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Issue 1, January 3, 2023

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CDC Science Clips: Volume 15, Issue 1, January 3, 2023

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

The report consists of these components:

  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. Prevalence of HIV drug resistance in Nigeria: results from a cross-sectional, population-based survey of Nigerian adults with unsuppressed viral load
        Aliyu GG, Lawton JG, Mitchell AB, Abimiku AG, Jelpe T, Bassey O, Riedel DJ, Swaminathan M, Chang JC, DeVos JR, Patel H, Charurat ME, Stafford KA.
        AIDS. 2023 Feb 1;37(2):333-339.
        BACKGROUND: HIV drug resistance (HIVDR) surveillance is an important tool to monitor threats to progress towards epidemic control. The characterization of HIVDR in Nigeria at the national level is needed to inform both clinical decisions and population-level HIV policy strategies. This study uses data obtained from the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) to describe the prevalence and distribution of HIVDR in Nigeria. METHODS: NAIIS was a cross-sectional, population-based survey of households throughout Nigeria in 2018. NAIIS was designed to provide estimates of HIV prevalence and related health indicators from a nationally representative sample. The study population included participants aged 15-64 years who tested positive for HIV, had a viral load at least 1000 copies/ml, and had available HIV drug resistance genotypes. HIV isolates were genotyped to detect drug resistance mutations. Individual characteristics of study participants associated with HIVDR were identified using a weighted multivariable logistic regression model. RESULTS: Of 1355 respondents with available HIV genotypes, 293 (19%) had evidence of drug-resistant mutations (DRMs) that conferred resistance to at least one antiretroviral drug. The majority of DRMs observed conferred resistance to NNRTIs (17.6%) and NRTIs (11.2%). HIVDR was associated with being ART-experienced, longer duration on ART, and lower CD4+ count but not sociodemographic characteristics. CONCLUSION: The population level DRM prevalence in Nigeria was consistent with what would be expected in a mature HIV treatment landscape. The continued roll out of dolutegravir-anchored regimens should mitigate the impact of NNRTI resistance on population viral load suppression and progress towards epidemic control.

        Jelpe, T. Bassey, O. Swaminathan, M. Chang, J. C. DeVos, J. R. Patel, H.

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

        Gouin, K. A. Hicks, L. A. Lind, J. N. Geller, A. I. Budnitz, D. S. Kabbani, S.

      3. BACKGROUND: The percentage of Neisseria gonorrhoeae (GC) isolates with resistance or elevated minimum inhibitory concentrations (MICs) to antimicrobials has steadily increased. Current estimates are based on the Gonococcal Isolate Surveillance Project (GISP), a sentinel surveillance study of male GC in the United States. This analysis seeks to assess for adjustment prior to treating aggregated GISP estimates as nationally representative of all reported male urogenital infections. METHODS: We used multilevel regression with poststratification (MRP) to compute national estimates of the proportion of antimicrobial resistance (AMR - defined as exceeding MIC thresholds) in male GC using data from 2008-2018 GISP and case reports. Sensitivity analyses investigated the impact of analysis assumptions and unmeasured variables. We additionally produced estimates of 2018 AMR GC cases among US males. RESULTS: National estimates were consistent with unweighted estimates. The estimated proportion of incident AMR GC infections in men with urogenital GC in 2018 was 51.5% (95% CI: 50.1% - 52.9%), equating to an estimated 366,300 incident AMR GC infections in US men aged 15-39 years. Estimates of AMR for tested antimicrobials in male GC infections in 2018 ranged from 0.16% (95% CI: 0.08% - 0.24%) for ceftriaxone to 29.9% (95% CI: 28.6% - 31.1%) for ciprofloxacin. Sensitivity analyses revealed that unmeasured data on sex of sex partners could substantially impact weighted estimates. CONCLUSIONS: AMR among reported incident male urogenital GC infections remains rare for ceftriaxone, the current standard of care. Aggregated GISP data are generally representative of men in the US who are reported with urogenital gonorrhea.

        Nielsen, K. E. St Cyr, S. B. Pham, C. D. Kreisel, K. M.

    • Chronic Diseases and Conditions
      1. Patient reported impact of symptoms in amyotrophic lateral sclerosis (PRISM-ALS): A national, cross-sectional study
        Zizzi C, Seabury J, Rosero S, Alexandrou D, Wagner E, Weinstein JS, Varma A, Dilek N, Heatwole J, Wuu J, Caress J, Bedlack R, Granit V, Statland JM, Mehta P, Benatar M, Heatwole C.
        EClinicalMedicine. 2023 Jan;55:101768.
        BACKGROUND: As novel therapeutic interventions are being developed and tested in the amyotrophic lateral sclerosis (ALS) population, there is a need to better understand the symptoms and issues that have the greatest impact on the lives of individuals with ALS. We aimed to determine the frequency and relative importance of symptoms experienced by adults in a national ALS sample and to identify factors that are associated with the greatest disease burden in this population. METHODS: We conducted 15 qualitative interviews of individuals with varied ALS phenotypes and analyzed 732 quotes regarding the symptomatic disease burden of ALS between August 2018 and March 2019. We subsequently conducted a national, cross-sectional study of 497 participants with ALS and ALS variants through the Centers for Disease Control and Prevention's (CDC) National ALS Registry between July 2019 and December 2019. Participants reported on the prevalence and relative importance of 189 symptomatic questions representing 17 symptomatic themes that were previously identified through qualitative interviews. Analysis was performed to determine how age, sex, education, employment, time since onset of symptoms, location of symptom onset, feeding tube status, breathing status and speech status relate to symptom and symptomatic theme prevalence. FINDINGS: Symptomatic themes with the highest prevalence in our sample were an inability to do activities (93.8%), fatigue (92.6%), problems with hands or fingers (87.7%), limitations with mobility or walking (86.7%), and a decreased performance in social situations (85.7%). Participants identified inability to do activities and limitations with mobility or walking as having the greatest overall effect on their lives. INTERPRETATION: Individuals with ALS experience a variety of symptoms that affect their lives. The prevalence and importance of these symptoms differ among the ALS population. The most prevalent and important symptoms offer potential targets for improvements in future therapeutic interventions. FUNDING: Research funding was provided by ALS Association.

        Mehta, P.

      2. Improving the efficiency of integrated cancer screening delivery across multiple cancers: case studies from Idaho, Rhode Island, and Nebraska
        Tangka FK, Subramanian S, Hoover S, Cariou C, Creighton B, Hobbs L, Marzano A, Marcotte A, Norton DD, Kelly-Flis P, Leypoldt M, Larkins T, Poole M, Boehm J.
        Implement Sci Commun. 2022 Dec 16;3(1):133.
        BACKGROUND: Three current and former awardees of the Centers for Disease Control and Prevention's Colorectal Cancer Control Program launched integrated cancer screening strategies to better coordinate multiple cancer screenings (e.g., breast, cervical, colorectal). By integrating the strategies, efficiencies of administration and provision of screenings can be increased and costs can be reduced. This paper shares findings from these strategies and describes their effects. METHODS: The Idaho Department of Health and Welfare developed a Baseline Assessment Checklist for six health systems to assess the current state of policies regarding cancer screening. We analyzed the checklist and reported the percentage of checklist components completed. In Rhode Island, we collaborated with a nurse-patient navigator, who promoted cancer screening, to collect details on patient navigation activities and program costs. We then described the program and reported total costs and cost per activity. In Nebraska, we described the experience of the state in administering an integrated contracts payment model across colorectal, breast, and cervical cancer screening and reported cost per person screened. Across all awardees, we interviewed key stakeholders. RESULTS: In Idaho, results from the checklist offered guidance on areas for enhancement before integrated cancer screening strategies, but identified challenges, including lack of capacity, limited staff availability, and staff turnover. In Rhode Island, 76.1% of 1023 patient navigation activities were for colorectal cancer screening only, with a much smaller proportion devoted to breast and cervical cancer screening. Although the patient navigator found the discussions around multiple cancer screening efficient, patients were not always willing to discuss all cancer screenings. Nebraska changed its payment system from fee-for-service to fixed cost subawards with its local health departments, which integrated cancer screening funding. Screening uptake improved for breast and cervical cancer but was mixed for colorectal cancer screening. CONCLUSIONS: The results from the case studies show that there are barriers and facilitators to integrating approaches to increasing cancer screening among primary care facilities. However, more research could further elucidate the viability and practicality of integrated cancer screening programs.

        Tangka, F. K. L. Larkins, T. Poole, M. Boehm, J.

      3. SARS-CoV-2 infections among vaccinated patients on maintenance dialysis, January 1-August 31, 2021, United States
        Bardossy AC, Angeles J, Booth S, Fike L, Wadley A, Rha B, Lacson E, Manley HJ, Johnson D, Apata IW, Novosad S.
        Kidney360. 2022 Nov 24;3(11):1934-1938.
        Dialysis facilities voluntarily reported severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in vaccinated dialysis patients detected between January 1, 2021, and August 31, 2021, to the Centers for Disease Control and Prevention.Among 4087 patients reported, most were symptomatic, a third required hospitalization, and 9% died within 30 days of diagnosis.Monitoring SARS-CoV-2 infections and outcomes among vaccinated people on dialysis provides valuable insight into this population.

        Bardossy, A. C. Angeles, J. Booth, S. Fike, L. Wadley, A. Rha, B. Apata, I. W. Novosad, S.

      4. COVID-19 and other underlying causes of cancer deaths - United States, January 2018-July 2022
        Henley SJ, Dowling NF, Ahmad FB, Ellington TD, Wu M, Richardson LC.
        MMWR Morb Mortal Wkly Rep. 2022 Dec 16;71(50):1583-1588.
        Cancer survivors (persons who have received a diagnosis of cancer, from the time of diagnosis throughout their lifespan)* have increased risk for severe COVID-19 illness and mortality (1). This report describes characteristics of deaths reported to CDC's National Vital Statistics System (NVSS), for which cancer was listed as the underlying or a contributing cause (cancer deaths) during January 1, 2018-July 2, 2022. The underlying causes of death, including cancer and COVID-19, were examined by week, age, sex, race and ethnicity, and cancer type. Among an average of approximately 13,000 weekly cancer deaths, the percentage with cancer as the underlying cause was 90% in 2018 and 2019, 88% in 2020, and 87% in 2021. The percentage of cancer deaths with COVID-19 as the underlying cause differed by time (2.0% overall in 2020 and 2.4% in 2021, ranging from 0.2% to 7.2% by week), with higher percentages during peaks in the COVID-19 pandemic. The percentage of cancer deaths with COVID-19 as the underlying cause also differed by the characteristics examined, with higher percentages observed in 2021 among persons aged ≥65 years (2.4% among persons aged 65-74 years, 2.6% among persons aged 75-84 years, and 2.4% among persons aged ≥85 years); males (2.6%); persons categorized as non-Hispanic American Indian or Alaska Native (AI/AN) (3.4%), Hispanic or Latino (Hispanic) (3.2%), or non-Hispanic Black or African American (Black) (2.5%); and persons with hematologic cancers, including leukemia (7.4%), lymphoma (7.3%), and myeloma (5.8%). This report found differences by age, sex, race and ethnicity, and cancer type in the percentage of cancer deaths with COVID-19 as the underlying cause. These results might guide multicomponent COVID-19 prevention interventions and ongoing, cross-cutting efforts to reduce health disparities and address structural and social determinants of health among cancer survivors, which might help protect those at disproportionate and increased risk for death from COVID-19.

        Henley, S. J. Dowling, N. F. Ahmad, F. B. Ellington, T. D. Wu, M. Richardson, L. C.

      5. Population-based prevalence and incidence estimates of mixed connective tissue disease from the Manhattan Lupus Surveillance Program
        Hasan G, Ferucci ED, Buyon JP, Belmont HM, Salmon JE, Askanase A, Bathon JM, Geraldino-Pardilla L, Ali Y, Ginzler EM, Putterman C, Gordon C, Helmick CG, Parton H, Izmirly PM.
        Rheumatology (Oxford). 2022 Dec 20.
        OBJECTIVE: Epidemiologic data for mixed connective tissue disease (MCTD) are limited. Leveraging data from the Manhattan Lupus Surveillance Program (MLSP), a racially/ethnically diverse population-based registry of cases with SLE and related diseases including MCTD, we provide estimates of the prevalence and incidence of MCTD. METHODS: MLSP cases were identified from rheumatologists, hospitals, and population databases using a variety of ICD-9 codes. MCTD was defined as one of the following: 1) fulfillment of our modified Alarcon-Segovia and Kahn criteria which required a positive RNP antibody and the presence of synovitis, myositis, and Raynaud's phenomenon, 2) a diagnosis of MCTD and no other diagnosis of another connective tissue disease (CTD), and 3) a diagnosis of MCTD regardless of another CTD diagnosis. RESULTS: Overall, 258 (7.7%) of cases met a definition of MCTD. Using our modified Alarcon-Segovia and Kahn criteria for MCTD, the age-adjusted prevalence was 1.28 (95%CI 0.72-2.09) per 100 000. Using our definition of a diagnosis of MCTD and no other diagnosis of another CTD yielded an age-adjusted prevalence and incidence of MCTD of 2.98 (95%CI 2.10-4.11) per 100 000 and 0.39 (95%CI 0.22-0.64) per 100 000, respectively. The age-adjusted prevalence and incidence were highest using a diagnosis of MCTD regardless of other CTD diagnoses and were 16.22 (95%CI 14.00-18.43) per 100 000 and 1.90 (95%CI 1.49-2.39) per 100 000 respectively. CONCLUSIONS: The MLSP provided estimates for prevalence and incidence of MCTD in a diverse population. The variation in estimates using different case definitions is reflective of the challenge of defining MCTD in epidemiologic studies.

        Helmick, C. G.

    • Communicable Diseases
      1. Cisgender women with HIV in the United States: how have HIV care continuum outcomes changed over time? 2015-2020
        O'Shea JG, Neblett Fanfair R, Dasgupta S, Tie Y, Yuan X, Beer L, Weiser J.
        AIDS. 2023 Feb 1;37(2):347-353.
        OBJECTIVE: To evaluate HIV care continuum trends over time among women with HIV (WWH). DESIGN: The Medical Monitoring Project (MMP) is a complex sample survey of adults with diagnosed HIV in the United States. METHODS: We used 2015-2019 MMP data collected from 5139 adults with diagnosed HIV infection who identified as cisgender women. We calculated weighted percentages with 95% confidence intervals (CIs) for all characteristics and estimated annual percentage change (EAPC) and the associated 95% CI to assess trends. EAPCs were considered meaningful from a public health perspective if at least 1% with P values less than 0.05. RESULTS: Among cisgender women with diagnosed HIV infection during 2015-2019, 58.8% were Black or African American (95% CI 54.4-63.3), 19% were Hispanic/Latina (95% CI 14.7-23.2), and 16% were Non-Hispanic White (95% CI 14.1-17.9) persons. There was a meaningful increase in the percentage who ever had stage 3 HIV disease from 55.8% (95% CI 51.0-60.5) in 2015 to 61.5% (95% CI 58.1-64.8) in 2019 (EAPC 1.7%; CI 1.5-1.9; P < 0.001). There were no meaningful changes over time among women, overall, in retention in care, antiretroviral therapy (ART) prescription, ART adherence, missed appointments, or recent or sustained viral suppression. CONCLUSION: The HIV care continuum outcomes among WWH did not meaningfully improve from 2015 to 2019, raising a concern that Ending the HIV Epidemic in the US (EHE) initiative goals will not be met. To improve health and reduce transmission of HIV among WWH, multifaceted interventions to retain women in care, increase ART adherence, and address social determinants of health are urgently needed.

        O'Shea, J. G. Neblett Fanfair, R. Dasgupta, S. Tie, Y. Beer, L. Weiser, J.

      2. Assessing the individual benefits of reducing HIV diagnosis delay and increasing adherence to HIV care and treatment
        Uzun Jacobson E, Li Z, Bingham A, Farnham PG, Sansom SL.
        AIDS Care. 2022 Dec 16:1-7.
        We used an agent-based simulation model (Progression and Transmission of HIV) to follow for 20 years a cohort of persons in the United States infected with HIV in 2015. We assessed the benefits of reducing the delay between HIV infection and diagnosis and increasing adherence to HIV care and treatment on the percent of persons surviving 20 years after infection, average annual HIV transmission rates, and time spent virally suppressed. We examined average diagnosis delays of 1.0-7.0 years, monthly care drop-out rates of 5% to 0.1%, and combinations of these strategies. The percent of the cohort surviving the first 20 years of infection varied from 70.8% to 77.5%, and the annual transmission risk, from 1.5 to 5.2 HIV transmissions per 100 person-years. Thus, individuals can enhance their survival and reduce their risk of transmission to partners by frequent testing for HIV and adhering to care and treatment.

        Uzun Jacobson, E. Li, Z. Bingham, A. Farnham, P. G. Sansom, S. L.

