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Issue 9, March 1, 2022

CDC Science Clips: Volume 14, Issue 9, March 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.
    • Antimicrobial Resistance and Antibiotic Stewardship
      1. Baseline HIV drug resistance testing: 12 U.S. jurisdictions, 2014-2019external icon
        Hugueley B, McClung RP, Saduvala N, Oster AM, France AM.
        AIDS. 2022 Feb 9.
        OBJECTIVE: To understand recent patterns in reported baseline HIV drug resistance testing over time in the United States. DESIGN: Data from the National HIV Surveillance System (NHSS) for persons who were aged at least 13 years at the time of HIV diagnosis during 2014-2019 and resided in one of 12 United States jurisdictions with high levels of reporting in 2014 and 2015. METHODS: Among persons included in the analysis, we calculated the total proportion of HIV diagnoses occurring during 2014-2019 with a reported baseline sequence by year of diagnosis and sequence type. A baseline sequence was defined as any PR/RT or IN sequence generated from a specimen collected ≤90 days after diagnosis. RESULTS: During 2014-2019, reported levels of baseline PR/RT (with or without IN) testing varied by year from 46.9% to 51.8% without any clear pattern over time. PR/RT with IN testing increased (8.3% to 19.4%), and IN-only testing remained low (1.9% to 1.3%). CONCLUSIONS: While reported levels of baseline PR/RT (with or without IN) testing have remained sufficiently high for the purposes of molecular cluster detection, higher levels would strengthen jurisdictions' and the Centers for Disease Control and Prevention's ability to monitor trends in HIV drug resistance and detect and respond to HIV molecular clusters. Efforts to increase levels of reported baseline testing likely need to address both gaps in testing as well as reporting.

      2. Trimethoprim-sulfamethoxazole resistance patterns among Staphylococcus aureus in the United States, 2012-2018external icon
        Ham DC, Fike L, Wolford H, Lastinger L, Soe M, Baggs J, Walters MS.
        Infect Control Hosp Epidemiol. 2022 Feb 15:1-4.
        We reviewed trimethoprim-sulfamethoxazole antibiotic susceptibility testing data among Staphylococcus aureus using 3 national inpatient databases. In all 3 databases, we observed an increases in the percentage of methicillin-resistant Staphylococcus aureus that were not susceptible to trimethoprim-sulfamethoxazole. Providers should select antibiotic regimens based on local resistance patterns and should report changes to the public health department.

      3. Molecular characterization of carbapenem-resistant enterobacterales collected in the United Statesexternal icon
        Karlsson M, Lutgring JD, Ansari U, Lawsin A, Albrecht V, McAllister G, Daniels J, Lonsway D, McKay S, Beldavs Z, Bower C, Dumyati G, Gross A, Jacob J, Janelle S, Kainer MA, Lynfield R, Phipps EC, Schutz K, Wilson L, Witwer ML, Bulens SN, Walters MS, Duffy N, Kallen AJ, Elkins CA, Rasheed JK.
        Microb Drug Resist. 2022 Feb 16.
        Carbapenem-resistant Enterobacterales (CRE) are a growing public health concern due to resistance to multiple antibiotics and potential to cause health care-associated infections with high mortality. Carbapenemase-producing CRE are of particular concern given that carbapenemase-encoding genes often are located on mobile genetic elements that may spread between different organisms and species. In this study, we performed phenotypic and genotypic characterization of CRE collected at eight U.S. sites participating in active population- and laboratory-based surveillance of carbapenem-resistant organisms. Among 421 CRE tested, the majority were isolated from urine (n = 349, 83%). Klebsiella pneumoniae was the most common organism (n = 265, 63%), followed by Enterobacter cloacae complex (n = 77, 18%) and Escherichia coli (n = 50, 12%). Of 419 isolates analyzed by whole genome sequencing, 307 (73%) harbored a carbapenemase gene; variants of bla(KPC) predominated (n = 299, 97%). The occurrence of carbapenemase-producing K. pneumoniae, E. cloacae complex, and E. coli varied by region; the predominant sequence type within each genus was ST258, ST171, and ST131, respectively. None of the carbapenemase-producing CRE isolates displayed resistance to all antimicrobials tested; susceptibility to amikacin and tigecycline was generally retained.

      4. Identifying higher-volume antibiotic outpatient prescribers using publicly available Medicare Part D data - United States, 2019external icon
        Gouin KA, Fleming-Dutra KE, Tsay S, Bizune D, Hicks LA, Kabbani S.
        MMWR Morb Mortal Wkly Rep. 2022 Feb 11;71(6):202-205.
        Antibiotic prescribing can lead to adverse drug events and antibiotic resistance, which pose ongoing urgent public health threats (1). Adults aged ≥65 years (older adults) are recipients of the highest rates of outpatient antibiotic prescribing and are at increased risk for antibiotic-related adverse events, including Clostridioides difficile and antibiotic-resistant infections and related deaths (1). Variation in antibiotic prescribing quality is primarily driven by prescribing patterns of individual health care providers, independent of patients' underlying comorbidities and diagnoses (2). Engaging higher-volume prescribers (the top 10% of prescribers by antibiotic volume) in antibiotic stewardship interventions, such as peer comparison audit and feedback in which health care providers receive data on their prescribing performance compared with that of other health care providers, has been effective in reducing antibiotic prescribing in outpatient settings and can be implemented on a large scale (3-5). This study analyzed data from the Centers for Medicare & Medicaid Services (CMS) Part D Prescriber Public Use Files (PUFs)* to describe higher-volume antibiotic prescribers in outpatient settings compared with lower-volume prescribers (the lower 90% of prescribers by antibiotic volume). Among the 59.4 million antibiotic prescriptions during 2019, 41% (24.4 million) were prescribed by the top 10% of prescribers (69,835). The antibiotic prescribing rate of these higher-volume prescribers (680 prescriptions per 1,000 beneficiaries) was 60% higher than that of lower-volume prescribers (426 prescriptions per 1,000 beneficiaries). Identifying health care providers responsible for a higher volume of antibiotic prescribing could provide a basis for additional assessment of appropriateness and outreach. Public health organizations and health care systems can use publicly available data to guide focused interventions to optimize antibiotic prescribing to limit the emergence of antibiotic resistance and improve patient outcomes.

    • Chronic Diseases and Conditions
      1. Cervical cancer screening and treatment, HIV infection, and age: Program implementation in seven regions of Namibiaexternal icon
        Korn AK, Muzingwani L, O'Bryan G, Ensminger A, Boylan AD, Kafidi EL, Kashali M, Ashipala L, Nitschke AM, Dziuban EJ, Forster N, Eckert LO, O'Malley G.
        PLoS One. 2022 ;17(2):e0263920.
        The aim of this study was to assess differences in cervical cancer screening and treatment outcomes by HIV status in a routine programmatic setting with a high generalized HIV prevalence. Women living with HIV (WLHIV) are at heightened risk of developing cervical cancer and the World Health Organization recommends all WLHIV who are sexually active be screened, regardless of age. In 2018, Namibia's Ministry of Health and Social Services introduced a screen-and-treat approach using visual inspection with acetic acid (VIA) and ablative treatment with cryotherapy or thermocoagulation with a focus on screening HIV-positive women due to Namibia's 11.5% prevalence of HIV in women aged 15-49. Using program data from October 2018 to March 2020 from seven of the country's 14 regions, we calculated descriptive statistics and chi-square tests to test the statistical significance of differences in VIA-positivity, ineligibility for ablative treatment, treatment completion, and same day treatment completion by HIV status. Between October 2018 and March 2020, the program conducted 14,786 cervical cancer screenings. Among 8,150 women who received their first VIA screening, more WLHIV screened VIA-positive (17%) than HIV-negative women (15%). This difference was statistically significant (p = 0.02). Among 2,272 women who screened VIA-positive at any screening, 1,159 (82%) completed ablative treatment. This suggests ablative treatment is feasible and acceptable in resource-limited settings. WLHIV were also more likely to complete treatment than HIV-negative women (p<0.01). Differences in health seeking behavior of sub-populations as well as resource availability between service delivery points should be considered for further investigation. Going forward in order to strengthen program implementation and expand screening access and uptake further investigation is needed to determine cancer incidence by HIV status, age, and time since last screening to assess cases that are averted as well as potential rates of overtreatment.

    • Communicable Diseases
      1. Household transmission of SARS-CoV-2 Alpha variant - United States, 2021external icon
        Donnelly MA, Chuey MR, Soto R, Schwartz NG, Chu VT, Konkle SL, Sleweon S, Ruffin J, Haberling DL, Guagliardo SA, Stoddard RA, Anderson RD, Morgan CN, Rossetti R, McCormick DW, Magleby R, Sheldon SW, Dietrich EA, Uehara A, Retchless AC, Tong S, Folster JM, Drobeniuc J, Petway ME, Austin B, Stous S, McDonald E, Jain S, Hudziec MM, Stringer G, Albanese BA, Totten SE, Staples JE, Killerby ME, Hughes L, Matanock A, Beatty M, Tate JE, Kirking HL, Hsu CH.
        Clin Infect Dis. 2022 Feb 11.
        BACKGROUND: In Spring 2021, SARS-CoV-2 B.1.1.7 (Alpha) became the predominant variant in the U.S. Research suggests that Alpha has increased transmissibility compared to non-Alpha lineages. We estimated household secondary infection risk (SIR), assessed characteristics associated with transmission, and compared symptoms of persons with Alpha and non-Alpha infections. METHODS: We followed households with SARS-CoV-2 infection for two weeks in San Diego County and metropolitan Denver, January to April 2021. We collected epidemiologic information and biospecimens for serology, RT-PCR, and whole genome sequencing. We stratified SIR and symptoms by lineage, and identified characteristics associated with transmission using Generalized Estimating Equations. RESULTS: We investigated 127 households with 322 household contacts; 72 households (56.7%) had member(s) with secondary infections. SIRs were not significantly higher for Alpha (61.0% [95% confidence interval (CI) 52.4-69.0%]) than non-Alpha (55.6% [CI 44.7-65.9%], P = 0.49). In households with Alpha, persons who identified as Asian or Hispanic/Latino had significantly higher SIRs than those who identified as White (P = 0.01 and 0.03, respectively). Close contact (e.g., kissing, hugging) with primary cases was associated with increased transmission for all lineages. Persons with Alpha infection were more likely to report constitutional symptoms than persons with non-Alpha (86.9% vs. 76.8%, P = 0.05). CONCLUSIONS: Household SIRs were similar for Alpha and non-Alpha. Comparable SIRs may be due to saturation of transmission risk in households owing to extensive close contact, or true lack of difference in transmission rates. Avoiding close contact within households may reduce SARS-CoV-2 transmission for all lineages among household members.

      2. Lower rates of emergency visits and hospitalizations among chronic hepatitis C patients with sustained virological response to interferon-free direct-acting antiviral therapy (2014-2018)external icon
        Gordon SC, Teshale EH, Spradling PR, Moorman AC, Boscarino JA, Schmidt MA, Daida YG, Rupp LB, Trudeau S, Zhang J, Lu M.
        Clin Infect Dis. 2022 Feb 11.
        We compared rates of emergency department (ED) visits and hospitalizations between HCV patients who achieved sustained virological response (SVR) after direct-acting antiviral (DAA) therapy (cases) to matched controls. Among 3049 pairs, cases demonstrated lower rates of liver-related ED visits (P=.01) than controls; all-cause and liver-related hospitalization rates and hospitalized days were also lower in cases (P<.0001).

      3. Cruise ship travel in the era of coronavirus disease 2019 (COVID-19): A summary of outbreaks and a model of public health interventionsexternal icon
        Guagliardo SA, Prasad PV, Rodriguez A, Fukunaga R, Novak RT, Ahart L, Reynolds J, Griffin I, Wiegand R, Quilter LA, Morrison S, Jenkins K, Wall HK, Treffiletti A, White SB, Regan J, Tardivel K, Freeland A, Brown C, Wolford H, Johansson MA, Cetron MS, Slayton RB, Friedman CR.
        Clin Infect Dis. 2022 Feb 11;74(3):490-497.
        BACKGROUND: Cruise travel contributed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission when there were relatively few cases in the United States. By 14 March 2020, the Centers for Disease Control and Prevention (CDC) issued a No Sail Order suspending US cruise operations; the last US passenger ship docked on 16 April. METHODS: We analyzed SARS-CoV-2 outbreaks on cruises in US waters or carrying US citizens and used regression models to compare voyage characteristics. We used compartmental models to simulate the potential impact of 4 interventions (screening for coronavirus disease 2019 (COVID-19) symptoms; viral testing on 2 days and isolation of positive persons; reduction of passengers by 40%, crew by 20%, and reducing port visits to 1) for 7-day and 14-day voyages. RESULTS: During 19 January to 16 April 2020, 89 voyages on 70 ships had known SARS-CoV-2 outbreaks; 16 ships had recurrent outbreaks. There were 1669 reverse transcription polymerase chain reaction (RT-PCR)-confirmed SARS-CoV-2 infections and 29 confirmed deaths. Longer voyages were associated with more cases (adjusted incidence rate ratio, 1.10, 95% confidence interval [CI]: 1.03-1.17, P < .003). Mathematical models showed that 7-day voyages had about 70% fewer cases than 14-day voyages. On 7-day voyages, the most effective interventions were reducing the number of individuals onboard (43.3% reduction in total infections) and testing passengers and crew (42% reduction in total infections). All four interventions reduced transmission by 80.1%, but no single intervention or combination eliminated transmission. Results were similar for 14-day voyages. CONCLUSIONS: SARS-CoV-2 outbreaks on cruises were common during January-April 2020. Despite all interventions modeled, cruise travel still poses a significant SARS-CoV-2 transmission risk.

