September 3, 2022
        Payne AB, Ray LC, Kugeler KJ, Fothergill A, White EB, Canning M, Farrar JL, Feldstein LR, Gundlapalli AV, Houck K, Kriss JL, Lewis NM, Sims E, Smith DK, Spicknall IH, Nakazawa Y, Damon IK, Cohn AC, Payne DC.
        MMWR Morb Mortal Wkly Rep. 2022 Oct 7;71(40):1278-1282.
        Human monkeypox is caused by Monkeypox virus (MPXV), an Orthopoxvirus, previously rare in the United States (1). The first U.S. case of monkeypox during the current outbreak was identified on May 17, 2022 (2). As of September 28, 2022, a total of 25,341 monkeypox cases have been reported in the United States.* The outbreak has disproportionately affected gay, bisexual, and other men who have sex with men (MSM) (3). JYNNEOS vaccine (Modified Vaccinia Ankara vaccine, Bavarian Nordic), administered subcutaneously as a 2-dose (0.5 mL per dose) series with doses administered 4 weeks apart, was approved by the Food and Drug Administration (FDA) in 2019 to prevent smallpox and monkeypox infection (4). U.S. distribution of JYNNEOS vaccine as postexposure prophylaxis (PEP) for persons with known exposures to MPXV began in May 2022. A U.S. national vaccination strategy(†) for expanded PEP, announced on June 28, 2022, recommended subcutaneous vaccination of persons with known or presumed exposure to MPXV, broadening vaccination eligibility. FDA emergency use authorization (EUA) of intradermal administration of 0.1 mL of JYNNEOS on August 9, 2022, increased vaccine supply (5). As of September 28, 2022, most vaccine has been administered as PEP or expanded PEP. Because of the limited amount of time that has elapsed since administration of initial vaccine doses, as of September 28, 2022, relatively few persons in the current outbreak have completed the recommended 2-dose series.(§) To examine the incidence of monkeypox among persons who were unvaccinated and those who had received ≥1 JYNNEOS vaccine dose, 5,402 reported monkeypox cases occurring among males(¶) aged 18-49 years during July 31-September 3, 2022, were analyzed by vaccination status across 32 U.S. jurisdictions.** Average monkeypox incidence (cases per 100,000) among unvaccinated persons was 14.3 (95% CI = 5.0-41.0) times that among persons who received 1 dose of JYNNEOS vaccine ≥14 days earlier. Monitoring monkeypox incidence by vaccination status in timely surveillance data might provide early indications of vaccine-related protection that can be confirmed through other well-controlled vaccine effectiveness studies. This early finding suggests that a single dose of JYNNEOS vaccine provides some protection against monkeypox infection. The degree and durability of such protection is unknown, and it is recommended that people who are eligible for monkeypox vaccination receive the complete 2-dose series.

      6. Development of a road map to scale up the uptake and utilization of influenza vaccine in 22 countries of Eastern Mediterranean Region
        Chughtai AA, Mohammed S, Al Ariqi L, McCarron M, Bresee J, Abubakar A, Khan W.
        Vaccine. 2022 Oct 5.
        BACKGROUND: The aim of this project was to develop a road map to support countries in Eastern Mediterranean Region in developing and implementing evidence-based seasonal influenza vaccination policy, strengthen influenza vaccination delivery program and address vaccine misperceptions and hesitancy. METHODS: The road map was developed through consultative meetings with countries' focal points, review of relevant literature and policy documents and analysis of WHO/UNICEF Joint Reporting Form on immunization ((JRF 2015-2020) data. Countries were categorised into three groups, based on the existence of influenza vaccination policy and national regulatory authority, availability of influenza vaccine in the country and number of influenza vaccine doses distributed/ 1000 population. The final road map was shared with representatives of all countries in Eastern Mediterranean Region and other stakeholders during a meeting in September 2021. RESULT: The goal for next 5 years is to increase access to and use of utilization of seasonal influenza vaccine in Eastern Mediterranean Region to reduce influenza-associated morbidity and mortality among priority groups for vaccination. Countries in the Eastern Mediterranean Region are at different stages of implementation of the influenza vaccination program, so activities are planned under four strategic priority areas based on current situations in countries. The consultative body recommended that some countries should establish a new seasonal influenza vaccination programme and ensure the availability of vaccines, while other countries need to reduce vaccine hesitancy and enhance current seasonal influenza vaccination coverage, particularly in all high-risk groups. Countries are also encouraged to leverage COVID-19 adult vaccination programs to improve seasonal influenza vaccine uptake. CONCLUSION: This road map was developed through a consultative process to scale up the uptake and utilization of influenza vaccine in all countries of Eastern Mediterranean Region. The road map proposes activities that should be adopted in the local context to develop/ update national policies and programs.