      3. Achieving the UNAIDS 90-90-90 targets: a comparative analysis of four large community randomised trials delivering universal testing and treatment to reduce HIV transmission in sub-Saharan Africa
        Sabapathy K, Balzer L, Larmarange J, Block L, Floyd S, Iwuji C, Wirth K, Ayles H, Fidler S, Kamya M, Petersen M, Havlir D, Dabis F, Moore J, Hayes R.
        BMC Public Health. 2022 Dec 13;22(1):2333.
        BACKGROUND: Four large community-randomized trials examining universal testing and treatment (UTT) to reduce HIV transmission were conducted between 2012-2018 in Botswana, Kenya, Uganda, Zambia and South Africa. In 2014, the UNAIDS 90-90-90 targets were adopted as a useful metric to monitor coverage. We systematically review the approaches used by the trials to measure intervention delivery, and estimate coverage against the 90-90-90 targets. We aim to provide in-depth understanding of the background contexts and complexities that affect estimation of population-level coverage related to the 90-90-90 targets. METHODS: Estimates were based predominantly on "process" data obtained during delivery of the interventions which included a combination of home-based and community-based services. Cascade coverage data included routine electronic health records, self-reported data, survey data, and active ascertainment of HIV viral load measurements in the field. RESULTS: The estimated total adult populations of trial intervention communities included in this study ranged from 4,290 (TasP) to 142,250 (Zambian PopART Arm-B). The estimated total numbers of PLHIV ranged from 1,283 (TasP) to 20,541 (Zambian PopART Arm-B). By the end of intervention delivery, the first-90 target (knowledge of HIV status among all PLHIV) was met by all the trials (89.2%-94.0%). Three of the four trials also achieved the second- and third-90 targets, and viral suppression in BCPP and SEARCH exceeded the UNAIDS target of 73%, while viral suppression in the Zambian PopART Arm-A and B communities was within a small margin (~ 3%) of the target. CONCLUSIONS: All four UTT trials aimed to implement wide-scale testing and treatment for HIV prevention at population level and showed substantial increases in testing and treatment for HIV in the intervention communities. This study has not uncovered any one estimation approach which is superior, rather that several approaches are available and researchers or policy makers seeking to measure coverage should reflect on background contexts and complexities that affect estimation of population-level coverage in their specific settings. All four trials surpassed UNAIDS targets for universal testing in their intervention communities ahead of the 2020 milestone. All but one of the trials also achieved the 90-90 targets for treatment and viral suppression. UTT is a realistic option to achieve 95-95-95 by 2030 and fast-track the end of the HIV epidemic.

        Block, L. Moore, J.

      4. Influence of COVID-19 for delaying the diagnosis and treatment of pulmonary tuberculosis-Tianjin, China
        Zhang G, Yu Y, Zhang W, Shang J, Chen S, Pang X, Oeltmann JE, Moonan PK, Chen M, Zhang F.
        Front Public Health. 2022 ;10:937844.
        BACKGROUND: The COVID-19 pandemic has disrupted the diagnosis, treatment, and care for tuberculosis (TB). Delays in seeking TB care may result in increased community transmission and unfavorable treatment outcomes. We sought to understand the influence of the COVID-19 pandemic on the proportion of patients with TB who delayed seeking the diagnosis and care for TB and explore the reasons for their postponement. METHODS: We surveyed a representative sample of outpatients treated for pulmonary TB from June to November 2020 using an anonymous standardized questionnaire. Multivariable logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CIs) of factors associated with the postponement of TB care. We used routinely collected surveillance data to assess trends of TB reports before and after the emergence of COVID-19 (2017-2019 vs. 2020-2022) in Tianjin, China. RESULTS: Among 358 participants who were diagnosed with pulmonary TB during the COVID-19 response, 61 (17%) postponed seeking TB diagnosis due to COVID-19, with 39 (64%) citing fear as the primary reason. Female sex (aOR:2.0; 95% CI: 1.1-3.7), previous antituberculosis treatment (aOR:3.2; 95%CI: 1.4-7.6), and TB diagnosis during the first-level response (aOR = 3.2, 1.7-6.2) were associated with the postponement. Among all 518 participants receiving antituberculosis treatment, 57 (11%) had postponed their regular healthcare visits due to COVID-19, 175 (34%) received no treatment supervision, and 32 (6%) experienced treatment interruption. Compared to 2017-2019, reported pulmonary TB declined by 36.8% during the first-level response to COVID-19, 23.5% during the second-level response, 14% during the third-level response in 2020, and 4.3% in 2021. CONCLUSION: The COVID-19 response reduced the number of people who sought and received diagnosis, treatment, and care for TB in Tianjin, China. Integrative programs to ensure access and continuity of TB services should be considered and dual testing for SARS-CoV-2 and M. tuberculosis may facilitate finding cases.

        Oeltmann, J. E. Moonan, P. K.

      5. Association between thromboembolic events and COVID-19 infection within 30 days: a case-control study among a large sample of adult hospitalized patients in the United States, March 2020-June 2021
        Huang YA, Yusuf H, Adamski A, Hsu J, Baggs J, Auf R, Adjei S, Stoney R, Hooper WC, Llata E, Koumans EH, Ko JY, Romano S, Boehmer TK, Harris AM.
        J Thromb Thrombolysis. 2022 Dec 14:1-6.
        The association between thromboembolic events (TE) and COVID-19 infection is not completely understood at the population level in the United States. We examined their association using a large US healthcare database. We analyzed data from the Premier Healthcare Database Special COVID-19 Release and conducted a case-control study. The study population consisted of men and non-pregnant women aged ≥ 18 years with (cases) or without (controls) an inpatient ICD-10-CM diagnosis of TE between 3/1/2020 and 6/30/2021. Using multivariable logistic regression, we assessed the association between TE occurrence and COVID-19 diagnosis, adjusting for demographic factors and comorbidities. Among 227,343 cases, 15.2% had a concurrent or prior COVID-19 diagnosis within 30 days of their index TE. Multivariable regression analysis showed a statistically significant association between a COVID-19 diagnosis and TE among cases when compared to controls (adjusted odds ratio [aOR] 1.75, 95% CI 1.72-1.78). The association was more substantial if a COVID-19 diagnosis occurred 1-30 days prior to index hospitalization (aOR 3.00, 95% CI 2.88-3.13) compared to the same encounter as the index hospitalization. Our findings suggest an increased risk of TE among persons within 30 days of being diagnosed COVID-19, highlighting the need for careful consideration of the thrombotic risk among COVID-19 patients, particularly during the first month following diagnosis.

        Huang, Y. A. Yusuf, H. Adamski, A. Hsu, J. Baggs, J. Auf, R. Adjei, S. Stoney, R. Hooper, W. C. Llata, E. Koumans, E. H. Ko, J. Y. Romano, S. Boehmer, T. K. Harris, A. M.

      6. Clinical characteristics and outcomes of patients hospitalized with COVID-19 during the first 4 waves in Zambia
        Minchella PA, Chanda D, Hines JZ, Fwoloshi S, Itoh M, Kampamba D, Chirwa R, Sivile S, Zyambo KD, Agolory S, Mulenga LB.
        JAMA Netw Open. 2022 Dec 1;5(12):e2246152.
        IMPORTANCE: Few epidemiologic studies related to COVID-19 have emerged from countries in Africa, where demographic characteristics, epidemiology, and health system capacity differ from other parts of the world. OBJECTIVES: To describe the characteristics and outcomes of patients admitted to COVID-19 treatment centers, assess risk factors for in-hospital death, and explore how treatment center admissions were affected by COVID-19 waves in Zambia. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study assessed patients admitted to COVID-19 treatment centers in 5 Zambian cities between March 1, 2020, and February 28, 2022. EXPOSURES: Risk factors for in-hospital mortality, including patient age and severity of COVID-19, at treatment center admission. MAIN OUTCOMES AND MEASURES: Patient information was collected, including inpatient disposition (discharged or died). Differences across and within COVID-19 waves were assessed. Mixed-effects logistic regression models were used to assess associations between risk factors and in-hospital mortality as well as between characteristics of admitted patients and timing of admission. RESULTS: A total of 3876 patients were admitted during 4 COVID-19 waves (mean [SD] age, 50.6 [19.5] years; 2103 male [54.3%]). Compared with the first 3 waves (pooled), the proportion of patients who were 60 years or older admitted during wave 4, when the Omicron variant was circulating, was significantly lower (250 of 1009 [24.8%] vs 1116 of 2837 [39.3%]; P < .001). Factors associated with in-hospital mortality included older age (≥60 vs <30 years; adjusted odds ratio [aOR], 3.55; 95% CI, 2.34-5.52) and HIV infection (aOR, 1.39; 95% CI, 1.07-1.79). Within waves, patients who were admitted during weeks 5 to 9 had significantly higher odds of being 60 years or older (aOR, 2.09; 95% CI, 1.79-2.45) or having severe COVID-19 at admission (aOR, 2.49; 95% CI, 2.14-2.90) than those admitted during the first 4 weeks. CONCLUSIONS AND RELEVANCE: The characteristics of admitted patients during the Omicron wave and risk factors for in-hospital mortality in Zambia reflect data reported elsewhere. Within-wave analyses revealed a pattern in which it appeared that admission of higher-risk patients was prioritized during periods when there were surges in demand for health services during COVID-19 waves. These findings support the need to expand health system capacity and improve health system resiliency in Zambia and other countries with resource-limited health systems.

        Minchella, P. A. Hines, J. Z. Itoh, M. Agolory, S.

      7. Expanding on previous work, we present an HIV Prevention Cycle of Care model to facilitate understanding of the complexity of issues involved in pre-exposure prophylaxis implementation for gay, bisexual, and other men who have sex with men (MSM) in the USA, including individual, client-provider, and overarching issues such as health equity, stigma, and prevention nomenclature. The HIV prevention cycle of care applies to MSM who test negative for HIV. The Prevention Cycle of Care model includes seven steps: prevention knowledge, prevention self-awareness and preferences, prevention motivation, health-care access and cost, provider issues, adherence and persistence, and periodic reassessment and adjustment. HIV prevention is complex in an era of emerging multiple modalities, and more research is needed to successfully implement pre-exposure prophylaxis options over time and across diverse communities of MSM who are sexually active.

        Mansergh, G. Kota, K. K. Daskalakis, D.

      8. Prevalence of SARS-CoV-2 and influenza coinfection and clinical characteristics among children and adolescents aged <18 years who were hospitalized or died with influenza - United States, 2021-22 influenza season
        Adams K, Tastad KJ, Huang S, Ujamaa D, Kniss K, Cummings C, Reingold A, Roland J, Austin E, Kawasaki B, Meek J, Yousey-Hindes K, Anderson EJ, Openo KP, Reeg L, Leegwater L, McMahon M, Bye E, Poblete M, Landis Z, Spina NL, Engesser K, Bennett NM, Gaitan MA, Shiltz E, Moran N, Sutton M, Abdullah N, Schaffner W, Talbot HK, Olsen K, Staten H, Taylor CA, Havers FP, Reed C, Budd A, Garg S, O'Halloran A, Brammer L.
        MMWR Morb Mortal Wkly Rep. 2022 Dec 16;71(50):1589-1596.
        The 2022-23 influenza season shows an early rise in pediatric influenza-associated hospitalizations (1). SARS-CoV-2 viruses also continue to circulate (2). The current influenza season is the first with substantial co-circulation of influenza viruses and SARS-CoV-2 (3). Although both seasonal influenza viruses and SARS-CoV-2 can contribute to substantial pediatric morbidity (3-5), whether coinfection increases disease severity compared with that associated with infection with one virus alone is unknown. This report describes characteristics and prevalence of laboratory-confirmed influenza virus and SARS-CoV-2 coinfections among patients aged <18 years who had been hospitalized or died with influenza as reported to three CDC surveillance platforms during the 2021-22 influenza season. Data from two Respiratory Virus Hospitalizations Surveillance Network (RESP-NET) platforms (October 1, 2021-April 30, 2022),(§) and notifiable pediatric deaths associated(¶) with influenza virus and SARS-CoV-2 coinfection (October 3, 2021-October 1, 2022)** were analyzed. SARS-CoV-2 coinfections occurred in 6% (32 of 575) of pediatric influenza-associated hospitalizations and in 16% (seven of 44) of pediatric influenza-associated deaths. Compared with patients without coinfection, a higher proportion of those hospitalized with coinfection received invasive mechanical ventilation (4% versus 13%; p = 0.03) and bilevel positive airway pressure or continuous positive airway pressure (BiPAP/CPAP) (6% versus 16%; p = 0.05). Among seven coinfected patients who died, none had completed influenza vaccination, and only one received influenza antivirals.(††) To help prevent severe outcomes, clinicians should follow recommended respiratory virus testing algorithms to guide treatment decisions and consider early antiviral treatment initiation for pediatric patients with suspected or confirmed influenza, including those with SARS-CoV-2 coinfection who are hospitalized or at increased risk for severe illness. The public and parents should adopt prevention strategies including considering wearing well-fitted, high-quality masks when respiratory virus circulation is high and staying up-to-date with recommended influenza and COVID-19 vaccinations for persons aged ≥6 months.

        Adams, K. Tastad, K. J. Huang, S. Ujamaa, D. Kniss, K. Cummings, C. Taylor, C. A. Havers, F. P. Reed, C. Budd, A. Garg, S. O'Halloran, A. Brammer, L.

      9. Factors associated with receiving longer than recommended therapy among culture-negative pulmonary tuberculosis patients
        Tsang CA, Patel NN, Stout JE, Fernando R, Pratt R, Goswami ND.
        Open Forum Infect Dis. 2022 Dec;9(12):ofac630.
        BACKGROUND: US tuberculosis (TB) guidelines recommend treatment ≥6 months with a regimen composed of multiple effective anti-TB drugs. Since 2003, a 4-month regimen for a specific subset of TB patients has also been recommended. METHODS: We used 2011-2018 US National Tuberculosis Surveillance System data to characterize factors associated with 4-month (111-140 days) therapy among adult patients who had completed treatment and were potentially eligible at that time for 4-month therapy (culture-negative pulmonary-only TB, absence of certain risk factors, and initial treatment that included pyrazinamide). We used modified Poisson regression with backward elimination of main effect variables to calculate adjusted relative risks (aRRs). RESULTS: During 2011-2018, 63 393 adults completed TB treatment: 5560 (8.8%) were potentially eligible for 4-month therapy; of these, 5560 patients (79%) received >4-month therapy (median, 193 days or ∼6 months). Patients with cavitary disease were more likely to receive >4-month therapy (aRR, 1.10; 95% CI, 1.07-1.14) vs patients without cavitary disease. Patients more likely to receive 4-month therapy included patients treated by health departments vs private providers only (aRR, 0.94; 95% CI, 0.91-0.98), those in the South and West vs the Midwest, non-US-born persons (aRR, 0.95; 95% CI, 0.91-0.99) vs US-born persons, and aged 25-64 years vs 15-24 years. CONCLUSIONS: Most patients potentially eligible for 4-month therapy were treated with standard 6-month courses. Beyond clinical eligibility criteria, other patient- and program-related factors might be more critical determinants of treatment duration.

        Tsang, C. A. Patel, N. N. Fernando, R. Pratt, R. Goswami, N. D.


    • Community Health Services
      1. Community health workers to increase cancer screening: 3 Community Guide systematic reviews
        Okasako-Schmucker DL, Peng Y, Cobb J, Buchanan LR, Xiong KZ, Mercer SL, Sabatino SA, Melillo S, Remington PL, Kumanyika SK, Glenn B, Breslau ES, Escoffery C, Fernandez ME, Coronado GD, Glanz K, Mullen PD, Vernon SW.
        Am J Prev Med. 2022 Dec 19.
        INTRODUCTION: Many in the U.S. are not up to date with cancer screening. This systematic review examined the effectiveness of interventions engaging community health workers to increase breast, cervical, and colorectal cancer screening. METHODS: Authors identified relevant publications from previous Community Guide systematic reviews of interventions to increase cancer screening (1966 through 2013) and from an update search (January 2014-November 2021). Studies written in English and published in peer-reviewed journals were included if they assessed interventions implemented in high-income countries; reported screening for breast, cervical, or colorectal cancer; and engaged community health workers to implement part or all of the interventions. Community health workers needed to come from or have close knowledge of the intervention community. RESULTS: The review included 76 studies. Interventions engaging community health workers increased screening use for breast (median increase=11.5 percentage points, interquartile interval=5.5‒23.5), cervical (median increase=12.8 percentage points, interquartile interval=6.4‒21.0), and colorectal cancers (median increase=10.5 percentage points, interquartile interval=4.5‒17.5). Interventions were effective whether community health workers worked alone or as part of a team. Interventions increased cancer screening independent of race or ethnicity, income, or insurance status. DISCUSSION: Interventions engaging community health workers are recommended by the Community Preventive Services Task Force to increase cancer screening. These interventions are typically implemented in communities where people are underserved to improve health and can enhance health equity. Further training and financial support for community health workers should be considered to increase cancer screening uptake.

