Issue 5, February 1, 2022

CDC Science Clips: Volume 14, Issue 5, February 1, 2022

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

  1. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Chronic Diseases and Conditions
      1. Comparative outcomes for mature T and NK/T-cell lymphomas in people with and without HIV and to AIDS-defining lymphomasexternal icon
        Koh MJ, Merrill MH, Koh MJ, Stuver R, Alonso CD, Foss FM, Mayor AM, Gill J, Epeldegui M, Cachay E, Thorne JE, Silverberg MJ, Horberg MA, Atlhoff KN, Nijhawan AE, McGinnis KA, Lee JS, Rabkin CS, Napravnik S, Li J, Castilho JL, Shen C, Jain S.
        Blood Adv. 2022 Jan 13.
        There are no studies comparing the prognosis for mature T-cell lymphoma (TCL) in people with human immunodeficiency virus (PWH) to people without HIV (PWoH) and to AIDS-defining B-cell lymphomas (A-BCL) in the modern antiretroviral therapy (ART) era. NA-ACCORD and COMPLETE are cohorts that enroll patients diagnosed with HIV and TCL, respectively. In our study 52, 64, 101, 500 and 246 PWH with histological confirmation of TCL, primary CNS, Burkitt's, diffuse large B-cell lymphoma (DLBCL) and Hodgkin's lymphoma (HL) respectively and 450 TCL without HIV were eligible for analysis. At the time of TCL diagnosis, Anaplastic large-cell lymphoma (ALCL) was the most common TCL subtype within PWH. While PWH with TCL diagnosed between 1996-2009, experienced a low 5-year survival probability at 0.23 (95% CI: 0.13, 0.41), we observed a marked improvement in their survival when diagnosed between 2010-2016 (0.69; 95% CI: 0.48, 1; p=0.04) in contrast to TCL among PWoH (0.45; 95% CI: 0.41, 0.51; p=0.53). Similarly, PWH with ALCL diagnosed between 1996-2009 were associated with a conspicuously inferior 5-year survival probability (0.17; 95% CI: 0.07, 0.42) and consistently lagged behind A-BCL subtypes such as Burkitt's (0.43; 95% CI:0.33, 0.57; p=0.09) and DLBCL (0.17; 95% CI: 0.06, 0.46; p=0.11) and behind HL (0.57; 95% CI: 0.50, 0.65; p <0.0001). Despite a small number, those diagnosed between 2010-2016, experienced a remarkable improvement in survival (0.67; 95% CI: 0.3, 1) in comparison to PWoH (0.76; 95% CI: 0.66, 0.87; p=0.58). Thus, our analysis confirms improved overall survival for aggressive B and T-cell malignancies among PWH in the last decade.

      2. Incidence of malignancies among patients with chronic hepatitis B in US health care organizations, 2006-2018external icon
        Spradling PR, Xing J, Zhong Y, Rupp LB, Moorman AC, Lu M, Teshale EH, Schmidt MA, Daida YG, Boscarino JA, Gordon SC.
        J Infect Dis. 2022 Jan 17.
        Hepatitis B virus (HBV) infection causes hepatocellular carcinoma but its association with other cancers is not well established. We compared age-adjusted incidence of primary cancers among 5,773 HBV-infected persons with US cancer registries during 2006-2018. Compared with the US population, substantially higher incidence among HBV-infected persons was observed for hepatocellular carcinoma (Standardized rate ratio [SRR] 30.79), gastric (SRR 7.95), neuroendocrine (SRR 5.88), cholangiocarcinoma (SRR 4.62), and ovarian (SRR 3.72) cancers, and non-Hodgkin lymphoma (SRR 2.52). Clinicians should be aware of a heightened potential for certain non-hepatic malignancies among hepatitis B patients, as earlier diagnosis favors improved survival.

      3. Prevalence and trends of coronary heart disease in the United States, 2011 to 2018external icon
        Lee YH, Fang J, Schieb L, Park S, Casper M, Gillespie C.
        JAMA Cardiol. 2022 Jan 19.

      4. Risk for newly diagnosed diabetes >30 days after SARS-COV-2 infection among persons aged <18 years - United States, March 1, 2020-June 28, 2021external icon
        Barrett CE, Koyama AK, Alvarez P, Chow W, Lundeen EA, Perrine CG, Pavkov ME, Rolka DB, Wiltz JL, Bull-Otterson L, Gray S, Boehmer TK, Gundlapalli AV, Siegel DA, Kompaniyets L, Goodman AB, Mahon BE, Tauxe RV, Remley K, Saydah S.
        MMWR Morb Mortal Wkly Rep. 2022 Jan 14;71(2):59-65.
        The COVID-19 pandemic has disproportionately affected people with diabetes, who are at increased risk of severe COVID-19.* Increases in the number of type 1 diabetes diagnoses (1,2) and increased frequency and severity of diabetic ketoacidosis (DKA) at the time of diabetes diagnosis (3) have been reported in European pediatric populations during the COVID-19 pandemic. In adults, diabetes might be a long-term consequence of SARS-CoV-2 infection (4-7). To evaluate the risk for any new diabetes diagnosis (type 1, type 2, or other diabetes) >30 days(†) after acute infection with SARS-CoV-2 (the virus that causes COVID-19), CDC estimated diabetes incidence among patients aged <18 years (patients) with diagnosed COVID-19 from retrospective cohorts constructed using IQVIA health care claims data from March 1, 2020, through February 26, 2021, and compared it with incidence among patients matched by age and sex 1) who did not receive a COVID-19 diagnosis during the pandemic, or 2) who received a prepandemic non-COVID-19 acute respiratory infection (ARI) diagnosis. Analyses were replicated using a second data source (HealthVerity; March 1, 2020-June 28, 2021) that included patients who had any health care encounter possibly related to COVID-19. Among these patients, diabetes incidence was significantly higher among those with COVID-19 than among those 1) without COVID-19 in both databases (IQVIA: hazard ratio [HR] = 2.66, 95% CI = 1.98-3.56; HealthVerity: HR = 1.31, 95% CI = 1.20-1.44) and 2) with non-COVID-19 ARI in the prepandemic period (IQVIA, HR = 2.16, 95% CI = 1.64-2.86). The observed increased risk for diabetes among persons aged <18 years who had COVID-19 highlights the importance of COVID-19 prevention strategies, including vaccination, for all eligible persons in this age group,(§) in addition to chronic disease prevention and management. The mechanism of how SARS-CoV-2 might lead to incident diabetes is likely complex and could differ by type 1 and type 2 diabetes. Monitoring for long-term consequences, including signs of new diabetes, following SARS-CoV-2 infection is important in this age group.

      5. Trends in breast cancer incidence, by race, ethnicity, and age among women aged ≥20 years - United States, 1999-2018external icon
        Ellington TD, Miller JW, Henley SJ, Wilson RJ, Wu M, Richardson LC.
        MMWR Morb Mortal Wkly Rep. 2022 Jan 14;71(2):43-47.
        Breast cancer is commonly diagnosed among women, accounting for approximately 30% of all cancer cases reported among women.* A slight annual increase in breast cancer incidence occurred in the United States during 2013-2017 (1). To examine trends in breast cancer incidence among women aged ≥20 years by race/ethnicity and age, CDC analyzed data from U.S. Cancer Statistics (USCS) during 1999-2018. Overall, breast cancer incidence rates among women decreased an average of 0.3% per year, decreasing 2.1% per year during 1999-2004 and increasing 0.3% per year during 2004-2018. Incidence increased among non-Hispanic Asian or Pacific Islander women and women aged 20-39 years and decreased among non-Hispanic White women and women aged 50-64 and ≥75 years. The U.S. Preventive Services Task Force currently recommends biennial screening mammography for women aged 50-74 years (2). These findings suggest that women aged 20-49 years might benefit from discussing potential breast cancer risk and ways to reduce risk with their health care providers. Further examination of breast cancer trends by demographic characteristics might help tailor breast cancer prevention and control programs to address state- or county-level incidence rates(†) and help prevent health disparities.

    • Communicable Diseases
      1. Transparent barriers were installed as a response to the SARS-COV-2 pandemic in many customer-facing industries. Transparent barriers are an engineering control that intercept particles traveling between customers and workers. Information on the effectiveness of these barriers against aerosols is limited. In this study, a cough simulator was used to represent a cough from a customer. Two optical particle counters were used (one on each side of the barrier, labeled customer and worker) to determine the number of particles that migrated around a transparent barrier. Ten configurations were tested with six replicates for both sitting and standing scenarios, representing nail salons and grocery stores, respectively. Barrier efficiency was calculated using a ratio of the particle count results (customer/worker). Barriers had better efficiency (up to 93%) when its top was 9 to 39 cm above cough height and its width was at least 91 cm. Barriers that extended 91 cm above table height for both scenarios blocked 71% or more of the particles between 0.35–0.725 µm and 68% for particles between 1 to 3 µm. A barrier that blocked an initial cough was effective at reducing particle counts. While the width of the barriers was not as significant as the height in determining barrier efficiency it is important that a barrier be placed where interactions between customers and workers are most frequent. Bystander exposure was not taken into consideration along with other limitations. © 2022 The Author(s). Published with license by Taylor and Francis Group, LLC.

      2. Strategies to improve HIV care outcomes for people with HIV who are out of care: a meta-analysisexternal icon
        Higa DH, Crepaz N, Mullins MM, Adegbite-Johnson A, Gunn JK, Denard C, Mizuno Y.
        Aids. 2022 Jan 12.
        OBJECTIVE: The aim of this study was to evaluate the effectiveness of five intervention strategies: patient navigation, appointment help/alerts, psychosocial support, transportation/appointment accompaniment, and data-to-care on HIV care outcomes among persons with HIV (PWH) who are out of care (OOC). DESIGN: A systematic review with meta-analysis. METHODS: We searched CDC's Prevention Research Synthesis (PRS) Project's cumulative HIV database to identify intervention studies conducted in the U.S., published between 2000 and 2020 that included comparisons between groups or prepost, and reported at least one relevant outcome (i.e., re-engagement and retention in HIV care, and viral suppression). Effect sizes were meta-analyzed using random-effect models to assess intervention effectiveness. RESULTS: Thirty-nine studies reporting on 42 unique interventions met the inclusion criteria. Overall, intervention strategies are effective in improving re-engagement in care [odds ratio (OR) = 1.79; 95% confidence interval (95% CI): 1.36-2.36, k = 14], retention in care (OR = 2.01; 95% CI: 1.64-2.64, k = 22), and viral suppression (OR = 2.50; 95% CI: 1.87-3.34, k = 27). Patient navigation, appointment help/alerts, psychosocial support, and transportation/appointment accompaniment improved all three HIV care outcomes. Data-to-care improved re-engagement and retention but had insufficient evidence for viral suppression. CONCLUSION: Several strategies are effective for improving HIV care outcomes among PWH who are OOC. More work is still needed for consistent definitions of OCC and HIV care outcomes, better reporting of intervention and cost data, and identifying how best to implement and scale-up effective strategies to engage and retain OOC PWH in care and reach the ending the HIV epidemic goals.

      3. Opening editorial AIDS and behavior special issue on stigmaexternal icon
        Henny KD, McCree DH, Mermin J.
        AIDS Behav. 2022 Jan 14.
        The papers in this Special Supplement provide insight into current research on and partnerships needed to address HIV-related stigma and better characterize the negative effects of HIV-related stigma on populations disproportionately affected by HIV in the United States. The findings may be used to inform evidence-based strategies and ideally additional interventional research with the goal of reducing stigma, new HIV infections, and improved health for persons with HIV.

      4. Prevalence of risk behaviors and correlates of SARS-CoV-2 positivity among in-school contacts of confirmed cases in a Georgia school district in the pre-vaccine era, December 2020-January 2021external icon
        Hast M, Swanson M, Scott C, Oraka E, Espinosa C, Burnett E, Kukielka EA, Rice ME, Mehari L, McCloud J, Miller D, Franklin R, Tate JE, Kirking HL, Morris E.
        BMC Public Health. 2022 Jan 14;22(1):101.
        BACKGROUND: There is a continuing risk for COVID-19 transmission in school settings while transmission is ongoing in the community, particularly among unvaccinated populations. To ensure that schools continue to operate safely and to inform implementation of prevention strategies, it is imperative to gain better understanding of the risk behaviors of staff and students. This secondary analysis describes the prevalence of COVID-19 risk behaviors in an exposed population of students and school staff in the pre-vaccine era and identifies associations between these behaviors and testing positive for SARS-CoV-2. METHODS: From December 2020-January 2021, school staff and students exposed to confirmed COVID-19 cases in a Georgia school district were tested for SARS-CoV-2 and surveyed regarding risk behaviors in and out of school. Prevalence of risk behaviors was described by age group and school level, and associations with SARS-CoV-2 positivity were identified using chi squared tests. RESULTS: Overall, 717 students and 79 school staff participated in the investigation; SARS-CoV-2 positivity was 9.2%. In the 2 weeks prior to COVID-19 exposure, 24% of participants reported unmasked indoor time at school, 40% attended social gatherings with non-household members, and 71% visited out-of-school indoor locations, including 19% who ate indoors in restaurants. Frequencies of risk behaviors increased by age. Among students, 17% participated in school sports, of whom 86% participated without a mask. SARS-CoV-2 positivity was significantly associated with school sports and unmasked time in sports. Among K-5 students, positivity was associated with exposure to a teacher index case. CONCLUSIONS: This analysis highlights the high prevalence of risk behaviors in an unvaccinated population exposed to COVID-19 in school and identifies an association between student sports participation and SARS-CoV-2 positivity. These findings illustrate the importance of school-level prevention measures to reduce SARS-CoV-2 transmission, including limiting close-contact indoor sports and promoting consistent mask use in unvaccinated individuals. Future research could explore the role of community vaccination programs as a strategy to reduce COVID-19 transmission and introductions into school settings.

      5. BACKGROUND: Blastomycosis, coccidioidomycosis, and histoplasmosis cause various symptoms and syndromes, which may present similarly to other infections such as bacterial or viral community-acquired pneumonia, influenza, and tuberculosis. METHODS: We used the IBM MarketScan Research Databases to identify adult outpatients with International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), diagnosis codes during 2016-2017 for blastomycosis, coccidioidomycosis, histoplasmosis, pneumonia (viral, bacterial, Streptococcus pneumoniae, and unspecified pneumonia), influenza; tuberculosis, and other lower and upper respiratory infections. We compared symptoms on and in the 90 days before diagnosis between patients with these diagnosis codes. RESULTS: Fever was less common in blastomycosis (2.6%), histoplasmosis (5.3%), and coccidioidomycosis (9.4%) than in patients with influenza (18.5%) or pneumonia (12.6-16.3%). Fungal diseases resembled bacterial, viral, and unspecified pneumonias for many pulmonary symptoms. However, cough was more common with coccidioidomycosis (31.4%) and less common with histoplasmosis (14.0%) and blastomycosis (13.1%) versus influenza (20.2%). Although less frequent, solitary pulmonary nodule (5.2-14.4%), enlarged lymph nodes (3.7-9.0%), hyperhidrosis (<2%), and erythema nodosum (<2%) were particularly suggestive of fungal diseases. CONCLUSIONS: Despite limitations inherent in administrative coding, this analysis of symptom codes across disease types suggests that fungal diseases may be difficult to clinically distinguish from other causes of pneumonia except when certain uncommon symptoms are present. Healthcare providers caring for patients with pneumonia, especially if nonresponsive to conventional treatment, should consider fungal diseases as possible etiologies.