      4. Genital immune cell activation and tenofovir gel efficacy: a case-control studyexternal icon
        Liebenberg LJ, Passmore JS, Osman F, Jewanraj J, Mtshali A, Garcia-Lerma JG, Heneine W, Holder A, Archary D, Ngcapu S, Sivro A, Mansoor LE, Abdool Karim Q, Abdool Karim SS, McKinnon LR.
        Clin Infect Dis. 2022 Feb 10.
        Genital inflammation (GI) undermines topical HIV pre-exposure prophylaxis (PrEP) efficacy through unknown mechanisms. Here, associations between activated endocervical CD4+ T cell numbers and higher deoxyadenosine triphosphate (dATP) concentrations suggest that competition for intracellular metabolites within HIV target cells may reduce the efficacy of antiretroviral-based PrEP in women with GI.

      5. Using national pharmacy claims data, during 2014-2020, 843,329 persons were treated for hepatitis C at least once. The proportion treated increased annually among persons aged <40 years, insured by Medicaid, and treated by primary care providers. Monitoring hepatitis C treatment is essential to identify barriers to treatment access.

      6. Clinical characteristics, risk factors and outcomes in patients with severe COVID-19 registered in the International Severe Acute Respiratory and Emerging Infection Consortium WHO clinical characterisation protocol: a prospective, multinational, multicentre, observational studyexternal icon
        Reyes LF, Murthy S, Garcia-Gallo E, Irvine M, Merson L, Martin-Loeches I, Rello J, Taccone FS, Fowler RA, Docherty AB, Kartsonaki C, Aragao I, Barrett PW, Beane A, Burrell A, Cheng MP, Christian MD, Cidade JP, Citarella BW, Donnelly CA, Fernandes SM, French C, Haniffa R, Harrison EM, Ho AY, Joseph M, Khan I, Kho ME, Kildal AB, Kutsogiannis D, Lamontagne F, Lee TC, Bassi GL, Lopez Revilla JW, Marquis C, Millar J, Neto R, Nichol A, Parke R, Pereira R, Poli S, Povoa P, Ramanathan K, Rewa O, Riera J, Shrapnel S, Silva MJ, Udy A, Uyeki T, Webb SA, Wils EJ, Rojek A, Olliaro PL.
        ERJ Open Res. 2022 Jan;8(1).
        Due to the large number of patients with severe coronavirus disease 2019 (COVID-19), many were treated outside the traditional walls of the intensive care unit (ICU), and in many cases, by personnel who were not trained in critical care. The clinical characteristics and the relative impact of caring for severe COVID-19 patients outside the ICU is unknown. This was a multinational, multicentre, prospective cohort study embedded in the International Severe Acute Respiratory and Emerging Infection Consortium World Health Organization COVID-19 platform. Severe COVID-19 patients were identified as those admitted to an ICU and/or those treated with one of the following treatments: invasive or noninvasive mechanical ventilation, high-flow nasal cannula, inotropes or vasopressors. A logistic generalised additive model was used to compare clinical outcomes among patients admitted or not to the ICU. A total of 40 440 patients from 43 countries and six continents were included in this analysis. Severe COVID-19 patients were frequently male (62.9%), older adults (median (interquartile range (IQR), 67 (55-78) years), and with at least one comorbidity (63.2%). The overall median (IQR) length of hospital stay was 10 (5-19) days and was longer in patients admitted to an ICU than in those who were cared for outside the ICU (12 (6-23) days versus 8 (4-15) days, p<0.0001). The 28-day fatality ratio was lower in ICU-admitted patients (30.7% (5797 out of 18 831) versus 39.0% (7532 out of 19 295), p<0.0001). Patients admitted to an ICU had a significantly lower probability of death than those who were not (adjusted OR 0.70, 95% CI 0.65-0.75; p<0.0001). Patients with severe COVID-19 admitted to an ICU had significantly lower 28-day fatality ratio than those cared for outside an ICU.

      7. The national burden of influenza-like illness and severe respiratory illness overall and associated with nine respiratory viruses in South Africa, 2013-2015external icon
        Tempia S, Moyes J, Cohen AL, Walaza S, McMorrow ML, Treurnicht FK, Hellferscee O, Wolter N, von Gottberg A, Dawood H, Variava E, Cohen C.
        Influenza Other Respir Viruses. 2022 Feb 11.
        BACKGROUND: Estimates of the disease burden associated with different respiratory viruses are severely limited in low- and middle-income countries, especially in Africa. METHODS: We estimated age-specific numbers and rates of medically and non-medically attended influenza-like illness (ILI) and severe respiratory illness (SRI) that were associated with influenza, respiratory syncytial virus (RSV), rhinovirus, human metapneumovirus, adenovirus, enterovirus and parainfluenza virus types 1-3 after adjusting for the attributable fraction (AF) of virus detection to illness in South Africa during 2013-2015. The base rates were estimated from five surveillance sites and extrapolated nationally. RESULTS: The mean annual rates per 100,000 population were 51,383 and 4196 for ILI and SRI, respectively. Of these, 26% (for ILI) and 46% (for SRI) were medically attended. Among outpatients with ILI, rhinovirus had the highest AF-adjusted rate (7221), followed by influenza (6443) and adenovirus (1364); whereas, among inpatients with SRI, rhinovirus had the highest AF-adjusted rate (400), followed by RSV (247) and influenza (130). Rhinovirus (9424) and RSV (2026) had the highest AF-adjusted rates among children aged <5 years with ILI or SRI, respectively, whereas rhinovirus (757) and influenza (306) had the highest AF-adjusted rates among individuals aged ≥65 years with ILI or SRI, respectively. CONCLUSIONS: There was a substantial burden of ILI and SRI in South Africa during 2013-2015. Rhinovirus and influenza had a prominent disease burden among patients with ILI. RSV and influenza were the most prominent causes of SRI in children and the elderly, respectively.

      8. Clinical outcomes of monoclonal antibody therapy during a COVID-19 outbreak in a skilled nursing facility-Arizona, 2021external icon
        Dale AP, Hudson MJ, Armenta D, Friebus H, Ellingson KD, Davis K, Cullen T, Brady S, Komatsu KK, Stone ND, Uyeki TM, Slifka KJ, Perez-Velez CM, Keaton AA.
        J Am Geriatr Soc. 2022 Feb 9.
        BACKGROUND: Adult residents of skilled nursing facilities (SNF) have experienced high morbidity and mortality from SARS-CoV-2 infection and are at increased risk for severe COVID-19 disease. Use of monoclonal antibody (mAb) treatment improves clinical outcomes among high-risk outpatients with mild-to-moderate COVID-19, but information on mAb effectiveness in SNF residents with COVID-19 is limited. We assessed outcomes in SNF residents with mild-to-moderate COVID-19 associated with an outbreak in Arizona during January-February 2021 that did and did not receive a mAb. METHODS: Medical records were reviewed to describe the effect of bamlanivimab therapy on COVID-19 mortality. Secondary outcomes included referral to an acute care setting and escalation of medical therapies at the SNF (e.g., new oxygen requirements). Residents treated with bamlanivimab were compared to residents who were eligible for treatment under the FDA's Emergency Use Authorization (EUA) but were not treated. Multivariable logistic regression was used to determine association between outcomes and treatment status. RESULTS: Seventy-five residents identified with COVID-19 during this outbreak met eligibility for mAb treatment, of whom 56 received bamlanivimab. Treated and untreated groups were similar in age and comorbidities associated with increased risk of severe COVID-19 disease. Treatment with bamlanivimab was associated with reduced 21-day mortality (adjusted OR = 0.06; 95% CI: 0.01, 0.39) and lower odds of initiating oxygen therapy (adjusted OR = 0.07; 95% CI: 0.02, 0.34). Referrals to acute care were not significantly different between treated and untreated residents. CONCLUSIONS: mAb therapy was successfully administered to SNF residents with COVID-19 in a large outbreak setting. Treatment with bamlanivimab reduced 21-day mortality and reduced initiation of oxygen therapy. As the COVID-19 pandemic evolves and newer immunotherapies gain FDA authorization, more studies of the effectiveness of mAb therapies for treating emerging SARS-CoV-2 variants of concern in high-risk congregate settings are needed. This article is protected by copyright. All rights reserved.

      9. In mid-December 2021, the B.1.1.529 (Omicron) variant of SARS-CoV-2, the virus that causes COVID-19, surpassed the B.1.617.2 (Delta) variant as the predominant strain in California.(§) Initial reports suggest that the Omicron variant is more transmissible and resistant to vaccine neutralization but causes less severe illness compared with previous variants (1-3). To describe characteristics of patients hospitalized with SARS-CoV-2 infection during periods of Delta and Omicron predominance, clinical characteristics and outcomes were retrospectively abstracted from the electronic health records (EHRs) of adults aged ≥18 years with positive reverse transcription-polymerase chain reaction (RT-PCR) SARS-CoV-2 test results admitted to one academic hospital in Los Angeles, California, during July 15-September 23, 2021 (Delta predominant period, 339 patients) and December 21, 2021-January 27, 2022 (Omicron predominant period, 737 patients). Compared with patients during the period of Delta predominance, a higher proportion of adults admitted during Omicron predominance had received the final dose in a primary COVID-19 vaccination series (were fully vaccinated) (39.6% versus 25.1%), and fewer received COVID-19-directed therapies. Although fewer required intensive care unit (ICU) admission and invasive mechanical ventilation (IMV), and fewer died while hospitalized during Omicron predominance, there were no significant differences in ICU admission or IMV when stratified by vaccination status. Fewer fully vaccinated Omicron-period patients died while hospitalized (3.4%), compared with Delta-period patients (10.6%). Among Omicron-period patients, vaccination was associated with lower likelihood of ICU admission, and among adults aged ≥65 years, lower likelihood of death while hospitalized. Likelihood of ICU admission and death were lowest among adults who had received a booster dose. Among the first 131 Omicron-period hospitalizations, 19.8% of patients were clinically assessed as admitted for non-COVID-19 conditions. Compared with adults considered likely to have been admitted because of COVID-19, these patients were younger (median age = 38 versus 67 years) and more likely to have received at least one dose of a COVID-19 vaccine (84.6% versus 61.0%). Although 20% of SARS-CoV-2-associated hospitalizations during the period of Omicron predominance might be driven by non-COVID-19 conditions, large numbers of hospitalizations place a strain on health systems. Vaccination, including a booster dose for those who are fully vaccinated, remains critical to minimizing risk for severe health outcomes among adults with SARS-CoV-2 infection.

    • Community Health Services
      1. Health care safety during the pandemic and beyond - building a system that ensures resilienceexternal icon
        Fleisher LA, Schreiber M, Cardo D, Srinivasan A.
        N Engl J Med. 2022 Feb 17;386(7):609-611.

    • Disease Reservoirs and Vectors
      1. Dynamics of Triatoma infestans populations in the Paraguayan Chaco: Population genetic analysis of household reinfestation following vector controlexternal icon
        Rojas de Arias A, Messenger LA, Rolon M, Vega MC, Acosta N, Villalba C, Marcet PL.
        PLoS One. 2022 ;17(2):e0263465.
        BACKGROUND: Although domestic infestations by Triatoma infestans have been successfully controlled across Latin America, in areas of the Gran Chaco region, recurrent post-spraying house colonization continues to be a significant challenge, jeopardizing Chagas disease vector control and maintaining active Trypanosoma cruzi transmission. METHODOLOGY/PRINCIPAL FINDINGS: To investigate the dynamics of triatomine reinfestation in a rural area of the Paraguayan Chaco, genetic characterization (based on 10 microsatellite loci and cytochrome B sequence polymorphisms) was performed on baseline and reinfestant T. infestans (n = 138) from four indigenous communities and adjacent sylvatic sites. House quality and basic economic activities were assessed across the four communities. Significant genetic differentiation was detected among all baseline triatomine populations. Faster reinfestation was observed in the communities with higher infestation rates pre-spraying. Baseline and reinfestant populations from the same communities were not genetically different, but two potentially distinct processes of reinfestation were evident. In Campo Largo, the reinfestant population was likely founded by domestic survivor foci, with reduced genetic diversity relative to the baseline population. However, in 12 de Junio, reinfestant bugs were likely derived from different sources, including survivors from the pre-spraying population and sympatric sylvatic bugs, indicative of gene-flow between these habitats, likely driven by high human mobility and economic activities in adjacent sylvatic areas. CONCLUSIONS/SIGNIFICANCE: Our results demonstrate that sylvatic T. infestans threatens vector control strategies, either as a reinfestation source or by providing a temporary refuge during insecticide spraying. Passive anthropogenic importation of T. infestans and active human interactions with neighboring forested areas also played a role in recolonization. Optimization of spraying, integrated community development and close monitoring of sylvatic areas should be considered when implementing vector control activities in the Gran Chaco.