      7. Immunogenicity of rVSVΔG-ZEBOV-GP Ebola vaccine (ERVEBO®) in African clinical trial participants by age, sex, and baseline GP-ELISA titer: A post hoc analysis of three Phase 2/3 trials
        Simon JK, Kennedy SB, Mahon BE, Dubey SA, Grant-Klein RJ, Liu K, Hartzel J, Coller BG, Welebob C, Hanson ME, Grais RF.
        Vaccine. 2022 Oct 5.
        BACKGROUND: ERVEBO®, a live recombinant vesicular stomatitis virus (VSV) vaccine containing the Zaire ebolavirus glycoprotein (GP) in place of the VSV GP (rVSVΔG-ZEBOV-GP), was advanced through clinical development by Merck & Co., Inc., Rahway, NJ, USA in collaboration with multiple partners to prevent Ebola virus disease (EVD) and has been approved for human use in several countries. METHODS: We evaluated data from three Phase 2/3 clinical trials conducted in Liberia (PREVAIL), Guinea (FLW), and Sierra Leone (STRIVE) during the 2013-2016 West African EVD outbreak to assess immune responses using validated assays. We performed a post hoc analysis of the association of vaccine response with sex, age (18-50 yrs & >50 yrs), and baseline (BL) GP-enzyme-linked immunosorbent assay (ELISA) titer (<200 & ≥200 EU/mL), including individual study (PREVAIL, FLW, or STRIVE) data and pooled data from all 3 studies. The endpoints were total IgG antibody response (EU/mL) measured by the GP-ELISA and neutralizing antibody response measured by the plaque reduction neutralization test (PRNT) to rVSVΔG-ZEBOV-GP at Days 28, 180, and 365 postvaccination. RESULTS: In the overall pooled population, in all subgroups, and in each trial independently, GP-ELISA and PRNT geometric mean titers increased from BL, generally peaking at Day 28 and persisting through Day 365. Immune responses were greater in women and participants with BL GP-ELISA ≥ 200 EU/mL, but did not differ across age groups. CONCLUSION: These data demonstrate that rVSVΔG-ZEBOV-GP elicits a robust and durable immune response through 12 months postvaccination in participants regardless of age, sex, or BL GP-ELISA titer. The higher immune responses observed in women and participants with pre-existing immunity are consistent with those described previously and for other vaccines. Trials were registered as follows: PREVAIL: ClinicalTrials.gov NCT02344407; FLW: Pan African Clinical Trials Registry PACTR201503001057193; STRIVE: ClinicalTrials.gov NCT02378753. Protocols V920-009, 011, and 018.

    • Informatics
      1. Health information exchange policy and standards for digital health systems in Africa: A systematic review
        Mamuye A, Yilma T, Abdulwahab A, Broomhead S, Zondo P, Kyeng M, Maeda J, Abdulaziz M, Wuhib T, Tilahun B.
        PLoS Digit Health. 2022 ;10(10).