      6. Trends in prescribing of antibiotics and drugs investigated for coronavirus disease 2019 (COVID-19) treatment in us nursing home residents during the COVID-19 pandemicexternal icon
        Gouin KA, Creasy S, Beckerson M, Wdowicki M, Hicks LA, Lind JN, Geller AI, Budnitz DS, Kabbani S.
        Clin Infect Dis. 2022 Jan 7;74(1):74-82.
        BACKGROUND: Trends in prescribing for nursing home (NH) residents, which may have been influenced by the coronavirus disease 2019 (COVID-19) pandemic, have not been characterized. METHODS: Long-term care pharmacy data from 1944 US NHs were used to evaluate trends in prescribing of antibiotics and drugs that were investigated for COVID-19 treatment, including hydroxychloroquine, famotidine, and dexamethasone. To account for seasonal variability in antibiotic prescribing and decreased NH occupancy during the pandemic, monthly prevalence of residents with a prescription dispensed per 1000 residents serviced was calculated from January to October and compared as relative percent change from 2019 to 2020. RESULTS: In April 2020, prescribing was significantly higher in NHs for drugs investigated for COVID-19 treatment than 2019; including hydroxychloroquine (+563%, 95% confidence interval [CI]: 5.87, 7.48) and azithromycin (+150%, 95% CI: 2.37, 2.63). Ceftriaxone prescribing also increased (+43%, 95% CI: 1.34, 1.54). Prescribing of dexamethasone was 36% lower in April (95% CI: .55, .73) and 303% higher in July (95% CI: 3.66, 4.45). Although azithromycin and ceftriaxone prescribing increased, total antibiotic prescribing among residents was lower from May (-5%, 95% CI: .94, .97) through October (-4%, 95% CI: .94, .97) in 2020 compared to 2019. CONCLUSIONS: During the pandemic, large numbers of residents were prescribed drugs investigated for COVID-19 treatment, and an increase in prescribing of antibiotics commonly used for respiratory infections was observed. Prescribing of these drugs may increase the risk of adverse events, without providing clear benefits. Surveillance of NH prescribing practices is critical to evaluate concordance with guideline-recommended therapy and improve resident safety.

      7. Impact of COVID-19 on HIV preexposure prophylaxis prescriptions in the United States - a time series analysisexternal icon
        Huang YA, Zhu W, Wiener J, Kourtis AP, Hall HI, Hoover KW.
        Clin Infect Dis. 2022 Jan 18.
        BACKGROUND: Uptake of HIV preexposure prophylaxis (PrEP) has been increasing in the United States since its FDA approval in 2012; however, the COVID-19 pandemic may have affected this trend. Our objective was to assess the impact of the COVID-19 pandemic on PrEP prescriptions in the United States. METHODS: We analyzed data from a national pharmacy database from January 2017 through March 2021 to fit an interrupted time-series model that predicted PrEP prescriptions and new PrEP users had the pandemic not occurred. Observed PrEP prescriptions and new users were compared with those predicted by the model. Main outcomes were weekly numbers of PrEP prescriptions and new PrEP users based on a previously developed algorithm. The impact of the COVID-19 pandemic was quantified by computing rate ratios and percent decreases between the observed and predicted counts during 3/15/2020 - 3/31/2021. RESULTS: In the absence of the pandemic, our model predicted that there would have been 1,058,162 PrEP prescriptions during 3/15/2020 - 3/31/2021. We observed 825,239 PrEP prescriptions, a 22.0% reduction (95% CI: 19.1%-24.8%) after the emergency declaration. The model predicted 167,720 new PrEP users during the same period; we observed 125,793 new PrEP users, a 25.0% reduction (95% CI: 20.9%-28.9%). The COVID-19 impact was greater among younger persons and those with commercial insurance. The impact of the pandemic varied markedly across states. CONCLUSION: The COVID-19 pandemic disrupted an increasing trend in PrEP prescriptions in the United States, highlighting the need for innovative interventions to maintain access to HIV prevention services during similar emergencies.

      8. Influenza associated pulmonary aspergillosis in California: A case seriesexternal icon
        Deng JZ, Beer KD, Toda M, Jackson B, Lin T, Javanbakht M, Stafylis C, Chiller T, Klausner JD.
        Clin Infect Pract. 2022 ;13.
        Introduction: Invasive pulmonary aspergillosis has been reported to occur in patients who are critically ill with severe influenza. The mortality rate is high. Methods: We reviewed electronic medical records from University of California at Los Angeles Health Hospitals for patients who had a positive influenza and Aspergillus test from September 1st, 2019 to May 6th, 2020. We classified cases using definitions from the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG), Aspergillus Intensive Care Unit (AspICU), and Influenza Associated Pulmonary Aspergillosis (IAPA) definition. Results: We identified 8 cases where the patient had both a positive influenza and Aspergillus test. Four (50%) of the 8 patients did not have underlying conditions that were considered typical risk factors for aspergillosis. Seven (87.5%) of the 8 patients were admitted to the intensive care unit and four (50%) of the 8 patients died. One patient met the diagnostic criteria by the EORTC/MSG guidelines, six by the AspICU, and seven by the IAPA definition. Conclusion: We found cases of influenza-associated pulmonary aspergillosis in a Los Angeles hospital population. Typical underlying conditions for aspergillosis were absent in four of the 8 cases. The ability to categorize the cases as influenza associated pulmonary aspergillosis varied. Further research and development of more sensitive guidelines to establish a diagnosis of invasive pulmonary aspergillosis in patients critically ill with influenza may be warranted. © 2021 The Authors

      9. Severity of the COVID-19 pandemic assessed with all-cause mortality in the United States during 2020external icon
        Dahlgren FS, Rossen LM, Fry AM, Reed C.
        Influenza Other Respir Viruses. 2022 Jan 19.
        BACKGROUND: In the United States, infection with SARS-CoV-2 caused 380,000 reported deaths from March to December 2020. METHODS: We adapted the Moving Epidemic Method to all-cause mortality data from the United States to assess the severity of the COVID-19 pandemic across age groups and all 50 states. By comparing all-cause mortality during the pandemic with intensity thresholds derived from recent, historical all-cause mortality, we categorized each week from March to December 2020 as either low severity, moderate severity, high severity, or very high severity. RESULTS: Nationally for all ages combined, all-cause mortality was in the very high severity category for 9 weeks. Among people 18 to 49 years of age, there were 29 weeks of consecutive very high severity mortality. Forty-seven states, the District of Columbia, and New York City each experienced at least 1 week of very high severity mortality for all ages combined. CONCLUSIONS: These periods of very high severity of mortality during March through December 2020 are likely directly or indirectly attributable to the COVID-19 pandemic. This method for standardized comparison of severity over time across different geographies and demographic groups provides valuable information to understand the impact of the COVID-19 pandemic and to identify specific locations or subgroups for deeper investigations into differences in severity.

      10. Best practices of highly infectious decedent management: Consensus recommendations from an international expert workshopexternal icon
        Le AB, Brown CK, Gibbs SG, Uhrig A, Green AD, Broch Brantsaeter A, Herstein JJ, Vasa A, Shugart J, Wilson Egbe W, Lowe JJ.
        J Occup Environ Hyg. 2022 Jan 13:1-19.
        With the increasing number of highly infectious disease incidents, outbreaks, and pandemics in our society (e.g., Ebola virus disease, Lassa fever, coronavirus diseases), the need for consensus and best practices on highly infectious decedent management is critical. In January 2020, a workshop of subject matter experts from across the world convened to discuss highly infectious live patient transport and highly infectious decedent management best practices. This commentary focuses on the highly infectious decedent management component of the workshop. The absence of guidance or disparate guidance on highly infectious decedent management can increase occupational safety and health risks for death care sector workers. To address this issue, the authorship presents these consensus recommendations on best practices in highly infectious decedent management, including discussion of what is considered a highly infectious decedent; scalability and storage for casualty events; integration of key stakeholders; infection control and facility considerations; transport; care and autopsy; psychological, ethical, and cultural considerations as well as multi-national care perspectives. These consensus recommendations are not intended to be exhaustive but rather to underscore this overlooked area and serve as a starting point for much-needed conversations.

      11. A description of COVID-19-directed therapy in children admitted to US intensive care units 2020external icon
        Schuster JE, Halasa NB, Nakamura M, Levy ER, Fitzgerald JC, Young CC, Newhams MM, Bourgeois F, Staat MA, Hobbs CV, Dapul H, Feldstein LR, Jackson AM, Mack EH, Walker TC, Maddux AB, Spinella PC, Loftis LL, Kong M, Rowan CM, Bembea MM, McLaughlin GE, Hall MW, Babbitt CJ, Maamari M, Zinter MS, Cvijanovich NZ, Michelson KN, Gertz SJ, Carroll CL, Thomas NJ, Giuliano JS, Singh AR, Hymes SR, Schwarz AJ, McGuire JK, Nofziger RA, Flori HR, Clouser KN, Wellnitz K, Cullimore ML, Hume JR, Patel M, Randolph AG.
        J Pediatric Infect Dis Soc. 2022 Jan 12.
        BACKGROUND: It is unclear how acute coronavirus disease 2019 (COVID-19)-directed therapies are used in children with life-threatening COVID-19 in US hospitals. We described characteristics of children hospitalized in the intensive care unit or step-down unit (ICU/SDU) who received COVID-19-directed therapies and the specific therapies administered. METHODS: Between March 15, 2020 and December 27, 2020, children <18 years of age in the ICU/SDU with acute COVID-19 at 48 pediatric hospitals in the United States were identified. Demographics, laboratory values, and clinical course were compared in children who did and did not receive COVID-19-directed therapies. Trends in COVID-19-directed therapies over time were evaluated. RESULTS: Of 424 children in the ICU/SDU, 235 (55%) received COVID-19-directed therapies. Children who received COVID-19-directed therapies were older than those who did not receive COVID-19-directed therapies (13.3 [5.6-16.2] vs 9.8 [0.65-15.9] years), more had underlying medical conditions (188 [80%] vs 104 [55%]; difference = 25% [95% CI: 16% to 34%]), more received respiratory support (206 [88%] vs 71 [38%]; difference = 50% [95% CI: 34% to 56%]), and more died (8 [3.4%] vs 0). Of the 235 children receiving COVID-19-directed therapies, 172 (73%) received systemic steroids and 150 (64%) received remdesivir, with rising remdesivir use over the study period (14% in March/April to 57% November/December). CONCLUSION: Despite the lack of pediatric data evaluating treatments for COVID-19 in critically ill children, more than half of children requiring intensive or high acuity care received COVID-19-directed therapies.

      12. Outcomes of SARS-COV-2-positive youths tested in emergency departments: The Global PERN-COVID-19 studyexternal icon
        Funk AL, Florin TA, Kuppermann N, Tancredi DJ, Xie J, Kim K, Neuman MI, Ambroggio L, Plint AC, Mintegi S, Klassen TP, Salvadori MI, Malley R, Payne DC, Simon NJ, Yock-Corrales A, Nebhrajani JR, Chaudhari PP, Breslin KA, Finkelstein Y, Campos C, Bergmann KR, Bhatt M, Ahmad FA, Gardiner MA, Avva UR, Shah NP, Sartori LF, Sabhaney VJ, Caperell K, Navanandan N, Borland ML, Morris CR, Gangoiti I, Pavlicich V, Kannikeswaran N, Lunoe MM, Rino PB, Kam AJ, Cherry JC, Rogers AJ, Chong SL, Palumbo L, Angelats CM, Morrison AK, Kwok MY, Becker SM, Dixon AC, Poonai N, Eckerle M, Wassem M, Dalziel SR, Freedman SB.
        JAMA Netw Open. 2022 Jan 4;5(1):e2142322.
        IMPORTANCE: Severe outcomes among youths with SARS-CoV-2 infections are poorly characterized. OBJECTIVE: To estimate the proportion of children with severe outcomes within 14 days of testing positive for SARS-CoV-2 in an emergency department (ED). DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study with 14-day follow-up enrolled participants between March 2020 and June 2021. Participants were youths aged younger than 18 years who were tested for SARS-CoV-2 infection at one of 41 EDs across 10 countries including Argentina, Australia, Canada, Costa Rica, Italy, New Zealand, Paraguay, Singapore, Spain, and the United States. Statistical analysis was performed from September to October 2021. EXPOSURES: Acute SARS-CoV-2 infection was determined by nucleic acid (eg, polymerase chain reaction) testing. MAIN OUTCOMES AND MEASURES: Severe outcomes, a composite measure defined as intensive interventions during hospitalization (eg, inotropic support, positive pressure ventilation), diagnoses indicating severe organ impairment, or death. RESULTS: Among 3222 enrolled youths who tested positive for SARS-CoV-2 infection, 3221 (>99.9%) had index visit outcome data available, 2007 (62.3%) were from the United States, 1694 (52.6%) were male, and 484 (15.0%) had a self-reported chronic illness; the median (IQR) age was 3 (0-10) years. After 14 days of follow-up, 735 children (22.8% [95% CI, 21.4%-24.3%]) were hospitalized, 107 (3.3% [95% CI, 2.7%-4.0%]) had severe outcomes, and 4 children (0.12% [95% CI, 0.03%-0.32%]) died. Characteristics associated with severe outcomes included being aged 5 to 18 years (age 5 to <10 years vs <1 year: odds ratio [OR], 1.60 [95% CI, 1.09-2.34]; age 10 to <18 years vs <1 year: OR, 2.39 [95% CI 1.38-4.14]), having a self-reported chronic illness (OR, 2.34 [95% CI, 1.59-3.44]), prior episode of pneumonia (OR, 3.15 [95% CI, 1.83-5.42]), symptoms starting 4 to 7 days prior to seeking ED care (vs starting 0-3 days before seeking care: OR, 2.22 [95% CI, 1.29-3.82]), and country (eg, Canada vs US: OR, 0.11 [95% CI, 0.05-0.23]; Costa Rica vs US: OR, 1.76 [95% CI, 1.05-2.96]; Spain vs US: OR, 0.51 [95% CI, 0.27-0.98]). Among a subgroup of 2510 participants discharged home from the ED after initial testing and who had complete follow-up, 50 (2.0%; 95% CI, 1.5%-2.6%) were eventually hospitalized and 12 (0.5%; 95% CI, 0.3%-0.8%) had severe outcomes. Compared with hospitalized SARS-CoV-2-negative youths, the risk of severe outcomes was higher among hospitalized SARS-CoV-2-positive youths (risk difference, 3.9%; 95% CI, 1.1%-6.9%). CONCLUSIONS AND RELEVANCE: In this study, approximately 3% of SARS-CoV-2-positive youths tested in EDs experienced severe outcomes within 2 weeks of their ED visit. Among children discharged home from the ED, the risk was much lower. Risk factors such as age, underlying chronic illness, and symptom duration may be useful to consider when making clinical care decisions.

      13. Notes from the field: HIV outbreak during the COVID-19 pandemic among persons who inject drugs -Kanawha County, West Virginia, 2019-2021external icon
        Hershow RB, Wilson S, Bonacci RA, Deutsch-Feldman M, Russell OO, Young S, McBee S, Thomasson E, Balleydier S, Boltz M, Hogan V, Atkins A, Worthington N, McDonald R, Adams M, Moorman A, Bixler D, Kowalewski S, Salmon M, McClung RP, Oster AM, Curran KG.
        MMWR Morb Mortal Wkly Rep. 2022 Jan 14;71(2):66-68.
        During October 2019, the West Virginia Bureau for Public Health (WVBPH) noted that an increasing number of persons who inject drugs (PWID) in Kanawha County received a diagnosis of HIV. The number of HIV diagnoses among PWID increased from less than five annually during 2016-2018 to 11 during January-October 2019 (Figure). Kanawha County (with an approximate population of 180,000*) has high rates of opioid use disorder and overdose deaths, which have been increasing since 2016,(†) and the county is located near Cabell County, which experienced an HIV outbreak among PWID during 2018-2019 (1,2). In response to the increase in HIV diagnoses among PWID in 2019, WVBPH released a Health Advisory(§); and WVBPH and Kanawha-Charleston Health Department (KCHD) convened an HIV task force, conducted care coordination meetings, received CDC remote assistance to support response activities, and expanded HIV testing and outreach.