        Okasako-Schmucker, D. L. Peng, Y. Cobb, J. Xiong, K. Z. Mercer, S. L. Sabatino, S. A. Melillo, S.

      2. OBJECTIVE: To compare the sociodemographic, clinical, and hospital related factors associated with discharge of acute ischemic stroke (AIS) survivors to inpatient rehabilitation (IRF) and skilled nursing facility (SNF) rehabilitation services. DESIGN: Retrospective descriptive study from the Paul Coverdell National Acute Stroke Program (PCNASP) participating hospitals during 2016 to 2019. SETTING: 9 Participating hospitals from PCNASP in United States PARTICIPANTS: 130,988 patients with AIS from 569 hospitals. INTERVENTIONS: Not applicable MAIN OUTCOME MEASURE: Discharge to IRF and SNF RESULTS: Patients discharged to a SNF had longer length of hospital stay, more comorbidities, and higher modified Rankin scores compared to patients discharged to an IRF. Nine characteristics were associated with being less likely to be discharged to an IRF than an SNF: older age (85+ years old, adjusted odds ratio [AOR]=0.20 [confidence interval [CI]=0.18- 0.21]), identifying as non-Hispanic Black (AOR=0.85 [CI=0.81-0.89]), identifying as Hispanic (AOR=0.80 [CI=0.74-0.87]), having Medicaid/Medicare (AOR=0.73 [CI=0.70-0.77]), being able to ambulate with assistance from another person (AOR=0.93 [CI=0.89-0.97]), being unable to ambulate (AOR =0.73 [CI=0.62-0.87]) and having comorbidities, prior stroke (AOR=0.69 [CI=0.66-0.73]), diabetes (AOR=0.85 [CI=0.82-0.88]), and myocardial infraction/coronary artery disease (AOR=0.94 [CI=0.90-0.97]). Four characteristics were associated with being more likely to be discharged to an IRF than an SNF: being a man (AOR=1.20 [CI=1.16-1.24]), and having a slight disability (Rankin Score 2) (AOR=1.41 [CI=1.29-1.54]), being at larger hospitals (200-399 beds: AOR=1.31 [CI=1.23-1.40]; 400+ beds: AOR=1.29 [CI=1.20-1.38]), and being at a hospital with stroke unit (AOR=1.12 [CI=1.07-1.17]). CONCLUSION: This study found differences in demographic, clinical, and hospital characteristics of AIS patients discharged for rehabilitation to an IRF versus SNF. The characteristics of patients receiving rehabilitation services may be helpful for researchers and hospitals making policies related to stroke discharge and practices that optimize patient outcomes. Populations experiencing inequities in access to rehabilitation services should be identified, and those who qualify for rehabilitation in IRF should receive this care in preference to rehabilitation in SNF.

        Odom, E. C. Tong, X. Yin, X. King, S. M. C.

      3. Feasibility assessment of a school nurse-led approach using chronic absenteeism to establish the school-based active surveillance process
        Maughan ED, Thompson ME, Walsh CA, Issa A, Lin JS.
        J Sch Nurs. 2022 Dec 20:10598405221144259.
        This article shares what was learned from the feasibility assessment of a nurse-led school-based active surveillance (SBAS) pilot to track chronic absenteeism using myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) as an exemplar. This pilot encompassed a 3-year period with training and feedback from school nurses (SNs) on data collection and ME/CFS. SNs found that the SBAS process helped them effectively identifying undiagnosed conditions. The assessment revealed the importance of focusing outreach efforts and establishing relationships with the school leadership in developing health policies and programs in the school setting. The pilot data were used to develop a manual to guide SNs for the SBAS process. This can be viewed as a model for SNs in establishing a surveillance to identify and track conditions like ME/CFS. With overlapping symptoms of Long COVID to ME/CFS, this assessment may provide insights for additional efforts to understand the impact of Long COVID on students' education.

        Issa, A. Lin, J. S.

      4. Assisted partner services (APS) is a longstanding public health strategy to reduce transmission of STI and HIV in the U.S. However, with rapidly increasing rates of STI, innovations to APS are needed to allow health departments to conserve limited public health resources while improving the effectiveness of APS. Disease Intervention Specialists (DIS), public health staff who conduct APS, have a wealth of experience in identifying, locating, and interviewing index patients and their sexual partners, but are currently limited in the services that they are able to provide in the field. While several state and local health departments are working to expand the role of DIS to incorporate less traditional APS activities, such programs are uncommon. We discuss several services that DIS could conceivably provide in the field, such as STI testing, treatment, and vaccination, and identify critical issues to be addressed in order to implement these changes in DIS activities on a larger scale. Broadening the scope of DIS activities may result in multiple benefits to health departments, including more effectively delivering STI testing and treatment to hard to reach populations, imparting more responsibility to DIS, thereby potentially increasing job satisfaction, and building a workforce that is better prepared for public health crises. Effective approaches to address variable state level regulations governing DIS scope of practice are needed.

        Bachmann, L. H.

    • Disease Reservoirs and Vectors
      1. Ideational factors and their association with insecticide treated net use in Magoe District, Mozambique
        Yukich JO, Hutchinson P, Candrinho B, Butts J, Murimirgua F, Eisele TP, Zulliger R.
        Malar J. 2022 Dec 17;21(1):387.
        BACKGROUND: Insecticide treated bed nets (ITN) are considered a core malaria vector control tool by the WHO and are the main contributor to the large decline in malaria burden in sub-Saharan Africa over the past 20 years, but they are less effective if they are not broadly and regularly used. ITN use may depend on factors including temperature, relative humidity, mosquito density, seasonality, as well as ideational or psychosocial factors including perceptions of nets and perceptions of net use behaviours. METHODS: A cross-sectional household survey was conducted as part of a planned randomized controlled trial in Magoe District, Mozambique. Interviewers captured data on general malaria and ITN perceptions including ideational factors related to perceived ITN response efficacy, self-efficacy to use an ITN, and community norms around ITN using a standardized questionnaire. Only households with sufficient ITNs present for all children to sleep under (at least one ITN for every two children under the age of five years) were eligible for inclusion in the study. Additional questions were added about seasonality and frequency of ITN use. RESULTS: One-thousand six hundred sixteen mother-child dyads were interviewed. Responses indicated gaps in use of existing nets and net use was largely independent of ideational factors related to ITNs. Self-reported ITN use varied little by season nor meaningfully when different methods were used to solicit responses on net use behaviour. Mothers' perceived response efficacy of ITNS was negatively associated with net use (high perceived response efficacy reduced the log-odds of net use by 0.27 (95% CI - 0.04 to - 0.51), implying that stronger beliefs in the effectiveness of ITNs might result in reduced net use among their children. CONCLUSIONS: In this context, ITN use among children was not clearly related to mothers' ideational factors measured in the study. Scales used in solicitation of ideation around ITN use and beliefs need careful design and testing across a broader range of populations in order to identify ideational factors related to ITN use among those with access.

        Butts, J. Zulliger, R.

    • Environmental Health
      1. Electrochemical fluorination manufacture of perfluorooctane sulfonic acid (PFOS), one of the most studied per- and polyfluoroalkyl substances, produces mixtures of linear and branched isomers, but little is known about human exposure to linear or branched PFOS isomers. We examined determinants affecting isomer-specific patterns of PFOS in serum in two adult populations in the United States, the National Health and Nutrition Examination Survey (NHANES) and the Study of Women's Health Across the Nation Multi-Pollutant Study (SWAN-MPS). After adjusting for demographic variables, fish consumption (in both populations), a glomerular filtration rate above 90 mL/min/1.73 m(2) (observed in NHANES; not tested in SWAN-MPS), premenopausal status (only observed in SWAN-MPS), and less consumption of processed food (observed in SWAN-MPS; not tested in NHANES) were associated with a higher proportion of linear PFOS. Non-Hispanic Black and Asian participants were likely to have a higher proportion of linear PFOS than non-Hispanic White participants in both populations. Our findings suggest that isomer-specific patterns of PFOS serum concentrations in humans vary depending on population characteristics that affect PFOS exposure and excretion. Consideration of specific PFOS isomers in future human biomonitoring and epidemiologic studies can provide useful insight to better understand PFOS exposure.

        Calafat, A. M.

      2. Associations of maternal gestational urinary environmental phenols concentrations with bone mineral density among 12-year-old children in the HOME Study
        Kuiper JR, Pan S, Lanphear BP, Calafat AM, Chen A, Cecil KM, Xu Y, Yolton K, Kalkwarf HJ, Braun JM, Buckley JP.
        Int J Hyg Environ Health. 2022 Dec 14;248:114104.
        BACKGROUND: Early life environmental exposures may affect bone mass accrual in childhood, but only one study has assessed the role of environmental phenols on child bone health. METHODS: We used data from 223 mother-child dyads enrolled in the Health Outcomes and Measures of the Environment (HOME) Study (Cincinnati, OH; 2003-2006). We quantified benzophenone-3, bisphenol A (BPA), 2,5-dichlorophenol, and triclosan in maternal urine collected at 16- and 26-weeks gestation and calculated the average of creatinine-adjusted concentrations. We performed dual x-ray absorptiometry at age 12 years and calculated Z-scores for whole body (less head), total hip, femoral neck, and 1/3rd distal radius bone mineral content (BMC) and areal bone mineral density (aBMD) as well as ultra-distal radius aBMD and spine BMC and bone mineral apparent density (BMAD). We estimated covariate-adjusted associations per doubling of maternal urinary environmental phenol concentrations in linear regression models. We also examined effect measure modification by child's sex and estimated associations of the environmental phenol mixture with BMC and aBMD using quantile g-computation. RESULTS: We observed generally null associations for all analytes and bone measures. Yet, in adjusted models, higher urinary 2,5-dichlorophenol concentrations were associated with higher 1/3rd distal radius BMC (β: 0.09; 95% CI: 0.02, 0.17) and aBMD (β: 0.09; 95% CI: 0.02, 0.17) Z-scores in the overall sample. In sex-stratified analyses, the magnitude of the BMC association was positive for females (β: 0.16; 95% CI: 0.06, 0.26) and null for males (β: 0.02; 95% CI: 0.08, 0.13). The environmental phenol mixture was associated with greater 1/3rd distal radius BMC and aBMD Z-scores in both sexes, which was mostly driven by benzophenone-3 in males and 2,5-dichlorophenol in females. CONCLUSION: In this prospective cohort study, we observed generally null associations for environmental phenols with BMC and aBMD at age 12 years. While there was a positive association of 2,5-dichlorophenol concentrations during fetal development with distal radius BMC and aBMD at age 12 years, future studies utilizing methods capable of differentiating cortical and trabecular bone are needed to elucidate potential mechanisms and implications for bone strength and microarchitecture.

        Calafat, A. M.

    • Epidemiology and Surveillance
      1. Scale-up of HIV index testing in an urban population: experiences and achievements from Nairobi County, Kenya
        Joel JN, Awuor P, Blanco N, Lavoie MC, Lascko T, Ngunu C, Mwangi J, Mutisya I, Ng'eno C, Wangusi R, Koech E.
        Trop Med Int Health. 2022 Dec 20.
        OBJECTIVE: To describe the implementation strategies of the index testing program across Nairobi County in Kenya, assess outcomes along the HIV index testing cascade (acceptance, elicitation ratio, HIV positivity, and linkage to treatment), and assess annual changes along the HIV index testing cascade during the first two years of implementation. METHODS: Retrospective analysis of programmatic aggregate data collected from October 2017 to September 2019 after the roll-out of index testing services in 48 health facilities in Nairobi County. Proportions and ratios were calculated for acceptance, elicitation ratio, testing uptake, and HIV positivity. We compared these outcomes between years using a chi-squared test, Fisher's exact test, or Wilcoxon sign test, and we assessed trends using the Mann-Kendall test. RESULTS: Testing among eligible partners increased from 42.4% (1,471/3,470) to 74.9% (6,114/8,159) in the general population, and the positivity yield remained high across both years (25.2% in year 1 and 24.1% in year 2). Index testing positivity yield remained significantly higher than other testing modalities (24.3% versus 1.3%, p<0.001). The contribution of index testing services to the total number of HIV-positive individuals identified increased from 7.5% in the first year to 28.6% in the second year (p<0.001). More men were tested, but the positivity yield was higher among women (30.0%) and those aged 50 years or older (32.4%). Testing eligible partners in key populations decreased from 52.4% (183/349) to 40.7% (109/268) (p=0.674); however, the HIV positivity yield increased from 8.6% to 23.9% (p<0.001) by the second year of implementation. The HIV positivity yield from index testing remained higher than other testing modalities (14% vs. 0.9%, p<0.001) for key populations. CONCLUSION: Index testing was well-accepted and effective in identifying individuals living with HIV in a Kenyan urban setting across both general populations and key populations. Ongoing adaptations to the strategies deployed as part of index testing services helped improve most of the outcomes along the index testing cascade. This article is protected by copyright. All rights reserved.

        Mwangi, J. Mutisya, I.

    • Food Safety
      1. Typhoid fever in the Eastern Mediterranean Region: A systematic review, 1990-2021
        Appiah GD, Le P, Prentice-Mott G, Bias M, Pratt C, Matar GM, Pindyck T, Fayad AA, Kim S, Mintz ED.
        Am J Trop Med Hyg. 2022 Dec 19.
        The occurrence and antimicrobial resistance (AMR) of typhoid fever in the WHO Eastern Mediterranean Region (EMR) are poorly characterized. Robust surveillance data are needed to inform strategies for typhoid control and prevention in the region. We conducted a systematic review of typhoid fever occurrence, complications, and AMR patterns in EMR countries. We identified 70 studies published from 1990 to 2021, including a total of 44,541 cases with blood culture confirmed typhoid fever in 12 EMR countries, with 48 (69%) studies and 42,008 cases from Pakistan. Among 56 studies with AMR data, fluroquinolone (68% of 13,013 tested isolates), and multidrug resistance (40% of 15,765 tested isolates) were common. Forty (57%) of the 56 studies were from Pakistan, and all reports of extensively drug resistant Salmonella Typhi (48% of 9,578 tested isolates) were from studies in Pakistan. Our findings support the need for continued efforts to strengthen surveillance and laboratory capacity for blood-culture detection of typhoid fever in the region, including data from an ongoing collaboration among CDC, the American University of Beirut, and the WHO EMR office.

        Appiah, G. D. Le, P. Prentice-Mott, G. Bias, M. Pratt, C. Pindyck, T. Kim, S. Mintz, E. D.

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

        Wikswo, M. E. Roberts, V. Marsh, Z. Manikonda, K. Gleason, B. Kambhampati, A. Mattison, C. Calderwood, L. Balachandran, N. Cardemil, C. Hall, A. J.

    • Genetics and Genomics
      1. Multiple introductions and recombination events underlie the emergence of a hyper-transmissible Cryptosporidium hominis subtype in the USA
        Huang W, Guo Y, Lysen C, Wang Y, Tang K, Seabolt MH, Yang F, Cebelinski E, Gonzalez-Moreno O, Hou T, Chen C, Chen M, Wan M, Li N, Hlavsa MC, Roellig DM, Feng Y, Xiao L.
        Cell Host Microbe. 2022 Dec 8.
        The parasite Cryptosporidium hominis is a leading cause of the diarrheal disease cryptosporidiosis, whose incidence in the United States has increased since 2005. Here, we show that the newly emerged and hyper-transmissible subtype IfA12G1R5 is now dominant in the United States. In a comparative analysis of 127 newly sequenced and 95 published C. hominis genomes, IfA12G1R5 isolates from the United States place into three of the 14 clusters (Pop6, Pop13, and Pop14), indicating that this subtype has multiple ancestral origins. Pop6 (IfA12G1R5a) has an East Africa origin and has recombined with autochthonous subtypes after its arrival. Pop13 (IfA12G1R5b) is imported from Europe, where it has recombined with the prevalent local subtype, whereas Pop14 (IfA12G1R5c) is a progeny of secondary recombination between Pop6 and Pop13. Selective sweeps in invasion-associated genes have accompanied the emergence of the dominant Pop14. These observations offer insights into the emergence and evolution of hyper-transmissible pathogens.

        Lysen, C. Wang, Y. Tang, K. Seabolt, M. H. Yang, F.