      2. Mixed-methods analysis of select issues reported in the 2016 World Health Organization verbal autopsy questionnaire
        Nichols E, Pettrone K, Vickers B, Gebrehiwet H, Surek-Clark C, Leitao J, Amouzou A, Blau DM, Bradshaw D, Abdelilah EM, Groenewald P, Munkombwe B, Mwango C, Notzon FS, Biko Odhiambo S, Scanlon P.
        PLoS One. 2022 ;17(10):e0274304.
        BACKGROUND: Use of a standardized verbal autopsy (VA) questionnaire, such as the World Health Organization (WHO) instrument, can improve the consistency and reliability of the data it collects. Systematically revising a questionnaire, however, requires evidence about the performance of its questions. The purpose of this investigation was to use a mixed methods approach to evaluate the performance of questions related to 14 previously reported issues in the 2016 version of the WHO questionnaire, where there were concerns of potential confusion, redundancy, or inability of the respondent to answer the question. The results from this mixed methods analysis are discussed across common themes that may have contributed to the underperformance of questions and have been compiled to inform decisions around the revision of the current VA instrument. METHODS: Quantitative analysis of 19,150 VAs for neonates, children, and adults from five project teams implementing VAs predominately in Sub-Saharan Africa included frequency distributions and cross-tabulations to evaluate response patterns among related questions. The association of respondent characteristics and response patterns was evaluated using prevalence ratios. Qualitative analysis included results from cognitive interviewing, an approach that provides a detailed understanding of the meanings and processes that respondents use to answer interview questions. Cognitive interviews were conducted among 149 participants in Morocco and Zambia. Findings from the qualitative and quantitative analyses were triangulated to identify common themes. RESULTS: Four broad themes contributing to the underperformance or redundancy within the instrument were identified: question sequence, overlap within the question series, questions outside the frame of reference of the respondent, and questions needing clarification. The series of questions associated with one of the 14 identified issues (the series of questions on injuries) related to question sequence; seven (tobacco use, sores, breast swelling, abdominal problem, vomiting, vaccination, and baby size) demonstrated similar response patterns among questions within each series capturing overlapping information. Respondent characteristics, including relationship to the deceased and whether or not the respondent lived with the deceased, were associated with differing frequencies of non-substantive responses in three question series (female health related issues, tobacco use, and baby size). An inconsistent understanding of related constructs was observed between questions related to sores/ulcers, birth weight/baby size, and diagnosis of dementia/presence of mental confusion. An incorrect association of the intended construct with that which was interpreted by the respondent was observed in the medical diagnosis question series. CONCLUSIONS: In this mixed methods analysis, we identified series of questions which could be shortened through elimination of redundancy, series of questions requiring clarification due to unclear constructs, and the impact of respondent characteristics on the quality of responses. These changes can lead to a better understanding of the question constructs by the respondents, increase the acceptance of the tool, and improve the overall accuracy of the VA instrument.

      3. Race and ethnicity data in the cardiac arrest registry to enhance survival: Insights from Medicare self-reported data
        Chan PS, Merritt R, Chang A, Girotra S, Kotini-Shah P, Al-Araji R, McNally B.
        Resuscitation. 2022 Sep 22;180:64-67.
        BACKGROUND: For out-of-hospital cardiac arrest (OHCA), assignment of race/ethnicity data can be challenging. Validation of race/ethnicity in registry data with patients' self-reported race/ethnicity would provide insights regarding misclassification. METHODS: Using recently linked 2013-2019 Cardiac Arrest Registry to Enhance Survival (CARES) data with Medicare files, we examined the concordance of race/ethnicity in CARES with self-reported race/ethnicity in Medicare. Among patients with unknown race/ethnicity in CARES, race/ethnicity data from Medicare files were reported. RESULTS: Of 26,875 patients in the linked data, 5757 (21.4%) had unknown race/ethnicity in CARES. Of the remaining 21,118 patients, 14,284 (67.6%) were identified in CARES as non-Hispanic White, 4771 (22.6%) as non-Hispanic Black, 1213 (5.7%) as Hispanic, 760 (3.6%) as Asian or Pacific Islander, and 90 (0.4%) as American Indian or Alaskan Native. The concordance rate for race/ethnicity between CARES and Medicare was 93.4% for patients reported as non-Hispanic White in CARES, 89.1% for non-Hispanic Blacks, 74.6% for Hispanics, 69.6% for Asians and Pacific Islanders, and 37.8% for American Indian or Alaskan Natives. For the 5757 patients with unknown race/ethnicity in CARES, 3973 (69.0%) self-reported in Medicare as non-Hispanic White, 617 (10.7%) as non-Hispanic Black, 425 (7.4%) as Hispanic, 491 (8.5%) as Asian or Pacific Islander, and 52 (0.9%) as American Indian or Alaskan Native. Race/ethnicity remained unknown in 199 (3.5%) of patients. CONCLUSION: Race/ethnicity in CARES was highly concordant with self-reported race/ethnicity in Medicare, especially for non-Hispanic White and Black individuals. For patients with unknown race/ethnicity data in CARES, the vast majority were of White race.