      14. Impact of the DREAMS Program on new HIV diagnoses in adolescent girls and young women attending antenatal care - Lesotho, 2015-2020external icon
        Pelletier AR, Derado J, Maoela L, Lekhotsa T, Sechache M, Nkuatsana K.
        MMWR Morb Mortal Wkly Rep. 2022 Jan 14;71(2):48-51.
        Lesotho is a small, landlocked country in southern Africa with a population of approximately 2 million persons, approximately two thirds of whom live in rural areas (1). Lesotho has the second highest prevalence of HIV infection in the world (2). In 2017, 25.6% of persons aged 15-59 years living in Lesotho were HIV-positive (3). Strategies implemented in recent years to control HIV include efforts to reduce mother-to-child transmission and improve coverage with antiretroviral therapy, as well as increasing testing for HIV. Among persons aged 15-24 years, the HIV prevalence among females in 2017 (11.1%) was approximately three times that among males (3.4%) (3). The Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe (DREAMS)* program in Lesotho was started during October 2016 in two districts. DREAMS comprises a package of biomedical, behavioral, and structural interventions to address factors that make adolescent girls and young women vulnerable to HIV acquisition (4). The goal of the DREAMS program was to decrease HIV incidence among adolescent girls and young women by 25% after 1 year and by 40% after 2 years (4). After 3.5 years of program implementation in Lesotho, new HIV diagnoses among adolescent girls and young women attending antenatal care (ANC) decreased 71.4% in the two districts that implemented DREAMS compared with a reduction of 48.4% in three comparison districts without the program (p = 0.002). During 2016-2020, reductions in new HIV diagnoses among adolescent girls and young women attending ANC in Lesotho have been substantial, both in districts that have and have not implemented the DREAMS program (DREAMS and non-DREAMS districts). Apart from the DREAMS program, the decrease in new HIV diagnoses might be a result of the reduction in viral load in the population because more persons living with HIV infection became virally suppressed while on antiviral therapy, as well as other interventions such as preexposure prophylaxis, voluntary medical male circumcision, behavior change, and increased HIV diagnostic coverage.

      15. Estimating the contribution of HIV-infected adults to household pneumococcal transmission in South Africa, 2016-2018: A hidden Markov modelling studyexternal icon
        Thindwa D, Wolter N, Pinsent A, Carrim M, Ojal J, Tempia S, Moyes J, McMorrow M, Kleynhans J, Gottberg AV, French N, Cohen C, Flasche S.
        PLoS Comput Biol. 2021 Dec;17(12):e1009680.
        Human immunodeficiency virus (HIV) infected adults are at a higher risk of pneumococcal colonisation and disease, even while receiving antiretroviral therapy (ART). To help evaluate potential indirect effects of vaccination of HIV-infected adults, we assessed whether HIV-infected adults disproportionately contribute to household transmission of pneumococci. We constructed a hidden Markov model to capture the dynamics of pneumococcal carriage acquisition and clearance observed during a longitudinal household-based nasopharyngeal swabbing study, while accounting for sample misclassifications. Households were followed-up twice weekly for approximately 10 months each year during a three-year study period for nasopharyngeal carriage detection via real-time PCR. We estimated the effect of participant's age, HIV status, presence of a HIV-infected adult within the household and other covariates on pneumococcal acquisition and clearance probabilities. Of 1,684 individuals enrolled, 279 (16.6%) were younger children (<5 years-old) of whom 4 (1.5%) were HIV-infected and 726 (43.1%) were adults (≥18 years-old) of whom 214 (30.4%) were HIV-infected, most (173, 81.2%) with high CD4+ count. The observed range of pneumococcal carriage prevalence across visits was substantially higher in younger children (56.9-80.5%) than older children (5-17 years-old) (31.7-50.0%) or adults (11.5-23.5%). We estimate that 14.4% (95% Confidence Interval [CI]: 13.7-15.0) of pneumococcal-negative swabs were false negatives. Daily carriage acquisition probabilities among HIV-uninfected younger children were similar in households with and without HIV-infected adults (hazard ratio: 0.95, 95%CI: 0.91-1.01). Longer average carriage duration (11.4 days, 95%CI: 10.2-12.8 vs 6.0 days, 95%CI: 5.6-6.3) and higher median carriage density (622 genome equivalents per millilitre, 95%CI: 507-714 vs 389, 95%CI: 311.1-435.5) were estimated in HIV-infected vs HIV-uninfected adults. The use of ART and antibiotics substantially reduced carriage duration in all age groups, and acquisition rates increased with household size. Although South African HIV-infected adults on ART have longer carriage duration and density than their HIV-uninfected counterparts, they show similar patterns of pneumococcal acquisition and onward transmission.

      16. Implementation of a COVID-19 screening testing program in a rural, tribal nation: Experience of the San Carlos Apache Tribe, January-February 2021external icon
        Zhou N, Agathis N, Lees Y, Stevens H, Clark J, Reede D, Kunkel A, Balajee SA.
        Public Health Rep. 2022 Jan 13:333549211061770.
        The COVID-19 pandemic has disproportionately affected tribal populations, including the San Carlos Apache Tribe. Universal screening testing in a community using rapid antigen tests could allow for near-real-time identification of COVID-19 cases and result in reduced SARS-CoV-2 transmission. Published experiences of such testing strategies in tribal communities are lacking. Accordingly, tribal partners, with support from the Centers for Disease Control and Prevention, implemented a serial testing program using the Abbott BinaxNOW rapid antigen test in 2 tribal casinos and 1 detention center on the San Carlos Apache Indian Reservation for a 4-week pilot period from January to February 2021. Staff members at each setting, and incarcerated adults at the detention center, were tested every 3 or 4 days with BinaxNOW. During the 4-week period, 3834 tests were performed among 716 participants at the sites. Lessons learned from implementing this program included demonstrating (1) the plausibility of screening testing programs in casino and prison settings, (2) the utility of training non-laboratory personnel in rapid testing protocols that allow task shifting and reduce the workload on public health employees and laboratory staff, (3) the importance of building and strengthening partnerships with representatives from the community and public and private sectors, and (4) the need to implement systems that ensure confidentiality of test results and promote compliance among participants. Our experience and the lessons learned demonstrate that a serial rapid antigen testing strategy may be useful in work settings during the COVID-19 pandemic as schools and businesses are open for service.

      17. Risk of HIV acquisition among high-risk heterosexuals with nonviral sexually transmitted infections: A systematic review and meta-analysisexternal icon
        Barker EK, Malekinejad M, Merai R, Lyles CM, Sipe TA, DeLuca JB, Ridpath AD, Gift TL, Tailor A, Kahn JG.
        Sex Transm Dis. 2022 Jan 14.
        BACKGROUND: Nonviral sexually transmitted infections (STIs) increase risk of sexually-acquired HIV infection. Updated risk estimates carefully scrutinizing temporality bias of studies are needed. METHODS: We conducted a systematic review (PROSPERO # CRD42018084299) of peer-reviewed studies evaluating variation in risk of HIV infection among high-risk heterosexuals diagnosed with any of: Chlamydia trachomatis, Mycoplasma genitalium, Neisseria gonorrhoeae, Treponema pallidum, and/or Trichomonas vaginalis. We searched PubMed, Web of Science, and Embase databases through December 2017 and included studies where STIs and HIV were assessed using laboratory tests or medical exams and where STI was diagnosed before HIV. After dual screening, data extraction, and risk of bias assessment, we meta-analytically pooled risk ratios (RR). RESULTS: We found 32 eligible studies reporting k = 97 effect size estimates of HIV acquisition risk due to infection with one of the above STIs. Most data were based on females engaged in sex work or other high-risk occupations in developing countries. Many studies did not measure or adjust for known confounders including drug injection and condom use and most were at medium or high risk of bias due to potential for undetected HIV infection to have occurred prior to STI infection. HIV acquisition risk increased among females infected with any pathogen; the effect was greatest for females infected with Mycoplasma genitalium (RR = 3.10; 95% CI 1.63, 5.92; k = 2) and gonorrhea (RR = 2.81; 95% CI 2.25, 3.50; k = 16) but also statistically significant for females infected with syphilis (RR = 1.67; 95% CI 1.23, 2.27; k = 17), trichomonas (RR = 1.54; 95% CI 1.31, 1.82; k = 17) and chlamydia (RR = 1.49; 95% CI 1.08, 2.04; k = 14). For males, data were space except for syphilis (RR = 1.77; 95% CI 1.22, 2.58; k = 5). CONCLUSION: Nonviral STI increases risk of heterosexual HIV acquisition, although uncertainty remains due to risk of bias in primary studies.

      18. Detection of lymphogranuloma venereum-associated chlamydia trachomatis l2 serovars in remnant rectal specimens collected from 7 US public health laboratoriesexternal icon
        Chi KH, de Voux A, Morris M, Katz SS, Pillay A, Danavall D, Bowden KE, Gaynor AM, Kersh EN.
        Sex Transm Dis. 2022 Jan 1;49(1):e26-e28.
        The frequency of lymphogranuloma venereum or invasive Chlamydia trachomatis infection with serovar L1, L2, or L3 is unknown in the United States. While no diagnostic test is commercially available, we used a laboratory-developed test and detected lymphogranuloma venereum-associated serovar L2 in 14% of 132 remnant C. trachomatis-positive rectal swabs.

      19. We assessed sexually transmitted disease/human immunodeficiency virus (HIV) service availability at the primary sexually transmitted disease safety net clinic by phase I Ending the HIV Epidemic jurisdiction status. HIV testing was >90%. In Ending the HIV Epidemic jurisdictions, 22% of primary safety net clinics initiated and/or provided preexposure prophylaxis (PrEP), 46.6% provided PrEP education or referral only, and 29.9% did not provide any PrEP services.

    • Community Health Services
      1. Expanding PrEP services for men who have sex with men and transgender persons through health department programs: Key processes and outcomes from Project PrIDE, 2015-2019external icon
        Mulatu MS, Carter JW, Flores SA, Benton S, Galindo CA, Johnson WD, Wilkes AL, Prather C.
        Public Health Rep. 2022 Jan 13:333549211058173.
        OBJECTIVE: Pre-exposure prophylaxis (PrEP) Implementation, Data to Care, and Evaluation (PrIDE) was a demonstration project implemented by 12 state and local health departments during 2015-2019 to expand PrEP services for men who have sex with men (MSM) and transgender persons at risk for HIV infection. We describe findings from the cross-jurisdictional evaluation of the project. METHODS: We analyzed work plans, annual progress reports, and aggregate quantitative program data submitted by funded health departments (n = 12) to identify key activities implemented and summarize key project outcomes. RESULTS: PrIDE jurisdictions implemented multiple health equity-focused activities to expand PrEP services to priority populations, including building program capacity, conducting knowledge and awareness campaigns, providing PrEP support services, and addressing barriers to PrEP use. Overall, PrIDE jurisdictions identified 44 813 persons with PrEP indications. Of these, 74.8% (n = 33 500) were referred and 33.1% (n = 14 821) were linked to PrEP providers, and 25.3% (n = 11 356) were prescribed PrEP. Most persons prescribed PrEP were MSM or transgender persons (87.9%) and persons from racial and ethnic minority groups (65.6%). However, among persons with PrEP indications, non-Hispanic Black/African American persons (14.9% of 18 782) were less likely than non-Hispanic White persons (31.0% of 11 633) to be prescribed PrEP (z = -33.57; P < .001). CONCLUSIONS: PrIDE jurisdictions successfully expanded PrEP services for MSM, transgender persons, and racial and ethnic minority groups by implementing health equity-focused activities that addressed barriers to PrEP services. However, PrEP prescription was generally low, with significant disparities by demographic characteristics. Additional targeted interventions are needed to expand PrEP services, achieve equity in PrEP use, and contribute to ending the HIV epidemic in the United States.

    • Environmental Health
      1. Nano-enhanced treatment of per-fluorinated and poly-fluorinated alkyl substances (PFAS)external icon
        Birch QT, Birch ME, Nadagouda MN, Dionysiou DD.
        Curr Opin Chem Eng. 2022 ;35.
        Per-fluorinated and poly-fluorinated alkyl substances (PFAS) are environmentally pervasive and persistent. They have been associated with adverse health effects and are a major public health concern. Water contamination is a highly challenging problem due to the large number of PFAS and the limitations of conventional treatments. Nanoscale technologies offer new approaches such as high-capacity, selective sorbents with rapid uptake and regeneration, and integrated methods that capture and destroy PFAS. Nano-enhanced materials can improve the kinetics and selectivity of PFAS uptake (physical removal) and destruction, and the treatment materials can potentially be reused/recycled. Nanoscale technologies also offer opportunities to improve the performance of most conventional treatments. Some recent nano-enhanced approaches for PFAS treatment of aqueous media are discussed in this paper. © 2021 Elsevier B.V.

      2. Pregnancy exposure to phthalates and DNA methylation in male placenta - An epigenome-wide association studyexternal icon
        Jedynak P, Tost J, Calafat AM, Bourova-Flin E, Broséus L, Busato F, Forhan A, Heude B, Jakobi M, Schwartz J, Slama R, Vaiman D, Lepeule J, Philippat C.
        Environ Int. 2022 Jan 13;160:107054.
        BACKGROUND: Exposure to phthalates during pregnancy may alter DNA methylation in the placenta, a crucial organ for the growth and development of the fetus. OBJECTIVES: We studied associations between urinary concentrations of phthalate biomarkers during pregnancy and placental DNA methylation. METHODS: We measured concentrations of 11 phthalate metabolites in maternal spot urine samples collected between 22 and 29 gestational weeks in 202 pregnant women. We analyzed DNA methylation levels in placental tissue (fetal side) collected at delivery. We first investigated changes in global DNA methylation of repetitive elements Alu and LINE-1. We then performed an adjusted epigenome-wide association study using IlluminaHM450 BeadChips and identified differentially methylated regions (DMRs) associated with phthalate exposure. RESULTS: Monobenzyl phthalate concentration was inversely associated with placental methylation of Alu repeats. Moreover, all phthalate biomarkers except for monocarboxy-iso-octyl phthalate and mono(2-ethyl-5-hydroxyhexyl) phthalate were associated with at least one DMR. All but three DMRs showed increased DNA methylation with increased phthalate exposure. The largest identified DMR (22 CpGs) was positively associated with monocarboxy-iso-nonyl phthalate and encompassed heat shock proteins (HSPA1A, HSPA1L). The remaining DMRs encompassed transcription factors and nucleotide exchange factors, among other genes. CONCLUSIONS: This is the first description of genome-wide modifications of placental DNA methylation in association with pregnancy exposure to phthalates. Our results suggest epigenetic mechanisms by which exposure to these compounds could affect fetal development. Of interest, four identified DMRs had been previously associated with maternal smoking, which may suggest particular sensitivity of these genomic regions to the effect of environmental contaminants.