      2. Over-expression of miR-183-5p or miR-492 triggers invasion and proliferation and loss of polarity in non-neoplastic breast epithelium
        Naser Al Deen N, Atallah Lanman N, Chittiboyina S, Fostok S, Nasr R, Lelièvre S, Talhouk R.
        Sci Rep. 2022 Dec 20;12(1):21974.
        microRNAs (miRNAs) serve as novel noninvasive cancer biomarkers. In an HMT-3522 S1 (S1) breast epithelial risk-progression three-dimensional (3D) culture model, non-neoplastic S1 cells form a fully polarized epithelium. When silenced for the gap junction and tumor suppressor Cx43, Cx43-KO-S1 cells recapitulate pre-neoplastic phenotypes observed in tissues at risk for breast cancer in vivo. To delineate the role of miRNAs in breast tumorigenesis and identify key miRNA players in breast epithelial polarity, the miRNA profile specific to Cx43 loss in Cx43-KO-S1 compared to S1 cells was sequenced, revealing 65 differentially expressed miRNAs. A comparative analysis was conducted between these miRNAs and tumor-associated miRNAs from a young Lebanese patient validation cohort. miR-183-5p, downstream of Cx43 loss, was commonly upregulated in the patient cohort and the 3D culture model. miR-492, not attributed to Cx43 loss, was only specifically up-regulated in the young Lebanese patients. Ectopic expression of either miR-183-5p or miR-492 in S1 cells, through pLenti-III-miR-GPF vectors, resulted in the formation of larger multi-layered acini devoid of lumen, with disrupted epithelial polarity, as shown by an altered localization of Cx43, ß-catenin and Scrib, and decreased nuclear circularity in 3D cultures. Enhanced proliferation and invasion capacity were also observed. Over-expression of miR-183-5p or miR-492, therefore, induces pre-neoplastic phenotypes similar to those reported upon Cx43 loss, and may act as oncomiRs and possible biomarkers of increased breast cancer risk.

        Nasr, R.

    • Health Behavior and Risk
      1. BACKGROUND: Handwashing with soap and water is an important way to prevent transmission of viruses and bacteria and worldwide it is estimated handwashing can prevent 1 in 5 viral respiratory infections. Frequent handwashing is associated with a decreased risk for infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). Using a hand sanitizer with at least 60% alcohol when handwashing is not feasible can also help prevent the transmission of viruses and bacteria. OBJECTIVE: Since early 2020, the public has been encouraged to handwash frequently with soap and water and use alcohol-based hand sanitizer when soap and water are not available to reduce COVID-19 transmission. This study's objectives were to assess U.S. adults' perceptions of components of the Capability, Opportunity, Motivation and Behavior (COM-B) Model in relation to these two hand hygiene behaviors and to identify relationships between these components and hand hygiene behaviors. METHODS: Items assessing capability, opportunity, motivation, and hand hygiene behaviors were included in FallStyles, a survey completed by 3,625 adults in the fall of 2020 through an online panel representative of the U.S. POPULATION: We calculated composite capability, opportunity, and motivation measures and descriptive statistics for all measures. Finally, we conducted multiple logistic regressions to identify predictors of handwashing and hand sanitizer use. RESULTS: Most respondents reported frequently washing hands with soap and water (89%) and using alcohol-based hand sanitizer (72%) to prevent coronavirus. For capability, over 90% of respondents said that neither behavior takes a lot of effort, but fewer agreed that they knew when, or how, they should engage in handwashing (67%; 74%) and hand sanitizer use (62%; 64%). For opportunity, over 95% of respondents said lack of time didn't make it hard to engage in either behavior; fewer said visual cues reminded them to engage in the behaviors (handwashing: 30%; sanitizer use: 48%). For motivation, the majority believed the two behaviors were good ways to prevent coronavirus illness (handwashing: 76%; sanitizer use: 59%). Regressions indicated that capability, opportunity, and particularly motivation were positively associated with both hand hygiene behaviors. CONCLUSIONS: The COM-B model was a helpful framework for increasing understanding of hand hygiene behavior; it identified capability, opportunity, and motivation as predictors of both handwashing and hand sanitizer use.

        Brown, L. G. Hoover, E. R. Besrat, B. N. Burns-Lynch, C. Frankson, R. Jones, S. L. Garcia-Williams, A. G.

      2. HIV self-testing and risk behaviors among men who have sex with men in 23 US cities, 2017
        Bien-Gund CH, Shaw PA, Agnew-Brune C, Baugher A, Brady KA, Gross R.
        JAMA Netw Open. 2022 Dec 1;5(12):e2247540.
        IMPORTANCE: HIV self-testing (HIVST) is a promising strategy to expand the HIV care continuum, particularly among priority populations at high risk of HIV infection. However, little is known about HIVST uptake among men who have sex with men (MSM) outside of clinical trial settings. OBJECTIVE: To evaluate HIVST use among urban MSM in the US who reported testing within the past 12 months. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study of adult MSM in the 2017 National HIV Behavioral Surveillance system, which used venue-based sampling methods to collect data related to HIV testing, receipt of prevention services, and risk factors for HIV, was conducted at 588 venues in 23 urban areas in the contiguous US and Puerto Rico. All participants were offered HIV testing. Adult cisgender MSM who reported HIV-negative or unknown HIV status and obtained HIV testing in the past 12 months were included. Data for this study were collected between June 4, 2017, and December 22, 2017, and analyzed between October 23, 2020, and August 20, 2021. MAIN OUTCOMES AND MEASURES: Self-reported HIVST in the past year. Adjusted prevalence ratios (aPRs) using survey weights were calculated to assess factors associated with HIVST. RESULTS: A total of 6563 MSM in 23 urban areas met inclusion criteria, of whom 506 (7.7%) individuals reported HIVST in the past year. The median age of self-testers was 29 (IQR, 25-35) years, 52.8% had completed college, and 37.9% reported non-Hispanic White race. One self-tester reported seroconverting in the prior 12 months, and an additional 10 self-testers were diagnosed with HIV during the survey. HIVST was associated with sexual orientation disclosure (aPR, 10.27; 95% CI, 3.45-30.60; P < .001), perceived discrimination against people with HIV (aPR, 1.53; 95% CI, 1.09-2.03; P = .01), younger age (aPR, 0.74; 95% CI, 0.66-0.84; P < .001), higher educational level (aPR, 1.20; 95% CI, 1.04-1.37; P = .01), and higher income levels (aPR, 1.18; 95% CI, 1.04-1.32; P = .009). No association was noted with condomless anal sex (aPR, 0.96; 95% CI, 0.88-1.06, P = .88), sexually transmitted infections (aPR, 0.96; 95% CI, 0.70-1.30; P = .77), or preexposure prophylaxis use (aPR, 0.99; 95% CI, 0.75-1.30; P = .92). CONCLUSIONS AND RELEVANCE: In this study, HIVST was relatively uncommon in this sample of urban MSM. HIVST may not be reaching those with lower socioeconomic status or who have not disclosed their sexual identity. The findings of this study suggest that efforts to increase HIVST should focus on engaging underserved and vulnerable subgroups of MSM.

        Agnew-Brune, C. Baugher, A. Brady, K. A.

    • Health Economics
      1. Community Guide methods for systematic reviews of economic evidence
        Chattopadhyay SK, Jacob V, Hopkins DP, Lansky A, Elder R, Cuellar AE, Calonge N, Clymer JM.
        Am J Prev Med. 2022 Dec 16.
        INTRODUCTION: Community Guide systematic economic reviews provide information on the cost, economic benefit, cost-benefit, and cost-effectiveness of public health interventions recommended by the Community Preventive Services Task Force on the basis of evidence of effectiveness. The number and variety of economic evaluation studies in public health have grown substantially over time, contributing to methodologic challenges that required updates to the methods for Community Guide systematic economic reviews. This paper describes these updated methods. METHODS: The 9-step Community Guide economic review process includes prioritization of topic, creation of a coordination team, conceptualization of review, literature search, screening studies for inclusion, abstraction of studies, analysis of results, translation of evidence to Community Preventive Services Task Force economic findings, and dissemination of findings and evidence gaps. The methods applied in each of these steps are reported in this paper. RESULTS: Two published Community Guide reviews, tailored pharmacy-based interventions to improve adherence to medications for cardiovascular disease and permanent supportive housing with housing first to prevent homelessness, are used to illustrate the application of the updated methods. The Community Preventive Services Task Force reached a finding of cost-effectiveness for the first intervention and a finding of favorable cost-benefit for the second on the basis of results from the economic reviews. CONCLUSIONS: The updated Community Guide economic systematic review methods provide transparency and improve the reliability of estimates that are used to derive a Community Preventive Services Task Force economic finding. This may in turn augment the utility of Community Guide economic reviews for communities making decisions about allocating limited resources to effective programs.

        Chattopadhyay, S. K. Jacob, V. Hopkins, D. P. Lansky, A. Elder, R.

    • Health Equity and Health Disparities
      1. Perceived stress independently predicts worse disease activity and symptoms in a multi-racial/ethnic systemic lupus cohort
        Patterson S, Trupin L, Hartogensis W, DeQuattro K, Lanata C, Gordon C, Barbour KE, Greenlund KJ, Dall'Era M, Yazdany J, Katz P.
        Arthritis Care Res (Hoboken). 2022 Dec 20.
        OBJECTIVE: Studies have suggested a potential link between traumatic experiences, psychological stress, and autoimmunity, but the impact of stress on disease activity and symptom severity in systemic lupus erythematosus (SLE) remains unclear. We examined whether increases in perceived stress independently associate with worse SLE disease outcomes over three years of follow-up. METHODS: Participants were drawn from the California Lupus Epidemiology Study (CLUES). Stress was measured annually using the 4-item Perceived Stress Scale (PSS). Participants with PSS increases ≥0.5 standard deviation were defined as having an increase in stress. Four outcomes were measured at the year 3 follow-up visit: physician-assessed disease activity (Systemic Lupus Disease Activity Index), patient-reported disease activity (Systemic Lupus Activity Questionnaire), pain (PROMIS Pain Interference), and fatigue (PROMIS Fatigue). Multivariable linear regression evaluated longitudinal associations of increase in stress with all four outcomes while controlling for potential confounders. RESULTS: The sample (n=260) was 91% female, 36% Asian, 30% White, 22% Hispanic, and 11% African American; mean age 46 (±14) years. In adjusted longitudinal analyses, increase in stress independently associated with greater physician-assessed disease activity (p=0.015), greater self-reported disease activity (p<0.001), more pain (p=0.019), and more fatigue (p<0.001). CONCLUSION: In a racially diverse sample of persons with SLE, those who experienced an increase in stress had significantly worse disease activity and greater symptom burden at follow-up compared to those with stress levels that remained stable or declined. Findings underscore the need for interventions to bolster stress resilience and support effective coping strategies among individuals living with lupus. This article is protected by copyright. All rights reserved.

        Barbour, K. E.

      2. OBJECTIVES: The COVID-19 pandemic has disproportionately affected racial and ethnic minority populations in the United States. The National Center for Health Statistics adapted the Research and Development Survey (RANDS), a commercial panel survey, to track selected health outcomes during the pandemic using the series RANDS during COVID-19 (RC-19). We examined access to preventive care among adults by chronic condition status, race, and Hispanic origin. METHODS: NORC at the University of Chicago conducted RC-19 among US adults in 3 rounds (June-July 2020 [round 1, N = 6800], August 2020 [round 2, N = 5981], and May-June 2021 [round 3, N = 5458]) via online survey and telephone. We evaluated reduced access to ≥1 type of preventive care due to the pandemic in the past 2 months for each round by using logistic regression analysis stratified by chronic condition status and race and Hispanic origin, adjusting for sociodemographic and health variables. RESULTS: Overall, 35.8% of US adults reported missing ≥1 type of preventive care in the previous 2 months in round 1, 26.0% in round 2, and 11.2% in round 3. Reduced access to preventive care was significantly higher among adults with ≥1 chronic condition (vs no chronic conditions) in rounds 1 and 2 (adjusted odds ratios [aOR)] = 1.5 and 1.4, respectively). Compared with non-Hispanic White adults, non-Hispanic Black adults reported significantly lower reduced access to preventive care in round 1 (aOR = 0.7), and non-Hispanic Other adults reported significantly higher reduced access to preventive care in round 2 (aOR = 1.5). CONCLUSIONS: Our findings may inform policies and programs for people at risk of reduced access to preventive care.

        Irimata, K. E. Pleis, J. R. Heslin, K. C. He, Y.

    • Healthcare Associated Infections
      1. Investigation of a Candida auris outbreak in a Skilled Nursing Facility - Virginia, United States, October 2020-June 2021
        Waters A, Chommanard C, Baltozer S, Angel LC, Abdelfattah R, Lyman M, Forsberg K, Misas E, Litvintseva AP, Fields V, Lineberger S, Bernard S.
        Am J Infect Control. 2022 Dec 16.
        Candida auris, an emerging multi-drug resistant organism (MDRO), is an urgent public health threat. We report on a C. auris outbreak investigation at a Virginia ventilator skilled nursing facility (vSNF). During October 2020-June 2021, we identified 28 cases among residents in the ventilator unit. Genomic evidence suggested ≥2 distinct C. auris introductions to the facility. We identified multiple infection and prevention control challenges, highlighting the importance of strengthening MDRO prevention efforts at vSNFs.

        Lyman, M. Forsberg, K. Misas, E. Litvintseva, A. P.

    • Immunity and Immunization
      1. Factors associated with intention to vaccinate children 0-11 years of age against COVID-19
        Stockwell MS, Porucznik CA, Dixon A, Duque J, Stanford JB, Veguilla V, Dawood FS.
        J Am Board Fam Med. 2022 Dec 16.
        BACKGROUND: Millions of children have tested positive for SARS-CoV-2, and over 1000 children have died in the US. However, vaccination rates for children 5 to 11 years old are low. METHODS: Starting in August 2020, we conducted a prospective SARS-CoV-2 household surveillance study in Spanish and English-speaking households in New York City and Utah. From October 21 to 25, 2021, we asked caregivers about their likelihood of getting COVID-19 vaccine for their child, and reasons that they might or might not vaccinate that child. We compared intent to vaccinate by site, demographic characteristics, SARS-CoV-2 infection detected by study surveillance, and parents' COVID-19 vaccination status using Chi-square tests and a multivariable logistic regression model, accounting for within-household clustering. RESULTS: Among parents or caregivers of 309 children (0 to 11 years) in 172 households, 87% were very or somewhat likely to intend to vaccinate their child. The most prevalent reasons for intending to vaccinate were to protect family and friends and the community; individual prevention was mentioned less often. The most prevalent reasons for not intending to vaccinate were side effect concerns and wanting to wait and see.In multivariable analysis, parents had much lower odds of intending to vaccinate if someone in the household had tested SARS-CoV-2-positive during the study (adjusted odds ratio = 0.09; 95% confidence interval, 0.03-0.3). CONCLUSION: This study highlighted several themes for clinicians and public health officials to consider including the importance and safety of vaccination for this age-group even if infected previously, and the benefits of vaccination to protect family, friends, and community.

        Dixon, A. Veguilla, V. Dawood, F. S.

      2. Progress toward measles and rubella elimination - India, 2005-2021
        Murugan R, VanderEnde K, Dhawan V, Haldar P, Chatterjee S, Sharma D, Dzeyie KA, Pattabhiramaiah SB, Khanal S, Sangal L, Bahl S, Tanwar SS, Morales M, Kassem AM.
        MMWR Morb Mortal Wkly Rep. 2022 Dec 16;71(50):1569-1575.
        In 2019, India, along with other countries in the World Health Organization (WHO) South-East Asia Region,* adopted the goal of measles and rubella elimination by 2023,(†) a revision of the previous goal of measles elimination and control of rubella and congenital rubella syndrome (CRS) by 2020(§) (1-3). During 2017-2021, India adopted a national strategic plan for measles and rubella elimination (4), introduced rubella-containing vaccine (RCV) into the routine immunization program, launched a nationwide measles-rubella supplementary immunization activity (SIA) catch-up campaign, transitioned from outbreak-based surveillance to case-based acute fever and rash surveillance, and more than doubled the number of laboratories in the measles-rubella network, from 13 to 27. Strategies included 1) achieving and maintaining high population immunity with at least 95% vaccination coverage by providing 2 doses of measles- and rubella-containing vaccines; 2) ensuring a sensitive and timely case-based measles, rubella and CRS surveillance system; 3) maintaining an accredited measles and rubella laboratory network; 4) ensuring adequate outbreak preparedness and rapid response to measles and rubella outbreaks; and 5) strengthening support and linkages to achieve these strategies, including planning and progress monitoring, advocacy, social mobilization and communication, identification and utilization of synergistic linkages of integrated program efforts, research, and development. This report describes India's progress toward the elimination of measles and rubella during 2005-2021, with a focus on the years 2017-2021.(¶) During 2005-2021, coverage with the first dose of a measles-containing vaccine (MCV) administered through routine immunization increased 31%, from 68% to 89%. During 2011-2021, coverage with a second MCV dose (MCV2) increased by 204%, from 27% to 82%. During 2017-2021, coverage with a first dose of RCV (RCV1) increased almost 14-fold, from 6% to 89%. More than 324 million children received a measles- and rubella-containing vaccine (MRCV) during measles-rubella SIAs completed in 34 (94%) of 36 states and union territories (states) during 2017-2019. During 2017-2021, annual measles incidence decreased 62%, from 10.4 to 4.0 cases per 1 million population, and rubella incidence decreased 48%, from 2.3 to 1.2 cases per 1 million population. India has made substantial progress toward measles and rubella elimination; however, urgent and intensified efforts are required to achieve measles and rubella elimination by 2023.

        VanderEnde, K. Tanwar, S. S. S. Morales, M. Kassem, A. M.