    • Injury and Violence
      1. Community engagement, greening, and violent crime: A test of the greening hypothesis and Busy Streets
        Gong CH, Bushman G, Hohl BC, Kondo MC, Carter PM, Cunningham RM, Rupp LA, Grodzinski A, Branas CC, Vagi KJ, Zimmerman MA.
        Am J Community Psychol. 2022 Oct 10.
        Researchers have documented that vacant lot greening can reduce community-level crime and violence. Busy Streets Theory (BST) suggests that residents who are involved in the greening process can help to improve physical environments and build social connections that deter crime and violence. Yet few researchers have explored how community engagement in the greening process may affect crime and violence outcomes. We applied BST to test the effects of community-engaged vacant lot greening compared to vacant lots that received either professional mowing or no treatment, on the density of violent crime around study lots. Using mixed effects regression models, we analyzed trends in violent crime density over the summer months from 2016 to 2018 at 2102 street segments in Youngstown, OH. These street segments fell within 150 meters of an intervention parcel that was classified as one of three conditions: community-engaged maintenance, professional mowing, or no treatment (control). We found that street segments in areas receiving community-engaged maintenance or professional mowing experienced greater declines in violent crime density than street segments in areas receiving no treatment, and more decline occurred in the community-engaged condition compared to the professional mow condition. Our findings support BST and suggest that community-engaged greening of vacant lots in postindustrial cities with a concentrated vacancy can reduce crime and violence.

      2. BACKGROUND: Sexual violence is a serious public health concern worldwide. In Lesotho, one in seven women and one in twenty men aged 18 years and older experienced sexual violence during childhood. Sexual violence victimization may lead to long-term mental and physical health issues among victims, regardless of gender. OBJECTIVE: To estimate the prevalence of lifetime sexual violence victimization (SV) among 13-24-year-olds in Lesotho and assess its association with selected health conditions and risk behaviors. PARTICIPANTS AND SETTING: Data from 13 to 24-year-old participants (n = 8568) of the 2018 Lesotho Violence Against Children and Youth Survey were analyzed. METHODS: SV was defined as reporting one or more types of sexual violence at any age. Logistic regression analyses measured associations between SV and selected health conditions (suicidal thoughts, self-harm behaviors, mental distress, STIs, and HIV), and risk behaviors (binge drinking in the past 30 days, drug use in the past 30 days, infrequent condom use in the past 12 months, multiple sex partners in the past 12 months, and transactional sex in the past 12 months). RESULTS: After controlling for study covariates, SV was significantly associated with self-harm behaviors, suicidal thoughts, ever having an STI, binge drinking in the past 30 days, infrequent condom use in the past 12 months, and multiple sex partners in the past 12 months for both males and females; and mental distress and transactional sex in the past 12 months for females. CONCLUSIONS: Preventing SV against children and youth in Lesotho may improve their health and wellbeing.

      3. Notes from the Field: Increases in Firearm Homicide and Suicide Rates - United States, 2020-2021
        Simon TR, Kegler SR, Zwald ML, Chen MS, Mercy JA, Jones CM, Mercado-Crespo MC, Blair JM, Stone DM.
        MMWR Morb Mortal Wkly Rep. 2022 Oct 7;71(40):1286-1287.