      3. Associations between eight earth observation-derived climate variables and enteropathogen infection: An independent participant data meta-analysis of surveillance studies with broad spectrum nucleic acid diagnosticsexternal icon
        Colston JM, Zaitchik BF, Badr HS, Burnett E, Ali SA, Rayamajhi A, Satter SM, Eibach D, Krumkamp R, May J, Chilengi R, Howard LM, Sow SO, Jahangir Hossain M, Saha D, Imran Nisar M, Zaidi AK, Kanungo S, Mandomando I, Faruque AS, Kotloff KL, Levine MM, Breiman RF, Omore R, Page N, Platts-Mills JA, Ashorn U, Fan YM, Shrestha PS, Ahmed T, Mduma E, Yori PP, Bhutta Z, Bessong P, Olortegui MP, Lima AA, Kang G, Humphrey J, Prendergast AJ, Ntozini R, Okada K, Wongboot W, Gaensbauer J, Melgar MT, Pelkonen T, Freitas CM, Kosek MN.
        Geohealth. 2022 Jan;6(1):e2021GH000452.
        Diarrheal disease, still a major cause of childhood illness, is caused by numerous, diverse infectious microorganisms, which are differentially sensitive to environmental conditions. Enteropathogen-specific impacts of climate remain underexplored. Results from 15 studies that diagnosed enteropathogens in 64,788 stool samples from 20,760 children in 19 countries were combined. Infection status for 10 common enteropathogens-adenovirus, astrovirus, norovirus, rotavirus, sapovirus, Campylobacter, ETEC, Shigella, Cryptosporidium and Giardia-was matched by date with hydrometeorological variables from a global Earth observation dataset-precipitation and runoff volume, humidity, soil moisture, solar radiation, air pressure, temperature, and wind speed. Models were fitted for each pathogen, accounting for lags, nonlinearity, confounders, and threshold effects. Different variables showed complex, non-linear associations with infection risk varying in magnitude and direction depending on pathogen species. Rotavirus infection decreased markedly following increasing 7-day average temperatures-a relative risk of 0.76 (95% confidence interval: 0.69-0.85) above 28°C-while ETEC risk increased by almost half, 1.43 (1.36-1.50), in the 20-35°C range. Risk for all pathogens was highest following soil moistures in the upper range. Humidity was associated with increases in bacterial infections and decreases in most viral infections. Several virus species' risk increased following lower-than-average rainfall, while rotavirus and ETEC increased with heavier runoff. Temperature, soil moisture, and humidity are particularly influential parameters across all enteropathogens, likely impacting pathogen survival outside the host. Precipitation and runoff have divergent associations with different enteric viruses. These effects may engender shifts in the relative burden of diarrhea-causing agents as the global climate changes.

      4. Aging influence on pulmonary and systemic inflammation and neural metabolomics arising from pulmonary multi-walled carbon nanotube exposure in apolipoprotein E-deficient and C57BL/6 female miceexternal icon
        Young TL, Scieszka D, Begay JG, Lucas SN, Herbert G, Zychowski K, Hunter R, Salazar R, Ottens AK, Erdely A, Gu H, Campen MJ.
        Inhal Toxicol. 2022 Jan 17:1-15.
        OBJECTIVE: Environmental exposures exacerbate age-related pathologies, such as cardiovascular and neurodegenerative diseases. Nanoparticulates, and specifically carbon nanomaterials, are a fast-growing contributor to the category of inhalable pollutants, whose risks to health are only now being unraveled. The current study assessed the exacerbating effect of age on multiwalled-carbon nanotube (MWCNT) exposure in young and old C57BL/6 and ApoE(-/-) mice. MATERIALS AND METHODS: Female C57BL/6 and apolipoprotein E-deficient (ApoE(-/-)) mice, aged 8 weeks and 15 months, were exposed to 0 or 40 µg MWCNT via oropharyngeal aspiration. Pulmonary inflammation, inflammatory bioactivity of serum, and neurometabolic changes were assessed at 24 h post-exposure. RESULTS: Pulmonary neutrophil infiltration was induced by MWCNT in bronchoalveolar lavage fluid in both C57BL/6 and ApoE(-/-). Macrophage counts decreased with MWCNT exposure in ApoE(-/-) mice but were unaffected by exposure in C57BL/6 mice. Older mice appeared to have greater MWCNT-induced total protein in lavage fluid. BALF cytokines and chemokines were elevated with MWCNT exposure, but CCL2, CXCL1, and CXCL10 showed reduced responses to MWCNT in older mice. However, no significant serum inflammatory bioactivity was detected. Cerebellar metabolic changes in response to MWCNT were modest, but age and strain significantly influenced metabolite profiles assessed. ApoE(-/-) mice and older mice exhibited less robust metabolite changes in response to exposure, suggesting a reduced health reserve. CONCLUSIONS: Age influences the pulmonary and neurological responses to short-term MWCNT exposure. However, with only the model of moderate aging (15 months) in this study, the responses appeared modest compared to inhaled toxicant impacts in more advanced aging models.

    • Epidemiology and Surveillance
      1. Incidence of amyotrophic lateral sclerosis in the United States, 2014-2016external icon
        Mehta P, Raymond J, Punjani R, Larson T, Han M, Bove F, Horton DK.
        Amyotroph Lateral Scler Frontotemporal Degener. 2022 Jan 13:1-5.
        Objective: To estimate the incidence of amyotrophic lateral sclerosis (ALS) in the United States for calendar years 2014-2016 using data from the National ALS Registry (Registry). The Registry collects data on ALS patients in the United States to better describe the epidemiology of ALS, examine risk factors such as environmental and occupational exposures, and characterize the demographics of those living with the disease. Methods: To identify adult incident cases of ALS, the Registry compiles data from three national administrative databases (maintained by the Centers for Medicare and Medicaid Services, the Veterans Health Administration, and the Veterans Benefits Administration). For cases that are not included in these databases, the Registry includes data collected from patients who voluntarily enroll via a secure web portal. Results: The Registry identified 5695 ALS cases in 2014; 6045 cases in 2015; and 4861 cases in 2016 for age-adjusted incidence rates of 1.7 (2014), 1.5 (2015), and 1.5 (2016) per 100,000 U.S. population, respectively. ALS was more common among whites, males, and persons aged 60-79 years. Conclusions: This is the first time administrative and self-reported databases have been used to describe the incidence of ALS for the United States resulting in a better estimate of disease demographics.

      2. Differentiating between viruses and virus species by writing their names correctlyexternal icon
        Zerbini FM, Siddell SG, Mushegian AR, Walker PJ, Lefkowitz EJ, Adriaenssens EM, Alfenas-Zerbini P, Dutilh BE, García ML, Junglen S, Krupovic M, Kuhn JH, Lambert AJ, Łobocka M, Oksanen HM, Robertson DL, Rubino L, Sabanadzovic S, Simmonds P, Suzuki N, Van Doorslaer K, Vandamme AM, Varsani A.
        Arch Virol. 2022 Jan 19.
        Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly. Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.Following the results of the International Committee on Taxonomy of Viruses (ICTV) Ratification Vote held in March 2021, a standard two-part "binomial nomenclature" is now the norm for naming virus species. Adoption of the new nomenclature is still in its infancy; thus, it is timely to reiterate the distinction between "virus" and "virus species" and to provide guidelines for naming and writing them correctly.

      3. BACKGROUND: Home-based swabbing has not been widely used. The objective of this analysis was to compare respiratory swabs collected by mothers of 7-12-year-olds living in low-income, multilingual communities in the United States with technician collected swabs. METHODS: Retrospective data analysis of respiratory samples collected at home by mothers compared to technicians. Anterior nasal and throat specimens collected using flocked swabs were combined in dry tubes. Test was done using TaqMan array cards for viral and bacterial pathogens. Cycle threshold (Ct) values of ribonuclease P (RNP) gene were used to assess specimen quality. Ct < 40 was interpreted as a positive result. Concordance of pathogen yield from mother versus technician collected swabs were analyzed using Cohen's Kappa coefficients. Correlation analysis, paired t-test, and Wilcoxon signed-rank test for paired samples were used for RNP Ct values. RESULTS: We enrolled 36 households in Cincinnati (African American) and 44 (predominately Chinese or Latino) in Boston. In Cincinnati, eight of 32 (25%) mothers did not finish high school, and 11 (34%) had finished high school only. In Boston, 13 of 44 (30%) mothers had less than a high school diploma, 23 (52%) had finished high school only. Mother versus technician paired swabs (n = 62) had similar pathogen yield (paired t-test and Wilcoxon signed rank test p-values = 0.62 and 0.63, respectively; 95% confidence interval of the difference between the two measurements = - 0.45-0.75). Median Ct value for RNP was 22.6 (interquartile range, IQR = 2.04) for mother-collected and 22.4 (IQR = 2.39) for technician-collected swabs (p = 0.62). Agreement on pathogen yield between samples collected by mothers vs. technicians was higher for viruses than for bacterial pathogens, with high concordance for rhinovirus/enterovirus, human metapneumovirus, and adenovirus (Cohen's kappa coefficients ≥80%, p < 0.0001). For bacterial pathogens, concordance was lower to moderate, except for Chlamydia pneumoniae, for which kappa coefficient indicated perfect agreement. CONCLUSION: Mothers with a range of education levels from low-income communities were able to swab their children equally well as technicians. Home-swabbing using dry tubes, and less invasive collection procedures, could enhance respiratory disease surveillance.

      4. Five-year community surveillance study for acute respiratory infections using text messaging: Findings from the MoSAIC studyexternal icon
        Stockwell MS, Reed C, Vargas CY, Wang L, Alba LR, Jia H, LaRussa P, Larson EL, Saiman L.
        Clin Infect Dis. 2022 Jan 17.
        BACKGROUND: Acute respiratory infections (ARI) are the most common infectious diseases globally. Community surveillance may provide a more comprehensive picture of disease burden than medically-attended illness alone. METHODS: In this longitudinal study conducted from 2012-2017 in the Washington Heights/Inwood area of New York City, we enrolled 405 households with 1,915 individuals. Households were sent research text messages twice weekly inquiring about ARI symptoms. Research staff confirmed symptoms by follow-up call. If ≥2 criteria for ARI were met (fever/feverish, cough, congestion, pharyngitis, myalgias), staff obtained a mid-turbinate nasal swab in participants' homes. Swabs were tested using the FilmArray RT-PCR respiratory panel. RESULTS: Among participants, 43.9% were children, and 12.8% had a chronic respiratory condition. During the five years, 114,724 text messages were sent; the average response rate was 78.8% +/- 6.8%. Swabs were collected for 91.4% (2756/3016) of confirmed ARI; 58.7% had a pathogen detected. Rhino/enteroviruses (51.9%), human coronaviruses (13.9%) and influenza (13.2%) were most commonly detected. The overall incidence was 0.62 ARI/person-year, highest (1.73) in <2 year-olds and lowest (0.46) in 18-49 year-olds. Approximately one-fourth of those with ARI sought healthcare; percents differed by pathogen, demographic factors, and presence of a chronic respiratory condition. CONCLUSIONS: Text messaging is a novel method for community-based surveillance that could be used both seasonally as well as during outbreaks, epidemics and pandemics. The importance of community surveillance to accurately estimate disease burden is underscored by the findings of low rates of care-seeking that varied by demographic factors and pathogens.

      5. Identification and description of patients with multisystem inflammatory syndrome in adults associated with SARS-CoV-2 infection using the Premier Healthcare Databaseexternal icon
        DeCuir J, Baggs J, Melgar M, Patel P, Wong KK, Schwartz NG, Bamrah Morris S, Godfred-Cato S, Belay ED.
        Epidemiol Infect. 2022 Jan 17:1-22.

    • Genetics and Genomics
      1. Rapid alignment updating with Extensiphyexternal icon
        Field JT, Abrams AJ, Cartee JC, McTavish EJ.
        Methods Ecol Evol. 2021 .
        High-throughput sequencing has become commonplace in evolutionary studies. Large, rapidly collected genomic datasets are used to capture biodiversity and for monitoring global and national scale disease transmission patterns, among many other applications. Updating homologous sequence datasets with new samples is cumbersome, requiring excessive program runtimes and data processing. We describe Extensiphy, a bioinformatics tool to efficiently update multiple sequence alignments with whole-genome short-read data. Extensiphy performs reference based sequence assembly and alignment in one process while maintaining the alignment length of the original alignment. Input data-types for Extensiphy are any multiple sequence alignment in fasta format and whole-genome, short-read fastq sequences. To validate Extensiphy, we compared its results to those produced by two other methods that construct whole-genome scale multiple sequence alignments. We measured our comparisons by analysing program runtimes, base-call accuracy, dataset retention in the presence of missing data and phylogenetic accuracy. We found that Extensiphy rapidly produces high-quality updated sequence alignments while preventing alignment shrinkage due to missing data. Phylogenies estimated from alignments produced by Extensiphy show similar accuracy to other commonly used alignment construction methods. Extensiphy is suitable for updating large sequence alignments and is ideal for studies of biodiversity, ecology and epidemiological monitoring efforts. © 2021 The Authors. Methods in Ecology and Evolution published by John Wiley & Sons Ltd on behalf of British Ecological Society

    • Health Behavior and Risk
      1. Behavioral efficacy of a sexual health mobile app for men who have sex with men: The M-cubed randomized controlled trialexternal icon
        Sullivan PS, Stephenson R, Hirshfield S, Mehta CC, Zahn RJ, Bauermeister J, Horvath KJ, Chiasson MA, Gelaude D, Mullin S, Downing MJ, Olansky E, Wiatrek S, Rogers EQ, Rosenberg ES, Siegler AJ, Mansergh G.
        J Med Internet Res. 2021 Dec 21.
        BACKGROUND: Gay, bisexual, and other men who have sex with men (GBMSM) face the highest burden of HIV in the United States, and there is a paucity of efficacious mobile health (mHealth) HIV prevention and care interventions tailored specifically for GBMSM. We tested a mobile app combining prevention messages and access to core prevention services for GBMSM. OBJECTIVE: To measure the efficacy of the Mobile Messaging for Men (M-cubed) app and related service to increase HIV prevention and care behaviors in diverse US GBMSM. METHODS: We conducted a randomized open label study with a waitlist control group among GBMSM (in three groups: lower-risk HIV-negative, higher-risk HIV negative, and living with HIV) recruited online and in venues in Atlanta, Detroit and New York. Participants were randomly assigned to receive access to the app immediately or at 9 months after randomization. The app provided prevention messages in six domains of sexual health and offered ordering of at-home HIV and STI test kits, receiving PrEP evaluations and navigation, and service locators. Serostatus- and risk-specific prevention outcomes were evaluated at baseline, at the end of the intervention period, and at 3, 6 and 9 months after the intervention period. RESULTS: 1226 GBMSM were enrolled and randomized; 611 were assigned to and 608 were analyzed in the intervention group, and 615 were assigned to and 611 were analyzed in the control group. For higher-risk GBMSM, allocation to the intervention arm was associated with a higher odds of HIV testing during the intervention period (aOR 2.02, 95% CI 1.11-3.66) and with a higher odds of using PrEP in the 3 months after the intervention period (aOR 2.41, CI:1.00-5.76, p<0.05). No changes in HIV prevention or care were associated with allocation to the intervention arm for the lower-risk HIV-negative or living with HIV groups. CONCLUSIONS: Access to the M-cubed app was associated with increased HIV testing and PrEP use among higher-risk HIV-negative GBMSM in three US cities. The app could be made available through funded HIV prevention providers; additional efforts are needed to understand optimal strategies to implement the app outside of the research setting. CLINICALTRIAL:, NCT03666247. INTERNATIONAL REGISTERED REPORT: RR2-10.2196/16439.

    • Health Communication and Education
      1. Diabetes self-management education and association with diabetes self-care and clinical preventive care practicesexternal icon
        Mendez I, Lundeen EA, Saunders M, Williams A, Saaddine J, Albright A.
        Sci Diabetes Self Manag Care. 2022 Jan 13:26350106211065378.
        PURPOSE: The purpose of the study is to assess self-reported receipt of diabetes education among people with diabetes and its association with following recommended self-care and clinical preventive care practices. METHODS: We analyzed data from the 2017 and 2018 Behavioral Risk Factor Surveillance System for 61 424 adults (≥18 years) with self-reported diabetes in 43 states and Washington, DC. Diabetes education was defined as ever taking a diabetes self-management class. The association of diabetes education with self-care practices (daily glucose testing, daily foot checks, smoking abstention, and engaging in leisure-time physical activity) and clinical practices (pneumococcal vaccination, biannual A1C test, and an annual dilated eye exam, influenza vaccination, health care visit for diabetes, and foot exam by a medical professional) was assessed. Multivariable logistic regression with predicted margins was used to predict the probability of following these practices, by diabetes education, controlling for sociodemographic factors. RESULTS: Of adults with diabetes, only half reported receiving diabetes education. Results indicate that receipt of diabetes education is associated with following self-care and clinical preventive care practices. Those who did receive diabetes education had a higher predicted probability for following all 4 self-care practices (smoking abstention, daily glucose testing, daily foot check, and engaging in leisure-time physical activity) and all 6 clinical practices (pneumonia vaccination, biannual A1C test, and an annual eye exam, flu vaccination, health care visit, and medical foot exam). CONCLUSIONS: The prevalence of adults with diabetes receiving diabetes education remains low. Increasing receipt of diabetes education may improve diabetes-related preventive care.