    • Epidemiology and Surveillance
      1. Epidemiology of extended-spectrum β-lactamase-producing Enterobacterales in five US sites participating in the Emerging Infections Program, 2017external icon
        Duffy N, Karlsson M, Reses HE, Campbell D, Daniels J, Stanton RA, Janelle SJ, Schutz K, Bamberg W, Rebolledo PA, Bower C, Blakney R, Jacob JT, Phipps EC, Flores KG, Dumyati G, Kopin H, Tsay R, Kainer MA, Muleta D, Byrd-Warner B, Grass JE, Lutgring JD, Rasheed JK, Elkins CA, Magill SS, See I.
        Infect Control Hosp Epidemiol. 2022 Feb 14:1-9.
        OBJECTIVE: The incidence of infections from extended-spectrum β-lactamase (ESBL)-producing Enterobacterales (ESBL-E) is increasing in the United States. We describe the epidemiology of ESBL-E at 5 Emerging Infections Program (EIP) sites. METHODS: During October-December 2017, we piloted active laboratory- and population-based (New York, New Mexico, Tennessee) or sentinel (Colorado, Georgia) ESBL-E surveillance. An incident case was the first isolation from normally sterile body sites or urine of Escherichia coli or Klebsiella pneumoniae/oxytoca resistant to ≥1 extended-spectrum cephalosporin and nonresistant to all carbapenems tested at a clinical laboratory from a surveillance area resident in a 30-day period. Demographic and clinical data were obtained from medical records. The Centers for Disease Control and Prevention (CDC) performed reference antimicrobial susceptibility testing and whole-genome sequencing on a convenience sample of case isolates. RESULTS: We identified 884 incident cases. The estimated annual incidence in sites conducting population-based surveillance was 199.7 per 100,000 population. Overall, 800 isolates (96%) were from urine, and 790 (89%) were E. coli. Also, 393 cases (47%) were community-associated. Among 136 isolates (15%) tested at the CDC, 122 (90%) met the surveillance definition phenotype; 114 (93%) of 122 were shown to be ESBL producers by clavulanate testing. In total, 111 (97%) of confirmed ESBL producers harbored a blaCTX-M gene. Among ESBL-producing E. coli isolates, 52 (54%) were ST131; 44% of these cases were community associated. CONCLUSIONS: The burden of ESBL-E was high across surveillance sites, with nearly half of cases acquired in the community. EIP has implemented ongoing ESBL-E surveillance to inform prevention efforts, particularly in the community and to watch for the emergence of new ESBL-E strains.

    • Genetics and Genomics
      1. BACKGROUND: Reductions in tuberculosis (TB) transmission have been instrumental in lowering TB incidence in the United States. Sustaining and augmenting these reductions are key public health priorities. METHODS: We fit mechanistic transmission models to distributions of genotype clusters of TB cases reported to CDC during 2012-2016 in the United States and separately in California, Florida, New York, and Texas. Using these models, we estimated the mean number of secondary cases generated per infectious case (R0) and individual-level heterogeneity in R0 at state and national levels. We also assessed how different definitions of clustering and variation in case ascertainment affected these estimates. RESULTS: In clusters of genotypically linked TB cases occurring within a state over a 5-year period (reference scenario), the estimated R0 was 0.29 (95% CI: 0.28-0.31) in the United States. Transmission was highly heterogeneous: 0.24% of simulated cases with individual R0>10 generated 19% of all recent secondary transmissions. R0 estimate was 0.16 (0.15-0.17) when a cluster was defined as cases occurring within the same county over a 3-year period. Transmission varied across states: estimated R0s were 0.34 (0.3-0.4) in California, 0.28 (0.24-0.36) in Florida, 0.19 (0.15-0.27) in New York, and 0.38 (0.33-0.46) in Texas. CONCLUSIONS: TB transmission in the United States is characterized by pronounced heterogeneity at the individual and state levels. Improving detection of transmission clusters through incorporation of whole-genome sequencing and identifying the drivers of this heterogeneity will be essential to reducing TB transmission in the United States and worldwide.

      2. Towards comprehensive understanding of bacterial genetic diversity: large-scale amplifications in Bordetella pertussis and Mycobacterium tuberculosisexternal icon
        Abrahams JS, Weigand MR, Ring N, MacArthur I, Etty J, Peng S, Williams MM, Bready B, Catalano AP, Davis JR, Kaiser MD, Oliver JS, Sage JM, Bagby S, Tondella ML, Gorringe AR, Preston A.
        Microb Genom. 2022 Feb;8(2).
        Bacterial genetic diversity is often described solely using base-pair changes despite a wide variety of other mutation types likely being major contributors. Tandem duplication/amplifications are thought to be widespread among bacteria but due to their often-intractable size and instability, comprehensive studies of these mutations are rare. We define a methodology to investigate amplifications in bacterial genomes based on read depth of genome sequence data as a proxy for copy number. We demonstrate the approach with Bordetella pertussis, whose insertion sequence element-rich genome provides extensive scope for amplifications to occur. Analysis of data for 2430 B. pertussis isolates identified 272 putative amplifications, of which 94 % were located at 11 hotspot loci. We demonstrate limited phylogenetic connection for the occurrence of amplifications, suggesting unstable and sporadic characteristics. Genome instability was further described in vitro using long-read sequencing via the Nanopore platform, which revealed that clonally derived laboratory cultures produced heterogenous populations rapidly. We extended this research to analyse a population of 1000 isolates of another important pathogen, Mycobacterium tuberculosis. We found 590 amplifications in M. tuberculosis, and like B. pertussis, these occurred primarily at hotspots. Genes amplified in B. pertussis include those involved in motility and respiration, whilst in M. tuberuclosis, functions included intracellular growth and regulation of virulence. Using publicly available short-read data we predicted previously unrecognized, large amplifications in B. pertussis and M. tuberculosis. This reveals the unrecognized and dynamic genetic diversity of B. pertussis and M. tuberculosis, highlighting the need for a more holistic understanding of bacterial genetics.

      3. Widespread sharing of pneumococcal strains in a rural African setting: proximate villages are more likely to share similar strains that are carried at multiple timepointsexternal icon
        Senghore M, Chaguza C, Bojang E, Tientcheu PE, Bancroft RE, Lo SW, Gladstone RA, McGee L, Worwui A, Foster-Nyarko E, Ceesay F, Okoi CB, Klugman KP, Breiman RF, Bentley SD, Adegbola R, Antonio M, Hanage WP, Kwambana-Adams BA.
        Microb Genom. 2022 Feb;8(2).
        The transmission dynamics of Streptococcus pneumoniae in sub-Saharan Africa are poorly understood due to a lack of adequate epidemiological and genomic data. Here we leverage a longitudinal cohort from 21 neighbouring villages in rural Africa to study how closely related strains of S. pneumoniae are shared among infants. We analysed 1074 pneumococcal genomes isolated from 102 infants from 21 villages. Strains were designated for unique serotype and sequence-type combinations, and we arbitrarily defined strain sharing where the pairwise genetic distance between strains could be accounted for by the mean within host intra-strain diversity. We used non-parametric statistical tests to assess the role of spatial distance and prolonged carriage on strain sharing using a logistic regression model. We recorded 458 carriage episodes including 318 (69.4 %) where the carried strain was shared with at least one other infant. The odds of strain sharing varied significantly across villages (χ(2)=47.5, df=21, P-value <0.001). Infants in close proximity to each other were more likely to be involved in strain sharing, but we also show a considerable amount of strain sharing across longer distances. Close geographic proximity (<5 km) between shared strains was associated with a significantly lower pairwise SNP distance compared to strains shared over longer distances (P-value <0.005). Sustained carriage of a shared strain among the infants was significantly more likely to occur if they resided in villages within a 5 km radius of each other (P-value <0.005, OR 3.7). Conversely, where both infants were transiently colonized by the shared strain, they were more likely to reside in villages separated by over 15 km (P-value <0.05, OR 1.5). PCV7 serotypes were rare (13.5 %) and were significantly less likely to be shared (P-value <0.001, OR -1.07). Strain sharing was more likely to occur over short geographical distances, especially where accompanied by sustained colonization. Our results show that strain sharing is a useful proxy for studying transmission dynamics in an under-sampled population with limited genomic data. This article contains data hosted by Microreact.

      4. Genomic surveillance for SARS-CoV-2 variants: Predominance of the Delta (B.1.617.2) and Omicron (b.1.1.529) variants - United States, June 2021-January 2022external icon
        Lambrou AS, Shirk P, Steele MK, Paul P, Paden CR, Cadwell B, Reese HE, Aoki Y, Hassell N, Zheng XY, Talarico S, Chen JC, Oberste MS, Batra D, McMullan LK, Halpin AL, Galloway SE, MacCannell DR, Kondor R, Barnes J, MacNeil A, Silk BJ, Dugan VG, Scobie HM, Wentworth DE.
        MMWR Morb Mortal Wkly Rep. 2022 Feb 11;71(6):206-211.
        Genomic surveillance is a critical tool for tracking emerging variants of SARS-CoV-2 (the virus that causes COVID-19), which can exhibit characteristics that potentially affect public health and clinical interventions, including increased transmissibility, illness severity, and capacity for immune escape. During June 2021-January 2022, CDC expanded genomic surveillance data sources to incorporate sequence data from public repositories to produce weighted estimates of variant proportions at the jurisdiction level and refined analytic methods to enhance the timeliness and accuracy of national and regional variant proportion estimates. These changes also allowed for more comprehensive variant proportion estimation at the jurisdictional level (i.e., U.S. state, district, territory, and freely associated state). The data in this report are a summary of findings of recent proportions of circulating variants that are updated weekly on CDC's COVID Data Tracker website to enable timely public health action.(†) The SARS-CoV-2 Delta (B.1.617.2 and AY sublineages) variant rose from 1% to >50% of viral lineages circulating nationally during 8 weeks, from May 1-June 26, 2021. Delta-associated infections remained predominant until being rapidly overtaken by infections associated with the Omicron (B.1.1.529 and BA sublineages) variant in December 2021, when Omicron increased from 1% to >50% of circulating viral lineages during a 2-week period. As of the week ending January 22, 2022, Omicron was estimated to account for 99.2% (95% CI = 99.0%-99.5%) of SARS-CoV-2 infections nationwide, and Delta for 0.7% (95% CI = 0.5%-1.0%). The dynamic landscape of SARS-CoV-2 variants in 2021, including Delta- and Omicron-driven resurgences of SARS-CoV-2 transmission across the United States, underscores the importance of robust genomic surveillance efforts to inform public health planning and practice.

    • Global Health
      1. Future-proofing and maximizing the utility of metadata: The PHA4GE SARS-CoV-2 contextual data specification packageexternal icon
        Griffiths EJ, Timme RE, Mendes CI, Page AJ, Alikhan NF, Fornika D, Maguire F, Campos J, Park D, Olawoye IB, Oluniyi PE, Anderson D, Christoffels A, da Silva AG, Cameron R, Dooley D, Katz LS, Black A, Karsch-Mizrachi I, Barrett T, Johnston A, Connor TR, Nicholls SM, Witney AA, Tyson GH, Tausch SH, Raphenya AR, Alcock B, Aanensen DM, Hodcroft E, Hsiao WW, Vasconcelos AT, MacCannell DR.
        Gigascience. 2022 Feb 16;11.
        BACKGROUND: The Public Health Alliance for Genomic Epidemiology (PHA4GE) (https://pha4ge.org) is a global coalition that is actively working to establish consensus standards, document and share best practices, improve the availability of critical bioinformatics tools and resources, and advocate for greater openness, interoperability, accessibility, and reproducibility in public health microbial bioinformatics. In the face of the current pandemic, PHA4GE has identified a need for a fit-for-purpose, open-source SARS-CoV-2 contextual data standard. RESULTS: As such, we have developed a SARS-CoV-2 contextual data specification package based on harmonizable, publicly available community standards. The specification can be implemented via a collection template, as well as an array of protocols and tools to support both the harmonization and submission of sequence data and contextual information to public biorepositories. CONCLUSIONS: Well-structured, rich contextual data add value, promote reuse, and enable aggregation and integration of disparate datasets. Adoption of the proposed standard and practices will better enable interoperability between datasets and systems, improve the consistency and utility of generated data, and ultimately facilitate novel insights and discoveries in SARS-CoV-2 and COVID-19. The package is now supported by the NCBI's BioSample database.

    • Health Communication and Education
      1. Considerations and opportunities for multilevel HPV vaccine communication interventionsexternal icon
        Oh A, Gaysynsky A, Winer RL, Lee HY, Brewer NT, White A.
        Transl Behav Med. 2022 Feb 16;12(2):343-349.

    • Health Equity and Health Disparities
      1. Intersection of syphilis and human immunodeficiency virus (HIV) networks to identify opportunities to enhance HIV preventionexternal icon
        Dennis AM, Cressman A, Pasquale D, Frost SD, Kelly E, Guy J, Mobley V, Samoff E, Hurt CB, McNeil C, Hightow-Weidman L, Carry M, Hogben M, Seña AC.
        Clin Infect Dis. 2022 Feb 11;74(3):498-506.
        BACKGROUND: Human immunodeficiency virus (HIV) and syphilis infection continue at disproportionate rates among minority men who have sex with men (MSM) in the United States. The integration of HIV genetic clustering with partner services can provide important insight into local epidemic trends to guide interventions and control efforts. METHODS: We evaluated contact networks of index persons defined as minority men and transgender women diagnosed with early syphilis and/or HIV infection between 2018 and 2020 in 2 North Carolina regions. HIV clusters were constructed from pol sequences collected through statewide surveillance. A combined "HIV-risk" network, which included persons with any links (genetic or sexual contact) to HIV-positive persons, was evaluated by component size, demographic factors, and HIV viral suppression. RESULTS: In total, 1289 index persons were identified and 55% named 1153 contacts. Most index persons were Black (88%) and young (median age 30 years); 70% had early syphilis and 43% had prevalent HIV infection. Most people with HIV (65%) appeared in an HIV cluster. The combined HIV-risk network (1590 contact network and 1500 cluster members) included 287 distinct components; however, 1586 (51%) were in a single component. Fifty-five percent of network members with HIV had no evidence of viral suppression. Overall, fewer index persons needed to be interviewed to identify 1 HIV-positive member without viral suppression (1.3 vs 4.0 for contact tracing). CONCLUSIONS: Integration of HIV clusters and viral loads illuminate networks with high HIV prevalence, indicating recent and ongoing transmission. Interventions intensified toward these networks may efficiently reach persons for HIV prevention and care re-engagement.