      3. Optimising reporting of adverse events following immunisation by healthcare workers in Ghana: A qualitative study in four regions
        Aborigo RA, Welaga P, Oduro A, Shaum A, Opare J, Dodoo A, Ampadu H, Gidudu JF.
        PLoS One. 2022 ;17(12):e0277197.
        INTRODUCTION: Despite the emphasis on reporting of Adverse Events Following Immunisation (AEFIs) during didactic training sessions, especially prior to new vaccine introductions, it remains low in Ghana. We explored the factors underlying the under-reporting of AEFI by healthcare workers (HCWs) to provide guidance on appropriate interventions to increase reporting. METHODS: We conducted an exploratory descriptive in-depth study of the factors contributing to low reporting of AEFI among HCWs in four regions in Ghana. Key informant interviews (KII) were held with purposively selected individuals that are relevant to the AEFI reporting process at the district, regional, and national levels. We used KII guides to conduct in-depth interviews and used NVivo 10 qualitative software to analyse the data. Themes on factors influencing AEFI reporting were derived inductively from the data, and illustrative quotes from respondents were used to support the narratives. RESULTS: We conducted 116 KIIs with the health managers, regulators and frontline HCWs and found that lack of information on reportable AEFIs and reporting structures, misunderstanding of reportable AEFIs, heavy workload, cost of reporting AEFIs, fear of blame by supervisors, lack of motivation, and inadequate feedback as factors responsible for underreporting of AEFIs. Respondents suggested that capacity building for frontline HCWs, effective supervision, the provision of motivation and feedback, simplification of reporting procedures, incentives for integrating AEFI reporting into routine monitoring and reporting, standardization of reporting procedures across regions, and developing appropriate interventions to address the fear of personal consequences would help improve AEFI reporting. CONCLUSION: From the perspectives of a broad range of key informants at all levels of the vaccine safety system, we found multiple factors (both structural and behavioural), that may impact HCW reporting of AEFI in Ghana. Improvements in line with the suggestions are necessary for increased AEFI reporting in Ghana.

        Shaum, A. Gidudu, J. F.

      4. Impact of prenatal COVID-19 vaccination on delivery and neonatal outcomes: Results from a New York City cohort
        Ibroci E, Liu X, Lieb W, Jessel R, Gigase FA, Chung K, Graziani M, Lieber M, Ohrn S, Lynch J, Castro J, Marshall C, Tubassum R, Mutawakil F, Kaplowitz ET, Ellington S, Molenaar N, Sperling RS, Howell EA, Janevic T, Dolan SM, Stone J, De Witte LD, Bergink V, Rommel AS.
        Vaccine. 2022 Dec 14.
        Research suggest prenatal vaccination against coronavirus disease-19 (COVID-19) is safe. However, previous studies utilized retrospectively collected data or examined late pregnancy vaccinations. We investigated the associations of COVID-19 vaccination throughout pregnancy with delivery and neonatal outcomes. We included 1,794 mother-neonate dyads enrolled in the Generation C Study with known prenatal COVID-19 vaccination status and complete covariate and outcome data. We used multivariable quantile regressions to estimate the effect of prenatal COVID-19 vaccination on birthweight, delivery gestational age, and blood loss at delivery; and Poisson generalized linear models for Caesarean delivery (CD) and Neonatal Intensive Care Unit (NICU) admission. Using the above methods, we estimated effects of trimester of vaccine initiation on these outcomes. In our sample, 13.7% (n = 250) received at least one prenatal dose of any COVID-19 vaccine. Vaccination was not associated with birthweight (β = 12.42 g [-90.5, 114.8]), gestational age (β = 0.2 days [-1.1, 1.5]), blood loss (β = -50.6 ml [-107.0, 5.8]), the risks of CD (RR = 0.8; [0.6, 1.1]) or NICU admission (RR = 0.9 [0.5, 1.7]). Trimester of vaccine initiation was also not associated with these outcomes. Our findings suggest that there is no associated risk between prenatal COVID-19 vaccination and adverse delivery and neonatal outcomes in a cohort sample from NYC.

        Ellington, S.

      5. Factors associated with humoral immune response in older adults who received egg-free influenza vaccine
        Williams KV, Moehling Geffel K, Alcorn JF, Patricia Nowalk M, Levine MZ, Kim SS, Flannery B, Susick M, Zimmerman RK.
        Vaccine. 2022 Dec 19.
        BACKGROUND: Immune responses to influenza vaccination tend to be lower among older, frequently vaccinated adults. Use of egg-free influenza vaccines is increasing, but limited data exist on factors associated with their immunogenicity in older adults. METHODS: Community-dwelling older adults ≥ 56 years of age were enrolled in a prospective, observational study of immunogenicity of 2018-2019 influenza vaccine. Hemagglutination inhibition (HAI) antibody titers were measured pre-vaccination (Day 0) and four weeks after vaccination (Day 28) to calculate geometric mean titers, seropositivity (HAI titers ≥ 1:40), seroconversion (fourfold rise in HAI titer with post-vaccination titer ≥ 1:40) and geometric mean fold rise (GMFR). Linear regression models assessed the association of predictors of GMFR for each vaccine antigen. RESULTS: Among 91 participants who received egg-free influenza vaccines, 84 (92.3 %) received quadrivalent recombinant influenza vaccine (RIV4, Flublok, Sanofi Pasteur), and 7 (7.7 %) received quadrivalent cell culture-based influenza vaccine (ccIIV4, Flucelvax, Seqirus). Pre-vaccination seropositivity was 52.8 % for A(H1N1), 94.5 % for A(H3N2), 61.5 % for B/Colorado and 48.4 % for B/Phuket. Seroconversion by antigen ranged from 16.5 % for A(H1N1) and B/Colorado to 37.4 % for A(H3N2); 40 participants failed to seroconvert to any antigen. Factors independently associated with higher GMFR in multivariable models included lower pre-vaccination HAI antibody titer for A(H1N1), B/Colorado and B/Phuket, and younger age for A(H1N1). CONCLUSION: Overall pre-vaccination seropositivity was high and just over half of the cohort seroconverted to ≥ 1 vaccine antigen. Antibody responses were highest among participants with lower pre-vaccination titers. Among older adults with high pre-existing antibody titers, approaches to improve immune responses are needed.

        Levine, M. Z. Kim, S. S. Flannery, B.

    • Informatics

      2. Overcoming challenges to HIV medical care-seeking and treatment among data-to-care program clients in Baton Rouge and New Orleans, Louisiana
        Carey JW, Roland KB, Bessler PA, Tesfaye CL, Randall LA, Frew PM.
        J Assoc Nurses AIDS Care. 2022 Dec 16.
        Data to Care (D2C) uses US public health surveillance data to identify persons with diagnosed HIV who are not receiving adequate medical care. These persons are linked to care and ancillary social services through personalized outreach. We conducted semistructured interviews with 36 adults with HIV in Louisiana who were engaged for the first time or reengaged back into HIV care through D2C efforts. Before D2C program staff contact, nearly 40% were not contemplating HIV care. Program clients cited barriers to HIV care, including difficulties with appointment scheduling and transportation, health care service and drug costs, low motivation, and competing non-HIV health needs. Thirty-four of the 36 clients said that D2C staff helped them overcome these barriers. Clients also described psychosocial support from D2C staff. After receiving D2C program assistance, more than 90% of clients reported consistently receiving HIV medical care and taking medications. Our findings suggest that D2C staff successfully identified client needs and provided tailored assistance.

        Carey, J. W. Roland, K. B. Bessler, P. A.

      3. Respondent burden has important implications for survey outcomes, including response rates and attrition in panel surveys. Despite this, respondent burden remains an understudied topic in the field of survey methodology, with few researchers systematically measuring objective and subjective burden factors in surveys used to produce official statistics. This research was designed to assess the impact of proxy measures of respondent burden, drawing on both objective (survey length and frequency), and subjective (effort, saliency, and sensitivity) burden measures on response rates over time in the Current Population Survey (CPS). Exploratory Factor Analysis confirmed the burden proxy measures were interrelated and formed five distinct factors. Regression tree models further indicated that both objective and subjective proxy burden factors were predictive of future CPS response rates. Additionally, respondent characteristics, including employment and marital status, interacted with these burden factors to further help predict response rates over time. We discuss the implications of these findings, including the importance of measuring both objective and subjective burden factors in production surveys. Our findings support a growing body of research suggesting that subjective burden and individual respondent characteristics should be incorporated into conceptual definitions of respondent burden and have implications for adaptive design. © 2022 Morgan Earp et al.

        Earp, M.

      4. Council of State and Territorial Epidemiologists/CDC surveillance case definition for multisystem inflammatory syndrome in children associated with SARS-CoV-2 infection - United States
        Melgar M, Lee EH, Miller AD, Lim S, Brown CM, Yousaf AR, Zambrano LD, Belay ED, Godfred-Cato S, Abrams JY, Oster ME, Campbell AP.
        MMWR Recomm Rep. 2022 Dec 16;71(4):1-14.
        THIS REPORT SUMMARIZES THE EVIDENCE AND RATIONALE SUPPORTING THE COMPONENTS OF THE CSTE/CDC MIS-C SURVEILLANCE CASE DEFINITION AND DESCRIBES THE METHODS USED TO DEVELOP THE DEFINITION. THESE METHODS INCLUDED CONVENING MIS-C CLINICAL EXPERTS (I.E., CONSULTANTS): regarding identification of MIS-C and its distinction from other pediatric conditions, a review of available literature comparing MIS-C phenotype with that of pediatric COVID-19 and other hyperinflammatory syndromes, and retrospective application of different criteria to data from MIS-C cases previously reported to CDC.

        Melgar, M. Miller, A. D. Yousaf, A. R. Zambrano, L. D. Belay, E. D. Godfred-Cato, S. Abrams, J. Y. Oster, M. E. Campbell, A. P.

      5. Using spatial and population mobility models to inform outbreak response approaches in the Ebola affected area, Democratic Republic of the Congo, 2018-2020
        Huber C, Watts A, Thomas-Bachli A, McIntyre E, Tuite A, Khan K, Cetron M, Merrill RD.
        Spat Spatiotemporal Epidemiol. 2023 ;44.
        The Democratic Republic of the Congo's (DRC) 10th known Ebola virus disease (EVD) outbreak occurred between August 1, 2018 and June 25, 2020, and was the largest EVD outbreak in the country's history. During this outbreak, the DRC Ministry of Health initiated traveller health screening at points of control (POC, locations not on the border) and points of entry (POE) to minimize disease translocation via ground and air travel. We sought to develop a model-based approach that could be applied in future outbreaks to inform decisions for optimizing POC and POE placement, and allocation of resources more broadly, to mitigate the risk of disease translocation associated with ground-level population mobility. We applied a parameter-free mobility model, the radiation model, to estimate likelihood of ground travel between selected origin locations (including Beni, DRC) and surrounding population centres, based on population size and drive-time. We then performed a road network route analysis and included estimated population movement results to calculate the proportionate volume of travellers who would move along each road segment; this reflects the proportion of travellers that could be screened at a POC or POE. For Beni, the road segments estimated to have the highest proportion of travellers that could be screened were part of routes into Uganda and Rwanda. Conversely, road segments that were part of routes to other population centres within the DRC were estimated to have relatively lower proportions. We observed a posteriori that, in many instances, our results aligned with locations that were selected for actual POC or POE placement through more time-consuming methods. This study has demonstrated that mobility models and simple spatial techniques can help identify potential locations for health screening at newly placed POC or existing POE during public health emergencies based on expected movement patterns. Importantly, we have provided methods to estimate the proportionate volume of travellers that POC or POE screening measures would assess based on their location. This is critical information in outbreak situations when timely decisions must be made to implement public health interventions that reach the most individuals across a network. © 2022 Elsevier Ltd

        McIntyre, E. Cetron, M. Merrill, R. D.

      6. Patient flow time data of COVID-19 vaccination clinics in 23 sites, United States, April and May 2021
        Cho BH, Athar HM, Bates LG, Yarnoff BO, Harris LQ, Washington ML, Jones-Jack NH, Pike JJ.
        Vaccine. 2022 Dec 12.
        INTRODUCTION: Public health department (PHD) led COVID-19 vaccination clinics can be a critical component of pandemic response as they facilitate high volume of vaccination. However, few patient-time analyses examining patient throughput at mass vaccination clinics with unique COVID-19 vaccination challenges have been published. METHODS: During April and May of 2021, 521 patients in 23 COVID-19 vaccination sites counties of 6 states were followed to measure the time spent from entry to vaccination. The total time was summarized and tabulated by clinic characteristics. A multivariate linear regression analysis was conducted to evaluate the association between vaccination clinic settings and patient waiting times in the clinic. RESULTS: The average time a patient spent in the clinic from entry to vaccination was 9 min 5 s (range: 02:00-23:39). Longer patient flow times were observed in clinics with higher numbers of doses administered, 6 or fewer vaccinators, walk-in patients accepted, dedicated services for people with disabilities, and drive-through clinics. The multivariate linear regression showed that longer patient waiting times were significantly associated with the number of vaccine doses administered, dedicated services for people with disabilities, the availability of more than one brand of vaccine, and rurality. CONCLUSIONS: Given the standardized procedures outlined by immunization guidelines, reducing the wait time is critical in lowering the patient flow time by relieving the bottleneck effect in the clinic. Our study suggests enhancing the efficiency of PHD-led vaccination clinics by preparing vaccinators to provide vaccines with proper and timely support such as training or delivering necessary supplies and paperwork to the vaccinators. In addition, patient wait time can be spent answering questions about vaccination or reviewing educational materials on other public health services.

        Cho, B. H. Athar, H. M. Harris, L. Q. Washington, M. L. Jones-Jack, N. H. Pike, J. J.

      7. A broad assessment of COVID-19 vaccine safety using tree-based data-mining in the vaccine safety datalink
        Yih WK, Daley MF, Duffy J, Fireman B, McClure D, Nelson J, Qian L, Smith N, Vazquez-Benitez G, Weintraub E, Williams JT, Xu S, Maro JC.
        Vaccine. 2022 Dec 16.
        BACKGROUND: Except for spontaneous reporting systems, vaccine safety monitoring generally involves pre-specifying health outcomes and post-vaccination risk windows of concern. Instead, we used tree-based data-mining to look more broadly for possible adverse events after Pfizer-BioNTech, Moderna, and Janssen COVID-19 vaccination. METHODS: Vaccine Safety Datalink enrollees receiving ≥1 dose of COVID-19 vaccine in 2020-2021 were followed for 70 days after Pfizer-BioNTech or Moderna and 56 days after Janssen vaccination. Incident diagnoses in inpatient or emergency department settings were analyzed for clustering within both the hierarchical ICD-10-CM code structure and the post-vaccination follow-up period. We used the self-controlled tree-temporal scan statistic and TreeScan software. Monte Carlo simulation was used to estimate p-values; p = 0.01 was the pre-specified cut-off for statistical significance of a cluster. RESULTS: There were 4.1, 2.6, and 0.4 million Pfizer-BioNTech, Moderna, and Janssen vaccinees, respectively. Clusters after Pfizer-BioNTech vaccination included: (1) unspecified adverse effects, (2) common vaccine reactions, such as fever, myalgia, and headache, (3) myocarditis/pericarditis, and (4) less specific cardiac or respiratory symptoms, all with the strongest clusters generally after Dose 2; and (5) COVID-19/viral pneumonia/sepsis/respiratory failure in the first 3 weeks after Dose 1. Moderna results were similar but without a significant myocarditis/pericarditis cluster. Further investigation suggested the fifth signal group was a manifestation of mRNA vaccine effectiveness after the first 3 weeks. Janssen vaccinees had clusters of unspecified or common vaccine reactions, gait/mobility abnormalities, and muscle weakness. The latter two were deemed to have arisen from confounding related to practices at one site. CONCLUSIONS: We detected post-vaccination clusters of unspecified adverse effects, common vaccine reactions, and, for the mRNA vaccines, chest pain and palpitations, as well as myocarditis/pericarditis after Pfizer-BioNTech Dose 2. Unique advantages of this data mining are its untargeted nature and its inherent adjustment for the multiplicity of diagnoses and risk intervals scanned.

        Duffy, J. Weintraub, E.