    • Health Disparities
      1. Lower prevalence of SARS-cov-2 infection among people experiencing homelessness tested in outdoor encampments compared with overnight shelters - Denver, Colorado, June - July 2020external icon
        Rowan SE, McCormick DW, Wendel KA, Scott T, Chavez-van de Hey J, Wilcox K, Stella SA, Kamis K, Burman WJ, Marx GE.
        Clin Infect Dis. 2022 Jan 18.
        BACKGROUND: A better understanding of the risk for COVID-19 that people experiencing homelessness (PEH) face in congregate shelters versus unsheltered encampments is critical for an effective pandemic response. METHODS: We analyzed factors associated with current and past SARS-CoV-2 infection among PEH in day and overnight shelters and encampments in Denver, Colorado, during June 2-July 28, 2020, and constructed multivariable logistic regression models to examine risk factors for SARS-CoV-2 RNA and seropositivity with age, race/ethnicity, testing location, testing month, and symptom status as predictor variables. RESULTS: A total of 823 participants were tested for SARS-CoV-2 RNA, and 276 individuals were tested for SARS-CoV-2 antibodies. A greater percentage of PEH at overnight shelters tested positive for SARS-CoV-2 RNA (8.6% vs 2.5%, p<0.01) and antibodies (21.5% vs 8.7%, p=0.03) compared to encampments. In regression models, testing at an overnight shelter compared to testing at encampments (OR=3.03, 95% CI 1.16-9.02) had increased odds of a positive SARS-CoV-2 RNA result. Age >60 years compared to age <40 years (OR=5.92, 95% CI 1.83-20.3), Hispanic ethnicity (OR=3.43, 95% CI 1.36-8.95) and non-Hispanic Black race compared to non-Hispanic White race (OR=3.07, 95% CI 1.16-8.26), and testing at an overnight shelter compared to testing at encampments (OR=2.45, 95% CI 1.04-6.17) had increased odds of a positive antibody result. CONCLUSIONS: Our findings support the need for continuing assessment of mitigation strategies in shelters, increasing access to individual rooms and linkage to housing options for PEH, and supporting people to remain in encampments when these options are not available.

      2. Improving access to and quality of sexual and reproductive health services for adolescents in the United Statesexternal icon
        Brittain AW, Steiner RJ, Fasula AM, Hatfield-Timajchy K, Kulkarni A, Koumans EH.
        J Womens Health (Larchmt). 2022 Jan;31(1):7-12.
        Equitable access to high quality adolescent sexual and reproductive health (ASRH) services can help reduce unintended pregnancies, sexually transmitted diseases, and disparities in these outcomes. The Centers for Disease Control and Prevention (CDC), Division of Reproductive Health, has a long history of working to improve access to and quality of ASRH services through applied research and public health practice. This report from CDC summarizes the evolution of these efforts from more than a decade of work-from community-based demonstration projects to an initiative to support wide-scale implementation. We describe a community-wide teen pregnancy prevention program model that includes a component addressing ASRH services (2010-2015), focused efforts related to quality improvement (QI) of and community-clinic linkages to ASRH services (2015-2020), and the development of a QI package that collates implementation strategies and tools to improve ASRH services (2020-2022). We conclude by discussing future directions. In disseminating key strategies and resources from this work, we aim to support broader public health and clinical efforts to strengthen ASRH care in the United States in ways that promote health equity.

      3. Hospitalizations for COVID-19 among US people experiencing incarceration or homelessnessexternal icon
        Montgomery MP, Hong K, Clarke KE, Williams S, Fukunaga R, Fields VL, Park J, Schieber LZ, Kompaniyets L, Ray CM, Lambert LA, D'Inverno AS, Ray TK, Jeffers A, Mosites E.
        JAMA Netw Open. 2022 Jan 4;5(1):e2143407.
        IMPORTANCE: People experiencing incarceration (PEI) and people experiencing homelessness (PEH) have an increased risk of COVID-19 exposure from congregate living, but data on their hospitalization course compared with that of the general population are limited. OBJECTIVE: To compare COVID-19 hospitalizations for PEI and PEH with hospitalizations among the general population. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional analysis used data from the Premier Healthcare Database on 3415 PEI and 9434 PEH who were evaluated in the emergency department or were hospitalized in more than 800 US hospitals for COVID-19 from April 1, 2020, to June 30, 2021. EXPOSURES: Incarceration or homelessness. MAIN OUTCOMES AND MEASURES: Hospitalization proportions were calculated. and outcomes (intensive care unit admission, invasive mechanical ventilation [IMV], mortality, length of stay, and readmissions) among PEI and PEH were compared with outcomes for all patients with COVID-19 (not PEI or PEH). Multivariable regression was used to adjust for potential confounders. RESULTS: In total, 3415 PEI (2952 men [86.4%]; mean [SD] age, 50.8 [15.7] years) and 9434 PEH (6776 men [71.8%]; mean [SD] age, 50.1 [14.5] years) were evaluated in the emergency department for COVID-19 and were hospitalized more often (2170 of 3415 [63.5%] PEI; 6088 of 9434 [64.5%] PEH) than the general population (624 470 of 1 257 250 [49.7%]) (P < .001). Both PEI and PEH hospitalized for COVID-19 were more likely to be younger, male, and non-Hispanic Black than the general population. Hospitalized PEI had a higher frequency of IMV (410 [18.9%]; adjusted risk ratio [aRR], 1.16; 95% CI, 1.04-1.30) and mortality (308 [14.2%]; aRR, 1.28; 95% CI, 1.11-1.47) than the general population (IMV, 88 897 [14.2%]; mortality, 84 725 [13.6%]). Hospitalized PEH had a lower frequency of IMV (606 [10.0%]; aRR, 0.64; 95% CI, 0.58-0.70) and mortality (330 [5.4%]; aRR, 0.53; 95% CI, 0.47-0.59) than the general population. Both PEI and PEH had longer mean (SD) lengths of stay (PEI, 9 [10] days; PEH, 11 [26] days) and a higher frequency of readmission (PEI, 128 [5.9%]; PEH, 519 [8.5%]) than the general population (mean [SD] length of stay, 8 [10] days; readmission, 28 493 [4.6%]). CONCLUSIONS AND RELEVANCE: In this cross-sectional study, a higher frequency of COVID-19 hospitalizations for PEI and PEH underscored the importance of adhering to recommended prevention measures. Expanding medical respite may reduce hospitalizations in these disproportionately affected populations.

    • Health Economics
      1. Review of publicly available state policies for long-acting reversible contraception device reimbursementexternal icon
        Romero L, Sappenfield OR, Uesugi K, Howland JF, Kroelinger CD, Okoroh EM, Erondu C, Cox S.
        J Womens Health (Larchmt). 2022 Jan 17.
        Background: Provider challenges to accessing long-acting reversible contraception (LARC) include level of reimbursement for LARC device acquisition and cost to stock. State-level LARC device reimbursement policies that cover a greater proportion of the cost of the LARC device and enable providers to purchase LARC upfront may improve contraceptive access. Materials and Methods: To summarize state-level policies that include language on LARC device reimbursement in the outpatient setting, we conducted a systematic, web-based review among all 50 states of publicly available LARC device reimbursement policies that include coverage of LARC devices as a medical or pharmacy benefit, the use of the 340B Drug Pricing Program to purchase LARC devices, and separate payment for LARC devices outside of the Medicaid Prospective Payment System (PPS) payment rate for Federally Qualified Health Centers or Rural Health Clinics. Results: Forty-two percent (21/50) of states with publicly available state-level policies included language on LARC device reimbursement. Among the states, 24% (5/21) had coverage policies as a medical benefit, 33% (7/21) as a pharmacy benefit, and 19% (4/21) as both a medical benefit and pharmacy benefit; 38% (8/21) used the 340B Program to purchase LARC devices; and 62% (13/21) indicated separate payment for LARC devices outside of the Medicaid PPS payment rate. Conclusion: State-level policies for LARC device reimbursement vary, highlighting differences in reimbursement strategies across the U.S. Future research could explore how the implementation of these payment methods may impact LARC device reimbursement and whether increased reimbursement may improve access to the full range of contraceptive methods.

      2. Cost assessment of a program for laboratory testing of plasma trans-fatty acids in Thailandexternal icon
        Datta BK, Aekplakorn W, Chittamma A, Meemeaw P, Vesper H, Kuiper HC, Steele L, Cobb LK, Li C, Husain MJ, Ketgudee L, Kostova D, Richter P.
        Public Health Pract (Oxf). 2021 ;2.
        Objectives: Intake of trans fatty acids (TFA) increases the risk of cardiovascular disease. Assessment of TFA exposure in the population is key for determining TFA burden and monitoring change over time. One approach for TFA monitoring is measurement of TFA levels in plasma. Understanding costs associated with this approach can facilitate program planning, implementation and scale-up. This report provides an assessment of costs associated with a pilot program to measure plasma TFA levels in Thailand. Study design: Cost analysis in a laboratory facility in Thailand. Methods: We defined three broad cost modules: laboratory, personnel, and facility costs, which were further classified into sub-components and into fixed and variable categories. Costs were estimated based on the number of processed plasma samples (100–2700 in increments of 50) per year over a certain number of years (1–5), in both USD and Thai Baht. Total cost and average costs per sample were estimated across a range of samples processed. Results: The average cost per sample of analyzing 900 samples annually over 5 years was estimated at USD186. Laboratory, personnel, and facility costs constitute 67%, 23%, and 10% of costs, respectively. The breakdown across fixed costs, such as laboratory instruments and personnel, and variable costs, such as chemical supplies, was 60% and 40%, respectively. Average costs decline as more samples are processed: the cost per sample for analyzing 100, 500, 1500, and 2500 samples per year over 5 years is USD1351, USD301, USD195; and USD177, respectively. Conclusions: Laboratory analysis of plasma TFA levels has high potential for economies of scale, encouraging a long-term approach to TFA monitoring initiatives, particularly in countries that already maintain national biometric repositories. © 2021 The Authors

    • Healthcare Associated Infections
      1. Antibiotic multidrug resistance of escherichia coli causing device- and procedure-related infections in the United States reported to the National Healthcare Safety Network, 2013-2017external icon
        Kourtis AP, Sheriff EA, Weiner-Lastinger LM, Elmore K, Preston LE, Dudeck M, McDonald LC.
        Clin Infect Dis. 2021 Dec 6;73(11):e4552-e4559.
        BACKGROUND: Escherichia coli is one of the most common causes of healthcare-associated infections (HAIs); multidrug resistance reduces available options for antibiotic treatment. We examined factors associated with the spread of multidrug-resistant E. coli phenotypes responsible for device- and procedure-related HAIs from acute care hospitals, long-term acute care hospitals, and inpatient rehabilitation facilities, using isolate and antimicrobial susceptibility data reported to the National Healthcare Safety Network during 2013-2017. METHODS: We used multivariable logistic regression to examine associations between co-resistant phenotypes, patient and healthcare facility characteristics, and time. We also examined the geographic distribution of co-resistant phenotypes each year by state and by hospital referral region to identify hot spots. RESULTS: A total of 96 672 E. coli isolates were included. Patient median age was 62 years, and 60% were female; more than half (54%) were reported from catheter-associated urinary tract infections. From 2013 to 2017, 35% of the isolates were nonsusceptible to fluoroquinolones (FQs), 17% to extended-spectrum cephalosporins (ESCs), and 13% to both ESCs and FQs. The proportion of isolates co-resistant to ESCs and FQs was higher in 2017 (14%) than in 2013 (11%) (P < .0001); overall prevalence and increases were heterogeneously distributed across healthcare referral regions. Co-resistance to FQs and ESCs was independently associated with male sex, central line-associated bloodstream infections, long-term acute care hospitals, and the 2016-2017 (vs 2013-2014) reporting period. CONCLUSIONS: Multidrug resistance among E. coli causing device- and procedure-related HAIs has increased in the United States. FQ and ESC co-resistant strains appear to be spreading heterogeneously across hospital referral regions.

      2. Lack of association of post-discharge prophylactic antibiotics with decreased risk of surgical site infection following spinal fusionexternal icon
        Olsen MA, Greenberg JK, Peacock K, Nickel KB, Fraser VJ, Warren DK.
        J Antimicrob Chemother. 2022 Jan 18.
        OBJECTIVES: To determine the prevalence and factors associated with post-discharge prophylactic antibiotic use after spinal fusion and whether use was associated with decreased risk of surgical site infection (SSI). METHODS: Persons aged 10-64 years undergoing spinal fusion between 1 January 2010 and 30 June 2015 were identified in the MarketScan Commercial Database. Complicated patients and those coded for infection from 30 days before to 2 days after the surgical admission were excluded. Outpatient oral antibiotics were identified within 2 days of surgical discharge. SSI was defined using ICD-9-CM diagnosis codes within 90 days of surgery. Generalized linear models were used to determine factors associated with post-discharge prophylactic antibiotic use and with SSI. RESULTS: The cohort included 156 446 fusion procedures, with post-discharge prophylactic antibiotics used in 9223 (5.9%) surgeries. SSIs occurred after 2557 (1.6%) procedures. Factors significantly associated with post-discharge prophylactic antibiotics included history of lymphoma, diabetes, 3-7 versus 1-2 vertebral levels fused, and non-infectious postoperative complications. In multivariable analysis, post-discharge prophylactic antibiotic use was not associated with SSI risk after spinal fusion (relative risk 0.98; 95% CI 0.84-1.14). CONCLUSIONS: Post-discharge prophylactic oral antibiotics after spinal fusion were used more commonly in patients with major medical comorbidities, more complex surgeries and those with postoperative complications during the surgical admission. After adjusting for surgical complexity and infection risk factors, post-discharge prophylactic antibiotic use was not associated with decreased SSI risk. These results suggest that prolonged prophylactic antibiotic use should be avoided after spine surgery, given the lack of benefit and potential for harm.

      3. Distinctive features of ertapenem-mono-resistant carbapenem-resistant enterobacterales in the United States: A cohort studyexternal icon
        Adelman MW, Bower CW, Grass JE, Ansari UA, Soda EA, See I, Lutgring JD, Jacob JT.
        Open Forum Infect Dis. 2022 Jan;9(1):ofab643.
        BACKGROUND: Carbapenem-resistant Enterobacterales (CRE) are highly antibiotic-resistant bacteria. Whether CRE resistant only to ertapenem among carbapenems (ertapenem "mono-resistant") represent a unique CRE subset with regards to risk factors, carbapenemase genes, and outcomes is unknown. METHODS: We analyzed surveillance data from 9 CDC Emerging Infections Program (EIP) sites. A case was the first isolation of a carbapenem-resistant Enterobacter cloacae complex, Escherichia coli, Klebsiella aerogenes, K. oxytoca, K. pneumoniae, or K. variicola from a normally sterile site or urine in an EIP catchment area resident in 2016-2017. We compared risk factors, carbapenemase genes, antibiotic susceptibility, and mortality of ertapenem "mono-resistant" cases to "other" CRE cases (resistant to ≥1 carbapenem other than ertapenem) and analyzed risk factors for mortality. RESULTS: Of 2009 cases, 1249 (62.2%) were ertapenem-mono-resistant and 760 (37.8%) were other CRE. Ertapenem-mono-resistant CRE cases were more frequently ≥80 years old (29.1% vs 19.5%; P < .0001) and female (67.9% vs 59.0%; P < .0001). Ertapenem-mono-resistant isolates were more likely to be Enterobacter cloacae complex (48.4% vs 15.4%; P < .0001) but less likely to be isolated from a normally sterile site (7.1% vs 11.7%; P < .01) or to have a carbapenemase gene (2.4% vs 47.4%; P < .0001). Ertapenem-mono-resistance was not associated with 90-day mortality in logistic regression models. Carbapenemase-positive isolates were associated with mortality (odds ratio, 1.93; 95% CI, 1.30-2.86). CONCLUSIONS: Ertapenem-mono-resistant CRE rarely have carbapenemase genes and have distinct clinical and microbiologic characteristics from other CRE. These findings may inform antibiotic choice and infection prevention practices, particularly when carbapenemase testing is not available.