      2. Association between LGBTQ student nondiscrimination laws in selected states and school district support for gay-straight alliancesexternal icon
        Harper CR, Johns MM, Orenstein D, Pampati S, Jones TM, Leonard S, Taylor KR, Robin L.
        J Adolesc Health. 2022 Feb 11.
        PURPOSE: To examine the association between state laws protecting lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) students and school districts' recommendations or requirements for establishing gay-straight alliances (GSAs) in schools. Beginning in fall 2013, 19 state education agencies (SEAs) engaged in HIV/STI and pregnancy prevention activities in "priority" school districts. SEAs provided support to priority districts to require or recommend GSAs in their schools. METHODS: This study used semi-annually collected program evaluation data and state law data from the Gay, Lesbian, and Straight Education Network. We assessed whether increases in the percentage of priority districts recommending or requiring schools to provide GSAs varied by the presence of nondiscrimination or enumerated antibullying laws with a difference-in-difference design. RESULTS: States with nondiscrimination laws began with more priority districts recommending or requiring schools to provide GSAs (52.5%) compared to states without laws (47.5%). We found a significant interaction (p < .01) between increases in the percentage of priority districts recommending or requiring a GSA and having a state nondiscrimination law. Across the first 3 years of program implementation, there was a 30% increase (p < .01) in priority districts recommending or requiring schools to provide GSAs in states with nondiscrimination laws, compared to a 12% increase (p < .01) in states without laws. There was no significant interaction between states with enumerated antibullying laws and districts recommending or requiring a GSA. DISCUSSION: State LGBTQ nondiscrimination laws for students may facilitate school district support of GSAs, which may decrease health risks among LGBTQ youth.

      3. PURPOSE: The present study tests the hypothesis that there has been a significant increase in the implementation of six LGBTQ-supportive school practices in US states between 2010 and 2018. METHODS: Data were drawn from the publicly available School Health Profiles reports published by the Centers for Disease Control and Prevention, Division of Adolescent and School Health. We conducted unadjusted linear regression models separately for each practice to examine state-specific linear trends in the percentage of secondary schools reportedly engaging in six LGBTQ-supportive practices across all 50 states. In addition, we conducted an unadjusted linear regression on the trend to estimate changes in the median percentage of schools across all states engaging in each of the six practices through time. RESULTS: In 2010, 5.7% of schools reported implementing all six practices, which increased to 15.3% in 2018. In the period from 2010 to 2018, the implementation of four of six key practices increased significantly in more than half of US states. Most states experienced a mix of either increases in practices or no change in practice prevalence, with no state experiencing a significant decrease. DISCUSSION: There have been significant gains in the percentage of schools implementing LGBTQ-supportive practices. Yet, despite increases in the examined practices, the median percentage of schools in the United States that implement all six remains low. There is considerable room to improve on the use of these practices in schools across the United States, including increased attention to the quality of implementation and the barriers and facilitators to their instantiation.

      4. BACKGROUND: Invasive pneumococcal disease (IPD) isolates forming genomic clusters can reflect rapid disease transmission between vulnerable individuals. METHODS: We performed whole genome sequencing of 2820 IPD isolates recovered during 2019 through CDC's Active Bacterial Core surveillance (ABCs) to provide strain information (serotypes, resistance, genotypes), and 2778 of these genomes were analyzed to detect highly related genomic clusters. RESULTS: Isolates from persons experiencing homelessness (PEH) were more often within genomic clusters than those from persons not experiencing homelessness (PNEH) (105/198, 53.0% vs 592/2551, 23.2%, p<0.001). The 4 western sites accounted for 33.4% (929/2778) of isolates subjected to cluster analysis yet accounted for 48.7% (343/705) of clustering isolates (p<0.001) and 150/198 (75.8%) isolates recovered from PEH (p<0.001). Serotypes most frequent among PEH were (in rank order) 12F, 4, 3, 9N, 8, 20, and 22F, all of which were among the 10 serotypes exhibiting the highest proportions of clustering isolates among all cases. These serotypes accounted for 44.9% (1265/2820) of all IPD cases and are included within available vaccines. CONCLUSIONS: We identified serotype-specific and geographic differences in IPD transmission. We show the vulnerability of PEH within different regions to rapidly spreading IPD transmission networks representing several pneumococcal serotypes included in available vaccines.

      5. Engagement in the pre-exposure prophylaxis (PrEP) cascade among a respondent-driven sample of sexually active men who have sex with men and transgender women during early PrEP implementation in Zimbabweexternal icon
        Parmley LE, Harris TG, Chingombe I, Mapingure M, Mugurungi O, Rogers JH, Gozhora P, Wu Y, Samba C, Musuka G, Hakim AJ.
        J Int AIDS Soc. 2022 Feb;25(2):e25873.
        INTRODUCTION: Zimbabwe is scaling up pre-exposure prophylaxis (PrEP) for key populations, including men who have sex with men (MSM) and transgender women (TGW). To assess implementation and inform HIV programming, we evaluated gaps in PrEP awareness, uptake and use, and correlates of awareness and uptake among a sample of MSM, TGW and genderqueer individuals (GQ) in Harare and Bulawayo, Zimbabwe. METHODS: Respondent-driven sampling was used to recruit 1194 MSM and 344 TGW/GQ aged ≥18 to participate in a cross-sectional survey assessing HIV-related outcomes in 2019. Consenting participants completed a questionnaire on socio-demographic information, sexual risk practices and engagement in HIV services and underwent HIV testing. Descriptive statistics were used to assess the PrEP cascade. Multiple logistic regression models were used to identify factors associated with PrEP awareness and uptake among HIV-negative participants. Data were unweighted as the sample did not reach convergence on key estimates. RESULTS: Among the 1167 HIV-negative participants, most (79.2%) were MSM compared to TGW/GQ (20.8%). Median age was 24 years. Overall, 45.8% were aware of PrEP and of those, 31.3% had ever taken PrEP. Most (71.1%) reporting never taking PrEP were willing to start PrEP; the main reasons for never starting PrEP included not knowing where to access it (24.8%) and fearing side effects (20.4%). Among those who had ever taken PrEP, 74.9% had taken PrEP in the last 6 months; of these, 42.4% had taken PrEP the day of or day preceding the survey. Side effects represented the most common (59.5%) reason for discontinuing PrEP. MSM (adjusted odds ratio [aOR]: 2.5, 95% confidence interval [CI]: 1.8-3.6) and TGW/GQ in Harare (aOR: 3.1, 95% CI: 2.1-4.7), and TGW/GQ in Bulawayo (aOR: 2.4, 95% CI: 1.1-5.3) had higher awareness of PrEP than MSM in Bulawayo. Overall, TGW/GQ were more likely to have ever taken PrEP compared to MSM (aOR: 1.6, 95% CI: 1.01-2.4). CONCLUSIONS: Findings emphasize the need for tailored interventions to promote PrEP among key populations. As HIV programs in Zimbabwe continue to expand PrEP services, these data, including barriers to starting and continuing PrEP, can inform strategies to address gaps along the PrEP cascade.

      6. HIV care cascade and associated factors among men who have sex with men, transgender women, and genderqueer individuals in Zimbabwe: findings from a biobehavioural survey using respondent-driven samplingexternal icon
        Harris TG, Wu Y, Parmley LE, Musuka G, Mapingure MP, Chingombe I, Mugurungi O, Hakim A, Gozhora P, Miller SS, Lamb MR, Samba C, Rogers JH.
        Lancet HIV. 2022 Feb 9.
        BACKGROUND: Globally, men who have sex with men (MSM), transgender women, and genderqueer individuals are at greater risk for HIV than the general population although little data are available from these groups in Zimbabwe, a country with a national adult HIV prevalence of 12·9%. We aimed to examine progress towards the UNAIDS 90-90-90 treatment targets and factors associated with meeting the targets among a sample of MSM, transgender women, and genderqueer individuals in Zimbabwe. METHODS: In this cross-sectional survey in 2019, we used respondent-driven sampling to identify MSM, transgender women, and genderqueer individuals aged at least 18 years to participate in a biobehavioural survey in Harare and Bulawayo, Zimbabwe. Participants were eligible to participate if they were assigned male at birth; had engaged in anal or oral sex with a man in the past 12 months; resided in Harare or Bulawayo for at least 1 month; spoke English, Shona, or Ndebele; provided written informed consent; and were in possession of a valid recruitment coupon if applicable. Enrolled participants completed a questionnaire and underwent HIV testing, and off-site viral load testing was done on all HIV-positive samples. Unweighted bivariate analyses and multivariable logistic regression models were used to evaluate the association of sociodemographic, behavioural, and other factors with HIV-positive status awareness among MSM, transgender women, and genderqueer individuals, and with viral load suppression among MSM. Analyses were done firstly using self-reported information and then by classifying those with a viral load of less than 200 copies per mL as being aware of their status and on treatment (viral load recategorisation). FINDINGS: Among MSM, 248 (21%; 95% CI 19-24) of 1176 tested positive for HIV. Of those who tested positive, based on self-report, 119 (48%; 95% CI 42-54) reported knowing their HIV status, of whom 112 (94%; 88-98) reported using antiretroviral therapy (ART), of whom 89 (79%; 71-87) had viral load suppression. Based on viral load recategorisation, 180 (73%; 67-78) of 248 MSM testing HIV positive reported knowing their HIV status, of whom 174 (97%; 93-99) reported using ART, of whom 151 (87%; 81-91) had viral load suppression. 92 (28%; 23-33) of 335 transgender women and genderqueer individuals tested positive for HIV. Based on self-reports from these individuals 34 (37%; 27-48) of 92 participants reported knowing their HIV status, of whom 31 (91%; 76-98) reported using ART, of whom 27 (87%; 70-96%) had viral load suppression. Based on viral load recategorisation of data from transgender women and genderqueer participants, 53 (58%; 47-58) of 92 reported awareness of their HIV status, of whom 50 (94%; 84-99) reported using ART, of whom 46 (92%; 81-98) had viral load suppression. HIV-positive MSM aged 18-24 years had lower odds of being aware of their status than those aged at least 35 years (adjusted odds ratio [aOR] 0·34; 95% CI 0·13-0·92), as did HIV-positive MSM aged 25-34 years (aOR 0·26; 0·12-0·56). HIV-positive MSM aged 18-24 years also had a lower odds of having viral load suppression than those aged 35 years and older (aOR 0·35; 0·16-0·78), as did those aged 25-34 years (aOR 0·36; 0·19-0·67). No factors were significantly associated with awareness among transgender women and genderqueer individuals in multivariable models. INTERPRETATION: Our survey showed that HIV prevalence was high and the largest difference between our results and the 90-90-90 treatment targets was in HIV status awareness, indicating the need for improvements in engaging MSM (especially young MSM), transgender women, and genderqueer individuals in HIV testing services. FUNDING: US President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention.

      7. Test-to-stay programs in schools are effective but are they equitable?external icon
        Neatherlin J, Thomas ES, Barrios LC.
        Pediatrics. 2022 Feb 11.
        During the 2020/2021 school year, kindergarten through grade 12 (K-12) schools in under-resourced communities were more likely to close due to the coronavirus disease (COVID-19) pandemic, and students in these schools missed more in-person learning days.1 Evidence collected during this time demonstrated in-person learning for all K-12 students could be conducted safely with layered prevention strategies.2 In August 2021, most U.S. school districts opened with 100% in-person learning. Despite a decrease in cases after the start of fall semester, cases among school-aged populations again increased in December prior to the winter break due to the highly transmissible B.1.1.529 (Omicron) variant.3.

    • Immunity and Immunization
      1. Vaccine effectiveness against COVID-19 among symptomatic persons aged ≥12 years with reported contact with COVID-19 cases, February-September 2021external icon
        Chung JR, Kim SS, Belongia EA, McLean HQ, King JP, Nowalk MP, Zimmerman RK, Moehling Geffel K, Martin ET, Monto AS, Lamerato LE, Gaglani M, Hoffman E, Volz M, Jackson ML, Jackson LA, Patel MM, Flannery B.
        Influenza Other Respir Viruses. 2022 Feb 15.
        BACKGROUND: Individuals in contact with persons with COVID-19 are at high risk of developing COVID-19; protection offered by COVID-19 vaccines in the context of known exposure is poorly understood. METHODS: Symptomatic outpatients aged ≥12 years reporting acute onset of COVID-19-like illness and tested for SARS-CoV-2 between February 1 and September 30, 2021 were enrolled. Participants were stratified by self-report of having known contact with a COVID-19 case in the 14 days prior to illness onset. Vaccine effectiveness was evaluated using the test-negative study design and multivariable logistic regression. RESULTS: Among 2229 participants, 283/451 (63%) of those reporting contact and 331/1778 (19%) without known contact tested SARS-CoV-2-positive. Adjusted vaccine effectiveness was 71% (95% confidence interval [CI], 49%-83%) among fully vaccinated participants reporting a known contact versus 80% (95% CI, 72%-86%) among those with no known contact (p-value for interaction = 0.2). CONCLUSIONS: This study contributes to growing evidence of the benefits of vaccinations in preventing COVID-19 and support vaccination recommendations and the importance of efforts to increase vaccination coverage.