    • Injury and Violence
      1. Associations between adverse childhood experiences and pandemic-related stress and the impact on adolescent mental health during the COVID-19 pandemic
        Verlenden J, Kaczkowski W, Li J, Hertz M, Anderson KN, Bacon S, Dittus P.
        J Child Adolesc Trauma. 2022 Dec 14:1-15.
        Vulnerabilities of adolescents during times of crisis have been previously identified, but little research has investigated the compounding effects of lifetime adversities and pandemic-related stress on adolescent mental health. This study uses adolescent self-report data to model relationships between stress exposures and indicators of poor mental health from the longitudinal COVID Experiences (CovEx) Surveys. These surveys were administered online in English to U.S. adolescents ages 13-19 using the NORC AmeriSpeak® panel, a probability-based panel designed to be representative of the U.S. household population. Two waves of data were collected (Wave 1: October-November 2020, n = 727; Wave 2: March-May 2021, n = 569). Measures included demographics, adverse childhood experiences (ACEs, 8 items), pandemic-related stress (Pandemic-Related Stress Index [PRSI], 7 items), and depression symptoms (Patient Health Questionnaire for Adolescents [PHQ-A], 9 items). Path analyses were conducted to examine pathways between Wave 1 ACEs, Wave 1 PRSI, and Wave 2 PHQ with covariates of sex and race/ethnicity. Females had higher ACEs, PRSI, and PHQ scores than males. The PRSI score at Wave 1 was positively associated with the PHQ at Wave 2 (b = 0.29, SE = 0.14, p < 0.001). ACEs at Wave 1 were positively associated with PRSI at Wave 1 (b = 0.31, SE = 0.03, p < 0.001) and with PHQ at Wave 2 (b = 0.32, SE = 0.12, p < 0.001). The direct effect of ACEs on PHQ (b = 0.23, SE = 0.12, p < 0.001) remained significant even after accounting for the indirect effect of pandemic-related stress (b = 0.09, SE = 0.05, p < 0.001). Pandemic-related stress had a direct, adverse impact on adolescent depressive symptoms and demonstrates a compounding effect of childhood adversity and pandemic-related stress on depression. Findings can aid the design of interventions that promote mental health and support adolescent coping and recovery. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40653-022-00502-0.

        Verlenden, J. Kaczkowski, W. Li, J. Hertz, M. Anderson, K. N. Bacon, S. Dittus, P.

      2. The COVID-19 pandemic created an environment of disruption and adversity for many adolescents. We sought to establish the prevalence of non-dating sexual violence, sexual dating violence, and physical dating violence victimization among adolescents during the COVID-19 pandemic and to investigate whether experiences of disruption and adversity placed adolescents at greater risk for these forms of interpersonal violence. We conducted a secondary analysis of data from the Adolescent Behavior and Experiences Survey, collected January to June 2021 from a nationally representative sample of U.S. high school students (N = 7,705). Exposures included abuse by a parent; economic, housing, and food and nutrition insecurity; interpersonal connectedness; and personal well-being. Among female students, 8.0% experienced non-dating sexual violence; 12.5% experienced sexual dating violence; and 7.7% experienced physical dating violence. Among male students, 2.2% experienced non-dating sexual violence; 2.4% experienced sexual dating violence; and 4.9% experienced physical dating violence. Among female students, both emotional and physical abuse by a parent was related to non-dating sexual violence, emotional abuse was related to sexual dating violence, and physical abuse was related to physical dating violence. Among males, emotional abuse by a parent was related to physical dating violence and physical abuse by a parent was related to sexual dating violence. Hunger was associated with sexual and physical dating violence among female students and homeless was associated with physical dating violence among male students. Although there were differences by sex, abuse by a parent, hunger, and homelessness created precarity that may have increased the likelihood that adolescents would be exposed to risky peer or dating relationships. Adolescents need support that stops and prevents experiences of non-dating sexual and dating violence connected to interventions that address adversities experienced during the COVID-19 pandemic.

        Krause, K. H. DeGue, S. Kilmer, G. Niolon, P. H.

      3. Trends in homicide rates for US children aged 0 to 17 years, 1999 to 2020
        Wilson RF, Fortson BL, Zhou H, Lyons BH, Sheats KJ, Betz CJ, Blair JM, Self-Brown S.
        JAMA Pediatr. 2022 Dec 19.
        IMPORTANCE: Homicide is a leading cause of death among children in the US. OBJECTIVE: To examine trends in child homicide rates and characteristics most commonly associated with these deaths. DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional study, the study team used National Vital Statistics System WONDER mortality data for  362 homicide victims aged 0 to 17 years for 1999 to 2020 and National Violent Death Reporting System data for child homicide victims for 2003 to 2019 in 45 states, Washington, DC, and Puerto Rico. WONDER data are based on death certificates for US residents. National Violent Death Reporting System data include characteristics of violent deaths, linking information from death certificates, and law enforcement, coroner, and medical examiner reports. EXPOSURES: Child homicide was defined using underlying cause-of-death codes U01 to U02, X85 to Y09, and Y87.1 from the International Classification of Diseases, Tenth Revision, Clinical Modification. MAIN OUTCOMES AND MEASURES: Trends in homicide rates per 100 000 children were tested using joinpoint regression analysis; differences in rates from 2019 to 2020 were evaluated using z tests. Circumstances of child homicides were described. RESULTS: This study included 38 362 homicide victims (69.4% male). The overall child homicide rate (per 100 000 children) has increased annually, on average 4.3% since 2013, with a precipitous rise from 2019 to 2020 (2019 rate, 2.2; 2020 rate, 2.8; overall increase of 27.7%). Homicide rates recently increased significantly for boys (2018 rate, 2.9; 2020 rate, 4.1; overall increase of 16.1%), 6- to 10-year-olds (2014 rate, 0.5; 2020 rate, 0.8; overall increase of 5.6%), 11- to 15-year-olds (2018 rate, 1.3; 2020 rate, 2.2; overall increase of 26.9%), 16- to 17-year-olds (2018 rate, 6.6; 2020 rate, 10.0; overall increase of 19.0%), Black children (2012 rate, 5.9; 2018 rate, 6.8; 2020 rate, 9.9; overall increase of 16.6% from 2018 to 2020), Hispanic children (2014 rate, 1.6; 2020 rate, 2.2; overall increase of 4.7%), children in the South (2013 rate, 2.1; 2020 rate, 3.5; overall increase of 6.4%), and in rural (2011 rate, 1.8; 2020 rate, 2.4; overall increase of 3.2%) and urban areas (2013 rate, 1.9; 2020 rate, 2.9; overall increase of 4.4%). Since 1999, homicide rates have decreased for girls (1999 rate, 1.9; 2020 rate, 1.5; overall decrease of 1.4%), infants (1999 rate, 8.7; 2020 rate, 6.6; overall decrease of 1.3%), 1- to 5-year-olds (1999 rate, 2.1; 2020 rate, 1.8; overall decrease of 1.0%), Asian or Pacific Islander children (1999 rate, 2.0; 2020 rate, 0.5; overall decrease of 4.4%), White children (1999 rate, 1.5; 2020 rate, 1.3; overall decrease of 0.7%), and children in the Northeast (1999 rate, 2.0; 2020 rate, 1.7; overall decrease of 1.4%). Homicides of children 10 years or younger were most commonly precipitated by abuse/neglect, perpetrated by parents/caregivers. Homicides of 11- to 17-year-olds were most commonly precipitated by crime and arguments and perpetrated by someone known to them, especially friends and acquaintances. CONCLUSIONS AND RELEVANCE: The decline in homicide rates for some geographic and child demographic groups is encouraging; however, rates recently increased across several subpopulations, with some racial and ethnic disparities persisting for more than 20 years. More targeted strategies are needed to (1) protect 6- to 10-year-olds, 11- to 17-year-olds, and children in certain geographic areas and (2) urgently address firearm violence, racism, and inequities at the root of youth violence.

        Wilson, R. F. Zhou, H. Lyons, B. H. Sheats, K. J. Betz, C. J. Blair, J. M.

    • Laboratory Sciences
      1. Determining actinides in urine is vital for occupational exposure monitoring and radiological emergency response because of the toxicity and radiological dose effects of actinides on human health. Traditional radiochemistry analytical methods used to determine actinide concentrations in urine are time-consuming (sample analysis takes several days) and are hindered by a variety of technical and instrumentation-related obstacles. A high-throughput, fully automated, precise, and accurate in-line method was developed for determining five actinides ((241)Am, (239)Pu, (237)Np, (232)Th, and (238)U) at ng/L levels in urine using extraction chromatography combined with quadrupole inductively coupled plasma mass spectrometry (EC-ICP-MS). In this method, the five actinides were successfully separated with the required sensitivity, peak shape, and resolution using a simplified single Eichrom TRU column with a Dionex ICS-5000 system. The separated actinides were subsequently injected into an in-line PerkinElmer (PE) NexION 300D ICP-MS for quantitative determination. The sample-to-sample run time was 23 min for automatic chemical separation and quantification using only 0.5 mL of urine. The limits of detection (LOD) obtained using this method were 0.015, 0.022, 0.039, 4.5, and 2.4 ng/L for (241)Am, (239)Pu, (237)Np, (232)Th, and (238)U, respectively. The method routinely had a chemical yield of >84% as well as a linearity (R(2)) coefficient of ≥0.999 for the calibrators. The method proved to be rapid, reliable, and effective for actinide quantification in urine and therefore is appropriate for radiological emergency response incidents.

        Liu, Y. Xiao, G. Jones, R. L.

      2. Tissue replication and mucosal swab detection of Sosuga virus in Syrian hamsters in the absence of overt tissue pathology and clinical disease
        Welch SR, Ritter JM, Schuh AJ, Genzer SC, Sorvillo TE, Harmon JR, Coleman-McCray JD, Jain S, Shrivastava-Ranjan P, Seixas JN, Estetter LB, Fair PS, Towner JS, Montgomery JM, Albariño CG, Spiropoulou CF, Spengler JR.
        Antiviral Res. 2022 Dec 12;209:105490.
        Human infection with Sosuga virus (SOSV), a recently discovered pathogenic paramyxovirus, has been reported in one individual to date. No animal models of disease are currently available for SOSV. Here, we describe initial characterization of experimental infection in Syrian hamsters, including kinetics of virus dissemination and replication, and the corresponding clinical parameters, immunological responses, and histopathology. We demonstrate susceptibility of hamsters to infection in the absence of clinical signs or significant histopathologic findings in tissues.

        Welch, S. R. Ritter, J. M. Schuh, A. J. Genzer, S. C. Sorvillo, T. E. Harmon, J. R. Coleman-McCray, J. D. Jain, S. Shrivastava-Ranjan, P. Seixas, J. N. Estetter, L. B. Fair, P. S. Towner, J. S. Montgomery, J. M. Albariño, C. G. Spiropoulou, C. F. Spengler, J. R.

      3. Repeated antigen testing among severe acute respiratory coronavirus virus 2 (SARS-CoV-2)-positive nursing home residents
        Moritz ED, McKay SL, Tobolowsky FA, LaVoie SP, Waltenburg MA, Lecy KD, Thornburg NJ, Harcourt JL, Tamin A, Folster JM, Negley J, Brown AC, McDonald LC, Kutty PK.
        Infect Control Hosp Epidemiol. 2022 Dec;43(12):1918-1921.
        Repeated antigen testing of 12 severe acute respiratory coronavirus virus 2 (SARS-CoV-2)-positive nursing home residents using Abbott BinaxNOW identified 9 of 9 (100%) culture-positive specimens up to 6 days after initial positive test. Antigen positivity lasted 2-24 days. Antigen positivity might last beyond the infectious period, but it was reliable in residents with evidence of early infection.

        Moritz, E. D. McKay, S. L. Tobolowsky, F. A. LaVoie, S. P. Waltenburg, M. A. Lecy, K. D. Thornburg, N. J. Harcourt, J. L. Tamin, A. Folster, J. M. Negley, J. Brown, A. C. McDonald, L. C. Kutty, P. K.

      4. Use of a rapid digital microfluidics-powered immunoassay for assessing measles and rubella infection and immunity in outbreak settings in the Democratic Republic of the Congo
        Knipes AK, Summers A, Sklavounos AA, Lamanna J, de Campos RP, Narahari T, Dixon C, Fobel R, Ndjakani YD, Lubula L, Magazani A, Muyembe JJ, Lay Y, Pukuta E, Waku-Kouomou D, Hao L, Kayembe JK, Fobel C, Dahmer J, Lee A, Ho M, Valenzuela JG, Rackus DG, Shih R, Seale B, Chang A, Paluku G, Rota PA, Wheeler AR, Scobie HM.
        PLoS One. 2022 ;17(12):e0278749.
        The Democratic Republic of the Congo (DRC) has a high measles incidence despite elimination efforts and has yet to introduce rubella vaccine. We evaluated the performance of a prototype rapid digital microfluidics powered (DMF) enzyme-linked immunoassay (ELISA) assessing measles and rubella infection, by testing for immunoglobulin M (IgM), and immunity from natural infection or vaccine, by testing immunoglobulin G (IgG), in outbreak settings. Field evaluations were conducted during September 2017, in Kinshasa province, DRC. Blood specimens were collected during an outbreak investigation of suspected measles cases and tested for measles and rubella IgM and IgG using the DMF-ELISA in the field. Simultaneously, a household serosurvey for measles and rubella IgG was conducted in a recently confirmed measles outbreak area. DMF-ELISA results were compared with reference ELISA results tested at DRC's National Public Health Laboratory and the US Centers for Disease Control and Prevention. Of 157 suspected measles cases, rubella IgM was detected in 54% while measles IgM was detected in 13%. Measles IgG-positive cases were higher among vaccinated persons (87%) than unvaccinated persons (72%). In the recent measles outbreak area, measles IgG seroprevalence was 93% overall, while rubella seroprevalence was lower for children (77%) than women (98%). Compared with reference ELISA, DMF-ELISA sensitivity and specificity were 82% and 78% for measles IgG; 88% and 89% for measles IgM; 85% and 85% for rubella IgG; and 81% and 83% for rubella IgM, respectively. Rubella infection was detected in more than half of persons meeting the suspected measles case definition during a presumed measles outbreak, suggesting substantial unrecognized rubella incidence, and highlighting the need for rubella vaccine introduction into the national schedule. The performance of the DMF-ELISA suggested that this technology can be used to develop rapid diagnostic tests for measles and rubella.

        Knipes, A. K. Summers, A. Ndjakani, Y. D. Waku-Kouomou, D. Hao, L. Rota, P. A. Scobie, H. M.

    • Maternal and Child Health
      1. Health facility users' knowledge, perceptions, and practices about infant feeding in the context of option B+ in South Africa: a qualitative study
        Nsibande DF, Magasana V, Zembe W, Kindra G, Mogashoa M, Goga A, Ramokolo V.
        Int Breastfeed J. 2022 Dec 20;17(1):89.
        BACKGROUND: HIV and sub-optimal infant feeding practices remain important threats to child growth, development, and survival in low- and middle-income countries. To our knowledge, few studies have explored health service users' perspective of infant feeding in the context of WHO Option B+ policy to prevent vertical HIV transmission (PMTCT). This paper is a sub-analysis of qualitative data from a mixed-methods multi-level process evaluation of Option B+ implementation in South Africa (SA). In this study we explored health facility users' infant feeding knowledge, perceptions, and practices one year after SA adopted the 2016 updated World Health Organization prevention of mother-to-child transmission of HIV Option B+ infant feeding guidelines. METHODS: Nineteen focus group discussions (FGDs) were held with six groups of men and women whose infants were aged < 6 months. Participants were attending randomly selected primary health care facilities within six purposively selected priority districts. The six groups included in the FGDs were: (i) adolescent girls and young women living with HIV (WHIV), (ii) adolescent girls and young women not living with HIV (WNHIV), (iii) older postnatal WHIV (iv) older postnatal WNHIV (v) pregnant women, and (vi) men. Data collection took place between April and December 2018. Data analysis involved coding and thematic framework analysis. RESULTS: Women and men have suboptimal knowledge of the recommended breastfeeding duration and exclusive breastfeeding, especially for HIV-exposed infants. Most women received sub-optimal infant feeding counselling and mixed messages from health care workers. Fewer WHIV initiated breastfeeding at birth compared to WNHIV. Most parents believed that HIV-exposed infants should be breastfed for 6 months and many postnatal women on antiretroviral drugs and younger mothers lacked confidence to breastfeed beyond 6 months. Mixed feeding was predominant among all women due to individual, family, and socio-structural barriers. Many men were supportive on infant feeding; however, they lacked the appropriate information and skills to influence their partners' infant feeding decisions. CONCLUSIONS: Differences in breastfeeding practices between WHIV and WNHIV are highly influenced by the lack of knowledge of infant feeding policy recommendations. Multiple-level factors deter many mothers from adhering to recommended guidelines. Appropriate ongoing infant feeding counselling and breastfeeding support are required for women and their partners.

        Kindra, G. Mogashoa, M.

      2. Parents' report on the health care management of spina bifida in early childhood
        Ong KS, Reeder M, Alriksson-Schmidt A, Rice S, Feldkamp ML.
        J Pediatr Rehabil Med. 2022 Dec 13.
        PURPOSE: This study aimed to describe health care use by type of health providers and care settings visited by children with spina bifida (SB) and to compare this use between children with and without a shunt. METHODS: Health care use data were extracted from a larger study on the health and functioning of children with SB aged 3-6 years. The present study focused on the medical information subsection of a parent-reported survey related to SB care, general care, specialty care (e.g., neurosurgery), emergency care, and complications related to SB and shunts. RESULTS: Parents of 101 children with SB participated. Most of the children were male with myelomeningocele SB and had a shunt. They visited a health care provider for SB care an average of 7.4 times and a specialist an average of 11.9 times in the previous 12 months. Most visited a multidisciplinary clinic for SB-related care and a private physician's office for general care. Children with a shunt had more SB-related medical visits, more visits to a specialist, and a greater number of different types of specialists than those without it. Frequency of emergency room visits did not differ between the two groups. Health providers informed parents about headaches, vomiting, and fever as signs of complications, and some parents did report shunt-related complications. CONCLUSION: SB is a complex medical condition requiring that children receive medical care from various medical specialists, especially for children with a shunt. Findings on health care use suggest high levels of monitoring and care coordination that parents navigate to care for their child.