      4. Factors influencing environmental sampling recovery of healthcare pathogens from non-porous surfaces with cellulose spongesexternal icon
        Rose LJ, Houston H, Martinez-Smith M, Lyons AK, Whitworth C, Reddy SC, Noble-Wang J.
        PLoS One. 2022 ;17(1):e0261588.
        Results from sampling healthcare surfaces for pathogens are difficult to interpret without understanding the factors that influence pathogen detection. We investigated the recovery of four healthcare-associated pathogens from three common surface materials, and how a body fluid simulant (artificial test soil, ATS), deposition method, and contamination levels influence the percent of organisms recovered (%R). Known quantities of carbapenemase-producing KPC+ Klebsiella pneumoniae (KPC), Acinetobacter baumannii, vancomycin-resistant Enterococcus faecalis, and Clostridioides difficile spores (CD) were suspended in Butterfield's buffer or ATS, deposited on 323cm2 steel, plastic, and laminate surfaces, allowed to dry 1h, then sampled with a cellulose sponge wipe. Bacteria were eluted, cultured, CFU counted and %R determined relative to the inoculum. The %R varied by organism, from <1% (KPC) to almost 60% (CD) and was more dependent upon the organism's characteristics and presence of ATS than on surface type. KPC persistence as determined by culture also declined by >1 log10 within the 60 min drying time. For all organisms, the %R was significantly greater if suspended in ATS than if suspended in Butterfield's buffer (p<0.05), and for most organisms the %R was not significantly different when sampled from any of the three surfaces. Organisms deposited in multiple droplets were recovered at equal or higher %R than if spread evenly on the surface. This work assists in interpreting data collected while investigating a healthcare infection outbreak or while conducting infection intervention studies.

    • Immunity and Immunization
      1. Case series of thrombosis with thrombocytopenia syndrome after COVID-19 vaccination-United States, December 2020 to August 2021external icon
        See I, Lale A, Marquez P, Streiff MB, Wheeler AP, Tepper NK, Woo EJ, Broder KR, Edwards KM, Gallego R, Geller AI, Jackson KA, Sharma S, Talaat KR, Walter EB, Akpan IJ, Ortel TL, Urrutia VC, Walker SC, Yui JC, Shimabukuro TT, Mba-Jonas A, Su JR, Shay DK.
        Ann Intern Med. 2022 Jan 18.
        BACKGROUND: Thrombosis with thrombocytopenia syndrome (TTS) is a potentially life-threatening condition associated with adenoviral-vectored COVID-19 vaccination. It presents similarly to spontaneous heparin-induced thrombocytopenia. Twelve cases of cerebral venous sinus thrombosis after vaccination with the Ad26.COV2.S COVID-19 vaccine (Janssen/Johnson & Johnson) have previously been described. OBJECTIVE: To describe surveillance data and reporting rates of all reported TTS cases after COVID-19 vaccination in the United States. DESIGN: Case series. SETTING: United States. PATIENTS: Case patients receiving a COVID-19 vaccine from 14 December 2020 through 31 August 2021 with thrombocytopenia and thrombosis (excluding isolated ischemic stroke or myocardial infarction) reported to the Vaccine Adverse Event Reporting System. If thrombosis was only in an extremity vein or pulmonary embolism, a positive enzyme-linked immunosorbent assay for antiplatelet factor 4 antibodies or functional heparin-induced thrombocytopenia platelet test result was required. MEASUREMENTS: Reporting rates (cases per million vaccine doses) and descriptive epidemiology. RESULTS: A total of 57 TTS cases were confirmed after vaccination with Ad26.COV2.S (n = 54) or a messenger RNA (mRNA)-based COVID-19 vaccine (n = 3). Reporting rates for TTS were 3.83 per million vaccine doses (Ad26.COV2.S) and 0.00855 per million vaccine doses (mRNA-based COVID-19 vaccines). The median age of patients with TTS after Ad26.COV2.S vaccination was 44.5 years (range, 18 to 70 years), and 69% of patients were women. Of the TTS cases after mRNA-based COVID-19 vaccination, 2 occurred in men older than 50 years and 1 in a woman aged 50 to 59 years. All cases after Ad26.COV2.S vaccination involved hospitalization, including 36 (67%) with intensive care unit admission. Outcomes of hospitalizations after Ad26.COV2.S vaccination included death (15%), discharge to postacute care (17%), and discharge home (68%). LIMITATIONS: Underreporting and incomplete case follow-up. CONCLUSION: Thrombosis with thrombocytopenia syndrome is a rare but serious adverse event associated with Ad26.COV2.S vaccination. The different demographic characteristics of the 3 cases reported after mRNA-based COVID-19 vaccines and the much lower reporting rate suggest that these cases represent a background rate. PRIMARY FUNDING SOURCE: Centers for Disease Control and Prevention.

      2. Vaccine effectiveness against life-threatening influenza illness in US childrenexternal icon
        Olson SM, Newhams MM, Halasa NB, Feldstein LR, Novak T, Weiss SL, Coates BM, Schuster JE, Schwarz AJ, Maddux AB, Hall MW, Nofziger RA, Flori HR, Gertz SJ, Kong M, Sanders RC, Irby K, Hume JR, Cullimore ML, Shein SL, Thomas NJ, Stewart LS, Barnes JR, Patel MM, Randolph AG.
        Clin Infect Dis. 2022 Jan 13.
        BACKGROUND: Predominance of 2 antigenically drifted influenza viruses during the 2019-2020 season offered an opportunity to assess vaccine effectiveness against life-threatening pediatric influenza disease from vaccine-mismatched viruses in the United States. METHODS: We enrolled children aged <18 years admitted to the intensive care unit with acute respiratory infection across 17 hospitals. Respiratory specimens were tested using reverse-transcription polymerase chain reaction for influenza viruses and sequenced. Using a test-negative design, we estimated vaccine effectiveness comparing odds of vaccination in test-positive case patients vs test-negative controls, stratifying by age, virus type, and severity. Life-threating influenza included death or invasive mechanical ventilation, vasopressors, cardiopulmonary resuscitation, dialysis, or extracorporeal membrane oxygenation. RESULTS: We enrolled 159 critically ill influenza case-patients (70% ≤8 years; 51% A/H1N1pdm09 and 25% B-Victoria viruses) and 132 controls (69% were aged ≤8 years). Among 56 sequenced A/H1N1pdm09 viruses, 29 (52%) were vaccine-mismatched (A/H1N1pdm09/5A+156K) and 23 (41%) were vaccine-matched (A/H1N1pdm09/5A+187A,189E). Among sequenced B-lineage viruses, majority (30 of 31) were vaccine-mismatched. Effectiveness against critical influenza was 63% (95% confidence interval [CI], 38% to 78%) and similar by age. Effectiveness was 75% (95% CI, 49% to 88%) against life-threatening influenza vs 57% (95% CI, 24% to 76%) against non-life-threating influenza. Effectiveness was 78% (95% CI, 41% to 92%) against matched A(H1N1)pdm09 viruses, 47% (95% CI, -21% to 77%) against mismatched A(H1N1)pdm09 viruses, and 75% (95% CI, 37% to 90%) against mismatched B-Victoria viruses. CONCLUSIONS: During a season when vaccine-mismatched influenza viruses predominated, vaccination was associated with a reduced risk of critical and life-threatening influenza illness in children.

      3. Incidence of SARS-CoV-2 infection among COVID-19 vaccinated and unvaccinated healthcare personnel, first responders, and other essential and frontline workers: Eight US locations, January-September 2021external icon
        Naleway AL, Grant L, Caban-Martinez AJ, Wesley MG, Burgess JL, Groover K, Gaglani M, Yoon SK, Tyner HL, Meece J, Kuntz JL, Yoo YM, Schaefer-Solle N, Olsho LE, Gerald JK, Rose S, Thiese MS, Lundgren J, Groom HC, Mak J, Louzado Feliciano P, Edwards LJ, Lutrick K, Dunnigan K, Phillips AL, Lamberte JM, Noriega R, Sokol BE, Odean M, Ellingson KD, Smith M, Hegmann KT, Respet K, Dickerson M, Cruz A, Fleary DE, Murthy K, Hunt A, Azziz-Baumgartner E, Gallimore-Wilson D, Harder JA, Odame-Bamfo L, Viergutz J, Arvay M, Jones JM, Mistry P, Thompson MG, Fowlkes AL.
        Influenza Other Respir Viruses. 2022 Jan 13.
        BACKGROUND: We sought to evaluate the impact of changes in estimates of COVID-19 vaccine effectiveness on the incidence of laboratory-confirmed infection among frontline workers at high risk for SARS-CoV-2. METHODS: We analyzed data from a prospective frontline worker cohort to estimate the incidence of COVID-19 by month as well as the association of COVID-19 vaccination, occupation, demographics, physical distancing, and mask use with infection risk. Participants completed baseline and quarterly surveys, and each week self-collected mid-turbinate nasal swabs and reported symptoms. RESULTS: Among 1018 unvaccinated and 3531 fully vaccinated workers, the monthly incidence of laboratory-confirmed SARS-CoV-2 infection in January 2021 was 13.9 (95% confidence interval [CI]: 10.4-17.4), declining to 0.5 (95% CI -0.4-1.4) per 1000 person-weeks in June. By September 2021, when the Delta variant predominated, incidence had once again risen to 13.6 (95% CI 7.8-19.4) per 1000 person-weeks. In contrast, there was no reportable incidence among fully vaccinated participants at the end of January 2021, and incidence remained low until September 2021 when it rose modestly to 4.1 (95% CI 1.9-3.8) per 1000. Below average facemask use was associated with a higher risk of infection for unvaccinated participants during exposure to persons who may have COVID-19 and vaccinated participants during hours in the community. CONCLUSIONS: COVID-19 vaccination was significantly associated with a lower risk of SARS-CoV-2 infection despite Delta variant predominance. Our data demonstrate the added protective benefit of facemask use among both unvaccinated and vaccinated frontline workers.

      4. The impact of 10-valent pneumococcal vaccine introduction on invasive disease in Fijiexternal icon
        Reyburn R, Tuivaga EJ, Ratu FT, Dunne EM, Nand D, Kado J, Jenkins K, Tikoduadua L, Jenney A, Howden BP, Ballard SA, Fox K, Devi R, Satzke C, Rafai E, Kama M, Flasche S, Mulholland EK, Russell FM.
        Lancet Reg Health West Pac. 2022 Mar;20:100352.
        BACKGROUND: In 2012, Fiji introduced the 10-valent pneumococcal conjugate vaccine (PCV10). We assessed the impact of PCV10 on invasive pneumococcal disease (IPD), probable bacterial or pneumococcal meningitis (PBPM), meningitis and sepsis 3-5 years post-introduction. METHODS: Laboratory-confirmed IPD and PBPM cases were extracted from national laboratory records. ICD-10-AM coded all-cause meningitis and sepsis cases were extracted from national hospitalisation records. Incidence rate ratios were used to compare outcomes pre/post-PCV10, stratified by age groups: 1-23m, 2-4y, 5-9y, 10-19y, 20-54y, ≥55y. To account for different detection and serotyping methods in the pre-and post-PCV10 period, a Bayesian inference model estimated serotype-specific changes in IPD, using pneumococcal carriage and surveillance data. FINDINGS: There were 423 IPD, 1,029 PBPM, 1,391 all-cause meningitis and 7,611 all-cause sepsis cases. Five years post-PCV10 introduction, IPD declined by 60% (95%CI: 37%, 76%) in children 1-23m months old, and in age groups 2-4y, 5-9y, 10-19y although confidence intervals spanned zero. PBPM declined by 36% (95%CI: 21%, 48%) among children 1-23 months old, and in all other age groups, although some confidence intervals spanned zero. Among children <5y of age, PCV10-type IPD declined by 83% (95%CI; 70%, 90%) and with no evidence of change in non-PCV10-type IPD (9%, 95%CI; -69, 43%). There was no change in all-cause meningitis or sepsis. Post-PCV10, the most common serotypes in vaccine age-eligible and non-age eligible people were serotypes 8 and 23B, and 3 and 7F, respectively. INTERPRETATIONS: Our study demonstrates the effectiveness of PCV10 against IPD in a country in the Asia-Pacific of which there is a paucity of data. FUNDING: This study was support by the Department of Foreign Affairs and Trade of the Australian Government and Fiji Health Sector Support Program (FHSSP). FHSSP is implemented by Abt JTA on behalf of the Australian Government.

      5. Effectiveness of BNT162b2 (Pfizer-BioNTech) mRNA vaccination against multisystem inflammatory syndrome in children among persons aged 12-18 years - United States, July-December 2021external icon
        Zambrano LD, Newhams MM, Olson SM, Halasa NB, Price AM, Boom JA, Sahni LC, Kamidani S, Tarquinio KM, Maddux AB, Heidemann SM, Bhumbra SS, Bline KE, Nofziger RA, Hobbs CV, Bradford TT, Cvijanovich NZ, Irby K, Mack EH, Cullimore ML, Pannaraj PS, Kong M, Walker TC, Gertz SJ, Michelson KN, Cameron MA, Chiotos K, Maamari M, Schuster JE, Orzel AO, Patel MM, Campbell AP, Randolph AG.
        MMWR Morb Mortal Wkly Rep. 2022 Jan 14;71(2):52-58.
        Multisystem inflammatory syndrome in children (MIS-C) is a severe postinfectious hyperinflammatory condition, which generally occurs 2-6 weeks after a typically mild or asymptomatic infection with SARS-CoV-2, the virus that causes COVID-19 (1-3). In the United States, the BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine is currently authorized for use in children and adolescents aged 5-15 years under an Emergency Use Authorization and is fully licensed by the Food and Drug Administration for persons aged ≥16 years (4). Prelicensure randomized trials in persons aged ≥5 years documented high vaccine efficacy and immunogenicity (5),(§) and real-world studies in persons aged 12-18 years demonstrated high vaccine effectiveness (VE) against severe COVID-19 (6). Recent evidence suggests that COVID-19 vaccination is associated with lower MIS-C incidence among adolescents (7); however, VE of the 2-dose Pfizer-BioNTech regimen against MIS-C has not been evaluated. The effectiveness of 2 doses of Pfizer-BioNTech vaccine received ≥28 days before hospital admission in preventing MIS-C was assessed using a test-negative case-control design(¶) among hospitalized patients aged 12-18 years at 24 pediatric hospitals in 20 states** during July 1-December 9, 2021, the period when most MIS-C patients could be temporally linked to SARS-CoV-2 B.1.617.2 (Delta) variant predominance. Patients with MIS-C (case-patients) and two groups of hospitalized controls matched to case-patients were evaluated: test-negative controls had at least one COVID-19-like symptom and negative SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) or antigen-based assay results, and syndrome-negative controls were hospitalized patients without COVID-19-like illness. Among 102 MIS-C case-patients and 181 hospitalized controls, estimated effectiveness of 2 doses of Pfizer-BioNTech vaccine against MIS-C was 91% (95% CI = 78%-97%). All 38 MIS-C patients requiring life support were unvaccinated. Receipt of 2 doses of the Pfizer-BioNTech vaccine is associated with a high level of protection against MIS-C in persons aged 12-18 years, highlighting the importance of vaccination among all eligible children.