      2. Association of COVID-19 vaccination with symptomatic SARS-CoV-2 infection by time since vaccination and Delta variant predominanceexternal icon
        Britton A, Fleming-Dutra KE, Shang N, Smith ZR, Dorji T, Derado G, Accorsi EK, Ajani UA, Miller J, Schrag SJ, Verani JR.
        Jama. 2022 Feb 14.
        IMPORTANCE: Monitoring COVID-19 vaccine performance over time since vaccination and against emerging variants informs control measures and vaccine policies. OBJECTIVE: To estimate the associations between symptomatic SARS-CoV-2 infection and receipt of BNT162b2, mRNA-1273, and Ad26.COV2.S by day since vaccination before and during Delta variant predominance (pre-Delta period: March 13-May 29, 2021; Delta period: July 18-October 17, 2021). DESIGN, SETTING, AND PARTICIPANTS: Test-negative, case-control design with data from 6884 US COVID-19 testing sites in the pharmacy-based Increasing Community Access to Testing platform. This study included 1 634 271 laboratory-based SARS-CoV-2 nucleic acid amplification tests (NAATs) from adults 20 years and older and 180 112 NAATs from adolescents 12 to 19 years old with COVID-19-like illness from March 13 to October 17, 2021. EXPOSURES: COVID-19 vaccination (1 Ad26.COV2.S dose or 2 mRNA doses) 14 or more days prior. MAIN OUTCOMES AND MEASURES: Association between symptomatic infection and prior vaccination measured using the odds ratio (OR) from spline-based multivariable logistic regression. RESULTS: The analysis included 390 762 test-positive cases (21.5%) and 1 423 621 test-negative controls (78.5%) (59.9% were 20-44 years old; 9.9% were 12-19 years old; 58.9% were female; 71.8% were White). Among adults 20 years and older, the BNT162b2 mean OR for days 14 to 60 after a second dose (initial OR) was lower during the pre-Delta period (0.10 [95% CI, 0.09-0.11]) than during the Delta period (0.16 [95% CI, 0.16-0.17]) and increased with time since vaccination (per-month change in OR, pre-Delta: 0.04 [95% CI, 0.02-0.05]; Delta: 0.03 [95% CI, 0.02-0.03]). The initial mRNA-1273 OR was 0.05 (95% CI, 0.04-0.05) during the pre-Delta period, 0.10 (95% CI, 0.10-0.11) during the Delta period, and increased with time (per-month change in OR, pre-Delta: 0.02 [95% CI, 0.005-0.03]; Delta: 0.03 [95% CI, 0.03-0.04]). The Ad26.COV2.S initial OR was 0.42 (95% CI, 0.37-0.47) during the pre-Delta period and 0.62 (95% CI, 0.58-0.65) during the Delta period and did not significantly increase with time since vaccination. Among adolescents, the BNT162b2 initial OR during the Delta period was 0.06 (95% CI, 0.05-0.06) among 12- to 15-year-olds, increasing by 0.02 (95% CI, 0.01-0.03) per month, and 0.10 (95% CI, 0.09-0.11) among 16- to 19-year-olds, increasing by 0.04 (95% CI, 0.03-0.06) per month. CONCLUSIONS AND RELEVANCE: Among adults, the OR for the association between symptomatic SARS-CoV-2 infection and COVID-19 vaccination (as an estimate of vaccine effectiveness) was higher during Delta variant predominance, suggesting lower protection. For mRNA vaccination, the steady increase in OR by month since vaccination was consistent with attenuation of estimated effectiveness over time; attenuation related to time was greater than that related to variant.

      3. Intradermal administration of fractional doses of the inactivated poliovirus vaccine in a campaign: a pragmatic, open-label, non-inferiority trial in The Gambiaexternal icon
        Bashorun AO, Badjie Hydara M, Adigweme I, Umesi A, Danso B, Johnson N, Sambou NA, Fofana S, Kanu FJ, Jeyaseelan V, Verma H, Weldon WC, Oberste MS, Sutter RW, Jeffries D, Wathuo M, Mach O, Clarke E.
        Lancet Glob Health. 2022 Feb;10(2):e257-e268.
        BACKGROUND: A rapid increase in circulating vaccine-derived poliovirus type 2 outbreaks, and the need to reserve inactivated poliovirus vaccine (IPV) for routine immunisation, has increased the value of fractional dose IPV (fIPV) as a measure to prevent acute flaccid paralysis. However, the intradermal route of administration has been viewed as prohibitive to outbreak response campaigns. We aimed to establish the immunogenicity and safety of administering intradermal fIPV with a disposable syringe jet injector (DSJI) or an intradermal adaptor (IDA) compared with standard administration with a BCG needle and syringe (N&S). METHODS: This pragmatic, non-inferiority trial was undertaken in a campaign setting in communities in The Gambia. Children aged 4-59 months without contraindication to vaccination were eligible. Children were not individually randomly assigned; instead, the vaccination teams were randomly assigned (1:1:1) to one of three administration methods. Parents and the field team were not masked, but laboratory personnel were masked. Baseline demographic and anthropometric data were collected from the participants. Public health officers experienced at intradermal immunisation, and nurses without experience, had 2 h of training on each of the administration methods before the campaign. Participants were vaccinated using the administration method in use by the vaccination team in their community. Poliovirus serum neutralising antibodies (SNA) were measured in children aged 24-59 months before and 4 weeks after vaccination. Adverse events and data on injection quality were collected from all participants. The primary outcome was the type 2 immune response rate (seroconversion in seronegative [SNA titre <8] children plus a 4-fold titre rise in seropositive children). Adjusted differences in the immune response between the DSJI or IDA group versus the N&S group were calculated with 97·5% CIs. A margin of -10% was used to define the non-inferiority of DSJI or IDA compared to N&S. Immunogenicity analysis was done per protocol. The trial is registered with ClinicalTrials.govNCT02967783 and has been completed. FINDINGS: Between Oct 28 and Dec 29, 2016, 3189 children aged 4-59 months were recruited, of whom 3170 were eligible. Over 3 days, 2720 children were vaccinated (N&S, 917; IDA, 874; and DSJI, 929). Among 992 children aged 25-59 months with a baseline SNA available, 90·1% (95% CI 86·1-92·9; 281/312) of those vaccinated using the DSJI had an immune response to type 2 compared with 93·8% (90·6-95·8; 331/353) of those vaccinated with N&S and 96·6% (94·0-98·0; 316/327) of those vaccinated with IDA. All (53/53) type 2 seronegative children seroconverted. For polio type 2, non-inferiority was shown for both the IDA (adjusted difference 0·7% [97·5% CI -3·3 to 4·7], unadjusted difference 2·9% [-0·9 to 6·8]) and DSJI (adjusted difference -3·3% [-8·3 to 1·5], unadjusted difference -3·7% [-8·7 to 1·1]) compared with N&S. Non-inferiority was shown for type 1 and 3 for the IDA and DSJI. Neither injection quality nor the training and experience of the vaccinators had an effect on immune response. No safety concerns were reported. INTERPRETATION: In a campaign, intradermal fIPV is safe and generates consistent immune responses that are not dependent on vaccinator experience or injection quality when administered using an N&S, DSJI, or IDA. Countries facing vaccine-derived poliovirus type 2 outbreaks should consider fIPV campaigns to boost population immunity and prevent cases of acute flaccid paralysis. FUNDING: World Health Organization and the Medical Research Council.

      4. Progress toward rubella and congenital rubella syndrome control and elimination - worldwide, 2012-2020external icon
        Zimmerman LA, Knapp JK, Antoni S, Grant GB, Reef SE.
        MMWR Morb Mortal Wkly Rep. 2022 Feb 11;71(6):196-201.
        Rubella virus is a leading cause of vaccine-preventable birth defects and can cause epidemics. Although rubella virus infection usually produces a mild febrile rash illness in children and adults, infection during pregnancy, especially during the first trimester, can result in miscarriage, fetal death, stillbirth, or an infant born with a constellation of birth defects known as congenital rubella syndrome (CRS). A single dose of rubella-containing vaccine (RCV) can provide lifelong protection against rubella (1). The Global Vaccine Action Plan 2011-2020 (GVAP) included a target to achieve elimination of rubella in at least five of the six World Health Organization (WHO) regions* by 2020 (2), and WHO recommends capitalizing on the accelerated measles elimination activities as an opportunity to introduce RCV (1). This report updates a previous report (3) and summarizes global progress toward control and elimination of rubella and CRS from 2012, when accelerated rubella control activities were initiated, through 2020. Among 194 WHO Member States, the number with RCV in their immunization schedules has increased from 132 (68%) in 2012 to 173 (89%) in 2020; 70% of the world's infants were vaccinated against rubella in 2020. Reported rubella cases declined by 48%, from 94,277 in 2012 to 49,136 in 2019, and decreased further to 10,194 in 2020. Rubella elimination has been verified in 93 (48%) of 194 countries including the entire Region of the Americas (AMR). To increase the equity of protection and make further progress to eliminate rubella, it is important that the 21 countries that have not yet done so should introduce RCV. Likewise, countries that have introduced RCV can achieve and maintain rubella elimination with high vaccination coverage and surveillance for rubella and CRS. Four of six WHO regions have established rubella elimination goals; the two WHO regions that have not yet established an elimination goal (the African [AFR] and Eastern Mediterranean [EMR] regions) have expressed a commitment to rubella elimination and should consider establishing a goal.

      5. Evaluating stability of attenuated Sabin and two novel type 2 oral poliovirus vaccines in childrenexternal icon
        Wahid R, Mercer L, Gast C, De Leon T, Sáez-Llorens X, Fix A, Macadam A, Stephens L, Chumakov K, Smits SL, Murreddu M, Konopka-Anstadt JL, Steven Oberste M, Burns CC, Andino R, Bachtiar NS, Tritama E, Bandyopadhyay AS, Aguirre G, Rüttimann R, Konz JO.
        NPJ Vaccines. 2022 Feb 11;7(1):19.
        Novel oral poliovirus vaccine type 2 (nOPV2) is being developed to reduce the rare occurrence of disease and outbreaks associated with the genetic instability of the Sabin vaccine strains. Children aged 1 to 5 years were enrolled in two related clinical studies to assess safety, immunogenicity, shedding rates and properties of the shed virus following vaccination with nOPV2 (two candidates) versus traditional Sabin OPV type 2 (mOPV2). The anticipated pattern of reversion and increased virulence was observed for shed Sabin-2 virus, as assessed using a mouse model of poliovirus neurovirulence. In contrast, there were significantly reduced odds of mouse paralysis for shed virus for both nOPV2 candidates when compared to shed Sabin-2 virus. Next-generation sequencing of shed viral genomes was consistent with and further supportive of the observed neurovirulence associated with shed Sabin-2 virus, as well as the reduced reversion to virulence of shed candidate viruses. While shed Sabin-2 showed anticipated A481G reversion in the primary attenuation site in domain V in the 5' untranslated region to be associated with increased mouse paralysis, the stabilized domain V in the candidate viruses did not show polymorphisms consistent with reversion to neurovirulence. The available data from a key target age group for outbreak response confirm the superior genetic and phenotypic stability of shed nOPV2 strains compared to shed Sabin-2 and suggest that nOPV2 should be associated with less paralytic disease and potentially a lower risk of seeding new outbreaks.

      6. Diphtheria and tetanus seroepidemiology among children in Ukraine, 2017external icon
        Khetsuriani N, Zaika O, Slobodianyk L, Scobie HM, Cooley G, Dimitrova SD, Stewart B, Geleishvili M, Allahverdiyeva V, O'Connor P, Huseynov S.
        Vaccine. 2022 Feb 10.
        BACKGROUND: The drastic decline of Ukraine's immunization coverage since 2009 led to concerns about potential resurgence diphtheria and tetanus, along with other vaccine-preventable diseases. METHODS: To assess population immunity against diphtheria and tetanus, we tested specimens from the serosurvey conducted in 2017 among children born in 2006-2015, the birth cohorts targeted by the nationwide outbreak response immunization following a circulating vaccine-derived poliovirus type 1 outbreak in Zakarpattya province in 2015. We surveyed four regions of Ukraine, using cluster sampling in Zakarpattya, Sumy, and Odessa provinces and simple random sampling in Kyiv City. We tested serum specimens for IgG antibodies against diphtheria and tetanus, using microbead assays (MBA). We estimated seroprevalence and calculated 95% confidence intervals. We also obtained information on the immunization status of surveyed children. RESULTS: Seroprevalence of ≥0.1 IU/mL diphtheria antibodies was <80% in all survey sites (50.0%-79.2%). Seroprevalence of ≥0.1 IU/mL tetanus antibodies was ≥80% in Sumy, Kyiv City, and Odessa (80.2%-89.1%) and 61.6% in Zakarpattya. Across the sites, the proportion of children vaccinated age-appropriately with diphtheria-tetanus-containing vaccines (DTCV) was 28.5%-57.4% among children born in 2006-2010 and 34.1%-54.3% among children born in 2011-2015. The proportion of recipients of <3 DTCV doses increased from 7.1%-16.7% among children born in 2006-2010 to 19.8%-38.6% among children born in 2011-2015, as did the proportion of recipients of zero DTCV doses (2.6%-8.8% versus 8.0%-14.0%, respectively). CONCLUSIONS: Protection against diphtheria among children born in 2006-2015 was suboptimal (<80%), particularly in Zakarpattya. Protection against tetanus was adequate (≥80%) except in Zakarpattya. Diphtheria-tetanus immunization status was suboptimal across all sites. Catch-up vaccination of unvaccinated/under-vaccinated children and other efforts to increase immunization coverage would close these immunity gaps and prevent the resurgence of diphtheria and tetanus in Ukraine, particularly in Zakarpattya.