        Ong, K. S.

      3. A national communication effort addressing maternal mortality in the United States: Implementation of the Hear Her Campaign
        Behm B, Tevendale H, Carrigan S, Stone C, Morris K, Rosenthal J.
        J Womens Health (Larchmt). 2022 Dec;31(12):1677-1685.
        More than 700 women die each year in the United States from complications related to pregnancy, and considerable racial and ethnic disparities continue to exist. Recognizing the urgent maternal warning signs of pregnancy-related complications, getting an accurate and timely diagnosis and quality care can save lives. In August 2020, the Centers for Disease Control and Prevention, Division of Reproductive Health launched a national communication campaign called "Hear Her" to raise awareness of urgent maternal warning signs during pregnancy and in the year after pregnancy and improve communication between pregnant or postpartum people and their support systems and health care providers. Storytelling is a central strategy to the campaign, which features video stories of women's experiences with pregnancy-related conditions to bring voices to the statistics and to help motivate action. These stories and additional campaign resources are disseminated through a website, digital media, organic (free) and paid social media, earned media, public service announcement distribution, and partners, with increased outreach to disproportionately affected communities. Partners in maternal and child health played an important role from campaign development to outreach and message dissemination. In the first year of the campaign, there were >390,000 unique visitors to the Hear Her website and 180 million impressions (number of times that content was displayed to a user) from digital and social media. Digital media allowed the campaign to reach priority audiences at a time when news and social media had a number of other urgent public health messages related to the COVID-19 pandemic.

        Behm, B. Tevendale, H. Carrigan, S. Stone, C. Morris, K. Rosenthal, J.

      4. Infant receipt of health care services during the 2016-2017 Zika virus outbreak in Puerto Rico
        D'Angelo D, Smith RA, Salvesen von Essen B, Kortsmit K, Ellington S, Galang R, Hernández-Virella W, Shulman H, Vargas-Bernal M, Warner L.
        P R Health Sci J. 2022 Dec;41(4):202-209.
        OBJECTIVE: To assess the receipt of health care services among live-born infants of women with and without evidence of Zika virus (ZIKV) infection while pregnant during the 2016-2017 ZIKV outbreak in Puerto Rico. METHODS: We used data from the Pregnancy Risk Assessment Monitoring System-Zika Postpartum Emergency Response study telephone surveys to examine maternal reports of the receipt of health care services by infants born in Puerto Rico from August through December 2016 and November through December 2017. Evidence of ZIKV infection was ascertained from the infant's birth certificate or was self-reported in the survey. RESULTS: Fourteen percent of women in 2016 and 9% in 2017 had evidence of ZIKV infection during pregnancy. Most infants of women with evidence of ZIKV received the recommended health care services in 2016 and 2017, respectively, including a hearing test (91% vs. 92%), developmental assessment (90% vs. 92%), and an eye exam (74% vs. 70%); fewer received a head scan (45% vs. 36%) and evaluation for physical therapy (17% vs. 10%). From 2016 to 2017, the proportion of infants having a personal doctor increased for all infants; for infants of women without evidence of ZIKV infection, receiving hearing, developmental, and eye assessments increased. CONCLUSION: Most infants of women with evidence of ZIKV infection during pregnancy received the recommended hearing and developmental assessments during the ZIKV outbreak. Experiences with increasing service capacity during the ZIKV outbreak can be evaluated to inform the response to future emergencies that affect maternal and child health.

        D'Angelo, D. Smith, R. A. Salvesen von Essen, B. Kortsmit, K. Ellington, S. Galang, R. Shulman, H. Warner, L.

    • Nutritional Sciences
      1. Ultra-processed food intake and risk of depression: a systematic review
        Tian YR, Deng CY, Xie HC, Long QJ, Yao Y, Yan D, Zhao H, Li Y, Xiao L, Liu H.
        Nutr Hosp. 2022 Dec 14.
        OBJECTIVE: to conduct a systematic review of the observational studies analyzing the association between ultra-processed food (UPF) intake and the risk of depression. DESIGN: the search adhered to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA); a search for observational studies published until June 2020 was performed in PubMed, Embase, Cochrane Library, and Web of Science databases, followed by additional manual searches. Eight reviewers, working independently in teams of two, screened studies for eligibility, extracted data, and assessed risk of bias. We resolved disagreements through discussion or, if necessary, through adjudication by a third (LH). And the study assessed cross-sectional studies using the Agency for Healthcare Research and Quality (AHRQ) methodological checklist and cohort and case-control studies using the Newcastle-Ottawa Scale (NOS) for quality. We used a tabular format to summarize the articles. RESULTS: twenty-eight studies evaluating UPF intake and risk of depression were finally selected, 21 of which had a cross-sectional design, 6 studies had a cohort design, and 1 had a case-control design. Of these, 4 cohort studies and 17 cross-sectional studies found that consumption of UPF were positively associated with depression or depressive symptoms. CONCLUSIONS: our review demonstrated that most studies included in the systematic review showed that UPF consumption is associated with the risk of depression. Future studies should consider the use of validated food intake assessments and standardized depression assessment methods to promote comparability between studies.

        Tian, Y. R. Deng, C. Y. Xie, H. C. Long, Q. J. Yao, Y. Yan, D.

    • Occupational Safety and Health
      1. The World Trade Center Health Program: an introduction to best practices
        Calvert GM, Anderson K, Cochran J, Cone JE, Harrison DJ, Haugen PT, Lilly G, Lowe SM, Luft BJ, Moline JM, Reibman J, Rosen R, Udasin IG, Werth AS.
        Arch Environ Occup Health. 2022 Dec 19:1-7.
        More than 20 years have elapsed since the September 11, 2001 (9/11) terrorist attacks on the World Trade Center (WTC), Pentagon and at Shanksville, PA. Many persons continue to suffer a variety of physical and mental health conditions following their exposures to a mixture of incompletely characterized toxicants and psychological stressors at the terrorist attack sites. Primary care and specialized clinicians should ask patients who may have been present at any of the 9/11 sites about their 9/11 exposures, especially patients with cancer, respiratory symptoms, chronic rhinosinusitis, gastroesophageal reflux disease, psychiatric symptoms, and substance use disorders. Clinicians, especially those in the NY metropolitan area, should know how to evaluate, diagnose, and treat patients with conditions that could be associated with exposure to the 9/11 attacks and its aftermath. As such, this issue of Archives contains a series of updates to clinical best practices relevant to medical conditions whose treatment is covered by the WTC Health Program. This first paper in the 14-part series describes the purpose of this series, defines the WTC Health Program and its beneficiaries, and explains how relevant Clinical Practice Guidelines were identified. This paper also reminds readers that because physical and mental health conditions are often intertwined, a coordinated approach to care usually works best and referral to health centers affiliated with the WTC Health Program may be necessary, since all such Centers offer multidisciplinary care.

        Calvert, G. M. Anderson, K. Lilly, G.

      2. Exposure to the anti-microbial chemical triclosan disrupts keratinocyte function and skin integrity in a model of reconstructed human epidermis
        Baur R, Kashon M, Lukomska E, Weatherly LM, Shane HL, Anderson SE.
        J Immunotoxicol. 2023 Dec;20(1):1-11.
        Triclosan is an anti-microbial chemical incorporated into products that are applied to the skin of healthcare workers. Exposure to triclosan has previously been shown to be associated with allergic disease in humans and impact the immune responses in animal models. Additionally, studies have shown that exposure to triclosan dermally activates the NLRP3 inflammasome and disrupts the skin barrier integrity in mice. The skin is the largest organ of the body and plays an important role as a physical barrier and regulator of the immune system. Alterations in the barrier and immune regulatory functions of the skin have been demonstrated to increase the risk of sensitization and development of allergic disease. In this study, the impact of triclosan exposure on the skin barrier and keratinocyte function was investigated using a model of reconstructed human epidermis. The apical surface of reconstructed human epidermis was exposed to triclosan (0.05-0.2%) once for 6, 24, or 48 h or daily for 5 consecutive days. Exposure to triclosan increased epidermal permeability and altered the expression of genes involved in formation of the skin barrier. Additionally, exposure to triclosan altered the expression patterns of several cytokines and growth factors. Together, these results suggest that exposure to triclosan impacts skin barrier integrity and function of human keratinocytes and suggests that these alterations may impact immune regulation.

        Baur, R. Kashon, M. Lukomska, E. Weatherly, L. M. Shane, H. L. Anderson, S. E.

    • Parasitic Diseases
      1. The importance of partnership in the rollout of triple-drug therapy to eliminate lymphatic filariasis in the Pacific
        Rainima-Qaniuci M, Lepaitai HB, Bhagirov R, Padmasiri E, Naseri T, Thomsen R, Won KY, Brant TA, Dodd E, Nua MT, Utu F, Tufa A, Chutaro E, Camacho J, Suiaunoa-Scanlan L, Thean LJ, Mani J, Hardy M, Samuela J, Romani L, Kaldor J, Steer AC, Faktaufon D, Bechu V, Naqio F, Sosene V, Sekihara M, Otaki J, Buhagiar TS, Yajima A.
        Am J Trop Med Hyg. 2022 May 11;106(5_Suppl):39-47.
        We discuss the experience of some Pacific island countries in introducing the new WHO-recommended treatment protocol for lymphatic filariasis-a triple-drug therapy composed of ivermectin, diethylcarbamazine, and albendazole. The successful rollout of the new treatment protocol was dependent on strong partnerships among these countries' ministries of health, WHO, and other stakeholders. Effective communication among these partners allowed for lessons learned to cross borders and have a positive impact on the experiences of other countries. We also describe various challenges confronted during this process and the ways these countries overcame them.

        Won, K. Y. Brant, T. A. Dodd, E.

      2. Countrywide insecticide resistance monitoring and first report of the presence of the L1014S knock down resistance in Niger, West Africa
        Soumaila H, Hamani B, Arzika , Soumana A, Daouda A, Daouda FA, Iro SM, Gouro S, Zaman-Allah MS, Mahamadou I, Kadri S, Salé NM, Hounkanrin W, Mahamadou B, Zamaka HN, Labbo R, Laminou IM, Jackou H, Idrissa S, Coulibaly E, Bahari-Tohon Z, Mathieu E, Carlson J, Dotson E, Awolola TS, Flatley C, Chabi J.
        Malar J. 2022 Dec 16;21(1):385.
        BACKGROUND: Mass distribution of insecticide-treated nets (ITNs) is the principal malaria vector control strategy adopted by Niger. To better inform on the most appropriate ITN to distribute, the National Malaria Control Programme (NMCP) of Niger and its partners, conducted insecticide resistance monitoring in selected sites across the country. METHODS: The susceptibility of Anopheles gambiae sensu lato (s.l.) to chlorfenapyr and pyrethroid insecticides was investigated in a total of sixteen sites in 2019 and 2020, using 2-5-day-old adults reared from wild collected larvae per site. The susceptibility status, pyrethroid resistance intensity at 5 and 10 times the diagnostic concentrations, and piperonyl butoxide (PBO) synergism with diagnostic concentrations of deltamethrin, permethrin and alpha-cypermethrin were assessed using WHO bioassays. Two doses (100 and 200 µg/bottle) of chlorfenapyr were tested using the CDC bottle assay method. Species composition and allele frequencies for knock-down resistance (kdr-L1014F and L1014S) and acetylcholinesterase (ace-1 G119S) mutations were further characterized using polymerase chain reaction (PCR). RESULTS: High resistance intensity to all pyrethroids tested was observed in all sites except for alpha-cypermethrin in Gaya and Tessaoua and permethrin in Gaya in 2019 recording moderate resistance intensity. Similarly, Balleyara, Keita and Tillabery yielded moderate resistance intensity for alpha-cypermethrin and deltamethrin, and Niamey V low resistance intensity against deltamethrin and permethrin in 2020. Pre-exposure to PBO substantially increased susceptibility with average increases in mortality between 0 and 70% for tested pyrethroids. Susceptibility to chlorfenapyr (100 µg/bottle) was recorded in all sites except in Tessaoua and Magaria where susceptibility was recorded at the dose of 200 µg/bottle. Anopheles coluzzii was the predominant malaria vector species in most of the sites followed by An. gambiae sensu stricto (s.s.) and Anopheles arabiensis. The kdr-L1014S allele, investigated for the first time, was detected in the country. Both kdr-L1014F (frequencies [0.46-0.81]) and L1014S (frequencies [0.41-0.87]) were present in all sites while the ace-1 G119S was between 0.08 and 0.20. CONCLUSION: The data collected will guide the NMCP in making evidence-based decisions to better adapt vector control strategies and insecticide resistance management in Niger, starting with mass distribution of new generation ITNs such as interceptor G2 and PBO ITNs.

        Mathieu, E. Dotson, E. Awolola, T. S.

    • Physical Activity
      1. Prospective association of daily steps with cardiovascular disease: A harmonized meta-analysis
        Paluch AE, Bajpai S, Ballin M, Bassett DR, Buford TW, Carnethon MR, Chernofsky A, Dooley EE, Ekelund U, Evenson KR, Galuska DA, Jefferis BJ, Kong L, Kraus WE, Larson MG, Lee IM, Matthews CE, Newton RL, Nordström A, Nordström P, Palta P, Patel AV, Pettee Gabriel K, Pieper CF, Pompeii L, Rees-Punia E, Spartano NL, Vasan RS, Whincup PH, Yang S, Fulton JE.
        Circulation. 2022 Dec 20.
        BACKGROUND: Taking fewer than the widely promoted "10 000 steps per day" has recently been associated with lower risk of all-cause mortality. The relationship of steps and cardiovascular disease (CVD) risk remains poorly described. A meta-analysis examining the dose-response relationship between steps per day and CVD can help inform clinical and public health guidelines. METHODS: Eight prospective studies (20 152 adults [ie, ≥18 years of age]) were included with device-measured steps and participants followed for CVD events. Studies quantified steps per day and CVD events were defined as fatal and nonfatal coronary heart disease, stroke, and heart failure. Cox proportional hazards regression analyses were completed using study-specific quartiles and hazard ratios (HR) and 95% CI were meta-analyzed with inverse-variance-weighted random effects models. RESULTS: The mean age of participants was 63.2±12.4 years and 52% were women. The mean follow-up was 6.2 years (123 209 person-years), with a total of 1523 CVD events (12.4 per 1000 participant-years) reported. There was a significant difference in the association of steps per day and CVD between older (ie, ≥60 years of age) and younger adults (ie, <60 years of age). For older adults, the HR for quartile 2 was 0.80 (95% CI, 0.69 to 0.93), 0.62 for quartile 3 (95% CI, 0.52 to 0.74), and 0.51 for quartile 4 (95% CI, 0.41 to 0.63) compared with the lowest quartile. For younger adults, the HR for quartile 2 was 0.79 (95% CI, 0.46 to 1.35), 0.90 for quartile 3 (95% CI, 0.64 to 1.25), and 0.95 for quartile 4 (95% CI, 0.61 to 1.48) compared with the lowest quartile. Restricted cubic splines demonstrated a nonlinear association whereby more steps were associated with decreased risk of CVD among older adults. CONCLUSIONS: For older adults, taking more daily steps was associated with a progressively decreased risk of CVD. Monitoring and promoting steps per day is a simple metric for clinician-patient communication and population health to reduce the risk of CVD.

        Galuska, D. A. Fulton, J. E.