      6. On November 4, 2019, the Food and Drug Administration approved high-dose quadrivalent influenza vaccine (Fluzone High-Dose Quadrivalent; QIV-HD) for active immunization for the prevention of influenza disease in individuals 65 years of age and older. A prelicensure randomized, active-controlled, modified double-blind trial did not reveal any major differences in adverse events following QIV-HD versus Fluzone High-Dose (trivalent). To improve our understanding of the safety profile of QIV-HD, we reviewed and summarized reports of adverse events after QIV-HD to the Vaccine Adverse Event Reporting System (VAERS). From July 30, 2020 through June 30, 2021, VAERS received 2,122 reports after QIV-HD. The vast majority (2,018; 95.1%) were non-serious and included events that had been observed in the prelicensure clinical trial, such as injection site reactions, fever, headache, and nausea. The most common serious events included Guillain-Barré syndrome, cellulitis or other local reactions, constitutional signs/symptoms (e.g., fever), and cardiovascular events. Our review did not reveal any new safety concerns. This information may enable policy makers, health officials, clinicians, and patients to make a more informed decision regarding vaccination strategies.

    • Injury and Violence
      1. Associations of adverse childhood experiences (ACEs) with sleep duration and quality: the BCOPS studyexternal icon
        Charles LE, Mnatsakanova A, Fekedulegn D, Violanti JM, Gu JK, Andrew ME.
        Sleep Med. 2021 Dec 23;89:166-175.
        BACKGROUND: Adverse Childhood Experiences (ACEs) are associated with numerous adverse health outcomes in adulthood. Our objective was to investigate associations between ACEs and sleep measures among 206 police officers from the Buffalo Cardio-Metabolic Occupational Police Stress study. METHODS: ACEs (independent variable) was assessed using the ACE questionnaire. Sleep measures were assessed using the Pittsburgh Sleep Quality Index and actigraphy. ANOVA/ANCOVA were used to investigate associations between ACEs and sleep measures. RESULTS: The mean self-reported sleep duration was significantly lower among participants who reported ≥1 ACEs compared to those who reported no ACEs (6.0 ± 0.11 vs. 6.4 ± 0.14 h; multivariate-adjusted p = 0.035). Sleep efficiency was significantly lower among participants who reported ≥1 ACEs compared to those who reported none (mean = 88.7%, 95% CI = 87.7-89.6 vs. 90.2%, 89.2-91.2; unadjusted p = 0.031) but was slightly attenuated and lost statistical significance after multivariate-adjustment (88.8%, 87.8-89.7 vs. 90.1%, 88.9-91.1; p = 0.094). Compared to participants who reported no ACEs, those who reported ≥1 ACEs had a higher mean activity index score (36.9 ± 0.96 vs. 31.2 ± 1.25; multivariate-adjusted p = 0.001); a higher mean wake after sleep onset (WASO) (44.3 ± 2.24 vs. 35.3 ± 2.92 min; multivariate-adjusted p = 0.019); and a higher sleep fragmentation index (3.8 ± 1.65 vs. 3.3 ± 1.20 unadjusted p = 0.044 and 3.8 ± 0.13 vs. 3.3 ± 0.18; multivariate-adjusted p = 0.062). Among men (but not women) who reported ≥1 ACEs, self-reported sleep duration was significantly lower (5.9 ± 0.13 vs. 6.4 ± 0.15 h; multivariate-adjusted p = 0.025) and activity index was significantly higher (39.1 ± 1.3 vs. 33.2 ± 1.51; multivariate-adjusted p = 0.004) compared to those who reported no ACEs. CONCLUSION: Exposure to ≥1 ACE was associated with worse sleep measures.

    • Laboratory Sciences
      1. In 2019, the Centers for Disease Control and Prevention responded to an outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI). Bronchoalveolar-lavage (BAL) fluid from EVALI patients was available for analysis to investigate a range of potential toxicants that might be present at the presumed site of lung injury. Our laboratory developed and validated a novel method to measure cannabinoids and their metabolites in BAL fluid to aid in the investigation of the toxicants that might be the cause of EVALI. In this paper, we describe a sensitive liquid chromatography-tandem mass spectrometry method to measure the following six cannabinoids: Δ(9)-tetrahydrocannabinol (THC), THC metabolites 11-nor-9-carboxy-THC and 11-hydroxy-THC, cannabinol, cannabidiol (CBD), and CBD metabolite 7-nor-7-carboxycannabidiol. Cannabinoids were extracted from BAL fluid using solid-phase extraction. Accuracy, precision, stability, and limits of detection were determined from replicate analyses of spiked BAL pools. The lower limits of detection ranged from 0.019 to 0.153 ng/mL for a sample volume of 150 μL. Overall accuracy ranged from 71.0 to 100.8%. Within-run imprecision (measured by the coefficient of variation) was below 8%, and between-run imprecision was below 21% for all analytes and concentrations tested. The method was applied to samples from 59 EVALI case patients. We identified THC, CBD, or their metabolites in 76% of EVALI patient samples. These findings support previous evidence that THC-containing products played a major role in the EVALI outbreak and help to inform public health recommendations.

      2. Quantitative comparison of SARS-CoV-2 nucleic acid amplification test and antigen testing algorithms: a decision analysis simulation modelexternal icon
        Salvatore PP, Shah MM, Ford L, Delaney A, Hsu CH, Tate JE, Kirking HL.
        BMC Public Health. 2022 Jan 13;22(1):82.
        BACKGROUND: Antigen tests for SARS-CoV-2 offer advantages over nucleic acid amplification tests (NAATs, such as RT-PCR), including lower cost and rapid return of results, but show reduced sensitivity. Public health organizations recommend different strategies for utilizing NAATs and antigen tests. We sought to create a framework for the quantitative comparison of these recommended strategies based on their expected performance. METHODS: We utilized a decision analysis approach to simulate the expected outcomes of six testing algorithms analogous to strategies recommended by public health organizations. Each algorithm was simulated 50,000 times in a population of 100,000 persons seeking testing. Primary outcomes were number of missed cases, number of false-positive diagnoses, and total test volumes. Outcome medians and 95% uncertainty ranges (URs) were reported. RESULTS: Algorithms that use NAATs to confirm all negative antigen results minimized missed cases but required high NAAT capacity: 92,200 (95% UR: 91,200-93,200) tests (in addition to 100,000 antigen tests) at 10% prevalence. Selective use of NAATs to confirm antigen results when discordant with symptom status (e.g., symptomatic persons with negative antigen results) resulted in the most efficient use of NAATs, with 25 NAATs (95% UR: 13-57) needed to detect one additional case compared to exclusive use of antigen tests. CONCLUSIONS: No single SARS-CoV-2 testing algorithm is likely to be optimal across settings with different levels of prevalence and for all programmatic priorities. This analysis provides a framework for selecting setting-specific strategies to achieve acceptable balances and trade-offs between programmatic priorities and resource constraints.

      3. Evaluation of a parasite-density based pooled targeted amplicon deep sequencing (TADS) method for molecular surveillance of Plasmodium falciparum drug resistance genes in Haitiexternal icon
        Louha S, Herman C, Gupta M, Patel D, Kelley J, Oh JM, Guru J, Lemoine JF, Chang MA, Venkatachalam U, Rogier E, Talundzic E.
        PLoS One. 2022 ;17(1):e0262616.
        Sequencing large numbers of individual samples is often needed for countrywide antimalarial drug resistance surveillance. Pooling DNA from several individual samples is an alternative cost and time saving approach for providing allele frequency (AF) estimates at a population level. Using 100 individual patient DNA samples of dried blood spots from a 2017 nationwide drug resistance surveillance study in Haiti, we compared codon coverage of drug resistance-conferring mutations in four Plasmodium falciparum genes (crt, dhps, dhfr, and mdr1), for the same deep sequenced samples run individually and pooled. Samples with similar real-time PCR cycle threshold (Ct) values (+/- 1.0 Ct value) were combined with ten samples per pool. The sequencing success for samples in pools were higher at a lower parasite density than the individual samples sequence method. The median codon coverage for drug resistance-associated mutations in all four genes were greater than 3-fold higher in the pooled samples than in individual samples. The overall codon coverage distribution for pooled samples was wider than the individual samples. The sample pools with < 40 parasites/μL blood showed more discordance in AF calls for dhfr and mdr1 between the individual and pooled samples. This discordance in AF estimation may be due to low amounts of parasite DNA, which could lead to variable PCR amplification efficiencies. Grouping samples with an estimated ≥ 40 parasites/μL blood prior to pooling and deep sequencing yielded the expected population level AF. Pooling DNA samples based on estimates of > 40 parasites/μL prior to deep sequencing can be used for rapid genotyping of a large number of samples for these four genes and possibly other drug resistant markers in population-based studies. As Haiti is a low malaria transmission country with very few mixed infections and continued chloroquine sensitivity, the pooled sequencing approach can be used for routine national molecular surveillance of resistant parasites.

    • Maternal and Child Health
      1. Sensory features in autism: Findings from a large population-based surveillance systemexternal icon
        Kirby AV, Bilder DA, Wiggins LD, Hughes MM, Davis J, Hall-Lande JA, Lee LC, McMahon WM, Bakian AV.
        Autism Res. 2022 Jan 18.
        Sensory features (i.e., atypical responses to sensory stimuli) are included in the current diagnostic criteria for autism spectrum disorder. Yet, large population-based studies have not examined these features. This study aimed to determine the prevalence of sensory features among autistic children, and examine associations between sensory features, demographics, and co-occurring problems in other areas. Analysis for this study included a sample comprised of 25,627 four- or eight-year-old autistic children identified through the multistate Autism and Developmental Disabilities Monitoring Network (2006-2014). We calculated the prevalence of sensory features and applied multilevel logistic regression modeling. The majority (74%; 95% confidence interval: 73.5%-74.5%) of the children studied had documented sensory features. In a multivariable model, children who were male and those whose mothers had more years of education had higher odds of documented sensory features. Children from several racial and ethnic minority groups had lower odds of documented sensory features than White, non-Hispanic children. Cognitive problems were not significantly related to sensory features. Problems related to adaptive behavior, emotional states, aggression, attention, fear, motor development, eating, and sleeping were associated with higher odds of having documented sensory features. Results from a large, population-based sample indicate a high prevalence of sensory features in autistic children, as well as relationships between sensory features and co-occurring problems. This study also pointed to potential disparities in the identification of sensory features, which should be examined in future research. Disparities should also be considered clinically to avoid reduced access to supports for sensory features and related functional problems. LAY SUMMARY: In a large, population-based sample of 25,627 autistic children, 74% had documented differences in how they respond to sensation. We also identified significant associations of sensory features with adaptive behavior and problems in other domains. Sensory features were less common among girls, children of color, and children of mothers with fewer years of education, suggesting potential disparities in identification.

      2. Measurement of gender and sexuality in the Adolescent Brain Cognitive Development (ABCD) studyexternal icon
        Potter AS, Dube SL, Barrios LC, Bookheimer S, Espinoza A, Feldstein Ewing SW, Freedman EG, Hoffman EA, Ivanova M, Jefferys H, McGlade EC, Tapert SF, Johns MM.
        Dev Cogn Neurosci. 2022 Jan 4;53:101057.
        The Adolescent Brain Cognitive Development(SM) (ABCD) study is a longitudinal study of adolescent brain development and health that includes over 11,800 youth in the United States. The ABCD study includes broad developmental domains, and gender and sexuality are two of these with noted changes across late childhood and early adolescence. The Gender Identity and Sexual Health (GISH) workgroup recommends measures of gender and sexuality for the ABCD study, prioritizing those that are developmentally sensitive, capture individual differences in the experience of gender and sexuality, and minimize participant burden. This manuscript describes the gender and sexuality measures used in ABCD and provides guidance for researchers using these data. Data showing the utility of these measures and longitudinal trends are presented. Including assessment of gender and sexuality in ABCD allows for characterization of developmental trajectories of gender and sexuality, and the broad scope of ABCD data collection allows examination of identity development in an intersectional manner.

    • Nutritional Sciences
      1. BACKGROUND: Active screening of only pregnant and lactating mothers (PLMs) excludes other mothers of reproductive age susceptible to undernutrition. Our analysis evaluated if mothers presenting with wasted children were more likely to be undernourished themselves. METHODS: The observational study enrolled mother and child dyads presenting to an outpatient facility in Mogadishu, Somalia, between November 2019 and March 2020. Trained nurses recorded lower extremity oedema for children aged 6-59 months, parity and gestational status for women aged 19-50 years and age, access to care, height/length, mid-upper arm circumference (MUAC) and weight for both. Weight-for-height z-score (WHZ) for children and body mass index (BMI) for mothers were calculated using standard procedures. Wasting was defined as WHZ <-2, MUAC <12.5 cm and/or presence of oedema for children. Undernutrition was defined as MUAC <23 cm for PLMs and BMI <18.5 kg/m(2) for neither pregnant nor lactating mothers (non-PLMs). Four multivariable linear regression models were fit to evaluate maternal anthropometric indicators (BMI or MUAC) given child anthropometric indicators (MUAC or WHZ), adjusting for maternal age, parity and gestational status. RESULTS: A total of 93.6% (2142/2288) of enrolled dyads met inclusion criteria. Wasting was observed among 57.5% of children; 20.2% of pregnant mothers, 20.0% of lactating mothers and 7.95% of non-PLMs were undernourished. Models suggest significant, positive associations between child and maternal anthropometrics; a one-unit increase in WHZ and a 1 cm increase in child MUAC were associated with 0.22 kg/m(2) (95% CI 0.22 to 0.24) and 0.19 kg/m(2) (95% CI 0.16 to 0.21) increases in maternal BMI, respectively, and 0.20 cm (95% CI 0.18 to 0.22) and 0.24 cm (95% CI 0.23 to 0.25) increases in maternal MUAC, respectively. Adjusted R(2) values were low (range 0.06-0.10). CONCLUSIONS: Undernutrition among non-PLMs illustrates the importance of expanding screening. However, while significant, the strength of association between mother and child anthropometrics does not support child nutritional status as a screening tool for identifying at-risk mothers.