    • Informatics
      1. Opportunities to enhance the utility of cause of death information from death certificatesexternal icon
        Ling SM, Warner M, Anderson RN.
        Am J Public Health. 2022 Feb;112(S1):S42-s44.

      2. Implementation of DHIS2 for Disease Surveillance in Guinea: 2015-2020external icon
        Reynolds E, Martel LD, Bah MO, Bah M, Bah MB, Boubacar B, Camara N, Camara YB, Corvil S, Diallo BI, Diallo IT, Diallo MK, Diallo MT, Diallo T, Guilavogui S, Hemingway-Foday JJ, Hann F, Kaba A, Kaba AK, Kande M, Lamarana DM, Middleton K, Sidibe N, Souare O, Standley CJ, Stolka KB, Tchwenko S, Worrell MC, MacDonald PD.
        Front Public Health. 2021 ;9:761196.
        A robust epidemic-prone disease surveillance system is a critical component of public health infrastructure and supports compliance with the International Health Regulations (IHR). One digital health platform that has been implemented in numerous low- and middle-income countries is the District Health Information System Version 2 (DHIS2). In 2015, in the wake of the Ebola epidemic, the Ministry of Health in Guinea established a strategic plan to strengthen its surveillance system, including adoption of DHIS2 as a health information system that could also capture surveillance data. In 2017, the DHIS2 platform for disease surveillance was piloted in two regions, with the aim of ensuring the timely availability of quality surveillance data for better prevention, detection, and response to epidemic-prone diseases. The success of the pilot prompted the national roll-out of DHIS2 for weekly aggregate disease surveillance starting in January 2018. In 2019, the country started to also use the DHIS2 Tracker to capture individual cases of epidemic-prone diseases. As of February 2020, for aggregate data, the national average timeliness of reporting was 72.2%, and average completeness 98.5%; however, the proportion of individual case reports filed was overall low and varied widely between diseases. While substantial progress has been made in implementation of DHIS2 in Guinea for use in surveillance of epidemic-prone diseases, much remains to be done to ensure long-term sustainability of the system. This paper describes the implementation and outcomes of DHIS2 as a digital health platform for disease surveillance in Guinea between 2015 and early 2020, highlighting lessons learned and recommendations related to the processes of planning and adoption, pilot testing in two regions, and scale up to national level.

      3. An evaluation of the Text Illness Monitoring (TIM) platform for COVID-19: Cross-sectional online survey of public health usersexternal icon
        Joseph HA, Ingber SZ, Austin C, Westnedge C, Strona FV, Lee L, Shah AB, Roper L, Patel A.
        JMIR Public Health Surveill. 2022 Feb 7;8(2):e32680.
        BACKGROUND: The US public health response to the COVID-19 pandemic has required contact tracing and symptom monitoring at an unprecedented scale. The US Centers for Disease Control and Prevention and several partners created the Text Illness Monitoring (TIM) platform in 2015 to assist US public health jurisdictions with symptom monitoring for potential novel influenza virus outbreaks. Since May 2020, 142 federal, state, and local public health agencies have deployed TIM for COVID-19 symptom monitoring. OBJECTIVE: The aim of this study was to evaluate the utility, benefits, and challenges of TIM to help guide decision-making for improvements and expansion to support future public health emergency response efforts. METHODS: We conducted a brief online survey of previous and current TIM administrative users (admin users) from November 28 through December 21, 2020. Closed- and open-ended questions inquired about the onboarding process, decision to use TIM, groups monitored with TIM, comparison of TIM to other symptom monitoring systems, technical challenges and satisfaction with TIM, and user support. A total of 1479 admin users were invited to participate. RESULTS: A total of 97 admin users from 43 agencies responded to the survey. Most admin users represented the Indian Health Service (35/97, 36%), state health departments (26/97, 27%), and local or county health departments (18/97, 19%), and almost all were current users of TIM (85/94, 90%). Among the 43 agencies represented, 11 (26%) used TIM for monitoring staff exclusively, 13 (30%) monitored community members exclusively, and 19 (44%) monitored both staff and community members. Agencies most frequently used TIM to monitor symptom development in contacts of cases among community members (28/43, 65%), followed by symptom development among staff (27/43, 63%) and among staff contacts of cases (24/43, 56%). Agencies also reported using TIM to monitor patients with COVID-19 for the worsening of symptoms among staff (21/43, 49%) and community members (18/43, 42%). When asked to compare TIM to previous monitoring systems, 78% (40/51) of respondents rated TIM more favorably than their previous monitoring system, 20% (10/51) said there was no difference, and 2% (1/51) rated the previous monitoring system more favorably than TIM. Most respondents found TIM favorable in terms of time burden, staff burden, timeliness of the data, and the ability to monitor large population sizes. TIM compared negatively to other systems in terms of effort to enroll participants (ie, persons TIM monitors) and accuracy of the data. Most respondents (76/85, 89%) reported that they would highly or somewhat recommend TIM to others for symptom monitoring. CONCLUSIONS: This evaluation of TIM showed that agencies used TIM for a variety of purposes and rated TIM favorably compared to previously used monitoring systems. We also identified opportunities to improve TIM; for example, enhancing the flexibility of alert deliveries would better meet admin users' varying needs. We also suggest continuous program evaluation practices to assess and respond to implementation gaps.

    • Injury and Violence
      1. Cycles of violence among young women in Namibia: Exploring the links between childhood violence and adult intimate partner violence from the violence against children and youth surveyexternal icon
        Velloza J, Davies LD, Ensminger AL, Theofelus FM, Andjamba H, Kamuingona R, Masseti G, Coomer R, Forster N, O'Malley G.
        J Interpers Violence. 2022 Feb 13:8862605211073107.
        Background: Violence against children is a global public health crisis and is associated with poor mental and physical health outcomes. Childhood violence may also increase the risk of subsequent violence revictimization by an intimate partner. We aimed to understand cycles of violence among adolescent girls and young women in Namibia to inform violence prevention and treatment interventions. Methods: The 2019 Namibia Violence Against Children and Youth Survey (VACS) examined the prevalence of childhood violence and intimate partner violence among 18-24 year old adolescent girls and young women (N = 2434). Using the data, we assessed the prevalence of childhood violence, defined as any physical, sexual, or emotional violence victimization prior to age 18, and estimated the prevalence of intimate partner violence (IPV) after age 18. We used a weighted logistic regression to assess whether childhood violence exposure was associated with subsequent experience of IPV after age 18. Results: Adolescent girls and young women in Namibia had a statistically significant higher odds of experiencing IPV if they had experienced any childhood violence including physical, sexual, and/or emotional violence (adjusted odds ratio [aOR]: 2.93; 95% Confidence Interval [95% CI: 1.64-5.23). IPV was also significantly associated with childhood physical (aOR: 1.81; 95% CI: 1.07-3.05), sexual (aOR: 3.79; 95% CI: 2.54-5.67), or emotional (aOR: 2.39; 95% CI: 1.18-4.86) violence when each were considered separately. We also observed a dose-response relationship between the number of types of childhood violence and IPV experience as a young adult. Conclusions: Childhood violence is a significant predictor of subsequent violence revictimization by an intimate partner. This analysis provides unique insights on cycles of violence among adolescent girls and young women in Namibia and points to the need for interventions during childhood to prevent violence against children and break this cycle among young women in sub-Saharan Africa.

    • Laboratory Sciences
      1. Evaluating the presence of replication-competent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from nursing home residents with persistently positive reverse transcription polymerase chain reaction (RT-PCR) resultsexternal icon
        Lutgring JD, Tobolowsky FA, Hatfield KM, Lehnertz NB, Sullivan MM, Martin KG, Keaton A, Sexton DJ, Tamin A, Harcourt JL, Thornburg NJ, Reddy SC, Jernigan JA.
        Clin Infect Dis. 2022 Feb 11;74(3):525-528.
        Replication-competent virus has not been detected in individuals with mild to moderate coronavirus disease 2019 (COVID-19) more than 10 days after symptom onset. It is unknown whether these findings apply to nursing home residents. Of 273 specimens collected from nursing home residents >10 days from the initial positive test, none were culture positive.

      2. OBJECTIVES: Under the Global Programme to Eliminate Lymphatic Filariasis (LF), American Samoa conducted seven rounds of mass drug administration between 2000 and 2006. The territory passed transmission assessment surveys (TAS) in 2011 (TAS-1) and 2015 (TAS-2). In 2016, the territory failed TAS-3, indicating resurgence. This study aims to determine if antibodies (Ab) may have provided a timelier indication of LF resurgence in American Samoa. METHODS: We examined school-level antigen (Ag) and Ab status (presence/absence of Ag- and Ab-positive children) and prevalence of single and combined Ab responses to Wb123, Bm14, Bm33 Ags at each TAS. Pearson's chi-squared tests and logistic regression were used to examine associations between school-level Ab prevalence in TAS-1 and TAS-2 and school-level Ag status in TAS-3. RESULTS: Schools with higher prevalence of Wb123 Ab in TAS-2 had higher odds of being Ag-positive in TAS-3 (odds ratio [OR] 24.5, 95% CI:1.2-512.7). Schools that were Ab-positive for WB123 plus Bm14, Bm33 or both Bm14 and Bm33 in TAS-2 had higher odds of being Ag-positive in TAS-3 (OR 16.0-24.5). CONCLUSION: Abs could provide earlier signals of resurgence and enable a timelier response. The promising role of Abs in post-mass drug administration (MDA) surveillance and decision making should be further investigated in other settings.

      3. Twelve-month follow-up of early COVID-19 cases in the United States: Cellular and humoral immune longevityexternal icon
        Shah MM, Rasheed MA, Harcourt JL, Abedi GR, Stumpf MM, Kirking HL, Tamin A, Mills L, Armstrong M, Salvatore PP, Surasi K, Scott SE, Killerby ME, Briggs-Hagen M, Saydah S, Tate JE, Fry AM, Hall AJ, Thornburg NJ, Midgley CM.
        Open Forum Infect Dis. 2022 Mar;9(3):ofab664.
        We quantify antibody and memory B-cell responses to severe acute respiratory syndrome coronavirus 2 at 6 and 12 months postinfection among 7 unvaccinated US coronavirus disease 2019 cases. All had detectable S-specific memory B cells and immunoglobulin G at both time points, with geometric mean titers of 117.2 BAU/mL and 84.0 BAU/mL at 6 and 12 months, respectively.

      4. Performance of a novel rapid test for recent HIV infection among newly-diagnosed pregnant adolescent girls and young women in four high-HIV-prevalence districts-Malawi, 2017-2018external icon
        Agyemang EA, Kim AA, Dobbs T, Zungu I, Payne D, Maher AD, Curran K, Kim E, Kwalira H, Limula H, Adhikari A, Welty S, Kandulu J, Nyirenda R, Auld AF, Rutherford GW, Parekh BS.
        PLoS One. 2022 ;17(2):e0262071.
        Tests for recent HIV infection (TRI) distinguish recent from long-term HIV infections using markers of antibody maturation. The limiting antigen avidity enzyme immunoassay (LAg EIA) is widely used with HIV viral load (VL) in a recent infection testing algorithm (RITA) to improve classification of recent infection status, estimate population-level HIV incidence, and monitor trends in HIV transmission. A novel rapid test for recent HIV infection (RTRI), Asanté™, can determine HIV serostatus and HIV recency within minutes on a lateral flow device through visual assessment of test strip or reader device. We conducted a field-based laboratory evaluation of the RTRI among pregnant adolescent girls and young women (AGYW) attending antenatal clinics (ANC) in Malawi.We enrolled pregnant AGYW aged <25 years testing HIV-positive for the first time at their first ANC visit from 121 ANCs in four high-HIV burden districts. Consenting participants provided blood for recency testing using LAg EIA and RTRI, which were tested in central laboratories. Specimens with LAg EIA normalized optical density values ≤2.0 were classified as probable recent infections. RTRI results were based on: (1) visual assessment: presence of a long-term line (LT) indicating non-recent infection and absence of the line indicating recent infection; or (2) a reader; specimens with LT line intensity units <3.0 were classified as probable recent infections. VL was measured for specimens classified as a probable recent infections by either assay; those with HIV-1 RNA ≥1,000 copies/mL were classified as confirmed recent infections. We evaluated the performance of the RTRI by calculating correlation between RTRI and LAg EIA results, and percent agreement and kappa between RTRI and LAg EIA RITA results.Between November 2017 to June 2018, 380 specimens were available for RTRI evaluation; 376 (98.9%) were confirmed HIV-positive on RTRI. Spearman's rho between RTRI and LAg EIA was 0.72 indicating strong correlation. Percent agreement and kappa between RTRI- and LAg EIA-based RITAs were >90% and >0.65 respectively indicating substantial agreement between the RITAs.This was the first field evaluation of an RTRI in sub-Saharan Africa, which demonstrated good performance of the assay and feasibility of integrating RTRI into routine HIV testing services for real-time surveillance of recent HIV infection.