    • Public Health Leadership and Management
      1. Improving the effectiveness of Field Epidemiology Training Programs: characteristics that facilitated effective response to the COVID-19 pandemic in Uganda
        Harris JR, Kadobera D, Kwesiga B, Kabwama SN, Bulage L, Kyobe HB, Kagirita AA, Mwebesa HG, Wanyenze RK, Nelson LJ, Boore AL, Ario AR.
        BMC Health Serv Res. 2022 Dec 16;22(1):1532.
        BACKGROUND: The global need for well-trained field epidemiologists has been underscored in the last decade in multiple pandemics, the most recent being COVID-19. Field Epidemiology Training Programs (FETPs) are in-service training programs that improve country capacities to respond to public health emergencies across different levels of the health system. Best practices for FETP implementation have been described previously. The Uganda Public Health Fellowship Program (PHFP), or Advanced-FETP in Uganda, is a two-year fellowship in field epidemiology funded by the U.S. Centers for Disease Control and situated in the Uganda National Institute of Public Health (UNIPH). We describe how specific attributes of the Uganda PHFP that are aligned with best practices enabled substantial contributions to the COVID-19 response in Uganda. METHODS: We describe the PHFP in Uganda and review examples of how specific program characteristics facilitate integration with Ministry of Health needs and foster a strong response, using COVID-19 pandemic response activities as examples. We describe PHFP activities and outputs before and during the COVID-19 response and offer expert opinions about the impact of the program set-up on these outputs. RESULTS: Unlike nearly all other Advanced FETPs in Africa, PHFP is delinked from an academic degree-granting program and enrolls only post-Master's-degree fellows. This enables full-time, uninterrupted commitment of academically-trained fellows to public health response. Uganda's PHFP has strong partner support in country, sufficient technical support from program staff, Ministry of Health (MoH), CDC, and partners, and full-time dedicated directorship from a well-respected MoH staff member. The PHFP is physically co-located inside the UNIPH with the emergency operations center (EOC), which provides a direct path for health alerts to be investigated by fellows. It has recognized value within the MoH, which integrates graduates into key MoH and partner positions. During February 2020-September 2021, PHFP fellows and graduates completed 67 major COVID-related projects. PHFP activities during the COVID-19 response were specifically requested by the MoH or by partners, or generated de novo by the program, and were supervised by all partners. CONCLUSION: Specific attributes of the PHFP enable effective service to the Ministry of Health in Uganda. Among the most important is the enrollment of post-graduate fellows, which leads to a high level of utilization of the program fellows by the Ministry of Health to fulfill real-time needs. Strong leadership and sufficient technical support permitted meaningful program outputs during COVID-19 pandemic response. Ensuring the inclusion of similar characteristics when implementing FETPs elsewhere may allow them to achieve a high level of impact.

        Harris, J. R. Nelson, L. J. Boore, A. L.

      2. Drivers of COVID-19 policy stringency in 175 countries and territories: COVID-19 cases and deaths, gross domestic products per capita, and health expenditures
        Jalloh MF, Zeebari Z, Nur SA, Prybylski D, Nur AA, Hakim AJ, Winters M, Steinhardt LC, Gatei W, Omer SB, Brewer NT, Nordenstedt H.
        J Glob Health. 2022 Dec 17;12:05049.
        BACKGROUND: New data on COVID-19 may influence the stringency of containment policies, but these potential effect are not understood. We aimed to understand the associations of new COVID-19 cases and deaths with policy stringency globally and regionally. METHODS: We modelled the marginal effects of new COVID-19 cases and deaths on policy stringency (scored 0-100) in 175 countries and territories, adjusting for gross domestic product (GDP) per capita and health expenditure (% of GDP), and public expenditure on health. The time periods examined were March to August 2020, September 2020 to February 2021, and March to August 2021. RESULTS: Policy response to new cases and deaths was faster and more stringent early in the COVID-19 pandemic (March to August 2020) compared to subsequent periods. New deaths were more strongly associated with stringent policies than new cases. In an average week, one new death per 100 000 people was associated with a stringency increase of 2.1 units in the March to August 2020 period, 1.3 units in the September 2020 to February 2021 period, and 0.7 units in the March to August 2021 period. New deaths in Africa and the Western Pacific were associated with more stringency than in other regions. Higher health expenditure as a percentage of GDP was associated with less stringent policies. Similarly, higher public expenditure on health by governments was mostly associated with less stringency across all three periods. GDP per capita did not have consistent patterns of associations with stringency. CONCLUSIONS: The stringency of COVID-19 policies was more strongly associated with new deaths than new cases. Our findings demonstrate the need for enhanced mortality surveillance to ensure policy alignment during health emergencies. Countries that invest less in health or have a lower public expenditure on health may be inclined to enact more stringent policies. This new empirical understanding of COVID-19 policy drivers can help public health officials anticipate and shape policy responses in future health emergencies.

        Jalloh, M. F. Prybylski, D. Nur, A. A. Hakim, A. J. Steinhardt, L. C. Gatei, W.

    • Reproductive Health
      1. Attitudes and experiences surrounding female genital mutilation/cutting in the United States: A scoping review
        Besera G, Goldberg H, Okoroh EM, Snead MC, Johnson-Agbakwu CE, Goodwin MM.
        J Immigr Minor Health. 2022 Dec 21.
        To identify research and gaps in literature about FGM/C-related attitudes and experiences among individuals from FGM/C-practicing countries living in the United States, we conducted a scoping review guided by Arksey and O'Malley's framework. We searched Medline (OVID), Embase (OVID), PubMed, and SCOPUS and conducted a grey literature search for studies assessing attitudes or experiences related to FGM/C with data collected directly from individuals from FGM/C-practicing countries living in the United States. The search yielded 417 studies, and 40 met the inclusion criteria. Findings suggest that women and men from FGM/C-practicing countries living in the United States generally oppose FGM/C, and that women with FGM/C have significant physical and mental health needs and have found US healthcare providers to lack understanding of FGM/C. Future research can improve measurement of FGM/C by taking into account the sociocultural influences on FGM/C-related attitudes and experiences.

        Besera, G. Okoroh, E. M. Snead, M. C. Goodwin, M. M.

    • Substance Use and Abuse
      1. Drug overdose deaths among persons aged 10-19 years - United States, July 2019-December 2021
        Tanz LJ, Dinwiddie AT, Mattson CL, O'Donnell J, Davis NL.
        MMWR Morb Mortal Wkly Rep. 2022 Dec 16;71(50):1576-1582.
        U.S. drug overdose deaths increased 30% from 2019 to 2020 and 15% in 2021, resulting in an estimated 108,000 deaths in 2021.* Among persons aged 14-18 years, overdose deaths increased 94% from 2019 to 2020 and 20% from 2020 to 2021 (1), although illicit drug use declined overall among surveyed middle and high school students during 2019-2020 (2). Widespread availability of illicitly manufactured fentanyls (IMFs),(†) proliferation of counterfeit pills resembling prescription drugs but containing IMFs or other illicit drugs,(§) and ease of purchasing pills through social media(¶) have increased fatal overdose risk among adolescents (1,3). Using CDC's State Unintentional Drug Overdose Reporting System (SUDORS), this report describes trends and characteristics of overdose deaths during July 2019-December 2021 among persons aged 10-19 years (hereafter referred to as adolescents). From July-December 2019 to July-December 2021, median monthly overdose deaths increased 109%, and deaths involving IMFs increased 182%. Approximately 90% of overdose deaths involved opioids, and 83.9% involved IMFs; however, only 35% of decedents had documented opioid use history. Counterfeit pill evidence was present in 24.5% of overdose deaths, and 40.9% of decedents had evidence of mental health conditions or treatment. To prevent overdose deaths among adolescents, urgent efforts are needed, including preventing substance use initiation, strengthening partnerships between public health and public safety to reduce availability of illicit drugs, expanding efforts focused on resilience and connectedness of adolescents to prevent substance misuse and related harms, increasing education regarding IMFs and counterfeit pills, expanding naloxone training and access, and ensuring access to treatment for substance use and mental health disorders.

        Tanz, L. J. Dinwiddie, A. T. Mattson, C. L. O'Donnell, J. Davis, N. L.

      2. Changes in sales of e-cigarettes, cigarettes, and nicotine replacement therapy products before, during, and after the EVALI outbreak
        Wang X, Kim Y, Trivers KF, Tynan MA, Shrestha SS, Emery S, Borowiecki M, Hacker K.
        Prev Chronic Dis. 2022 Dec 15;19:E86.
        INTRODUCTION: In 2019, an outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) occurred in the US. We used Nielsen retail sales data to assess trends in sales of e-cigarettes, cigarettes, and nicotine replacement therapy (NRT) products before, during, and after the EVALI outbreak. METHODS: Monthly unit sales of e-cigarettes, cigarettes, and NRT products overall and by product type were assessed during January 2019 through June 2020 by using an interrupted time series model. Two time points were specified at the period ending July 13, 2019, and the period ending February 22, 2020, to partition before, during, and after the outbreak period. Sales trends by aggregated state-level EVALI case prevalence (low, medium, and high) were assessed to investigate interstate variations in changes of sales coinciding with the EVALI outbreak. RESULTS: Monthly e-cigarette sales increased 3.5% (P < .001) before the outbreak and decreased 3.1% (P < .001) during the outbreak, with no significant changes after the outbreak. Monthly cigarette sales increased 1.6% (P < .001) before the outbreak, decreased 1.8% (P < .001) during the outbreak, and increased 2.7% (P < .001) after the outbreak. NRT sales did not change significantly before or during the outbreak but decreased (2.8%, P = .01) after the outbreak. Sales trends by state-level EVALI case prevalence were similar to national-level sales trends. CONCLUSION: Cigarette and e-cigarette sales decreased during the EVALI outbreak, but no changes in overall NRT sales were observed until after the outbreak. Continued monitoring of tobacco sales data can provide insight into potential changes in use patterns and inform tobacco prevention and control efforts.

        Wang, X. Trivers, K. F. Tynan, M. A. Shrestha, S. S. Hacker, K.

    • Telehealth and Telemedicine
      1. Engagement in the Michigan screening and intervention for glaucoma and eye health through telemedicine program: Comparing the effect of clinic versus community-based recruitment strategies
        Elam AR, Mobolaji I, Flaharty K, Niziol LM, Woodward MA, Zhang J, Musch DC, Johnson L, Kershaw M, Bicket AK, Saaddine J, John D, Newman-Casey PA.
        Ophthalmol Glaucoma. 2022 Nov 1.
        PURPOSE: To determine the effectiveness of adding community-based recruitment to clinic-based recruitment to engage participants in a glaucoma detection program. DESIGN: Prospective cohort study. SUBJECTS: Anyone ≥ 18 years of age who does not meet exclusion criteria. METHODS: The Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine (MI-SIGHT) program tests a novel way of improving glaucoma detection in communities with populations at high risk for disease, including people who identify as Black and Hispanic and those living with low socioeconomic status. The MI-SIGHT program is conducted in a free clinic (Ypsilanti, MI) and in a federally qualified health center (FQHC) (Flint, MI). Community engagement methods were used to identify outreach strategies to enhance recruitment. Participants were asked "How did you hear about the MI-SIGHT program?" and responses were summarized overall and by clinic and compared between clinic-based and community-based recruitment strategies. MAIN OUTCOME MEASURES: Proportion recruited by location, within or outside of the clinic. RESULTS: In total, 647 participants were recruited in the first 11 months of the study, 356 (55.0%) at the free clinic over 11 months and 291 (45.0%) at the FQHC over 6 months. Participants were on average 54.4 years old (standard deviation = 14.2); 60.9% identified as female, 45.6% identified as Black, 37.8% identified as White, 9.6% identified as Hispanic, and 10.9% had less than high school education. Participants reported hearing about the MI-SIGHT program from a clinic phone call (n = 168, 26.1%), a friend (n = 112, 17.4%), nonmedical clinic staff (n = 100, 15.5%), a clinic doctor (n = 77, 11.9%), an in-clinic brochure or flyer (n = 51, 7.9%), a community flyer (n = 44, 6.8%), the clinic website or social media (n = 28, 4.3%), or an "other" source (n = 65, 10.1%). Recruiting from the community outside the medical clinics increased participation by 265% at the free clinic and 46% at the FQHC. CONCLUSIONS: The Community Advisory Board recommendation to use community-based recruitment strategies in addition to clinic-based strategies for recruitment resulted in increased program participation. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

        Saaddine, J.

    • Zoonotic and Vectorborne Diseases
      1. Neuroinvasive Onchocerca lupi infection in a ten-year-old girl
        Bowers Wu D, Ko B, Lopez Hernandez G, Botros J, Spader H, Sapp S, Qvarnstrom Y, Paddock CD, Cantey PT, Dehority W.
        Case Rep Infect Dis. 2022 ;2022:9773058.
        The nematode Onchocerca lupi is an emerging human pathogen. Though its life cycle is not well studied, it likely infects humans after a bite from a black fly vector, which in turn acquires infective microfilariae from an infected canid. These microfilariae mature into an infective larval stage within the fly. Among six reported cases in the United States, five involved children, and all occurred in the southwest. In this report, we present a case of O. lupi infection with cervical spine invasion in a healthy 10-year-old girl. She presented with five months of neurological symptoms from a rural and medically underserved area, highlighting a need for clinical vigilance in such settings for this emerging infectious threat in the American southwest.

        Sapp, S. Qvarnstrom, Y. Paddock, C. D. Cantey, P. T.

      2. Human rabies despite post-exposure prophylaxis: a systematic review of fatal breakthrough infections after zoonotic exposures
        Whitehouse ER, Mandra A, Bonwitt J, Beasley EA, Taliano J, Rao AK.
        Lancet Infect Dis. 2022 Dec 12.
        Post-exposure prophylaxis (PEP) for rabies is widely administered and highly effective. Nevertheless, sporadic breakthrough infections (ie, rabies in people who have started PEP) have been reported. We conducted a systematic review of articles published between Jan 1, 1980 and June 1, 2022 to characterise breakthrough infections. After reviewing 3380 articles from across all continents, we identified 52 articles, which included a total of 122 breakthrough infections. We classified breakthrough infections on the basis of adherence to core practices (ie, wound cleaning and vaccine administration). Of 86 breakthrough infections with data, median time from exposure to symptom onset was 20 days (IQR 16-24). Most (89 [77%] of 115) participants received PEP within 2 days of an exposure. Severe wounds (defined as those involving multiple wound sites or bites to the head, face, or neck) were common (80 [69%] of 116 [with data]). Deviations from core practices were reported in 68 (56%) of 122 cases. Other possible causes for breakthrough infections included errors in the administration of rabies immunoglobulin, delays in seeking health care, and comorbidities or immunosuppression. Cold-chain integrity assessments and potency testing of PEP biologics were only rarely assessed (8 [7%] of 122 cases), neither of which were found to be a cause of breakthrough infections. Timely and appropriate administration of PEP is crucial to prevent rabies, and although people with high-risk exposures or immunosuppression can develop rabies despite adherence to core practices, this occurrence remains exceedingly rare.

        Whitehouse, E. R. Mandra, A. Bonwitt, J. Beasley, E. A. Taliano, J. Rao, A. K.

      3. Notes from the field: Burkholderia pseudomallei detected in a raccoon carcass linked to a multistate aromatherapy-associated melioidosis outbreak - Texas, 2022
        Petras JK, Elrod MG, Ty M, Adams P, Zahner D, Adams A, Calfee MW, Tomlinson C, Serre S, Ryan S, Jakabhazy E, Gee JE, Weiner Z, Bower WA, Negron ME, Hoffmaster AR, Honza H.
        MMWR Morb Mortal Wkly Rep. 2022 Dec 16;71(50):1597-1598.

      4. Comprehensive characterization of toxins during progression of inhalation anthrax in a non-human primate model
        Boyer AE, Gallegos-Candela M, Lins RC, Solano MI, Woolfitt AR, Lee JS, Sanford DC, Knostman KA, Quinn CP, Hoffmaster AR, Pirkle JL, Barr JR.
        PLoS Pathog. 2022 Dec 19;18(12):e1010735.
        Inhalation anthrax has three clinical stages: early-prodromal, intermediate-progressive, and late-fulminant. We report the comprehensive characterization of anthrax toxins, including total protective antigen (PA), total lethal factor (LF), total edema factor (EF), and their toxin complexes, lethal toxin and edema toxin in plasma, during the course of inhalation anthrax in 23 cynomolgus macaques. The toxin kinetics were predominantly triphasic with an early rise (phase-1), a plateau/decline (phase-2), and a final rapid rise (phase-3). Eleven animals had shorter survival times, mean±standard deviation of 58.7±7.6 hours (fast progression), 11 animals had longer survival times, 113±34.4 hours (slow progression), and one animal survived. Median (lower-upper quartile) LF levels at the end-of-phase-1 were significantly higher in animals with fast progression [138 (54.9-326) ng/mL], than in those with slow progression [23.8 (15.6-26.3) ng/mL] (p = 0.0002), and the survivor (11.1 ng/mL). The differences were also observed for other toxins and bacteremia. Animals with slow progression had an extended phase-2 plateau, with low variability of LF levels across all time points and animals. Characterization of phase-2 toxin levels defined upper thresholds; critical levels for exiting phase-2 and entering the critical phase-3, 342 ng/mL (PA), 35.8 ng/mL (LF), and 1.10 ng/mL (EF). The thresholds were exceeded earlier in animals with fast progression (38.5±7.4 hours) and later in animals with slow progression (78.7±15.2 hours). Once the threshold was passed, toxin levels rose rapidly in both groups to the terminal stage. The time from threshold to terminal was rapid and similar; 20.8±7.4 hours for fast and 19.9±7.5 hours for slow progression. The three toxemic phases were aligned with the three clinical stages of anthrax for fast and slow progression which showed that anthrax progression is toxin- rather than time-dependent. This first comprehensive evaluation of anthrax toxins provides new insights into disease progression.

        Boyer, A. E. Gallegos-Candela, M. Lins, R. C. Solano, M. I. Woolfitt, A. R. Quinn, C. P. Hoffmaster, A. R. Pirkle, J. L. Barr, J. R.


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