      2. Maternal dietary patterns during pregnancy and exposure to persistent endocrine disrupting chemicals in two European birth cohortsexternal icon
        Marks KJ, Northstone K, Papadopoulou E, Brantsæter AL, Haug LS, Howards PP, Smarr MM, Flanders WD, Hartman TJ.
        Environ Adv. 2021 ;6.
        Food consumption, particularly of animal-based products, is considered the most important contributor to persistent endocrine disrupting chemical (EDC) exposure. This study aims to describe the association between maternal diet during pregnancy and exposure to persistent EDCs using dietary pattern analysis. This study is based on subsamples of the Avon Longitudinal Study of Parents and Children (ALSPAC) (N=422) and the Norwegian Mother, Father, and Child Cohort Study (MoBa) (N=276) which uses data from the Medical Birth Registry of Norway (MBRN). Women in both studies completed food frequency questionnaires (FFQs) during pregnancy, from which consumption data were categorized into 38 aggregated food groups. Maternal blood samples were collected during pregnancy and concentrations of perfluoroalkyl substances (PFAS), polychlorinated biphenyls (PCBs), and organochlorine pesticides (OCPs) in serum/plasma were measured. Dietary patterns were identified using reduced rank regression, with blood EDC concentrations as response variables. Within ALSPAC, all patterns (PFAS, PCB, and OCP) were characterized by high consumption of meat, poultry, white fish, and biscuits. In MoBa, high consumption of sausages and burgers (representing processed meats), pasta, and chocolate bars characterized PCB and OCP dietary patterns, while high consumption of cheese characterized the PFAS pattern. Across both cohorts, PFAS patterns were characterized by high consumption of cheese, PCB patterns by high consumption of rice, and OCP patterns by poultry. Dietary patterns explained between 8 and 20% of the variation in serum EDC concentrations, with explained variance being the highest for PCBs in both cohorts. In conclusion, dietary patterns high in animal-based products appear to be associated with persistent EDC concentrations among pregnant women. Diet explains more variation in PCB concentrations than for other persistent EDC classes. © 2021

    • Occupational Safety and Health - Mining
      1. BACKGROUND: In 2014, a federal rule reduced occupational exposure limits to coal mine dust and expanded medical surveillance eligibility beyond underground miners to surface and contract coal miners. This expansion may have provided an opportunity for more American Indian and Alaska Native (AI/AN) coal miners to participate in screening, since many surface coal mines are located near AI/AN communities and may employ AI/AN miners. Therefore we sought to better understand the respiratory health of AI/AN coal miners by characterizing prevalence of coal workers' pneumoconiosis (CWP), progressive massive fibrosis (PMF), and abnormal lung function in this population. METHODS: Descriptive analysis of 1405 chest radiographs and 627 spirometry test results for AI/AN miners who participated in the Coal Workers' Health Surveillance Program (CWHSP) during 2014-2019 was conducted. RESULTS: Most AI/AN miners (0-25+ years of tenure) were western United States residents (82.3%) and active surface miners (76.9%) with no underground tenure. Among miners with at least 10 years of tenure, prevalence of CWP was 3.0%, and of PMF was 0.3%. Lung function abnormalities were seen in 9.0% with primarily restrictive patterns. CONCLUSIONS: The prevalence of CWP, PMF, and lung function abnormality among active and former AI/AN coal miners was higher than seen in a larger CWHSP study of active western miners working primarily underground with 10+ years of tenure. Interventions that eliminate or control coal mine dust exposure, identify miners with CWP early, and limit respiratory disease progression and complications remain vital for eliminating the preventable adverse health effects of coal mining. Comprehensive demographic data on the coal mining workforce are needed to improve CWHSP participation assessment.

      2. In recent years, there has been increasing interest in the role that individual factors play in health and safety (H&S) outcomes in the mining industry. Two surveys, one measuring self-reported routine safety performance and one measuring individual perceived competence in the non-routine knowledge, skills, and abilities (KSAs) critical to emergency response, were administered to two samples of mineworkers in separate research studies over a 2-year period (N = 2,020 and 696, respectively). Eight demographic items were common to both surveys and their associations with each performance outcome were tested in response to a series of exploratory research questions. Significant relationships were found between both safety outcome variables and individual factors, including the length of experience in current job, current mine, and mining industry, as well as participant workgroup and work schedule. Notably, the length of experience in the mining industry was the only variable significantly associated with both routine and non-routine safety performance. This analysis suggests that individual factors such as length of job, industry, and mine experience are predictive of routine and/or non-routine safety performance outcomes in significant and sometimes unexpected ways. © 2022, This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.

    • Public Health Leadership and Management
      1. Standards required for the development of CDC evidence-based guidelinesexternal icon
        Carande-Kulis V, Elder RW, Koffman DM.
        MMWR Suppl. 2022 Jan 14;71(1):1-6.
        CDC is the nation's premier health promotion, prevention, and preparedness agency. As such, CDC is an important source of public health and clinical guidelines. If CDC guidelines are to be trusted by partners and the public, they must be clear, valid, and reliable. Methods and processes used in CDC guideline development should follow universally accepted standards. This report describes the standards required by CDC for the development of evidence-based guidelines. These standards cover topics such as guideline scoping, soliciting external input, summarizing evidence, and crafting recommendations. Following these standards can help minimize bias and enhance the quality and consistency of CDC guidelines.

    • Substance Use and Abuse
      1. Communicating during an HIV outbreak among people who inject drugs-West Virginia 2019external icon
        Watson M, Thomasson E, Adkins E, Batdorf S, Kilkenny M, Diaz SS, Pegram L, Rinderle JK, LaFlam M, Wingard R, McClung RP, Oster AM, Stryker J.
        AIDS Behav. 2022 Jan 14.
        In 2019, the West Virginia Bureau for Public Health (WV BPH), Cabell-Huntington Health Department (CHHD), and CDC collaborated to respond to an HIV outbreak among people who inject drugs (PWID). CDC, WV BPH, and CHHD formed a cross-agency communications team to establish situational awareness, identify knowledge gaps, and establish key audiences for messages, including the general population, PWID, and clinical and social service providers. The team disseminated up-to-date information about the outbreak, and prioritized messages addressing stigma related to drug use, syringe services programs, and HIV. Messages were continually updated to address the evolving situation and to resonate with local values. Messages were disseminated via advertisements, local news media, and directly to PWID, people experiencing homelessness, and providers. The response supplemented CHHD's assets, including strong relationships and community knowledge, with staff capacity and expertise from state and federal agencies. This collaborative approach is a useful model to address communication needs.

      2. Risk factors for COVID-19 among persons with substance use disorder (PWSUD) with hospital visits - United States, April 2020-December 2020external icon
        Board AR, Kim S, Park J, Schieber L, Miller GF, Pike J, Cremer LJ, Asher A.
        Drug Alcohol Depend. 2022 Jan 11;232:109297.
        INTRODUCTION: Sociodemographic factors and chronic conditions associated with coronavirus disease 2019 (COVID-19) among persons with substance use disorder (PWSUD) are not well understood. We identified risk factors associated with COVID-19 among PWSUD with hospital visits. METHODS: Using the Premier Healthcare Database Special COVID-19 Release, we conducted a case-control study using ICD-10-CM codes to identify PWSUD aged 12 years and older with hospital visits for any reason during April-December 2020. Multivariable logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) to identify factors associated with COVID-19 diagnosis among PWSUD (age, sex, race/ethnicity, U.S. Census Region, urban/rural classification, insurance payor type, comorbidities, and substance use disorder [SUD] type), and then stratified by SUD type. RESULTS: From April-December 2020, 18,298 (1.3%) of 1,429,154 persons with SUD in the database had a COVID-19 diagnosis. Among PWSUD, opioid use disorder (OUD; aOR = 1.24, 95% CI = 1.18-1.32), alcohol use disorder (AUD; aOR = 1.16, 95% CI = 1.11-1.22), cocaine or other stimulant use disorder (COUD; aOR = 1.28, 95% CI = 1.22-1.34), and multiple SUDs (aOR = 1.20, 95% CI = 1.15-1.26) were associated with higher odds of COVID-19, as were comorbidities such as chronic lower respiratory disease (aOR = 1.32, 95% CI = 1.26-1.37), chronic hepatitis (aOR = 1.45, 95% CI = 1.34-1.57), and diabetes (aOR = 1.78, 95% CI = 1.71-1.86). CONCLUSIONS: Among a sample of PWSUD, OUD, AUD, COUD, multiple SUDs, and associated comorbidities were associated with COVID-19 diagnosis. Integration of COVID-related care, care of other comorbidities, and SUD treatment may benefit PWSUD. Future studies are needed to better understand COVID-19 prevention in this population and to reduce disparities among subpopulations at increased risk.

      3. Trends and characteristics of cannabis-associated emergency department visits in the United States, 2006-2018external icon
        Roehler DR, Hoots BE, Holland KM, Baldwin GT, Vivolo-Kantor AM.
        Drug Alcohol Depend. 2022 Jan 10;232:109288.
        BACKGROUND: Cannabis policies are rapidly changing in the United States, yet little is known about how this has affected cannabis-associated emergency department (ED) visits. METHODS: We studied trends in cannabis-associated ED visits and identified differences by visit characteristics. Cannabis-associated ED visits from 2006 to 2018 were identified from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project's (HCUP) Nationwide Emergency Department Sample (NEDS). JoinPoint analysis was used to identify trends from 2006 to 2014, prior to medical coding changes in 2015, and Z-tests were used to compare annual rate changes from 2016 to 2018. Changes in rates from 2017 to 2018 were examined by visit characteristics. RESULTS: From 2006-2014, the rate of cannabis-associated ED visits increased, on average, 12.1% annually (p < 0.05), from 12.3 to 34.7 visits per 100,000 population. The rate increased 17.3% from 2016 to 2017 (p < 0.05) and 11.1% from 2017 to 2018 (p < 0.05). From 2017-2018, rates of visits increased for both males (8.7%; p < 0.05) and females (15.9%; p < 0.05). Patients 0-14 years and 25 years and older had significant rate increases from 2017 to 2018 as did the Midwest region (36.8%; p < 0.05), the Northeast (9.2%; p < 0.05), and the South (4.5%; p < 0.05). CONCLUSIONS: Cannabis-associated ED visits are on the rise and subgroups are at increased risk. Some potential explanations for increases in cannabis-associated ED visits include increased availability of cannabis products, increased use, and diversity of products available in marketplaces. Strategies are needed to prevent youth initiation, limit potentially harmful use among adults, and ensure safe storage where cannabis use is legal.

      4. Improving estimates of alcohol-attributable deaths in the United States: Impact of adjusting for the underreporting of alcohol consumptionexternal icon
        Esser MB, Sherk A, Subbaraman MS, Martinez P, Karriker-Jaffe KJ, Sacks JJ, Naimi TS.
        J Stud Alcohol Drugs. 2022 Jan;83(1):134-144.
        OBJECTIVE: Self-reported alcohol consumption in U.S. public health surveys covers only 30%-60% of per capita alcohol sales, based on tax and shipment data. To estimate alcohol-attributable harms using alcohol-attributable fractions, accurate measures of total population consumption and the distribution of this drinking are needed. This study compared methodological approaches of adjusting self-reported survey data on alcohol consumption to better reflect sales and assessed the impact of these adjustments on the distribution of average daily consumption (ADC) levels and the number of alcohol-attributable deaths. METHOD: Prevalence estimates of ADC levels (i.e., low, medium, and high) among U.S. adults who responded to the 2011-2015 Behavioral Risk Factor Surveillance System (BRFSS; N = 2,198,089) were estimated using six methods. BRFSS ADC estimates were adjusted using the National Alcohol Survey, per capita alcohol sales data (from the Alcohol Epidemiologic Data System), or both. Prevalence estimates for the six methods were used to estimate average annual alcohol-attributable deaths, using a population-attributable fraction approach. RESULTS: Self-reported ADC in the BRFSS accounted for 31.3% coverage of per capita alcohol sales without adjustments, 36.1% using indexed-BRFSS data, and 44.3% with National Alcohol Survey adjustments. Per capita sales adjustments decreased low ADC prevalence estimates and increased medium and high ADC prevalence estimates. Estimated alcohol-attributable deaths ranged from approximately 91,200 per year (BRFSS unadjusted; Method 1) to 125,200 per year (100% of per capita sales adjustment; Method 6). CONCLUSIONS: Adjusting ADC to reflect total U.S. alcohol consumption (e.g., adjusting to 73% of per capita sales) has implications for assessing the impact of excessive drinking on health outcomes, including alcohol-attributable death estimates.

      5. Evaluation of state-led surveillance of neonatal abstinence syndrome - six U.S. states, 2018-2021external icon
        Jilani SM, West K, Jacobus-Kantor L, Ali MM, Nyakeriga A, Lake-Burger H, Robinson M, Barnes AE, Jewell T, Gallaway S.
        MMWR Morb Mortal Wkly Rep. 2022 Jan 14;71(2):37-42.
        Opioid use disorder (OUD) is a significant public health problem in the United States, which affects children as well as adults. During 2010-2017, maternal opioid-related diagnoses increased approximately 130%, from 3.5 to 8.2 per 1,000 hospital deliveries, and neonatal abstinence syndrome (NAS) increased 83%, from 4.0 to 7.3 per 1,000 hospital deliveries (1). NAS, a withdrawal syndrome, can occur among infants following in utero exposure to opioids and other psychotropic substances (2). In 2018, a study of six states with mandated NAS case reporting for public health surveillance (2013-2017) found that mandated reporting helped quantify NAS incidence and guide programs and services (3). To review surveillance features and programmatic development in the same six states, a questionnaire and interview with state health department officials on postimplementation efforts were developed and implemented in 2021. All states reported ongoing challenges with initial case reporting, limited capacity to track social and developmental outcomes, and no requirement for long-term follow-up in state-mandated case reporting; only one state instituted health-related outcomes monitoring. The primary surveillance barrier beyond initial case reporting was lack of infrastructure. To serve identified needs of opioid- or other substance-exposed mother-infant dyads, state health departments reported programmatic successes expanding education and access to maternal medication for opioid use disorder (MOUD), community and provider education or support services, and partnerships with perinatal quality collaboratives. Development of additional infrastructure is needed for states aiming to advance NAS surveillance beyond initial case reporting.

    • Veterinary Medicine
      1. Investigation of SARS-CoV-2 infection and associated lesions in exotic and companion animalsexternal icon
        Rotstein DS, Peloquin S, Proia K, Hart E, Lee J, Vyhnal KK, Sasaki E, Balamayooran G, Asin J, Southard T, Rothfeldt L, Venkat H, Mundschenk P, McDermott D, Crossley B, Ferro P, Gomez G, Henderson EH, Narayan P, Paulsen DB, Rekant S, Schroeder ME, Tell RM, Torchetti MK, Uzal FA, Carpenter A, Ghai R.
        Vet Pathol. 2022 Jan 18:3009858211067467.
        Documented natural infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in exotic and companion animals following human exposures are uncommon. Those documented in animals are typically mild and self-limiting, and infected animals have only infrequently died or been euthanized. Through a coordinated One Health initiative, necropsies were conducted on 5 animals from different premises that were exposed to humans with laboratory-confirmed SARS-CoV-2 infection. The combination of epidemiologic evidence of exposure and confirmatory real-time reverse transcriptase-polymerase chain reaction testing confirmed infection in 3 cats and a tiger. A dog was a suspect case based on epidemiologic evidence of exposure but tested negative for SARS-CoV-2. Four animals had respiratory clinical signs that developed 2 to 12 days after exposure. The dog had bronchointerstitial pneumonia and the tiger had bronchopneumonia; both had syncytial-like cells with no detection of SARS-CoV-2. Individual findings in the 3 cats included metastatic mammary carcinoma, congenital renal disease, and myocardial disease. Based on the necropsy findings and a standardized algorithm, SARS-CoV-2 infection was not considered the cause of death in any of the cases. Continued surveillance and necropsy examination of animals with fatal outcomes will further our understanding of natural SARS-CoV-2 infection in animals and the potential role of the virus in development of lesions.

    • Zoonotic and Vectorborne Diseases
      1. Immunobiology of Crimean-Congo hemorrhagic feverexternal icon
        Rodriguez SE, Hawman DW, Sorvillo TE, O'Neal TJ, Bird BH, Rodriguez LL, Bergeron É, Nichol ST, Montgomery JM, Spiropoulou CF, Spengler JR.
        Antiviral Res. 2022 Jan 10:105244.
        Human infection with Crimean-Congo hemorrhagic fever virus (CCHFV), a tick-borne pathogen in the family Nairoviridae, can result in a spectrum of outcomes, ranging from asymptomatic infection through mild clinical signs to severe or fatal disease. Studies of CCHFV immunobiology have investigated the relationship between innate and adaptive immune responses with disease severity, attempting to elucidate factors associated with differential outcomes. In this article, we begin by highlighting unanswered questions, then review current efforts to answer them. We discuss in detail current clinical studies and research in laboratory animals on CCHF, including immune targets of infection and adaptive and innate immune responses. We summarize data about the role of the immune response in natural infections of animals and humans and experimental studies in vitro and in vivo and from evaluating immune-based therapies and vaccines, and present recommendations for future research.

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

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