      5. Chlamydia trachomatis variants escaping detection in the Aptima Combo 2® assay in the United Statesexternal icon
        Katz SS, Danavall DC, Morris MR, Herrod BP, Dale SE, Nye MB, Kersh EN, Kirkcaldy RD, Raphael BH.
        Sex Transm Dis. 2022 Feb 14.
        BACKGROUND: The Aptima Combo 2® (AC2) assay manufactured by Hologic, Inc. detects Neisseria gonorrhoeae (NG) and/or Chlamydia trachomatis (CT) in urogenital and extragenital specimens by targeting either a 16S rRNA (NG) or 23S rRNA (CT) region. In 2019, a mutation (C1515T) in the 23S rRNA region was reported to cause false negative/equivocal results in specimens collected in Finland. Specimens containing this variant (Fl-nvCT) were also discovered internationally. Working with specimens submitted to a large commercial laboratory, we sought to determine if this variant was also present in the United States. METHODS: A subset (N = 401) of specimens tested with the AC2 assay collected during a five-week period in late 2019/early 2020 were evaluated using an updated AC2 assay. RESULTS: While the FI-nvCT variant was not detected within this specimen panel, two CT variants containing 23S rRNA mutations (A1518G, G1526A) were identified. The updated AC2 assay targeting an additional region of the 23S rRNA detected both of these variants. A retrospective study of >18 million AC2 results tested between 2018-2019 did not display a decrease in CT positivity. CONCLUSIONS: Although we did not detect the Fl-nvCT variant among US specimens, we show evidence that the low occurrence of similar diagnostic escape mutants can be detected with an updated AC2 assay using multiple 23S rRNA targets.

      6. Burden of Diarrheagenic Escherichia coli in Santa Rosa, Guatemala in active health-services surveillance during 2008-2009 and 2014-2015external icon
        Jarquin C, Morales O, McCracken JP, Lopez MR, Lopez B, Reyes L, Gómez GA, Bryan JP, Peruski LF, Pattabiraman V, Parsons MB.
        Trop Med Int Health. 2022 Feb 13.
        OBJECTIVE: To describe the epidemiology of laboratory-confirmed Diarrheagenic Escherichia coli (DEC) cases from active facility-based surveillance in Guatemala. METHODS: We collected clinical and risk factor data on enrolled patients (aged 0-52 years) with acute diarrhea at government healthcare facilities (1 hospital and 6 clinics) in Santa Rosa, Guatemala, during 2008-2009 and 2014-2015. Stool samples were analyzed and E. coli identified through culture and biochemical tests, PCR amplification of genes encoding pathotype-specific virulence factors identified specific DEC pathotypes. Healthcare-seeking adjusted incidence rates were calculated. RESULTS: 3041 diarrhea cases were captured by surveillance (647 hospitalizations (H), 2394 clinic visits (CV)); general E. coli prevalence was 17.9%. DEC pathotypes were identified in 19% (n=95/497) and 21% (n=450/2113) in diarrhea H and CV, respectively. Enteropathogenic E. coli (EPEC) was most frequently isolated (8.2% (n=41) in diarrhea H, 12.0% (n =255) in diarrhea CV), followed by ETEC (6.8% (n=34) in H, 6% (n=128) in CV) and STEC (0.6% (n=3) in H, 0.6% (n=13) in CV). We did not find evidence of a difference in severity between DEC and non-DEC diarrhea. Incidence of DEC clinic visits and hospitalizations was 648.0 and 29.3, respectively, per 10,000 persons aged ≤5 years and 36.8 and 0.4, respectively, per 10,000 persons aged >5 years. CONCLUSIONS: DEC pathotypes, especially EPEC and ETEC, were detected frequently from patients presenting with diarrheal illness in Santa Rosa, Guatemala. Our findings suggest that preventive interventions should be prioritized for young children.

    • Maternal and Child Health
      1. Effects of individual differences, society, and culture on youth-rated problems and strengths in 38 societiesexternal icon
        Ivanova MY, Achenbach TM, Turner L, Almqvist F, Begovac I, Bilenberg N, Bird H, Broberg AG, Córdova Calderón MA, Chahed M, Dang HM, Dobrean A, Döpfner M, Erol N, Forns M, Guðmundsson HS, Hannesdóttir H, Hewitt-Ramirez N, Kanbayashi Y, Karki S, Koot HM, Lambert MC, Leung P, Magai DN, Maggiolini A, Metzke CW, Minaei A, Monzani da Rocha M, Moreira PA, Mulatu MS, Nøvik TS, Oh KJ, Petot D, Petot JM, Pisa C, Pomalima R, Roussos A, Rudan V, Sawyer MG, Shahini M, Simsek Z, Steinhausen HC, Verhulst FC, Weintraub S, Weiss B, Wolanczyk T, Zhang EY, Zilber N, Žukauskienė R.
        J Child Psychol Psychiatry. 2022 Feb 15.
        BACKGROUND: Clinicians increasingly serve youths from societal/cultural backgrounds different from their own. This raises questions about how to interpret what such youths report. Rescorla et al. (2019, European Child & Adolescent Psychiatry, 28, 1107) found that much more variance in 72,493 parents' ratings of their offspring's mental health problems was accounted for by individual differences than by societal or cultural differences. Although parents' reports are essential for clinical assessment of their offspring, they reflect parents' perceptions of the offspring. Consequently, clinical assessment also requires self-reports from the offspring themselves. To test effects of individual differences, society, and culture on youths' self-ratings of their problems and strengths, we analyzed Youth Self-Report (YSR) scores for 39,849 11-17 year olds in 38 societies. METHODS: Indigenous researchers obtained YSR self-ratings from population samples of youths in 38 societies representing 10 culture cluster identified in the Global Leadership and Organizational Behavioral Effectiveness study. Hierarchical linear modeling of scores on 17 problem scales and one strengths scale estimated the percent of variance accounted for by individual differences (including measurement error), society, and culture cluster. ANOVAs tested age and gender effects. RESULTS: Averaged across the 17 problem scales, individual differences accounted for 92.5% of variance, societal differences 6.0%, and cultural differences 1.5%. For strengths, individual differences accounted for 83.4% of variance, societal differences 10.1%, and cultural differences 6.5%. Age and gender had very small effects. CONCLUSIONS: Like parents' ratings, youths' self-ratings of problems were affected much more by individual differences than societal/cultural differences. Most variance in self-rated strengths also reflected individual differences, but societal/cultural effects were larger than for problems, suggesting greater influence of social desirability. The clinical significance of individual differences in youths' self-reports should thus not be minimized by societal/cultural differences, which-while important-can be taken into account with appropriate norms, as can gender and age differences.

      2. Toileting resistance among preschool-age children with and without autism spectrum disorderexternal icon
        Wiggins LD, Nadler C, Hepburn S, Rosenberg S, Reynolds A, Zubler J.
        J Dev Behav Pediatr. 2022 Feb 15.
        OBJECTIVE: Children with autism spectrum disorder (ASD) may achieve continence later than other children. Little is known about factors associated with toileting resistance in children with ASD and other developmental delays/disabilities (DD). We sought to describe toileting resistance in children with ASD and DD and those from the general population (POP) and identify factors associated with toileting resistance in children with ASD and DD. METHOD: Families and children aged 24 to 68 months were enrolled in the Study to Explore Early Development, a multisite case-control study on ASD. Children with ASD (N = 743) and DD (N = 766) and those from the POP (N = 693) who were 48 months or older were included in this study. Parents reported toileting resistance, gastrointestinal issues, behavior problems, and ASD symptoms in their children. Children completed an in-person evaluation to determine ASD status and developmental level. RESULTS: Toileting resistance was more common among children with ASD (49.1%) than children with DD (23.6%) and those from the POP (8.0%). Diarrhea and deficits in social awareness were significantly associated with toileting resistance in children with ASD and DD. Constipation, expressive language delays, and low social motivation were significantly associated with toileting resistance only in children with ASD; very low visual reception skills and oppositional behaviors were significantly associated with toileting resistance in only children with DD (all p ≤ 0.05). CONCLUSION: Evaluating gastrointestinal issues, developmental delays, and social deficits before toileting training may help identify children with atypical development who are likely to present with toileting resistance. These evaluations can be incorporated into health supervision visits.

      3. Changes in rates of adverse pregnancy outcomes during the COVID-19 pandemic: a cross-sectional study in the United States, 2019-2020external icon
        Simeone RM, Downing KF, Wallace B, Galang RR, DeSisto CL, Tong VT, Zapata LB, Ko JY, Ellington SR.
        J Perinatol. 2022 Feb 15.
        OBJECTIVE: Our objective was to assess differences in pregnancy outcomes during the COVID-19 pandemic compared to the previous year. STUDY DESIGN: In a cross-sectional study of delivery hospitalizations in the Premier Healthcare Database Special COVID-19 Release, we assessed differences in selected maternal and pregnancy outcomes occurring April-December in 2019 and 2020 in the United States. RESULT: Among 663,620 deliveries occurring in 2019 and 614,093 deliveries occurring in 2020, we observed an increase in in-hospital maternal death from 2019 to 2020, which was no longer statistically significant after excluding deliveries with a COVID-19 diagnosis. Intensive care unit admission and preterm birth decreased from 2019 to 2020. There was no difference in the prevalence of most other outcomes examined. CONCLUSION: The full impact of the COVID-19 pandemic on maternal and pregnancy outcomes remains to be understood. Most outcomes investigated experienced minimal change from 2019 to 2020.

      4. Preventive dental care and oral health of children and adolescents with and without heart conditions - United States, 2016-2019external icon
        Downing KF, Espinoza L, Oster ME, Farr SL.
        MMWR Morb Mortal Wkly Rep. 2022 Feb 11;71(6):189-195.
        Approximately 900,000 U.S. children have heart conditions, such as congenital heart disease (1). These children might be at increased risk for life-threatening infective endocarditis from oral bacteria in the bloodstream (2). Therefore, preventive dental care (i.e., check-ups, dental cleaning, radiographs, fluoride treatment, or sealant) to maintain oral health is important. Oral health status and receipt of preventive dental care were compared between children with heart conditions (2,928) and without (116,826) using population-based 2016-2019 National Survey of Children's Health (NSCH) data. Approximately 83% of children with and 80% without heart conditions received preventive dental care in the past year (p = 0.06). Children with heart conditions were more likely than were those without to have poor oral health (17.2% versus 13.7%; p = 0.02) and teeth in fair or poor condition (9.9% versus 5.3%; p<0.01). Among those with a heart condition, having low household income; an intellectual or developmental disability; and no well-child visit or medical home were associated with poor oral health. Receipt of preventive dental care was higher among children aged ≥6 years and those with insurance. Public health practitioners and health care providers can implement strategies (e.g., parent and patient education and collaboration between pediatricians, dentists, and cardiologists) to improve oral health and care among children with heart conditions, especially those with fewer resources and intellectual or developmental disabilities.

    • Occupational Safety and Health
      1. Occupational risk factors for SARS-CoV-2 Infection among healthcare personnel: A 6-month prospective analysis of the COVID-19 Prevention in Emory Healthcare Personnel (COPE) Studyexternal icon
        Howard-Anderson J, Adams C, Dube WC, Smith TC, Sherman AC, Edupuganti N, Mendez M, Chea N, Magill SS, Espinoza DO, Zhu Y, Phadke VK, Edupuganti S, Steinberg JP, Lopman BA, Jacob JT, Fridkin SK, Collins MH.
        Infect Control Hosp Epidemiol. 2022 Feb 14:1-30.
        OBJECTIVE: Determine the incidence of SARS-CoV-2 infection among healthcare personnel (HCP) and assess occupational risks for SARS-CoV-2 infection. DESIGN: Prospective cohort of HCP followed for 6-months from May-December 2020. SETTING: Large academic healthcare system including four hospitals and affiliated clinics in Atlanta, GA. PARTICIPANTS: HCP, including those with and without direct patient care activities, working during the COVID-19 pandemic. METHODS: Incident SARS-CoV-2 infections were determined through serologic testing for SARS-CoV-2 IgG at enrollment, 3 and 6 months. HCP completed monthly surveys regarding occupational activities. Multivariable logistic regression was used to identify occupational factors that increased the risk of SARS-CoV-2 infection. RESULTS: Of the 304 evaluable HCP that were seronegative at enrollment, 26 (9%) seroconverted for SARS-CoV-2 IgG by 6 months. Participants self-identified predominantly as White (n=219, 73%), nurses (n=119, 40%), and working in inpatient medical/surgical floors (n=121, 40%). In a multivariable analysis, HCP who identified as Black were more likely to seroconvert than HCP who identified as White (odds ratio 4.5, 95% confidence interval 1.3-14.2). Increased risk for SARS-CoV-2 infection was not identified for any occupational activity, including spending >50% of a typical shift at a patient's bedside, working in COVID-19 units, or performing/being present for aerosol generating procedures (AGPs). CONCLUSIONS: In our study cohort of HCP working in an academic healthcare system, <10% had evidence of SARS-CoV-2 infection over six months. No specific occupational activities were identified as increasing risk for SARS-CoV-2 infection.

      2. The future of work continues to undergo profound and fundamental changes in response to shifting social, technological, economic, environmental, and political contexts [...].