    • Laboratory Sciences
      1. Exposure to the immunomodulatory chemical triclosan differentially impacts immune cell populations in the skin of haired (BALB/c) and hairless (SKH1) mice
        Baur R, Shane HL, Weatherly LM, Lukomska E, Kashon M, Anderson SE.
        Tox Report. 2022 January;9:1766-1776.
        Workers across every occupational sector have the potential to be exposed to a wide variety of chemicals, and the skin is a primary route of exposure. Furthermore, exposure to certain chemicals has been linked to inflammatory and allergic diseases. Thus, understanding the immune responses to chemical exposures on the skin and the potential for inflammation and sensitization is needed to improve worker safety and health. Responses in the skin microenvironment impact the potential for sensitization; these responses may include proinflammatory cytokines, inflammasome activation, barrier integrity, skin microbiota, and the presence of immune cells. Selection of specific mouse strains to evaluate skin effects, such as haired (BALB/c) or hairless (SKH1) mice, varies dependent on experimental design and needs of a study. However, dermal chemical exposure may impact reactions in the skin differently depending on the strain of mouse. Additionally, there is a need for established methods to evaluate immune responses in the skin. In this study, exposure to the immunomodulatory chemical triclosan was evaluated in two mouse models using immunophenotyping by flow cytometry and gene expression analysis. BALB/c mice exposed to triclosan (2%) had a higher number and frequency of neutrophils and lower number and frequency of dendritic cells in the skin compared to controls. Although these changes were not observed in SKH1 mice, SKH1 mice exposed to triclosan had a higher number and frequency of type 2 innate lymphoid cells in the skin. Taken together, these results demonstrate that exposure to an immunomodulatory chemical, triclosan, differentially impacts immune cell populations in the skin of haired and hairless mice. Additionally, the flow cytometry panel reported in this manuscript, in combination with gene expression analysis, may be useful in future studies to better evaluate the effect of chemical exposures on the skin immune response. These findings may be important to consider during strain selection, experimental design, and result interpretation of chemical exposures on the skin. Copyright © 2022

    • Maternal and Child Health
      1. Impact of tenofovir disoproxil fumarate use during pregnancy on maternal bone mineral density
        Wang L, Kourtis AP, Wiener J, Chen L, Liu W, Fan B, Shepherd J, Bulterys M.
        Pediatr Infect Dis J. 2022 Oct 11.

    • Nutritional Sciences
      1. A Food is Medicine approach to achieve nutrition security and improve health
        Mozaffarian D, Blanck HM, Garfield KM, Wassung A, Petersen R.
        Nat Med. 2022 Oct 6.

      2. Considerations for determining safety of probiotics: A USP perspective
        Roe AL, Boyte ME, Elkins CA, Goldman VS, Heimbach J, Madden E, Oketch-Rabah H, Sanders ME, Sirois J, Smith A.
        Regul Toxicol Pharmacol. 2022 Oct 4;136:105266.
        A history of safe use is a backbone of safety assessments for many current probiotic species, however, there is no global harmonization regarding requirements for establishing probiotic safety for use in foods and supplements. As probiotic manufacturers are increasingly seeking to use new strains, novel species, and next-generation probiotics, justification based on a significant history of use may be challenged. There are efforts underway by a variety of stakeholders, including the United States Pharmacopeia (USP), to develop best practices guidelines for assessing the quality and safety of probiotics. A current initiative of the USP seeks to provide expert advice specific to safety considerations for probiotics. Toward this goal, this review provides a helpful summary guide to global regulatory guidelines. We question the suitability of traditional animal toxicology studies designed for testing chemicals for relevance in assessing probiotic safety. This includes discussion of the use of excessive dose levels, the length of repeated dose toxicity studies needed, and the most suitable animal species used in toxicology studies. In addition, the importance of proper manufacturing practices with regard to final product safety are also included. Thus, an outline of essential parameters of a comprehensive safety assessment for a probiotic are provided.

    • Occupational Safety and Health
      1. In this study, we systematically characterized the airborne dust generated from grinding engineered and natural stone products using a laboratory testing system designed and operated to collect representative respirable dust samples. Four stone samples tested included two engineered stones consisting of crystalline silica in a polyester resin matrix (formulations differed with Stones A having up to 90wt% crystalline silica and Stone B up to 50wt% crystalline silica), an engineered stone consisting of recycled glass in a cement matrix (Stone C), and a granite. Aerosol samples were collected by respirable dust samplers, total dust samplers, and a Micro-Orifice Uniform Deposit Impactor. Aerosol samples were analyzed by gravimetric analysis and x-ray diffraction to determine dust generation rates, crystalline silica generation rates, and crystalline silica content. Additionally, bulk dust settled on the floor of the testing system was analyzed for crystalline silica content. Real-time particle size distributions were measured using an Aerodynamic Particle Sizer. All stone types generated similar trimodal lognormal number-weighted particle size distributions during grinding with the most prominent mode at an aerodynamic diameter of about 2.0-2.3 μm, suggesting dust formation from grinding different stones is similar. Bulk dust from Stone C contained no crystalline silica. Bulk dust from Stone A, Stone B, and granite contained 60, 23, and 30wt% crystalline silica, respectively. In Stones A and B, the cristobalite form of crystalline silica was more plentiful than the quartz form. Only the quartz form was detected in granite. The bulk dust, respirable dust, and total dust for each stone had comparable amounts of crystalline silica, suggesting that crystalline silica content in the bulk dust could be representative of that in respirable dust generated during grinding. Granite generated more dust per unit volume of material removed than the engineered stones, which all had similar normalized dust generation rates. Stone A had the highest normalized generation rates of crystalline silica, followed by granite, Stone B, and Stone C (no crystalline silica), which likely leads to the same trend of respirable crystalline silica (RCS) exposure when working with these different stones. Manufacturing and adoption of engineered stone products with formulations such as Stone B or Stone C could potentially lower or eliminate RCS exposure risks. Combining all the effects of dust generation rate, size-dependent silica content, and respirable fraction, the highest normalized generation rate of RCS consistently occurs at 3.2-5.6 µm for all the stones containing crystalline silica. Therefore, removing particles in this size range near the generation sources should be prioritized when developing engineering control measures.

      2. Practices and activities among healthcare personnel with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection working in different healthcare settings-ten Emerging Infections Program sites, April-November 2020
        Chea N, Eure T, Penna AR, Brown CJ, Nadle J, Godine D, Frank L, Czaja CA, Johnston H, Barter D, Miller BF, Angell K, Marshall K, Meek J, Brackney M, Carswell S, Thomas S, Wilson LE, Perlmutter R, Marceaux-Galli K, Fell A, Lim S, Lynfield R, Davis SS, Phipps EC, Sievers M, Dumyati G, Concannon C, McCullough K, Woods A, Seshadri S, Myers C, Pierce R, Ocampo VL, Guzman-Cottrill JA, Escutia G, Samper M, Pena SA, Adre C, Groenewold M, Thompson ND, Magill SS.
        Infect Control Hosp Epidemiol. 2022 Aug;43(8):1058-1062.
        Healthcare personnel with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection were interviewed to describe activities and practices in and outside the workplace. Among 2,625 healthcare personnel, workplace-related factors that may increase infection risk were more common among nursing-home personnel than hospital personnel, whereas selected factors outside the workplace were more common among hospital personnel.

      3. Benefits and limitations of field-based monitoring approaches for respirable dust and crystalline silica applied in a sandstone quarry
        Cauda E, Dolan E, Cecala A, Louk K, Yekich M, Chubb L, Lingenfelter A.
        J Occup Environ Hyg. 2022 Oct 11:1-18.
        With the advent of new sensing technologies and robust field-deployable analyzers, monitoring approaches can now generate valuable hazard information directly in the workplace. This is the case for monitoring respirable dust and respirable crystalline silica concentration levels. Estimating the quartz amount of a respirable dust sample by nondestructive analysis can be carried out using portable Fourier transform infrared spectroscopy (FTIR) units. Real-time respirable dust monitors, combined with small video cameras, allow advanced assessments using the Helmet-CAM methodology. These two field-based monitoring approaches, developed by the National Institute for Occupational Safety and Health (NIOSH), have been trialed in a sandstone quarry. Twenty-six Helmet-CAM sessions were conducted, and forty-one dust samples were collected around the quarry and analyzed on site during two events. The generated data generated were used to characterize concentration levels for the monitored areas and workers, to identify good practices, and to illustrate activities that could be improved with additional engineered control technologies. Laboratory analysis on the collected samples complemented the field finding and provided an assessment of the performance of the field-based techniques. Only a fraction of the real-time respirable dust monitoring sessions data could be corrected with laboratory analysis. The average correction factor ratio was 5.0. Nevertheless, Helmet-CAM results provided valuable information for each session. The field-based quartz monitoring approach overestimated the concentration by a factor of 1.8, but it successfully assessed the quartz concentration trends in the quarry. The data collected could be used for the determination of a quarry calibration factor for future events. The quartz content in the dust was found to vary from 14% to 100%, and this indicates the need for multiple techniques in the characterization of respirable dust and quartz concentration and exposure. Overall, this study reports the importance of the adoption of field-based monitoring techniques when combined with a proper understanding and knowledge of the capabilities and limitations of each technique.