      3. Assessment of worker chemical exposures in California vape shopsexternal icon
        Attfield K, Zalay M, Zwack L, Glassford E, LeBouf R, Materna B.
        J Occup Environ Hyg. 2022 Feb 14:1-19.
        E-cigarettes are battery-operated devices that heat a liquid mixture to make an aerosol that is inhaled, or vaped, by the user. Vape shops are retail environments for customer demand of diverse e-liquid flavors and hardware options, which create unique worker exposure concerns. To characterize exposures to vape shop workers, especially to flavoring chemicals associated with known respiratory toxicity, this study recruited vape shops from the San Francisco Bay Area. In six shops, air concentrations were measured for volatile organic compounds, formaldehyde, flavoring chemicals, and nicotine in personal and/or area samples; analyzed components of e-liquids vaped during field visits; and assessed metals on surface wipe samples. Interviews and observations were conducted over the course of a workday in the same six shops and performed interviews only in an additional six where sampling was not conducted. Detections of the alpha-diketone butter flavoring chemicals diacetyl and/or 2,3-pentanedione were common: in the headspace of purchased e-liquids (18 of 26 samples), in personal air samples (five of 16), and in area air samples (two of six shops). Two exceedances of recommended exposure limits for 2,3-pentanedione (a short-term exposure limit and an eight-hour time weighted average) were measured in personal air samples. Other compounds detected in area and personal air samples included substitutes for diacetyl and 2,3-pentanedione (acetoin and 2,3-hexanedione) and compounds that may be contaminants or impurities. Furthermore, a large variety (82) of other flavoring chemicals were detected in area air samples. None of the 12 shops interviewed had a health and safety program. Six shops reported no use of any personal protective equipment (PPE) (e.g., gloves, chemical resistant aprons, eye protection) and the others stated occasional use; however, no PPE use was observed during any field investigation day. Recommendations were provided to shops that included making improvements to ventilation, hygiene, use of personal protective equipment, and, if possible, avoidance of products containing the alpha-diketone flavoring chemicals. Future research is needed to evaluate the long-term health risks among workers in the vape shop retail industry and for e-cigarette use generally. Specific areas include further characterizing e-liquid constituents and emissions, evaluating ingredient health risks, evaluating the contributions of different routes of exposure (dermal, inhalation, and ingestion) and determining effective exposure mitigation measures.

    • Occupational Safety and Health - Mining
      1. Mining vehicle manufacturers are developing lithium-ion (Li-ion) battery electric vehicles as an alternative to diesel-powered vehicles. In gassy underground mines, explosion-proof (XP) enclosures are commonly used to enclose electrical ignition sources to prevent propagation of an internal methane-air explosion to a surrounding explosive atmosphere. Li-ion batteries can create pressurized explosions within sealed enclosures due to thermal runaway (TR). NIOSH researchers measured TR pressures of nickel manganese cobalt (NMC) cathode type 18650 Li-ion cells, model MH1, as a function of free space within sealed enclosures and observed an inverse power relationship. TR pressure-rise rates, gas quantities, and temperatures were also measured. A confined NMC cell with 92.5 mL of free space produced 232 bar of pressure, far exceeding minimum pressure containment specifications for conventional XP enclosures. Approximately 287 times the cell volume of free space would be needed to reduce the TR pressure of these cells to 8.62 barg (125 psig) per U.S. Code of Federal Regulations, Title 30, Part 18. The NMC cell TR pressures were significantly higher than those measured previously for iron phosphate cathode Li-ion cells under comparable confinement conditions. © 2022

    • Parasitic Diseases
      1. Folic acid supplementation and malaria susceptibility and severity among people taking antifolate antimalarial drugs in endemic areasexternal icon
        Crider KS, Williams JL, Qi YP, Gutman J, Yeung LF, Mai CT, Finkelstein JL, Mehta S, Pons-Duran C, Menéndez C, Moraleda C, Rogers LM, Daniels K, Green P.
        Cochrane Database Syst Rev. 2022 ;2022(2).
        Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:. To examine the effects of folic acid supplementation, at various doses, on malaria susceptibility (risk of infection) and severity among people living in areas with various degrees of malaria endemicity. We will examine the interaction between folic acid supplements and antifolate antimalarial drugs. Specifically, we will aim to answer the following. Among uninfected people living in malaria endemic areas, who are taking or not taking antifolate antimalarials for malaria prophylaxis, does taking a folic acid-containing supplement increase susceptibility to or severity of malaria infection? Among people with malaria infection who are being treated with antifolate antimalarials, does folic acid supplementation increase the risk of treatment failure?. Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

    • Substance Use and Abuse
      1. As of February 18, 2020, the e-cigarette, or vaping, product use associated lung injury (EVALI) outbreak caused the hospitalization of a total of 2,807 patients and claimed 68 lives in the United States. Though investigations have reported a strong association with vitamin E acetate (VEA), evidence from reported EVALI cases is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC or non-THC products. This study characterized chemicals evolved when diluent oils were heated to temperatures that mimic e-cigarette, or vaping, products (EVPs) to investigate production of potentially toxic chemicals that might have caused lung injury. VEA, vitamin E, coconut, and medium chain triglyceride (MCT) oil were each diluted with ethanol and then tested for constituents and impurities using a gas chromatograph mass spectrometer (GC/MS). Undiluted oils were heated at 25°C (control), 150°C, and 250°C in an inert chamber to mimic a range of temperatures indicative of aerosolization from EVPs. Volatilized chemicals were collected using thermal desorption tubes, analyzed using a GC/MS, and identified. Presence of identified chemicals was confirmed using retention time and ion spectra matching with analytic standards. Direct analysis of oils, as received, revealed that VEA and vitamin E were the main constituents of their oils, and coconut and MCT oils were nearly identical having two main constituents: glycerol tricaprylate and 2-(decanoyloxy) propane-1,3-diyl dioctanoate. More chemicals were measured and with greater intensities when diluent oils were heated at 250°C compared to 150°C and 25°C. Vitamin E and coconut/MCT oils produced different chemical emissions. The presence of some identified chemicals is of potential health consequence because many are known respiratory irritants and acute respiratory toxins. Exposure to a mixture of hazardous chemicals may be relevant to the development or exacerbation of EVALI, especially when in concert with physical damage caused by lung deposition of aerosols produced by aerosolizing diluent oils.

      2. A field placement approach to enhance state and local capacity for opioid-related issues affecting pregnant and postpartum people and infants prenatally exposed to opioids and other substancesexternal icon
        Weber MK, Tran EL, Kroelinger CD, Ellison C, Mueller T, Romero L, Ellick KL, Rice ME, Garcia G, Pliska E, Akbarali S, Dronamraju R, Patterson K, Fehrenbach SN, Barfield WD.
        J Womens Health (Larchmt). 2022 Feb;31(2):145-153.
        Opioid use disorder (OUD) poses a significant public health concern impacting maternal and infant outcomes. In 2018, the Centers for Disease Control and Prevention (CDC) partnered with the Association of State and Territorial Health Officials (ASTHO) to develop the Opioid use disorder, Maternal outcomes, and Neonatal abstinence syndrome Initiative Learning Community (OMNI LC) to identify and disseminate best practices and strategies for implementing systems-level changes in state health departments to address OUD affecting pregnant and postpartum persons and infants prenatally exposed to opioids. In 2019, the OMNI LC incorporated a field placement approach that assigned temporary field placement staff in five select OMNI LC states to provide important linkages, facilitate information sharing, and strengthen capacity among state and local health departments and other partners supporting maternal and child health communities affected by the opioid crisis. Using an implementation science framework, the field placement approach was assessed using five implementation outcome measures: appropriateness, acceptability, implementation cost, sustainability, and feasibility. Written responses from the participating OMNI LC states on these implementation outcome measures were analyzed to (1) highlight key strategies used by field placement staff, (2) assess the implementation of the OMNI LC field placement approach within the context of implementation science, and (3) identify implementation barriers. This report describes the implementation of a temporary field placement approach and suggests that this approach could be replicated to enhance state and local capacity to respond to the opioid crisis or other high-consequence events.

      3. Evaluation of statewide restrictions on flavored e-cigarette sales in the US from 2014 to 2020external icon
        Ali FR, Vallone D, Seaman EL, Cordova J, Diaz MC, Tynan MA, Trivers KF, King BA.
        JAMA Netw Open. 2022 Feb 1;5(2):e2147813.
        IMPORTANCE: e-Cigarettes are the most commonly used tobacco product among US youths. Flavors are among the most cited reasons for use of e-cigarettes among youths, and therefore, some states have imposed restrictions on flavored e-cigarette sales. To our knowledge, no study has compared e-cigarette sales between states with statewide flavored e-cigarette restrictions and states without such restrictions while controlling for co-occurring events. OBJECTIVE: To assess whether implementation of statewide restrictions on flavored e-cigarette sales in Massachusetts, New York, Rhode Island, and Washington was associated with a reduction in total e-cigarette unit sales from 2014 to 2020. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study with difference-in-differences analysis used e-cigarette retail sales data from Massachusetts, Rhode Island, and Washington, which implemented restrictions on flavored e-cigarette sales in October 2019; New York, which implemented these restrictions in May 2020; and 35 states without these restrictions (control states). Sales were summed into 4-week periods from August 24, 2014, to December 27, 2020, for a total of 2988 state-period observations. MAIN OUTCOMES AND MEASURES: A difference-in-differences analysis was conducted to compare e-cigarette unit sales in the 4 states with flavor restrictions (before and after implementation) with those in the 35 control states. The model controlled for other population-based policies and emergent events (eg, the COVID-19 pandemic). Data on 4-week e-cigarette unit sales were sorted into 4 flavor categories (tobacco, menthol, mint, and other). Unit sales were standardized to reflect the most common package sizes for each product type. RESULTS: Statewide restrictions on non-tobacco-flavored e-cigarette sales were associated with the following reductions in mean 4-week total e-cigarette sales in intervention states compared with control states from October 2019 to December 2020: 30.65% (95% CI, 24.08%-36.66%) in New York, 31.26% (95% CI, 11.94%-46.34%) in Rhode Island, and 25.01% (95% CI, 18.43%-31.05%) in Washington. In Massachusetts, the comprehensive sales prohibition of all e-cigarette products was associated with a 94.38% (95% CI, 93.37%-95.23%) reduction in 4-week sales compared with control states. Except in Massachusetts, where all sales of flavored e-cigarettes decreased, reductions were found only for non-tobacco-flavored e-cigarette sales in the other states with restrictions. Among control states, mean sales decreased by 28.4% from August 2019 to February 2020 but then increased by 49.9% from February through December 2020. CONCLUSIONS AND RELEVANCE: In this cross-sectional study, statewide restrictions on the sale of flavored e-cigarettes in Massachusetts, New York, Rhode Island, and Washington were associated with a reduction in total e-cigarette sales. These findings suggest that not all e-cigarette users who purchased non-tobacco-flavored e-cigarettes switched to purchasing tobacco-flavored e-cigarettes after policy implementation.

    • Veterinary Medicine
      1. Bluetongue research at a crossroads: Modern genomics tools can pave the way to new insightsexternal icon
        Kopanke J, Carpenter M, Lee J, Reed K, Rodgers C, Burton M, Lovett K, Westrich JA, McNulty E, McDermott E, Barbera C, Cavany S, Rohr JR, Perkins TA, Mathiason CK, Stenglein M, Mayo C.
        Annu Rev Anim Biosci. 2022 Feb 15;10:303-324.
        Bluetongue virus (BTV) is an arthropod-borne, segmented double-stranded RNA virus that can cause severe disease in both wild and domestic ruminants. BTV evolves via several key mechanisms, including the accumulation of mutations over time and the reassortment of genome segments. Additionally, BTV must maintain fitness in two disparate hosts, the insect vector and the ruminant. The specific features of viral adaptation in each host that permit host-switching are poorly characterized. Limited field studies and experimental work have alluded to the presence of these phenomena at work, but our understanding of the factors that drive or constrain BTV's genetic diversification remains incomplete. Current research leveraging novel approaches and whole genome sequencing applications promises to improve our understanding of BTV's evolution, ultimately contributing to the development of better predictive models and management strategies to reduce future impacts of bluetongue epizootics.

    • Zoonotic and Vectorborne Diseases
      1. Seroprevalence of Powassan virus infection in an area experiencing a cluster of disease cases: Sussex County, New Jersey, 2019external icon
        Vahey GM, Wilson N, McDonald E, Fitzpatrick K, Lehman J, Clark S, Lindell K, Pastula DM, Perez S, Rhodes H, Gould CV, Staples JE, Cervantes K, Martin SW.
        Open Forum Infect Dis. 2022 Mar;9(3):ofac023.
        In 2019, a geographically focal cluster of 3 Powassan virus neuroinvasive disease cases occurred in New Jersey. We conducted a serosurvey of 273 adult area residents and estimated that immunoglobulin M seroprevalence was 0.31% (95% confidence interval [CI], .04%-1.00%) and 23% (95% CI, 7%-100%) of infections result in neuroinvasive disease.

      2. Cryptosporidium parvum outbreak associated with raccoons at a Wildlife Facility-Virginia, May-June 2019external icon
        Davis MK, Riley J, Darby B, Murphy J, Turner L, Segarra MD, Roellig DM.
        Zoonoses Public Health. 2022 Feb 14.
        Cryptosporidium parvum is a parasitic zoonotic pathogen responsible for diarrheal illness in humans and animals worldwide. We report an investigation of a cryptosporidiosis outbreak in raccoons and wildlife rehabilitation workers at a Virginia facility. Fifteen (31%) of 49 facility personnel experienced symptoms meeting the case definition, including four laboratory-confirmed cases. Seven juvenile raccoons were reported to have diarrhoea; six had laboratory-confirmed cryptosporidiosis. Cryptosporidium parvum of the same molecular subtype (IIaA16G3R2) was identified in two human cases and six raccoons. Raccoon illness preceded human illness by 11 days, suggesting possible zoonotic transmission from raccoons to humans. This appears to be the first report of a human cryptosporidiosis outbreak associated with exposure to raccoons infected with C. parvum. Raccoons might be an under-recognized reservoir for human C. parvum infections. Further study is needed to explore the prevalence of cryptosporidial species in raccoons and their role as a wildlife reservoir.

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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