    • Parasitic Diseases
      1. Malaria outbreak facilitated by increased mosquito breeding sites near houses and cessation of indoor residual spraying, Kole district, Uganda, January-June 2019
        Nabatanzi M, Ntono V, Kamulegeya J, Kwesiga B, Bulage L, Lubwama B, Ario AR, Harris J.
        BMC Public Health. 2022 Oct 12;22(1):1898.
        BACKGROUND: In June 2019, surveillance data from the Uganda's District Health Information System revealed an outbreak of malaria in Kole District. Analysis revealed that cases had exceeded the outbreak threshold from January 2019. The Ministry of Health deployed our team to investigate the areas and people affected, identify risk factors for disease transmission, and recommend control and prevention measures. METHODS: We conducted an outbreak investigation involving a matched case-control study. We defined a confirmed case as a positive malaria test in a resident of Aboke, Akalo, Alito, and Bala sub-counties of Kole District January-June 2019. We identified cases by reviewing outpatient health records. Exposures were assessed in a 1:1 matched case-control study (n = 282) in Aboke sub-county. We selected cases systematically from 10 villages using probability proportionate to size and identified age- and village-matched controls. We conducted entomological and environmental assessments to identify mosquito breeding sites. We plotted epidemic curves and overlaid rainfall, and indoor residual spraying (IRS). Case-control exposures were combined into: breeding site near house, proximity to swamp and breeding site, and proximity to swamp; these were compared to no exposure in a logistic regression analysis. RESULTS: Of 18,737 confirmed case-patients (AR = 68/1,000), Aboke sub-county residents (AR = 180/1,000), children < 5 years (AR = 94/1,000), and females (AR = 90/1,000) were most affected. Longitudinal analysis of surveillance data showed decline in cases after an IRS campaign in 2017 but an increase after IRS cessation in 2018-2019. Overlay of rainfall and case data showed two malaria upsurges during 2019, occurring 35-42 days after rainfall increases. Among 141 case-patients and 141 controls, the combination of having mosquito breeding sites near the house and proximity to swamps increased the odds of malaria 6-fold (OR = 6.6, 95% CI = 2.24-19.7) compared to no exposures. Among 84 abandoned containers found near case-patients' and controls' houses, 14 (17%) had mosquito larvae. Adult Anopheles mosquitoes, larvae, pupae, and pupal exuviae were identified near affected houses. CONCLUSION: Stagnant water formed by increased rainfall likely provided increased breeding sites that drove this outbreak. Cessation of IRS preceded the malaria upsurges. We recommend re-introduction of IRS and removal of mosquito breeding sites in Kole District.

    • Substance Use and Abuse
      1. Notes from the field: E-cigarette use among middle and high school students - United States, 2022
        Cooper M, Park-Lee E, Ren C, Cornelius M, Jamal A, Cullen KA.
        MMWR Morb Mortal Wkly Rep. 2022 Oct 7;71(40):1283-1285.

    • Telehealth and Telemedicine
      1. Telehealth services: Implications for enhancing sexually transmitted infection prevention
        Valentine JA, Mena L, Millett G.
        Sex Transm Dis. 2022 Nov 1;49(11S Suppl 2):S36-s40.
        In the United States, sexually transmitted infections (STIs) are among the most persistent threats to health equity. Increasing access to STI prevention and control services through the provision of Remote Health and Telehealth can improve sexual health outcomes. Telehealth has been shown to increase access to care and even improve health outcomes. The increased flexibility offered by Telehealth services accommodates both patient and provider. Although both Telehealth and Remote Health strategies are important for STI prevention, share common attributes, and, in some circumstances, overlap, this article will focus more specifically on considerations for Telehealth and how it can contribute to increasing health equity by offering an important complement to and, in some cases, substitute for in-person STI services for some populations. Telehealth assists a variety of different populations, including those experiencing STI disparities; however, although the Internet offers a promising resource for many American households and increasing percentages of Americans are using its many resources, not all persons have equal access to the Internet. In addition to tailoring STI programs to accommodate unique patient populations, these programs will likely be faced with adapting services to fit reimbursement and licensing regulations.

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